Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Springhill Village during CMS and state inspections, most recent first.
Failure to Provide Transfer Notice, Bed Hold Information, and Hospital Report: The facility failed to document written transfer notice and bed hold policy for one resident sent to the ED after facial swelling, and failed to document hospital report for another resident transferred after lethargy, slurred speech, and abnormal labs. Both residents had significant medical diagnoses, and the DON could not find evidence that the required transfer information or condition report was provided.
A resident with dementia and anxiety was observed eating without dentures, restless, and refusing staff help during a meal. Record review showed a significant weight discrepancy and documented weight loss, while the MAR did not record Ensure intake for multiple days. Staff said the resident often removed dentures, snacked frequently, and wandered, and the DON stated the weights were believed to be inaccurate but were not rechecked to confirm the loss.
The facility failed to properly store respiratory equipment for multiple residents using CPAP, BiPap, and nebulizer treatments. A resident with sleep apnea had a CPAP mask repeatedly observed unbagged in the room, and the record lacked a physician order and care plan for the CPAP equipment. Another resident’s CPAP mask was also repeatedly left unbagged on the bedside table, and a third resident’s nebulizer tubing, medication chamber, and BiPap mask/tubing were observed unbagged in the room. Staff stated respiratory equipment should be cleaned and stored in a bag when not in use, and the ED said the facility did not have a specific respiratory equipment policy.
The facility failed to ensure medications were dated when opened on 1 of 2 medication carts. An opened Basaglar insulin pen for one resident and an opened Lantus insulin pen for another resident were observed on the 100 hall cart without opened dates. An LPN stated insulin pens must be dated when opened and discarded after 30 days, and the DON provided the facility policy requiring opened dates on primary medication containers.
Failure to use PPE for a resident on droplet precautions: an AD entered a COVID-19 positive resident’s room to deliver lunch without donning PPE, despite signage and a PPE bin outside the door. Interviews showed multiple staff who assisted with tray passing were not informed of the resident’s status, and a home healthcare representative also entered the room without PPE before being told the resident was positive.
The facility failed to conduct quarterly care plan meetings for several residents, as required. A resident reported not attending a care plan meeting recently, with the last documented meeting occurring six months prior. Another resident could not recall attending a care plan meeting, and her record showed a lack of documentation for meetings. Additionally, the facility failed to ensure that a resident or her representative was present for an initial care plan meeting. The Social Services Director acknowledged the facility's inadequate system for tracking care plan meetings.
A resident who required assistance with ADLs, including shaving, was observed with extensive beard growth despite expressing a desire to be shaved. The facility's policy indicated residents should be shaved if needed or requested, but staff only shaved residents on shower days. The resident often refused showers, leading to inconsistent shaving assistance.
A resident identified as a high fall risk was transferred by a CNA without using a gait belt or ensuring the resident wore non-skid footwear, contrary to the facility's policy. The resident, who required extensive assistance and was unsteady, had a history of multiple falls and was cognitively intact. The care plan specified the need for shoes and non-skid socks, which were not used during the transfer.
A facility failed to maintain a medication error rate below 5%, resulting in a 6.9% error rate. An LPN administered Timolol and Dorzolamide eye drops to a resident with glaucoma without waiting the required three minutes between medications, as per facility policy. The LPN noted the absence of a specified waiting period in the physician's order, despite the policy's requirement for a three-minute interval to ensure proper absorption.
The facility failed to maintain sanitary conditions in the dining area, with staff improperly handling an ice scoop and neglecting hand hygiene between assisting residents. Observations revealed staff returning the ice scoop to the bucket without sanitation and assisting multiple residents without washing hands, contrary to facility policies.
A resident with Alzheimer's, a femur fracture, and chronic conditions experienced a change in condition that was not timely assessed or communicated by the facility. Despite observations of internal hip rotation and swelling, there was a lack of documentation and physician notification, leading to delayed treatment and hospitalization for a distal femur fracture.
