Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cox Medical Centers Meyer Orthopedic And Surgical during CMS and state inspections, most recent first.
Failure to maintain an annual facility assessment was identified when the facility could not produce a facility assessment document or a policy for it. The Administrator believed one had been completed previously, but it could not be located, and the Manager said she was not familiar with it. Regulatory affairs staff said work on the assessment was underway, but no assessment or policy was available.
Hot water temperatures in multiple resident room sinks exceeded the facility’s stated safe range, with observed and tested readings reaching 126 to 137 degrees F in both occupied and unoccupied rooms. The water management plan showed a central hot water system and mixing valves, but staff interviews revealed uncertainty about the required temperature range, how often temperatures were monitored, and whether sink temperatures were checked. The facility’s multimeter calibration had expired, and the AD of Engineering reported recent hot water fluctuations related to mixing valve repairs, a recirculating pump issue, and an incident where cleaning equipment interfered with the mixing valve lever.
Failure to assess and care-plan side rail use: The facility used side rails for multiple residents without documenting a specific side rail assessment, gap measurements, or care plan interventions. One resident with moderately impaired cognition and transfer dependence had bilateral upper and lower rails raised and said the rails stayed upright and were used for repositioning; two other residents also had rails up in bed, with staff confirming side rails were not addressed in the care plan and no specific assessment was completed.
A cognitively intact resident with a significant left leg wound attempted to direct the setup and performance of a dressing change, specifying the number of disposable pads and 4x4s, the use of a large container and 60 ml syringe for saline irrigation, and the placement and preparation of a supply table. An RN and an LPN repeatedly disagreed with and at times ignored these requests, arguing over the need for certain supplies and proceeding only partially in accordance with the resident’s instructions. The interaction became a power struggle, with staff later acknowledging they did not want to compromise because they felt the resident would think he or she was right. Additional RNs eventually complied with the resident’s detailed preferences for irrigation technique, drying, glove changes, and table placement, but only after initial resistance. This conduct failed to uphold the resident’s rights to dignity, respect, and participation in care decisions as outlined in the facility’s own patient rights policy.
A resident with both a G-tube and a J-tube had tube feeding and medication orders that did not specify which tube to use, and the chart lacked orders for J-tube flushes and dressing changes. Staff documented and performed J-tube flushes and dressing changes at both tube sites based on report and SBAR information, while an LPN administered meds through the G-tube and feeding through the J-tube during observation.
Failure to Implement EBP for a Resident With G-tube and J-tube A resident with a G-tube and J-tube did not have EBP in place, despite staff interviews stating feeding tubes required EBP. Observations showed no EBP signage on the door, and an LPN provided tube care and enteral feeding while wearing gloves but not an isolation gown. Staff gave conflicting statements about when EBP was required, and the RN director said she was not familiar with EBP procedures.
Failure to Maintain Annual Facility Assessment
Penalty
Summary
The facility failed to develop and update the comprehensive facility assessment annually and did not provide a policy regarding the facility assessment. Review also showed the facility did not provide a facility assessment document. During interviews, the Administrator said she believed the facility assessment had been completed in May 2025 before she took over, but the assessment could not be located and she stated it should be completed annually. The Manager said she was not familiar with the facility assessment and was not involved in working on it. Regulatory affairs staff said staff were working on the facility assessment, but she did not have one and did not find one, and she also did not have a policy for the facility assessment.
