Blue Springs Wellness & Rehabilitation
930 NE Duncan Road, Blue Springs, MO 64014 · Jackson County · 120 certified beds · avg 106 residents/day · certified since Dec 1, 1994
Abuse citation flag (CMS)
Part of chain: OPCO SKILLED MANAGEMENT (66 facilities, chain avg rating 2.3★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
2/5
Health inspection rating (on-site)
3
Serious findings on record
$96,959
Fines, last 3 years
2.22
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
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 · Oct 3, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
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: Oct 1, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Aug 24, 2023 · F-0584 · triggered by a complaint
The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Why it matters: An unsafe or unclean environment affects residents' health, comfort, and dignity every single day.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Sep 20, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 18, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
All citations in the current public record (66)
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 |
|---|---|---|
| Nov 18, 2025 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Nov 18, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Mar 28, 2025 | E · Potential for harm, repeated | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Mar 28, 2025 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Mar 28, 2025 | 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. |
| Mar 28, 2025 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Mar 28, 2025 | 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. |
| Mar 28, 2025 | D · Potential for harm, one-off | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. |
| Mar 28, 2025 | D · Potential for harm, one-off | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. |
| Mar 28, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Mar 28, 2025 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Mar 28, 2025 | D · Potential for harm, one-off | 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. |
| Mar 28, 2025 | D · Potential for harm, one-off | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. |
| Mar 28, 2025 | D · Potential for harm, one-off | 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. |
| Dec 2, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Oct 3, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Apr 22, 2024 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. · from a complaint |
| Aug 24, 2023 | ▲ K · Immediate jeopardy, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Aug 24, 2023 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Jul 21, 2023 | 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. |
| Jul 21, 2023 | 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. |
| Jul 21, 2023 | F · Potential for harm, facility-wide | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. |
| Jul 21, 2023 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Jul 21, 2023 | 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. |
| Jul 21, 2023 | 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. |
| Jul 21, 2023 | E · Potential for harm, repeated | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Jul 21, 2023 | 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. |
| Jul 21, 2023 | 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 21, 2023 | E · Potential for harm, repeated | 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. |
| Jul 21, 2023 | E · Potential for harm, repeated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| Jul 21, 2023 | E · Potential for harm, repeated | The facility did not have enough fresh-air ventilation, whether through windows, mechanical systems, or both. |
| Jul 21, 2023 | E · Potential for harm, repeated | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. |
| Jul 21, 2023 | D · Potential for harm, one-off | The facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings. |
| Jul 21, 2023 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Jul 21, 2023 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Jul 21, 2023 | 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. |
| Jul 21, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Jul 21, 2023 | 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. |
| Jul 21, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jul 21, 2023 | 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 21, 2023 | D · Potential for harm, one-off | The facility did not provide each resident with a nourishing, tasty, well-balanced diet that meets their daily nutritional and special dietary needs. |
| Jul 21, 2023 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Apr 7, 2022 | 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. |
| Apr 7, 2022 | 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. |
| Apr 7, 2022 | E · Potential for harm, repeated | The facility did not properly protect the personal money residents deposited with it for safekeeping. |
| Apr 7, 2022 | E · Potential for harm, repeated | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Apr 7, 2022 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Apr 7, 2022 | E · Potential for harm, repeated | The facility did not update each resident's care assessment at least once every 3 months. These regular check-ins keep the resident's care plan matched to their current condition. |
| Apr 7, 2022 | E · Potential for harm, repeated | The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require. |
| Apr 7, 2022 | 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. |
| Apr 7, 2022 | E · Potential for harm, repeated | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Apr 7, 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. |
| Apr 7, 2022 | E · Potential for harm, repeated | 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. |
| Apr 7, 2022 | E · Potential for harm, repeated | The facility did not have a policy covering how food brought in by family and visitors is used and stored safely. |
| Apr 7, 2022 | E · Potential for harm, repeated | The facility did not dispose of garbage and refuse properly. |
| Apr 7, 2022 | E · Potential for harm, repeated | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. |
| Apr 7, 2022 | E · Potential for harm, repeated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| Apr 7, 2022 | D · Potential for harm, one-off | The facility did not properly hold, secure, and manage residents' personal money that was deposited with it for safekeeping. Facilities holding residents' funds must keep careful, honest accounts. |
| Apr 7, 2022 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Apr 7, 2022 | 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. |
| Apr 7, 2022 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Apr 7, 2022 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Apr 7, 2022 | D · Potential for harm, one-off | The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. |
| Apr 7, 2022 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Apr 7, 2022 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Apr 7, 2022 | D · Potential for harm, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (23 → 12).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 24 | 0 | F |
| 2023 | 25 | 1 | K ▲ |
| 2024 | 3 | 1 | J ▲ |
| 2025 | 14 | 1 | G ▲ |
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 $96,959.
