Missouri ›Strafford

Strafford Rehabilitation & Health Care Center

505 West Evergreen, Strafford, MO 65757 · Greene County · 78 certified beds · avg 66 residents/day · certified since Aug 21, 1996

Part of chain: JAMES & JUDY LINCOLN (56 facilities, chain avg rating 2.4★)

1/5
Health inspection rating (on-site)
1
Serious findings on record
$52,456
Fines, last 3 years
3.26
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5

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 31, 2024 · 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 (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: Dec 13, 2024 (Deficient, Provider has date of correction)

All citations in the current public record (72)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
Mar 26, 2026F · Potential for harm, facility-wideThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint
Mar 26, 2026E · Potential for harm, repeatedThe 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
Mar 26, 2026D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Mar 26, 2026D · Potential for harm, one-offThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint
Mar 26, 2026D · Potential for harm, one-offThe facility did not honor residents' right to share a room with their spouse or a roommate of their choosing, or moved residents to a different room without written notice beforehand. · from a complaint
Mar 26, 2026D · Potential for harm, one-offThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Mar 26, 2026D · Potential for harm, one-offThe 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. · from a complaint
Mar 26, 2026D · Potential for harm, one-offThe facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint
Feb 25, 2026D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Feb 25, 2026D · Potential for harm, one-offThe 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
Jan 5, 2026D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Jan 5, 2026D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Dec 12, 2025E · Potential for harm, repeatedThe 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. · from a complaint
Dec 11, 2025D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Dec 11, 2025D · Potential for harm, one-offThe 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
Dec 10, 2025D · Potential for harm, one-offThe facility did not keep residents' personal and medical information private and confidential. · from a complaint
Dec 10, 2025D · Potential for harm, one-offThe 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. · from a complaint
Dec 10, 2025D · Potential for harm, one-offThe 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. · from a complaint
Dec 10, 2025D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
May 20, 2025D · Potential for harm, one-offThe 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
May 2, 2025E · Potential for harm, repeatedThe 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
May 2, 2025D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
May 2, 2025D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Apr 21, 2025F · Potential for harm, facility-wideThe 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.
Apr 21, 2025F · Potential for harm, facility-wideThe facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician.
Apr 21, 2025F · Potential for harm, facility-wideThe 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 21, 2025F · Potential for harm, facility-wideThe facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them.
Apr 21, 2025F · Potential for harm, facility-wideThe 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 21, 2025F · Potential for harm, facility-wideThe facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program.
Apr 21, 2025E · Potential for harm, repeatedThe facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection.
Apr 21, 2025E · Potential for harm, repeatedThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Apr 21, 2025E · Potential for harm, repeatedThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do.
Apr 21, 2025E · Potential for harm, repeatedThe 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.
Apr 21, 2025E · Potential for harm, repeatedThe 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.
Apr 21, 2025E · Potential for harm, repeatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Apr 21, 2025E · Potential for harm, repeatedThe facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly.
Apr 21, 2025E · Potential for harm, repeatedThe 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.
Apr 21, 2025E · Potential for harm, repeatedThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
Apr 21, 2025D · Potential for harm, one-offThe 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.
Apr 21, 2025D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Apr 21, 2025D · Potential for harm, one-offThe 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.
Apr 21, 2025D · Potential for harm, one-offThe facility did not provide safe and appropriate pain management for a resident who needed it.
Apr 21, 2025C · Minimal risk, facility-wideThe 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.
Feb 6, 2025E · Potential for harm, repeatedThe facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint
Feb 6, 2025E · Potential for harm, repeatedThe 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
Feb 6, 2025E · Potential for harm, repeatedThe 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
Dec 11, 2024D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Oct 31, 2024▲ J · Immediate jeopardy, one-offThe 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
Oct 31, 2024D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Oct 18, 2024F · Potential for harm, facility-wideThe facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint
Oct 18, 2024E · Potential for harm, repeatedThe facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint
Oct 18, 2024E · Potential for harm, repeatedThe facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint
Oct 18, 2024E · Potential for harm, repeatedThe 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
Oct 18, 2024E · Potential for harm, repeatedThe 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
Oct 18, 2024D · Potential for harm, one-offThe 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
Oct 18, 2024D · Potential for harm, one-offThe 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. · from a complaint
Jun 4, 2024D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Jun 4, 2024D · Potential for harm, one-offThe 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
Jun 4, 2024D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Apr 7, 2024D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Apr 7, 2024D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Apr 7, 2024D · Potential for harm, one-offThe 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
Apr 7, 2024D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Jun 29, 2023F · Potential for harm, facility-wideThe facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months.
Jun 29, 2023E · Potential for harm, repeatedThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Jun 29, 2023E · Potential for harm, repeatedThe 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.
Jun 29, 2023E · Potential for harm, repeatedThe 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.
Jun 29, 2023D · Potential for harm, one-offThe 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.
Jun 29, 2023D · Potential for harm, one-offThe 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.
Feb 13, 2020E · Potential for harm, repeatedThe 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.
Feb 13, 2020E · Potential for harm, repeatedThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Feb 13, 2020E · Potential for harm, repeatedThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (6 → 20).

YearCitationsSerious (G–L)Worst severity that year
202030E
202360F
2024171J ▲
2025340F
2026120F

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 $52,456, plus 1 Medicare payment denial period.

DateTypeAmount / length
Oct 18, 2024Fine$52,456
Oct 18, 2024Payment Denial84 days from Dec 12, 2024

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityMissouri avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)3.263.663.95bottom 35% in Missouri; bottom 25% in the U.S.
Registered Nurse hours0.310.490.69bottom 28% in Missouri; bottom 10% in the U.S.
Weekend total nurse staffing2.943.223.50bottom 40% in Missouri; bottom 28% in the U.S.
Weekend RN hours (not acuity-adjusted)0.210.330.48bottom 32% in Missouri; bottom 14% in the U.S.
Total nursing staff turnover (%)82.356.045.8bottom 2% in Missouri; bottom 2% in the U.S.
RN turnover (%)83.347.842.9bottom 9% in Missouri; bottom 4% 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 3.16, RN 0.30, weekend 2.84. 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: 1/5 · long-stay residents: 1/5 · short-stay residents: —/5

Who owns this facility

For profit - Limited Liability company

Owner / managerTypeRoleStakeSince
Lincoln, JamesIndividual5% or Greater Direct Ownership Interest50%08/01/2001
Lincoln, JudyIndividual5% or Greater Direct Ownership Interest50%08/01/2001
Bysor, BrandonIndividualCorporate DirectorNOT APPLICABLE04/25/2022
Drake, TimothyIndividualCorporate OfficerNOT APPLICABLE04/25/2022
Maness, BarbaraIndividualW-2 Managing EmployeeNOT APPLICABLE03/06/2013
Stutts, CharlotteIndividualCorporate DirectorNOT APPLICABLE10/11/2011
Stutts, CharlotteIndividualCorporate OfficerNOT APPLICABLE10/11/2011

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

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Facility data as of CMS processing date 2026-08-01. CCN 265656.