Hot Water Temperatures Exceeded Safe Range in Resident Rooms
Penalty
Summary
The facility failed to keep resident areas as free from accident hazards as possible when multiple resident room sinks produced hot water temperatures above the facility’s stated range. The water management plan identified a central domestic hot water system with gas-fired water heaters set at 140 degrees F and a mixing valve reducing water to 125 degrees F for building distribution, as well as three steam-powered instant hot water heaters with no mixing valve providing 125 degrees F water. The facility’s policy stated resident room water temperatures should be between 105 degrees F and 120 degrees F, but survey observations found several resident room sinks measuring between 129 degrees F and 137 degrees F by facility testing and between 126 degrees F and 131 degrees F by the Engineering Supervisor’s multimeter. During observation, unoccupied and occupied resident rooms on the unit had sink water temperatures above 120 degrees F, including one resident room with both the main sink and bathroom sink measuring 131 to 132 degrees F by direct observation and 126 to 128 degrees F by multimeter testing. Another resident room had sink temperatures of 131 degrees F in both the main room and bathroom sinks, with multimeter readings of 126 to 127 degrees F. A third resident room had sink temperatures of 131 to 132 degrees F, with multimeter readings of 127 to 128 degrees F. The facility multimeter used for testing had an expired calibration date. Interviews showed staff did not know the required hot water temperature range, how often temperatures were monitored, or whether sink temperatures were checked routinely. The Regulatory Affairs Safety Coordinator, Engineering Supervisor, EVS staff, LPN, maintenance staff, RN, Environmental Safety Officer, Manager, and Administrator all described uncertainty about monitoring frequency or reporting processes. The Administrative Director of Engineering stated the facility had recent water temperature fluctuations related to repairs of the hot water mixing valve, including a weekend issue in which housekeeping staff reported hot water temperatures on 300 hall and 400 hall after cleaning equipment had been hung on the mixing valve lever, preventing proper function, and a recirculating pump had also required replacement.
Failure to assess and care-plan side rail use
Penalty
Summary
The facility failed to assess the risks of entrapment from bed rails before installing them, failed to ensure bed dimensions were appropriate for each resident’s size and weight, and failed to develop and implement side rail interventions in the care plans for three residents. The facility also did not provide a policy regarding the use of side rails. The census was 7. For Resident #2, the record showed admission data, verbal consent from the responsible party for half side rails, and staff signature on the consent form. The resident’s MDS showed moderately impaired cognition, independent rolling left and right, and substantial to maximal assistance needed for transfers. The care plan addressed musculoskeletal problems, but staff did not complete or document a side rail assessment or gap measurements. Observations showed the resident in bed with bilateral upper side rails raised and the left lower side rail raised on multiple occasions, and the resident stated the upper side rails stayed upright, were used for repositioning, and that the resident did not know how to lower them or whether staff checked for gaps. RN B stated the resident could turn side to side independently, while the Assistant RN Director/MDS Care Plan Coordinator said the resident could not get out of bed on his/her own and side rails were not on the care plan. For Resident #10, the record showed admission on 12/12/25 and consent for half side rails, but the care plan did not address side rail use. An observation showed the resident in bed with both side rails up on both sides of the bed. The facility did not provide or document a side rail assessment or gap measurements, and the Assistant Manager/MDS Care Plan Coordinator stated the resident could not get up out of bed on his/her own and side rails were not on the care plan. For Resident #11, the record showed admission on 4/13/26, signed consent for half side rails, and a care plan revised on 4/14/26 that did not address side rail use. An observation showed the resident in bed with both side rails up at the head of the bed, and the resident said he/she used the side rails for mobility. The facility did not provide or document a side rail assessment or gap measurements, and staff stated they had not been directed to complete such assessments.
