Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Springfield Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to provide and document advance directive information: The facility did not consistently inform residents or their representatives in writing about the right to accept or refuse treatment and to formulate an advance directive. For multiple residents with intact cognition, impaired cognition, POAs, or guardians, the Advance Directives Policy and Record was left blank, and interviews showed residents and families often recalled only verbal discussions or no discussion at all. Staff stated code status was reviewed, but advance directives were not consistently documented or reviewed.
Medication Storage and Labeling Deficiency: The facility failed to ensure drugs and biologicals were properly labeled and stored on 1 of 4 med carts. On the East Unit Back Hall cart, surveyors found four insulin pens without opened or use-by dates, an opened Humulin 70/30 vial without a resident name or open date, and an opened bottle of UTI Stat past its expiration date. The RN, Unit Manager, DON, and Administrator all stated that opened insulin products should be dated and expired meds or supplements should be removed from the cart by the expiration date.
A resident with dementia, Parkinson's disease, and a g-tube was observed receiving medications via the g-tube without the RN first donning a gown, despite EBP signage on the room door requiring gloves and gown for feeding tube care. The facility's infection control policy did not include specific EBP guidance, and interviews showed staff expected gown use for g-tube medication administration, though the RN said he forgot.
Failure to Document and Provide Advance Directive Information
Penalty
Summary
The facility failed to inform and provide written information to adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident’s option, formulate an advance directive. For 12 of 14 sampled residents, the admission packet document titled Advance Directives Policy and Record had blank sections for living will, declaration or directive to physicians, and durable power of attorney for healthcare/surrogate decision maker for healthcare. The document also lacked completed sections showing no advance directives or that the resident or representative had been discussed with about advance directives. Several residents had intact cognition or were able to participate in decisions, yet the record did not show that advance directive information was provided or documented. Residents with BIMS scores of 15, 14, or 12 were interviewed and stated they did not recall receiving written information about advance directives, living wills, or power of attorney. One resident stated he had a POA but could not remember whether anything was discussed at admission, while another resident and family member stated they remembered only verbal discussion and received no paperwork explaining the differences. Residents with impaired cognition or legal representatives also lacked documentation of written advance directive information. One resident with severe cognitive impairment and a guardian had no completed advance directive record, and the guardian stated the facility had not provided written information or asked about it. Another resident with a designated POA had blank advance directive sections, and the POA stated he believed written information had been received but could not locate it. Facility staff, including the admission coordinator, social services director, DON, and administrator, stated that code status was reviewed, but advance directives were not consistently documented or reviewed, and the admission coordinator stated a regional contact was creating a document to address whether residents had an advance directive or declined to formulate one.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled in accordance with accepted professional principles, affecting 1 of 4 medication carts. Review of the facility policy titled, Label/Store Drugs & Biologicals Standard of Practice, showed that drugs and biologicals must be labeled with the expiration date when applicable, expired and/or discontinued medications must be removed from the medication storage area, and opened multi-dose vials must be dated and discarded within 28 days unless the manufacturer specifies otherwise. Observation of the East Unit Back Hall medication cart revealed four insulin pens without an opened date or use-by date, an opened vial of Humulin 70/30 insulin without a resident name label or open/use-by date, and an opened bottle of UTI Stat with a manufacturer expiration date of 06/27/2025. During interviews, the RN, Unit Manager, DON, and Administrator each stated that insulin pens and vials should be dated when opened and that expired medications or supplements should be removed from the cart by the expiration date.
Failure to Follow Gowning Requirements During G-Tube Medication Administration
Penalty
Summary
The facility failed to ensure staff complied with gowning requirements while administering medications via gastrostomy tube for one resident who was under Enhanced Barrier Precautions. The resident, admitted in 2012, had diagnoses including nontraumatic brain dysfunction, dementia, and Parkinson's disease, and received nutrition through a g-tube. During observation of medication administration, an RN administered medication via the resident's g-tube without first donning a protective gown, even though the resident's room had EBP signage indicating staff must wear gloves and a gown when caring for or using feeding tubes, central lines, urinary catheters, and tracheostomies. Record review showed the facility's Infection Control policy, last revised in 10/2018, did not include specific guidance for Enhanced Barrier Precautions. The CDC article reviewed by surveyors stated that gown and gloves were indicated for high-contact care activities for residents at high risk of colonization with MDROs, including device care or use for feeding tubes. In interviews, the RN stated he was expected to use a gown when giving medications via g-tube but forgot, and the ADON stated the facility did not have a specific EBP policy and followed CDC guidance. The DON and Administrator stated their expectation was that staff would use appropriate PPE when giving medications by g-tube.
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Illustrative
What surveyors actually found near you
We read the 31 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Springfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sansbury Care Center | 3.2 mi | ★★★★★ | 0 | 0 |
| Village Of Lebanon | 9.2 mi | ★★★★★ | 12 | 0 |
| Loretto Living Center At Loretto Motherhouse, Inc | 10.2 mi | ★★★★★ | 0 | 0 |
| Bardstown Health & Rehabilitation | 16.1 mi | ★★★★★ | 0 | 0 |
| Signature Healthcare At Colonial Rehab & Wellness | 16.8 mi | ★★★★★ | 6 | 0 |
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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.