Bishop Spencer Place, INC, the
4301 Madison Avenue, Kansas City, MO 64111 · Jackson County · 57 certified beds · avg 47 residents/day · certified since Nov 7, 2003
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Jul 29, 2024 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jul 25, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (25)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jan 9, 2026 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jan 9, 2026 | F · Potential for harm, facility-wide | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Jan 9, 2026 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. |
| Jan 9, 2026 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jan 9, 2026 | D · Potential for harm, one-off | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. |
| Jan 9, 2026 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Jan 9, 2026 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Jan 9, 2026 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Jan 9, 2026 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Jul 29, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Jul 29, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Feb 6, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Feb 6, 2024 | E · Potential for harm, repeated | The facility did not properly notify residents about the balance of money it holds for them, or failed to return those funds when a resident was discharged, evicted, or died. |
| Feb 6, 2024 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Feb 6, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Feb 6, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Feb 6, 2024 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Feb 6, 2024 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Feb 6, 2024 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Feb 6, 2024 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Aug 29, 2023 | D · Potential for harm, one-off | The facility did not properly prepare residents for a safe transfer or discharge. Before a resident leaves, the facility must get them ready and make sure the move is safe and orderly. · from a complaint |
| Jul 19, 2022 | E · Potential for harm, repeated | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Jul 19, 2022 | E · Potential for harm, repeated | The facility did not provide each resident with a nourishing, tasty, well-balanced diet that meets their daily nutritional and special dietary needs. |
| Jul 19, 2022 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Jul 19, 2022 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (9 → 9).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 4 | 0 | E |
| 2023 | 1 | 0 | D |
| 2024 | 11 | 1 | J ▲ |
| 2026 | 9 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $8,021.
| Date | Type | Amount / length |
|---|---|---|
| Jul 29, 2024 | Fine | $8,021 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Missouri avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 5.97 | 3.66 | 3.95 | top 3% in Missouri; top 4% in the U.S. |
| Registered Nurse hours | 0.92 | 0.49 | 0.69 | top 5% in Missouri; top 19% in the U.S. |
| Weekend total nurse staffing | 4.83 | 3.22 | 3.50 | top 5% in Missouri; top 8% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.37 | 0.33 | 0.48 | top 24% in Missouri; bottom 47% in the U.S. |
| Total nursing staff turnover (%) | 40.6 | 56.0 | 45.8 | top 14% in Missouri; top 38% in the U.S. |
| RN turnover (%) | 58.3 | 47.8 | 42.9 | bottom 34% in Missouri; bottom 24% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 5.46, RN 0.84, weekend 4.41. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 4/5 · short-stay residents: 2/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Achelphol, Richard | Individual | Corporate Director | NOT APPLICABLE | 01/01/2025 |
| Achelphol, Richard | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2025 |
| Calvin, Karen | Individual | Corporate Director | NOT APPLICABLE | 01/01/2022 |
| Calvin, Karen | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2022 |
| Coulter, James | Individual | Corporate Director | NOT APPLICABLE | 01/01/2024 |
| Coulter, James | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2024 |
| Elving, Beverly | Individual | Corporate Director | NOT APPLICABLE | 01/01/2019 |
| Elving, Beverly | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2019 |
| Havenhill, Lisa | Individual | Corporate Director | NOT APPLICABLE | 01/19/2020 |
| Havenhill, Lisa | Individual | Corporate Officer | NOT APPLICABLE | 01/19/2019 |
| Havenhill, Lisa | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/19/2020 |
| Hutcherson, Anne | Individual | Corporate Director | NOT APPLICABLE | 01/01/2024 |
| Hutcherson, Anne | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2024 |
| Jackson, Anthony | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2025 |
| Jackson, Anthony | Individual | ADP of the SNF | NOT APPLICABLE | 12/09/2025 |
| Johnson, Jani | Individual | Corporate Director | NOT APPLICABLE | 01/15/2020 |
| Johnson, Jani | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/15/2020 |
| Johnston, Nanette | Individual | Corporate Director | NOT APPLICABLE | 01/01/2025 |
| Johnston, Nanette | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2025 |
| Keyse, Andrew | Individual | Corporate Director | NOT APPLICABLE | 01/01/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Who oversees antibiotic use here, and how do you decide when an antibiotic is really needed?"
- "What specific steps do you take to prevent abuse and neglect, and how are staff trained on them?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "How soon after admission is a full assessment completed, and how are the findings shared with the family?"
- "How do you identify and arrange specialized services for residents with mental health conditions or disabilities?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Summit, the | 0.8 mi | Kansas City, MO | ★★☆☆☆ | 1/5 | |
| Clara Manor Nursing Home | 1.1 mi | Kansas City, MO | ★☆☆☆☆ | 1/5 | abuse |
| Parkway Health Care Center | 2.1 mi | Kansas City, MO | ★☆☆☆☆ | 1/5 | |
| Highland Rehabilitation & Health Care Center | 3.3 mi | Kansas City, MO | ★★★☆☆ | 2/5 | abuse |
| Myers Nursing & Convalescent Center | 3.6 mi | Kansas City, MO | ★★☆☆☆ | 2/5 | |
| The Village at Mission | 3.8 mi | Prairie Village, KS | ★★☆☆☆ | 2/5 | |
| Gregory Ridge Health Care Center | 4.5 mi | Kansas City, MO | ★☆☆☆☆ | 1/5 | abuseSFF |
| Armour Oaks Senior Living Community | 4.7 mi | Kansas City, MO | ★★☆☆☆ | 3/5 | |
| Rehab of Kansas City South | 4.7 mi | Kansas City, MO | ★☆☆☆☆ | 2/5 | abuse |
| Claridge Court | 5.0 mi | Prairie Village, KS | ★★★★★ | 5/5 | |
| Hope Care Center | 5.0 mi | Kansas City, MO | ★★★★★ | 4/5 | |
| Aspen Health and Wellness | 5.2 mi | Overland Park, KS | ★☆☆☆☆ | 1/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 265768.