Springfield, MO

Wilson's Creek Nursing & Rehab

3-star overall rating with 3-star inspections with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

3403 West Mt Vernon, Springfield, MO

(417) 864-5600

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

172

Certified beds

Average residents

128

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

James & Judy Lincoln

Operator or chain grouping

Approved since

1982-01-11

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

58 facilities

Chain averages 3 overall / 3 health / 2 staffing / 3 quality stars

Changed ownership

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

0.36

Licensed practical nurse staffing · state 0.68 · national 0.87

Aide hours / resident day

2.06

Nurse aide staffing · state 2.33 · national 2.35

Total nurse hours

2.75

All reported nurse hours · state 3.47 · national 3.89

Licensed hours

0.69

RN + LPN hours · state 1.14 · national 1.54

Weekend hours

2.47

Weekend nurse staffing · state 3.04 · national 3.43

Weekend RN hours

0.30

Weekend registered nurse coverage · state 0.33 · national 0.47

Physical therapist

0.00

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.50

CMS adjusted RN staffing hours

Adjusted total hours

4.18

CMS adjusted total nurse staffing hours

Case-mix index

0.90

Higher values indicate more complex resident acuity

RN turnover

30%

Annual RN turnover · state 51% · national 45%

Total nurse turnover

27%

Annual nurse turnover · state 57% · national 46%

SNF VBP

Value-based purchasing

Program rank

1,547

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

55.80

Composite VBP score used to determine payment impact.

Payment multiplier

1.0108

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

8.68

Baseline 34.29% · Performance 28.21% · Measure score 8.68 · Achievement 8.68 · Improvement 5.95

Adjusted total nurse staffing

2.48

Baseline 3.62 hours · Performance 3.78 hours · Measure score 2.48 · Achievement 2.48 · Improvement 0.26

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays 2 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 1 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	Not Available	1.02	Too few residents or stays to report publicly.
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · No data were submitted for this measure.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure.
Staff COVID-19 vaccination coverage	2.31%	8.2% 5.9 pts worse	Numerator 3 · Denominator 130
Staff flu vaccination coverage	61.29%	42% 19.3 pts better	Numerator 95 · Denominator 155
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	86.8%	84.8% 2 pts better	93.4% 6.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 81.1% · Q2 79.1% · Q3 89.2% · Q4 97.7% · 4Q avg 86.8%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	90.9% 9.1 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	1.2%	4.1% 2.9 pts better	3.3% 2.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 2.3% · Q4 1.6% · 4Q avg 1.2% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.2%	14.7% 14.5 pts better	11.4% 11.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2%
Percentage of long-stay residents who lose too much weight	5.1%	5.5% 0.4 pts better	5.4% 0.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.9% · Q3 7.3% · Q4 4.1% · 4Q avg 5.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	28.9%	25.3% 3.6 pts worse	19.6% 9.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 29.7% · Q2 29.3% · Q3 29.8% · Q4 26.8% · 4Q avg 28.9%
Percentage of long-stay residents who received an antipsychotic medication	45.4%	25.0% 20.4 pts worse	16.7% 28.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 45.1% · Q2 45.8% · Q3 46.3% · Q4 44.3% · 4Q avg 45.4% · 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	6.3%	20.3% 14 pts better	16.3% 10 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 8.4% · Q3 4.3% · Q4 5.6% · 4Q avg 6.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	11.3%	19.8% 8.5 pts better	14.9% 3.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 12.3% · Q3 8.5% · Q4 11.0% · 4Q avg 11.3% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.6%	1.4% 0.2 pts worse	1.0% 0.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 2.3% · Q3 1.5% · Q4 0.7% · 4Q avg 1.6% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.8%	2.6% 0.8 pts better	1.7% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.3% · Q3 2.3% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	10.9%	18.1% 7.2 pts better	19.8% 8.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 7.4% · Q3 16.7% · Q4 6.2% · 4Q avg 10.9%
Percentage of long-stay residents with pressure ulcers	2.0%	5.0% 3 pts better	5.1% 3.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.3% · Q3 3.8% · Q4 1.4% · 4Q avg 2.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	47.4%	66.4% 19 pts worse	81.7% 34.3 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 47.4%

Survey summary

Recent inspection cycles

Cycle 1 Health 2023-11-30 · Fire 2023-11-30

8 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2021-07-20 · Fire 2021-07-20

7 health deficiencies

Top issue: Environmental (1 deficiency)

6 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2019-10-31 · Fire 2019-10-31

6 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2023-11-30

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2023-12-12

F · Potential for more than minimal harm 2023-11-30

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2024-01-20

F · Potential for more than minimal harm 2023-11-30

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2024-01-08

F · Potential for more than minimal harm 2023-11-30

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-12-12

F · Potential for more than minimal harm 2023-11-30

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-01-10

E · Potential for more than minimal harm 2023-11-30

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-01-10

L · Immediate jeopardy 2021-07-20

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2021-07-26

F · Potential for more than minimal harm 2021-07-20

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2021-09-03

F · Potential for more than minimal harm 2021-07-20

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2021-07-26

F · Potential for more than minimal harm 2021-07-20

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2021-09-03

F · Potential for more than minimal harm 2021-07-20

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2021-09-03

F · Potential for more than minimal harm 2021-07-20

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2021-07-26

F · Potential for more than minimal harm 2019-10-31

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2019-12-10

E · Potential for more than minimal harm 2019-10-31

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-11-22

D · Potential for more than minimal harm 2019-10-31

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2019-11-22

Inspection history

Recent health citations

F · Potential for more than minimal harm 2023-11-30

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 2024-01-10

E · Potential for more than minimal harm 2023-11-30

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2024-01-01

E · Potential for more than minimal harm 2023-11-30

F758 · Pharmacy Service Deficiencies

Health

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.

Corrected 2024-01-10

D · Potential for more than minimal harm 2023-11-30

F625 · Resident Rights Deficiencies

Health

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected 2024-01-10

D · Potential for more than minimal harm 2023-11-30

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2024-01-14

D · Potential for more than minimal harm 2023-11-30

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2024-01-14

D · Potential for more than minimal harm 2023-11-30

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 2024-01-10

D · Potential for more than minimal harm 2023-11-30

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-01-02

D · Potential for more than minimal harm 2023-08-28

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 2023-10-11

D · Potential for more than minimal harm 2023-08-28

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 2023-10-11

D · Potential for more than minimal harm 2023-08-28

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2023-10-11

G · Actual harm 2021-07-20

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 2021-08-26

E · Potential for more than minimal harm 2021-07-20

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2021-09-03

E · Potential for more than minimal harm 2021-07-20

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 2021-08-26

E · Potential for more than minimal harm 2021-07-20

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2021-08-26

E · Potential for more than minimal harm 2021-07-20

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2021-09-03

D · Potential for more than minimal harm 2021-07-20

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2021-09-03

D · Potential for more than minimal harm 2021-07-20

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2021-08-26

F · Potential for more than minimal harm 2019-10-31

F577 · Resident Rights Deficiencies

Health

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Corrected 2019-11-11

E · Potential for more than minimal harm 2019-10-31

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 2019-11-10

D · Potential for more than minimal harm 2019-10-31