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

Staffing

Hours and turnover

RN hours / resident day

0.33

Registered nurse staffing

LPN hours / resident day

0.36

Licensed practical nurse staffing

Aide hours / resident day

2.06

Nurse aide staffing

Weekend hours

2.47

Weekend nurse staffing

RN turnover

30%

Annual RN turnover

Total nurse turnover

27%

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

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