Federal inspection record · CMS data as of October 1, 2026
Villages Of Jackson Creek
3980 South Jackson Drive, Independence, MO · (816) 795-1433
- Certified beds
- 120
- Residents per day
- 106
- Ownership
- For-Profit
- Chain
- Pacs Group
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- February 22, 2008
1
How this home got 2 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Missouri.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★2 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Missouri homes
Villages Of Jackson Creek carries 104.75 inspection points. That is fewer than 37% of Missouri's 479 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Missouri: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–20 pts
- 4★ 20–54 pts
- 3★ 54–93.75 pts
- 2★ 93.75–159 pts
- 1★ over 159 pts
Bars show every rated home in Missouri by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
39 health citations on record since 2022. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (1)
-
J
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Everything else, by area of care
Quality of Life and Care12D
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Provide enough food/fluids to maintain a resident's health.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- D
Provide activities to meet all resident's needs.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- D
Provide care or services that was trauma informed and/or culturally competent.
- D
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.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Resident Rights6E
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Nutrition and Dietary6F
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- E
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Infection Control4E
- E
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
Pharmacy Service4E
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- E
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Resident Assessment and Care Planning3E
- E
Ensure services provided by the nursing facility meet professional standards of quality.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Environmental2E
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- D
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Administration1E
- E
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspection history
2025-12-05
13 health deficiencies · 8 fire-safety deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2024-05-07
19 health deficiencies · 12 fire-safety deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
2022-08-10
7 health deficiencies · 8 fire-safety deficiencies
Top issue: Pharmacy Service (3 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 15 min of nursing staff time a day, 13 min of it from a registered nurse.
This home
3 h 15 min
Missouri average
3 h 24 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 52% of nursing staff and 17% of registered nurses left in the past year, along with 2 administrators.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$29,186 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2024-10-31 | Fine | $29,186 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.4 pts worse | 2.4 | 2.0 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.9 pts better | 1.3 | 2.2 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine13.3 pts better | 97.3% | 84.0% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine9.2 pts better | 100.0% | 90.8% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury1.3 pts better | 2.7% | 4.0% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms20 pts better | 0.0% | 20.0% | 13.5% |
| Percentage of long-stay residents who lose too much weight3.6 pts better | 1.5% | 5.1% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication8.9 pts better | 16.7% | 25.6% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication11.8 pts better | 11.7% | 23.5% | 15.4% |
| Percentage of long-stay residents who were physically restrainedAbout the same | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened0.7 pts better | 15.1% | 15.8% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased1 pts worse | 18.4% | 17.4% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.9 pts better | 0.0% | 0.9% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.3 pts better | 1.9% | 2.2% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence3.2 pts worse | 20.3% | 17.1% | 18.3% |
| Percentage of long-stay residents with pressure ulcers2 pts better | 2.4% | 4.4% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine29.1 pts better | 94.8% | 65.7% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit3.6 pts better | 9.8% | 13.4% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.8 pts better | 1.3% | 2.1% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine24.2 pts better | 85.6% | 61.4% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission4.9 pts worse | 30.6% | 25.7% | 23.4% |
·
Who owns and runs it
24 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| 3980 South Jackson Drive LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
| Bluebird Master Tenant LLC | Direct Ownership Interest · Organization | 0% | 2 facilities |
| Bushman, Matthew | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Bushman, Matthew | Adp Of The SNF · Individual | 0% | 1 facilities |
| Enriquez, Sol | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Enriquez, Sol | Adp Of The SNF · Individual | 0% | 1 facilities |
| Hancock, Mark | Adp Of The SNF · Individual | 0% | 159 facilities |
| Jergensen, Joshua | Corporate Officer · Individual | 0% | 262 facilities |
| Jergensen, Joshua | Operational/Managerial Control · Individual | 0% | 262 facilities |
| Lachance, Harris | Operational/Managerial Control · Individual | 0% | 2 facilities |
| Martin, Dominique | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Martin, Dominique | Adp Of The SNF · Individual | 0% | 1 facilities |
| Mitchell, John | Corporate Officer · Individual | 0% | 276 facilities |
| Mitchell, John | Operational/Managerial Control · Individual | 0% | 276 facilities |
| Murray, Jason | Indirect Ownership Interest · Individual | 0% | 41 facilities |
| Murray, Jason | Corporate Director · Individual | 0% | 41 facilities |
| Murray, Jason | Adp Of The SNF · Individual | 0% | 41 facilities |
| Pacs Group, Inc. | Indirect Ownership Interest · Organization | 0% | 21 facilities |
| Pacs Group, Inc. | Adp Of The SNF · Organization | 0% | 21 facilities |
| Pacs Holdings, LLC | Indirect Ownership Interest · Organization | 0% | 20 facilities |
| Pacs Holdings, LLC | Adp Of The SNF · Organization | 0% | 20 facilities |
| Providence Administrative Consulting Services Inc | Adp Of The SNF · Organization | 0% | 71 facilities |
| Providence Group Inc | Indirect Ownership Interest · Organization | 0% | 32 facilities |
| Zenzoo LLC | Adp Of The SNF · Organization | 0% | 2 facilities |
·
Fire safety
28 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke10F
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- D
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Inspect, test, and maintain automatic sprinkler systems.
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- E
Provide properly protected cooking facilities.
- E
Have properly installed hallway dispensers for alcohol-based hand rub.
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
Emergency Preparedness8F
- F
Address subsistence needs for staff and patients.
- F
Develop and maintain an Emergency Preparedness Program (EP).
- F
Address subsistence needs for staff and patients.
- F
Establish policies and procedures including evacuation.
- F
Create arrangements with other facilities to receive patients.
- F
List the names and contact information of those in the facility.
- D
Address patient/client population and determine types of services needed.
- F
Address subsistence needs for staff and patients.
Gas, Vacuum, and Electrical Systems5F
- E
Meet requirements for the use of electrical equipment.
- D
Have proper medical gas storage and administration areas.
- E
Have proper medical gas storage and administration areas.
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- F
Have generator or other power source capable of supplying service within 10 seconds.
Egress3F
- E
Have exits that are accessible at all times.
- E
Have exits that are accessible at all times.
- F
Install emergency lighting that can last at least 1 1/2 hours.
Miscellaneous2F
- E
Have restrictions on the use of portable space heaters.
- F
Meet Health Care Facilities Code mechanical requirements.
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