Failure to Provide Transfer Notice, Bed Hold Information, and Hospital Report
Penalty
Summary
The facility failed to ensure that written notice of transfer and the bed hold policy were provided for a resident who was sent to the emergency department after extensive swelling was observed on the right side of the face. The resident had diagnoses including Parkinson's disease and CHF, and an admission MDS indicated the resident was cognitively intact and needed assistance with daily care needs. The record showed the physician was notified and an order was received to send the resident to the ED, and the nurse later called the hospital to obtain report on the resident's condition, but the record lacked evidence that written transfer information and the bed hold policy were sent with the resident or that a transfer report was called to the hospital at the time of transfer. The facility also failed to document that the hospital was notified of the transfer and the resident's condition for another resident who was transferred after becoming lethargic and having slurred speech. That resident had diagnoses including chronic respiratory failure with hypoxia and chronic kidney disease stage 3a. The record showed the nurse practitioner evaluated the resident, recommended transfer to the ER for further evaluation and abnormal labs, and EMS later transported the resident to the hospital, but the record lacked documentation that the hospital received report on the transfer or the resident's condition before departure. The DON stated she could not find documentation that staff had notified the hospital of the transfer and condition prior to the resident leaving the facility.
Failure to Recheck Significant Weight Loss and Track Nutritional Intake
Penalty
Summary
The facility failed to address a significant weight discrepancy and failed to re-evaluate a resident’s weight for one of two residents reviewed for nutrition. The resident had diagnoses including dementia and anxiety, was severely cognitively impaired, and required extensive assistance with daily care needs. During observation, the resident was seen eating a noon meal without dentures in place, was very restless, and refused staff assistance while attempting to eat a sandwich. Record review showed documented weights of 100 lbs., 102 lbs., and 94 lbs., with the resident having lost 12.5% of body weight in 6 months and 1.14% in 30 days. The care plan identified the resident as at risk for altered nutritional status due to varied intake and dementia, with interventions including a regular diet, super cereal, ice cream, and Mighty Shake. A physician order directed Ensure Plus daily, but the MAR for January and February 2026 did not record the amount consumed for 18 days. Staff interviews indicated the resident often removed dentures, liked to snack, wandered, and had difficulty remaining seated for meals. The DON stated the resident’s weights were believed to be wrong, but a re-weight was not completed to confirm the loss, and the weight loss had not been addressed until that month.
Improper Storage and Missing Orders for Respiratory Equipment
Penalty
Summary
The facility failed to ensure respiratory equipment was properly stored for residents using CPAP, BiPap, and nebulizer equipment. Resident 14 reported using a CPAP machine at night that was brought from home, and multiple observations showed the resident’s CPAP mask left unbagged on the nightstand, on the bed, or beside other items in the room. Resident 14’s record identified obstructive sleep apnea and generalized anxiety disorder, but the record lacked a physician order for the CPAP equipment and lacked a care plan for its use. The record also showed the resident had reported needing the CPAP because the facility could not obtain the equipment quickly enough. Resident 1 was observed on multiple occasions with the CPAP mask sitting unbagged on the bedside table. The resident stated the facility had never provided a bag for the mask, and later indicated he wore the CPAP at night and no one had come in to do anything with it after he had been up for about 2 hours. Resident 1’s record showed diagnoses including COPD and obstructive sleep apnea, and a physician order directed the CPAP to be placed on at bedtime and off when awake. The record did not contain a physician order for storage of the CPAP mask when not in use. Resident 34 was observed with nebulizer tubing and medication chamber lying on top of a clear storage bag in the room, while the BiPap mask and tubing were also observed unbagged on the bedside table on multiple occasions. The resident stated she administered her own nebulizer treatments. RN 13 stated she set up the nebulizer treatment, stood by while the resident administered it, cleaned the equipment, and hung it up to dry. LPN 10 stated the nurse should assess the resident during and after the nebulizer treatment, rinse the nebulizer tubing and medication chamber, allow the equipment to air dry, and then place the equipment in a bag. The ED later provided a revised BIPAP/CPAP policy that stated the resident and physician’s order should be verified and that the order should include CPAP or BIPAP pressure and other details.
