Springfield Villa
1100 East Montclair, Springfield, MO 65807 · Greene County · 146 certified beds · avg 118 residents/day · certified since Jun 1, 2007
Part of chain: JAMES & JUDY LINCOLN (56 facilities, chain avg rating 2.4★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Feb 2, 2026 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Mar 10, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 28, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 10, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 16, 2023 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 19, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (40)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 17, 2026 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Apr 17, 2026 | F · Potential for harm, facility-wide | The facility did not have enough backup water supply for essential areas of the building. |
| Apr 17, 2026 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Apr 17, 2026 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. |
| Apr 17, 2026 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Apr 17, 2026 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Apr 17, 2026 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 17, 2026 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Apr 17, 2026 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 17, 2026 | E · Potential for harm, repeated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| Apr 17, 2026 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Apr 17, 2026 | D · Potential for harm, one-off | The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. |
| Apr 17, 2026 | C · Minimal risk, facility-wide | The facility did not make its inspection results easy for residents to see, or made it hard for residents to contact advocacy agencies like the ombudsman. |
| Feb 2, 2026 | ▲ J · Immediate jeopardy, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Feb 2, 2026 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Dec 11, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Dec 11, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 4, 2025 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Sep 4, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jul 10, 2025 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Jul 10, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jul 10, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Jun 5, 2025 | E · Potential for harm, repeated | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint |
| Jun 5, 2025 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Jun 5, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Feb 28, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Feb 28, 2025 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. · from a complaint |
| Nov 21, 2023 | F · Potential for harm, facility-wide | The facility did not have enough support staff to safely and effectively run its food and nutrition service. |
| Nov 21, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Nov 21, 2023 | E · Potential for harm, repeated | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Nov 21, 2023 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Nov 21, 2023 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Nov 21, 2023 | E · Potential for harm, repeated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| Nov 21, 2023 | D · Potential for harm, one-off | The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. |
| Nov 21, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Aug 16, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 17, 2021 | E · Potential for harm, repeated | The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require. |
| Sep 17, 2021 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Sep 17, 2021 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Sep 17, 2021 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (8 → 13).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2021 | 4 | 0 | E |
| 2023 | 9 | 1 | G ▲ |
| 2025 | 12 | 1 | G ▲ |
| 2026 | 15 | 1 | J ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $69,595.
| Date | Type | Amount / length |
|---|---|---|
| Dec 11, 2025 | Fine | $69,595 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Missouri avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.57 | 3.66 | 3.95 | bottom 50% in Missouri; bottom 40% in the U.S. |
| Registered Nurse hours | 0.26 | 0.49 | 0.69 | bottom 19% in Missouri; bottom 6% in the U.S. |
| Weekend total nurse staffing | 2.86 | 3.22 | 3.50 | bottom 36% in Missouri; bottom 23% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.15 | 0.33 | 0.48 | bottom 13% in Missouri; bottom 5% in the U.S. |
| Total nursing staff turnover (%) | 64.0 | 56.0 | 45.8 | bottom 29% in Missouri; bottom 11% in the U.S. |
| RN turnover (%) | 33.3 | 47.8 | 42.9 | top 26% in Missouri; top 33% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.96, RN 0.21, weekend 2.37. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 1/5 · short-stay residents: 5/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Lincoln, James | Individual | 5% or Greater Direct Ownership Interest | 50% | 05/01/2017 |
| Lincoln, Judy | Individual | 5% or Greater Direct Ownership Interest | 50% | 05/01/2017 |
| LTC Management Services LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 05/01/2017 |
| Spence, Jaquelyne | Individual | W-2 Managing Employee | NOT APPLICABLE | 07/01/2017 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "If the water supply is interrupted, how do you keep residents supplied with drinking water and sanitation?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "What specific steps do you take to prevent abuse and neglect, and how are staff trained on them?"
- "Can I see this month's activities calendar, and what do you offer residents who can't leave their rooms?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Cox Medical Centers Meyer Orthopedic and Surgical | 0.5 mi | Springfield, MO | ★★★★☆ | 4/5 | |
| Spring Valley Health & Rehabilitation Center | 0.6 mi | Springfield, MO | ★★☆☆☆ | 1/5 | |
| Birch Pointe Health and Rehabilitation | 0.9 mi | Springfield, MO | ★★★☆☆ | 3/5 | |
| Maples Health and Rehabilitation, the | 1.2 mi | Springfield, MO | ★★★★☆ | 3/5 | |
| Springfield Rehabilitation & Health Care Center | 1.6 mi | Springfield, MO | ★★★★★ | 4/5 | |
| Magnolia Square Nursing and Rehab | 1.8 mi | Springfield, MO | ★★☆☆☆ | 2/5 | |
| Neighborhoods at Quail Creek, the | 2.3 mi | Springfield, MO | ★★★☆☆ | 3/5 | |
| Sunterra Springs Springfield | 2.3 mi | Springfield, MO | ★★★★☆ | 3/5 | |
| Manor at Elfindale, the | 2.6 mi | Springfield, MO | ★★★★☆ | 4/5 | |
| James River Nursing and Rehabilitation | 3.2 mi | Springfield, MO | ★★★☆☆ | 3/5 | |
| Glendale Gardens Nursing & Rehab | 3.5 mi | Springfield, MO | ★★★☆☆ | 3/5 | |
| Wilson's Creek Nursing & Rehab | 4.9 mi | Springfield, MO | ★★★★★ | 5/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 265814.