Cycle 1
Health 2024-11-15 · Fire 2024-11-15
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
10 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Columbia, MO
Neighborhoods Rehabilitation And Skilled Nursing B
2-star overall rating with 2-star inspections with $68,105 in total fines with 10 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
3003 Falling Leaf Court, Columbia, MO
(573) 256-4620
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
89
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Americare Senior Living
Operator or chain grouping
Approved since
2011-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
23 facilities
Chain averages 4 overall / 4 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.33
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
1.37
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.95
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.64
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
1.70
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
4.27
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.18
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.35
CMS adjusted RN staffing hours
Adjusted total hours
4.93
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,692
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.28
Composite VBP score used to determine payment impact.
Payment multiplier
0.9890
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.39% · Performance 21.70% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
9.18
Baseline 6.29% · Performance 5.09% · Measure score 9.18 · Achievement 9.18 · Improvement 8.75
Total nurse turnover
0
Baseline 56.19% · Performance 63.97% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
4.94
Baseline 4.53 hours · Performance 4.48 hours · Measure score 4.94 · Achievement 4.94 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.11% |
10.72%
2.4 pts worse
|
No Different than the National Rate · Eligible stays 308 · Observed rate 14.29% · Lower 95% interval 9.54% |
| Discharge to community | 66.64% |
50.57%
16.1 pts better
|
Better than the National Rate · Eligible stays 296 · Observed rate 59.46% · Lower 95% interval 60.39% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.46% |
95.27%
2.2 pts better
|
Numerator 230 · Denominator 236 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 236 |
| Discharge self-care score | 59.21% |
53.69%
5.5 pts better
|
Numerator 90 · Denominator 152 |
| Discharge mobility score | 42.76% |
50.94%
8.2 pts worse
|
Numerator 65 · Denominator 152 |
| Pressure ulcers or injuries, new or worsened | 2.12% |
2.29%
0.2 pts better
|
Numerator 5 · Denominator 236 · Adjusted rate 1.97% |
| Healthcare-associated infections requiring hospitalization | 5.09% |
7.12%
2 pts better
|
No Different than the National Rate · Eligible stays 205 · Observed rate 3.41% · Lower 95% interval 3.29% |
| Staff COVID-19 vaccination coverage | 3.85% |
8.2%
4.3 pts worse
|
Numerator 5 · Denominator 130 |
| Staff flu vaccination coverage | 29.59% |
42%
12.4 pts worse
|
Numerator 50 · Denominator 169 |
| Discharge function score | 57.89% |
56.45%
1.4 pts better
|
Numerator 88 · Denominator 152 |
| Transfer of health information to provider | 94.67% |
95.95%
1.3 pts worse
|
Numerator 71 · Denominator 75 |
| Transfer of health information to patient | 97.5% |
96.28%
1.2 pts better
|
Numerator 117 · Denominator 120 |
| Resident COVID-19 vaccinations up to date | 9.56% |
25.2%
15.6 pts worse
|
Numerator 13 · Denominator 136 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
2.1
0.8 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 3.3 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.3
1.1 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.3 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.5% |
84.8%
11.7 pts better
|
93.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.5% · Q3 98.4% · Q4 89.2% · 4Q avg 96.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 83.6% |
90.9%
7.3 pts worse
|
95.5%
11.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 83.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
4.1%
2.2 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.5% · Q3 1.6% · Q4 3.1% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
14.7%
14.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 8.5% |
5.5%
3 pts worse
|
5.4%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 9.8% · Q3 4.2% · Q4 13.0% · 4Q avg 8.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.6% |
25.3%
7.7 pts better
|
19.6%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 15.4% · Q3 18.4% · Q4 19.1% · 4Q avg 17.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 36.2% |
25.0%
11.2 pts worse
|
16.7%
19.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.3% · Q2 32.3% · Q3 39.4% · Q4 48.0% · 4Q avg 36.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.3% |
20.3%
About the same
|
16.3%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.0% |
19.8%
10.8 pts better
|
14.9%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 11.5% · Q3 6.2% · Q4 8.9% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
1.4%
0.6 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 2.1% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.1% |
2.6%
0.5 pts worse
|
1.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 6.2% · Q3 0.0% · Q4 4.7% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.7% |
18.1%
11.6 pts worse
|
19.8%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.4% · Q2 38.2% · Q3 16.5% · Q4 27.4% · 4Q avg 29.7% |
| Percentage of long-stay residents with pressure ulcers | 8.8% |
5.0%
3.8 pts worse
|
5.1%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 8.0% · Q3 11.0% · Q4 9.5% · 4Q avg 8.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.9% |
66.4%
18.5 pts better
|
81.7%
3.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.2% · Q3 74.1% · Q4 68.4% · 4Q avg 84.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.7% |
13.4%
4.3 pts worse
|
12.0%
5.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.7% · Observed 16.7% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
2.2%
0.3 pts better
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 2.9% · Q4 2.2% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 36.7% |
63.5%
26.8 pts worse
|
79.7%
43 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 36.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.6% |