Undated Insulin Pens on Medication Cart
Penalty
Summary
The facility failed to ensure medications were dated when opened for 1 of 2 medication carts. During observation of the 100 hall medication cart with a QMA, an opened Basaglar insulin pen for Resident 30, ordered at 15 units at bedtime, was found without an opened date on the label. An opened Lantus insulin 3 milliliter pen for Resident 73, ordered at 15 units daily, was also observed without an opened date. During interview, an LPN stated insulin pens must be dated when opened and discarded after 30 days. The DON later provided the facility's Medication storage and expiration policy, which stated staff should record the date opened on the primary medication container and that opened multidose injectable medication should be dated and discarded within 28 days.
Failure to Use PPE for Resident on Droplet Precautions
Penalty
Summary
The facility failed to ensure staff donned appropriate PPE when entering the room of a resident who had tested positive for COVID-19 and was on droplet precautions. On 2/17/26 at 12:52 p.m., the Activity Director entered Resident 93’s room to deliver lunch and placed the tray on the overbed table directly in front of the resident without putting on or removing PPE. The resident’s door had signage indicating droplet precautions and a PPE bin was outside the room, but the Activity Director stated she was not aware the resident was on droplet precautions. During interviews, RN 5 stated the Regional Clinical Nurse had notified her that Resident 93 had tested positive for COVID-19, and she assumed the information had been passed to all staff on the hallway. The Activity Director stated she had not been told the resident had COVID-19 and did not wear PPE before entering. The Executive Director stated the resident had tested positive earlier that morning and staff had not worn PPE when entering the room. Other staff members who assisted with passing hall trays, including a QMA, Payroll Coordinator, BOM, and CNA, stated they were not informed the resident was COVID-19 positive or did not notice the signage until later. A home healthcare representative was also observed standing in the resident’s room without PPE and stated no one had made her aware of the resident’s positive status before she entered.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to conduct quarterly care plan meetings for several residents, as required. Resident 24 reported not attending a care plan meeting recently, with the last documented meeting occurring six months prior. The resident's record lacked documentation of quarterly care plan meetings from January 2024 to January 2025. Similarly, Resident 28 could not recall attending a care plan meeting, and her record showed a lack of documentation for meetings from June 2024 to January 2025. Resident 37 also indicated not attending a care plan meeting, and while her record showed meetings in May and October 2024, there was no documentation of other required meetings or attendance by interdisciplinary team members. Additionally, the facility failed to ensure that Resident 64 or her representative was present for an initial care plan meeting. The resident, who had severe cognitive deficits, had a Road to Recovery meeting document that lacked evidence of her or her representative's participation. The Social Services Director noted that a letter was sent to the resident's representative to schedule a meeting, but there was no documentation of follow-up or return contact from the representative. The Social Services Director acknowledged the facility's inadequate system for tracking care plan meetings and noted that reminders were sent to residents and their representatives, but these were often not acted upon. The facility's policy required interdisciplinary care plan reviews, including resident or representative participation, but the documentation did not reflect compliance with this policy.
Failure to Provide Shaving Assistance to Resident
Penalty
Summary
The facility failed to ensure that a resident who was dependent on staff for shaving facial hair received the necessary assistance. Resident 65, who was cognitively intact and required assistance with activities of daily living (ADL), was observed on multiple occasions with extensive beard growth. The resident expressed a desire to be shaved and indicated that staff had previously provided this service. However, observations on consecutive days showed that the resident had not been offered shaving assistance, despite his preference to be clean-shaven. Interviews with Certified Nurse Aides (CNAs) revealed that residents were typically shaved on their designated shower days. The Director of Nursing Services (DNS) noted that Resident 65 often refused showers, which were the days he would have been shaved. Despite this, records indicated that the resident had been shaved on other days. The facility's policy stated that residents should be shaved if needed or requested, but this was not consistently followed for Resident 65, leading to the deficiency.