| Date | Type | Amount / length |
|---|---|---|
| Sep 27, 2024 | Fine | $96,959 |
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) | 2.22 | 3.66 | 3.95 | bottom 8% in Missouri; bottom 2% in the U.S. |
| Registered Nurse hours | 0.24 | 0.49 | 0.69 | bottom 16% in Missouri; bottom 5% in the U.S. |
| Weekend total nurse staffing | 1.94 | 3.22 | 3.50 | bottom 8% in Missouri; bottom 1% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.24 | 0.33 | 0.48 | bottom 41% in Missouri; bottom 19% in the U.S. |
| Total nursing staff turnover (%) | 68.9 | 56.0 | 45.8 | bottom 17% in Missouri; bottom 7% in the U.S. |
| RN turnover (%) | 75.0 | 47.8 | 42.9 | bottom 15% in Missouri; bottom 9% 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 2.69, RN 0.30, weekend 2.35. Staffing rating: 1/5.
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: 5/5 · long-stay residents: 5/5 · short-stay residents: 4/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Blooming Willow Partners LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 12/02/2024 |
| Derhoben Trust | Organization | 5% or Greater Indirect Ownership Interest | — | 12/02/2024 |
| Garetz, David | Individual | Indirect Ownership Interest | NOT APPLICABLE | 12/02/2024 |
| Pas B Sol Trust | Organization | 5% or Greater Indirect Ownership Interest | — | 12/02/2024 |
| Wildflower Healthcare LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 12/02/2024 |
| 930 NE Duncan Road Mo, LLC | Organization | 5% or Greater Mortgage Interest | NOT APPLICABLE | 12/02/2024 |
| 930 NE Duncan Road Mo, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/02/2024 |
| Braswell, Amanda | Individual | ADP of the SNF | NOT APPLICABLE | 12/02/2024 |
| Brook Partners LLC | Organization | 5% or Greater Mortgage Interest | NOT APPLICABLE | 12/02/2024 |
| Brook Partners LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/02/2024 |
| Chung, Richard | Individual | ADP of the SNF | NOT APPLICABLE | 12/02/2024 |
| Davidovich, Niv | Individual | Trustee of the SNF | NOT APPLICABLE | 12/02/2024 |
| Garetz, David | Individual | Corporate Officer | NOT APPLICABLE | 12/02/2024 |
| Garetz, David | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/02/2024 |
| Hagins, Elizabeth | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 02/02/2025 |
| Kaplan, Mordechai | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 02/02/2025 |
| Knobel Realty Trust | Organization | 5% or Greater Mortgage Interest | NOT APPLICABLE | 12/02/2024 |
| Knobel Realty Trust | Organization | ADP of the SNF | NOT APPLICABLE | 12/02/2024 |
| Linz Trust | Organization | 5% or Greater Mortgage Interest | NOT APPLICABLE | 12/02/2024 |
| Linz Trust | Organization | ADP of the SNF | NOT APPLICABLE | 12/02/2024 |
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 is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "Does a pharmacist review every resident's medications and chart monthly, and how are their concerns acted on?"
- "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "How do you decide when a feeding tube is truly needed, and how do staff care for residents who have one?"
- "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 |
|---|---|---|---|---|---|
| Ignite Medical Resort St Marys LLC | 0.9 mi | Blue Springs, MO | ★★☆☆☆ | 2/5 | |
| Ignite Medical Resort Blue Springs | 4.7 mi | Blue Springs, MO | ★★★★★ | 4/5 | |
| Monterey Park Rehabilitation & Health Care Center | 5.1 mi | Independence, MO | ★★★☆☆ | 4/5 | |
| Villages of Jackson Creek | 5.5 mi | Independence, MO | ★★☆☆☆ | 2/5 | |
| Sunterra Springs Independence | 5.8 mi | Independence, MO | ★★★★★ | 4/5 | |
| Aspire Senior Living Oak Grove | 7.0 mi | Oak Grove, MO | ★★☆☆☆ | 4/5 | |
| Rehabilitation Center of Independence, the | 7.1 mi | Independence, MO | ★★☆☆☆ | 2/5 | abuse |
| Abode Health and Wellness Center | 7.2 mi | Independence, MO | ★☆☆☆☆ | 1/5 | abuseSFF |
| Wilshire at Lakewood Rehab Center | 7.2 mi | Lees Summit, MO | ★★★☆☆ | 4/5 | |
| University Health Lakewood Medical Center | 8.5 mi | Kansas City, MO | ★★★★☆ | 4/5 | |
| Seasons Rehab and Healthcare Center | 8.7 mi | Kansas City, MO | ★★★★☆ | 4/5 | |
| Carmel Hills Wellness & Rehabilitation | 8.9 mi | Independence, MO | ★☆☆☆☆ | 1/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 265595.