25.3%
4.3 pts worse
|
23.9%
5.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.6% · Observed 27.4% · Expected 22.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-27 · Fire 2023-10-27
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-05-05 · Fire 2022-05-05
11 health deficiencies
Top issue: Infection Control (2 deficiencies)
5 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-15
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-12-24
F · Potential for more than minimal harm
2024-11-15
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2024-12-24
F · Potential for more than minimal harm
2024-11-15
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-12-24
F · Potential for more than minimal harm
2024-11-15
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-12-24
F · Potential for more than minimal harm
2024-11-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-24
F · Potential for more than minimal harm
2024-11-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-24
F · Potential for more than minimal harm
2024-11-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-24
E · Potential for more than minimal harm
2024-11-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-12-24
E · Potential for more than minimal harm
2024-11-15
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-24
E · Potential for more than minimal harm
2024-11-15
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-12-24
F · Potential for more than minimal harm
2023-10-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-08
F · Potential for more than minimal harm
2023-10-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-08
F · Potential for more than minimal harm
2023-10-27
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-12-08
F · Potential for more than minimal harm
2023-10-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-08
F · Potential for more than minimal harm
2023-10-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-12-08
E · Potential for more than minimal harm
2023-10-27
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-12-08
F · Potential for more than minimal harm
2022-05-05
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2022-06-17
F · Potential for more than minimal harm
2022-05-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-06-17
F · Potential for more than minimal harm
2022-05-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-06-17
F · Potential for more than minimal harm
2022-05-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-06-17
E · Potential for more than minimal harm
2022-05-05
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-06-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-12-19
J · Immediate jeopardy
2025-09-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-25
J · Immediate jeopardy
2025-09-05
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-09-26
E · Potential for more than minimal harm
2025-04-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-21
J · Immediate jeopardy
2025-03-31
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-03-31
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-04-16
E · Potential for more than minimal harm
2024-11-15
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-12-24
E · Potential for more than minimal harm
2024-11-15
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-12-24
D · Potential for more than minimal harm
2024-11-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-12-24
F · Potential for more than minimal harm
2023-10-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-12-08
E · Potential for more than minimal harm
2023-10-27
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-12-08
E · Potential for more than minimal harm
2023-10-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-08
E · Potential for more than minimal harm
2023-10-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-12-08
E · Potential for more than minimal harm
2023-10-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-10-27
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-10-27
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-10-27
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-12-08
G · Actual harm
2023-07-06
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-06-21
F · Potential for more than minimal harm
2022-05-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-06-17
E · Potential for more than minimal harm
2022-05-05
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-06-17
E · Potential for more than minimal harm
2022-05-05
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-06-17
E · Potential for more than minimal harm
2022-05-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-06-17
E · Potential for more than minimal harm
2022-05-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-06-17
E · Potential for more than minimal harm
2022-05-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-05-05
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-05-05
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-06-17
C · Minimal harm
2022-05-05
F575 · Resident Rights Deficiencies
Health
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Corrected 2022-06-17
C · Minimal harm
2022-05-05
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2022-06-17
Penalties and ownership
What sits behind the stars
$68,105
2025-09-05
Fine
Fine · fine $68,105
Fine
Ownership
Montgomery, Anna
5% Or Greater Indirect Ownership Interest · Individual
Montgomery, Richard
5% Or Greater Indirect Ownership Interest · Individual
Americare Systems, Inc.
Operational/Managerial Control · Organization
Byergo, Lisa
W-2 Managing Employee · Individual
Montgomery, Richard
Corporate Director · Individual
R H Montgomery Properties, Inc
Operational/Managerial Control · Organization
Schade, Kyle
Corporate Officer · Individual
Schade, Kyle
Contracted Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Bluffs, The
Columbia, MO
2-star overall rating with 2-star inspections with $37,621 in total fines with 9 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Lenoir Health Care Center
Columbia, MO
5-star overall rating with 5-star inspections with 2 recent health deficiencies
#3
Columbia Manor Health & Rehabilitation
Columbia, MO
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Jump out