Failure to Use Proper Transfer Techniques and Equipment
Penalty
Summary
The facility failed to ensure adequate assistance devices and interventions were in place to prevent potential accidents for a resident observed for transfers. During an observation, a CNA transferred a resident from bed to chair without applying a gait belt or ensuring the resident wore shoes or non-skid socks. The CNA lifted the resident under the left arm, despite the resident requiring extensive assistance and being unsteady when standing. The CNA mentioned that the resident refused to wear shoes or socks and that she sometimes used a gait belt for transfers. The resident, who was cognitively intact, had a history of multiple falls and was identified as a high fall risk. The care plan indicated the need for shoes and non-skid footwear to be placed next to the bed. The facility's policy on transfers required non-skid footwear and the use of a gait belt, which were not followed during the observed transfer. The resident's medical history included vascular dementia, chronic congestive heart failure, type 2 diabetes, and hypertension, contributing to their high fall risk.
Medication Error Rate Exceeds 5% Due to Improper Eye Drop Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 6.9% error rate observed during a medication pass. This deficiency was identified when an LPN administered eye drops to a resident with glaucoma without adhering to the required waiting period between different medications. Specifically, the LPN administered Timolol 5% eye drops followed immediately by Dorzolamide HCL 2% eye drops without waiting the necessary three minutes between applications, as stipulated by the facility's medication administration policy. The resident involved, identified as Resident 172, was diagnosed with glaucoma and had physician orders for both Timolol and Dorzolamide eye drops to be administered twice daily. During an interview, the LPN acknowledged the usual practice of waiting five minutes between administering different eye drops but noted that the physician's order did not specify a waiting period. The facility's policy, however, required a three-minute interval between different eye drops to ensure proper absorption, which was not followed in this instance.
Sanitation and Hand Hygiene Deficiencies in Dining Area
Penalty
Summary
The facility failed to maintain sanitary conditions in the dining area, specifically regarding the handling of an ice scoop and hand hygiene practices. During observations in the main dining room, staff members were seen using an ice scoop to serve drinks to residents and then returning the scoop to the ice bucket without proper sanitation. This practice was contrary to the facility's policy, which required the ice scoop to be placed in a covered container or covered with a clean towel or plastic bag to prevent contamination. Interviews with staff confirmed that the ice scoop should not be left in the ice bucket, indicating a lapse in adherence to established procedures. Additionally, during dining observations, staff members assisting residents with their meals failed to perform hand hygiene between assisting different residents. A Qualified Medication Aide and a Certified Nursing Assistant were observed assisting multiple residents without washing their hands between interactions. This was further confirmed during a follow-up observation where another CNA was seen assisting residents without performing hand hygiene. The Director of Nursing acknowledged that staff should perform hand hygiene when assisting residents with meals, especially when moving between residents, as per the facility's policy on feeding residents.
Failure to Timely Assess and Treat Resident's Change in Condition
Penalty
Summary
The facility failed to ensure timely assessments and treatment for a resident, identified as Resident C, who experienced a change in condition. Resident C, who was admitted with diagnoses including Alzheimer's disease, a fracture of the lower end of the right femur, chronic congestive heart failure, and chronic pain, was noted to have a significant change in condition. The resident's care plan indicated risks for impaired mobility and pain, with interventions to notify therapy of declines in mobility and to observe for signs of pain. On a specific date, a physical therapy note indicated that Resident C was repositioned in a wheelchair due to leaning and internal rotation of the right hip. However, there was no documentation that the physical therapist notified the nurse of this condition. Subsequently, a nurse's progress note described the resident's skin as dark with a yellowish tint, and the right foot was contracted inward with a very swollen right knee. Despite these observations, the record lacked documentation of a detailed assessment of the right leg, physician notification, or additional observations. The resident was eventually transferred to the hospital emergency room and admitted for a distal femur fracture. The hospital record noted the right leg was bruised and swollen, with limited mobility. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's condition changes. The facility's policy required that all changes in resident condition be communicated to the physician and documented promptly, which was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Terre Haute
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westminster Village Health & Rehab | 1 mi | ★★★★★ | 1 | 0 |
| Westridge Health Care Center | 1.7 mi | ★★★★★ | 10 | 0 |
| Southwood Healthcare Center | 1.8 mi | ★★★★★ | 24 | 2 |
| Cobblestone Crossings Health Campus | 2.3 mi | ★★★★★ | 10 | 0 |
| Majestic Care Of Deming Park | 3.9 mi | ★★★★★ | 4 | 2 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.