Springfield Villa

1100 East Montclair · Springfield, MO · 65807 · 4175691114

146 certified beds For profit - Limited Liability company Chain: James & Judy Lincoln

Why this verdict

  • Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
  • Inspection record is far worse than the national median (deficiency count and severity).
  • Staffing levels are well below research benchmarks for safe care.
  • Inspection results are getting worse cycle over cycle, not better.

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Red flags

1 immediate-jeopardy citation in the most recent inspection cycle

Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.

$69,595 in federal fines in the last 24 months

1 fine — CMS fines are reserved for verified, serious non-compliance.

RN staffing in the bottom 10% nationally

0.18 registered-nurse hours per resident per day, vs a 0.58 national median and 0.75 benchmark.

Total nurse staffing below 3.0 hours per resident-day

2.92 reported hours vs the 3.48 minimum CMS's own staffing study recommends.

68% of nursing staff left within a year

High turnover disrupts continuity of care; the national median is 45%.

No standard inspection in over 2 years

The inspection record here is older than usual — conditions may have changed since.

Score breakdown

Inspection record 30% of score 30
Serious harm & abuse 20% 52
Staffing 20% 35
Federal penalties 15% 62
Trend 10% 33
Context 5% 85

Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.

CMS ratings & staffing

Overall: 1 of 5 Inspections: 1 of 5 Staffing: 1 of 5 Quality measures: 1 of 5

Total nurse hours / resident-day2.923.48 min · 4.1 strong
RN hours / resident-day0.180.55–0.75
Weekend hours / resident-day2.47≈ weekday level
Nursing turnover / year68%median 45%
Fines (3-yr window)1 · $69,595

Inspection citations (38 in the current record)

  • Immediate jeopardy · J February 2, 2026 · found via complaint

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Corrected March 10, 2026 · Quality of Life and Care

  • Potential for harm · D February 2, 2026 · found via complaint

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

    Corrected March 10, 2026 · Pharmacy Service

  • Potential for harm · D December 11, 2025 · found via complaint

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Corrected March 10, 2026 · Quality of Life and Care

  • Potential for harm · D December 11, 2025 · found via complaint

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Corrected January 19, 2026 · Quality of Life and Care

  • Potential for harm · D September 4, 2025 · found via complaint

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

    Corrected September 5, 2025 · Resident Rights

  • Potential for harm · D September 4, 2025 · found via complaint

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Corrected September 5, 2025 · Quality of Life and Care

  • Potential for harm · D July 10, 2025 · found via complaint

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

    Deficient, Provider has no plan of correction · Resident Rights

  • Potential for harm · D July 10, 2025 · found via complaint

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Deficient, Provider has no plan of correction · Quality of Life and Care

  • Potential for harm · D July 10, 2025 · found via complaint

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

    Corrected August 20, 2025 · Quality of Life and Care

  • Potential for harm · D June 5, 2025 · found via complaint

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

    Deficient, Provider has no plan of correction · Resident Rights

  • Potential for harm · E June 5, 2025 · found via complaint

    Protect each resident from the wrongful use of the resident's belongings or money.

    Corrected July 7, 2025 · Freedom from Abuse, Neglect, and Exploitation

  • Potential for harm · D June 5, 2025 · found via complaint

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Deficient, Provider has no plan of correction · Quality of Life and Care

  • Actual harm · G February 28, 2025 · found via complaint

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Corrected April 10, 2025 · Quality of Life and Care

  • Potential for harm · D February 28, 2025 · found via complaint

    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

    Corrected April 10, 2025 · Resident Rights

  • Potential for harm · E November 21, 2023

    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

    Corrected January 5, 2024 · Resident Rights

  • Potential for harm · E November 21, 2023

    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 January 5, 2024 · Resident Rights

  • Potential for harm · D November 21, 2023

    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 January 5, 2024 · Quality of Life and Care

  • Potential for harm · D November 21, 2023

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Corrected January 5, 2024 · Quality of Life and Care

  • Potential for harm · F November 21, 2023

    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

    Corrected January 5, 2024 · Nutrition and Dietary

  • Potential for harm · E November 21, 2023

    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

    Corrected January 5, 2024 · Nutrition and Dietary

  • Potential for harm · F November 21, 2023

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Corrected January 5, 2024 · Nutrition and Dietary

  • Potential for harm · E November 21, 2023

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

    Corrected January 5, 2024 · Environmental

  • Actual harm · G August 16, 2023 · found via complaint

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Corrected September 19, 2023 · Quality of Life and Care

  • Actual harm · G June 27, 2023 · found via complaint

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Corrected September 19, 2023 · Quality of Life and Care

  • Potential for harm · D June 27, 2023 · found via complaint

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

    Corrected August 11, 2023 · Quality of Life and Care

Showing the 25 most recent. The Safety Report includes every citation with full findings.

Federal penalties

DateTypeAmount / length
December 11, 2025Fine$69,595

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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 265814 · certified since June 1, 2007. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.