Failure to Honor Resident’s Right to Direct Wound Care and Be Treated With Dignity
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact resident’s rights to dignity, respect, and self-determination during wound care to the resident’s left leg. The resident, who was independent with toileting and mobility and care planned as able to participate in treatment decisions, attempted to direct the setup and performance of a complex dressing change. During an observed wound care session, an RN and an LPN from the Skin Wound Ostomy Team entered the resident’s room and the resident immediately began specifying the needed supplies, including multiple disposable pads, a large container, and a 60 ml syringe for saline irrigation. The RN repeatedly disagreed with the resident’s requests, stating fewer pads and less saline were needed, and declined to obtain the large container the resident preferred, despite the resident’s insistence and explanation that the container helped avoid spillage and repeated refilling. As the dressing change progressed, the resident continued to request specific supplies and arrangements, such as four 4x4 gauze pads, additional saline, and placement of a table at the foot of the bed covered with a pad after being dried. The RN and LPN initially ignored or minimized several of these requests, with the RN stating that fewer gauze pads were sufficient and that the large container was unnecessary, and using a smaller sterile container instead. The resident repeatedly asked staff not to begin the procedure until all requested supplies were assembled and to position the table and trash can in particular locations to facilitate the procedure and maintain cleanliness. The RN and LPN partially complied only after multiple requests and at times did so in a manner that suggested they were doing it merely to “make the resident happy,” rather than acknowledging the resident’s right to direct care. The interaction escalated into a power struggle, as described by staff, with the RN openly disagreeing with the resident about the need for the large container and the number of pads and gauze, and the resident expressing frustration, stating that he/she should not have to go through such resistance to have care provided as requested. When additional staff, including the SWOT Manager and another RN, entered the room, the resident objected to having an “entourage” present. The resident continued to direct the technique of irrigation and drying (requesting vertical top-to-bottom motions) and glove changes between steps, and while the SWOT Manager ultimately complied with these directions, she initially attempted to educate the resident rather than immediately honoring the preferences. Interviews with staff afterward confirmed that the RN likely argued with the resident over the container size, that staff consciously chose not to compromise with the resident at first because they did not want the resident to think he/she was “right,” and that the interaction was viewed as a power struggle. Leadership staff stated it was not appropriate for staff to argue with residents and that residents should have their preferences honored within reason, underscoring that the observed conduct did not align with the facility’s own policy requiring residents be treated with respect and dignity and be involved in their care decisions.
Missing Tube-Specific Orders for G-Tube and J-Tube Care
Penalty
Summary
The facility failed to obtain specific orders for flushing and dressing changes and failed to ensure physician orders identified which tube to use for medications and which tube to use for feedings for a resident with both a G-tube and a J-tube. The resident was admitted with altered nutrient intake and had an active feeding tube order set, including gastric tube care and medication flush instructions, but the record did not contain orders for J-tube flushes or dressing changes at either insertion site. The care plan did not include interventions related to the resident’s G-tube, J-tube, or tube feedings. The resident’s record showed an order for Jevity 1.5 cal at 70 ml/hour for 12 hours daily, but the order did not specify which tube to use for the feeding. Another medication order for wheat dextrin could be given orally or via feeding tube, but it also did not specify which tube to use. The Avatar flowsheet documented staff flushing the J-tube multiple times without an order for J-tube flushes and documenting split gauze dressing changes at the G-tube and J-tube sites without orders for those interventions. During observation, an LPN administered medications through the G-tube, flushed it before and after medication administration, flushed the J-tube, changed the dressings around both tube sites, and later connected the Jevity feeding to the J-tube. Staff interviews confirmed that the resident had both tubes and that the team relied on report and the SBAR form to know which tube to use for medications and feedings, even though the medical record did not contain specific orders for the J-tube flushes, dressing changes, or tube-specific administration instructions.
Failure to Implement EBP for Resident With Feeding Tubes
Penalty
Summary
The facility failed to maintain an effective and complete infection control program when staff did not implement Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy tube (G-tube) and a jejunostomy tube (J-tube). The resident’s admission assessment showed intact cognitive skills and the presence of a feeding tube, and the current care plan and physician orders did not address EBP. During observation, the resident was seen in the room with both tube insertion sites covered by gauze dressings, and there was no signage on the door indicating EBP. During multiple observations, an LPN provided G-tube and J-tube care, including administering medication through the G-tube, flushing both tubes, cleaning and dressing the insertion sites, and starting continuous enteral feeding through the J-tube. In both instances, the LPN performed hand hygiene and donned gloves, but did not don an isolation gown. The resident stated that staff did not wear isolation gowns when providing care for the G-tube and J-tube. No EBP signage was observed on the resident’s door during these observations. Interviews showed inconsistent understanding among staff about when EBP was required. One LPN stated the facility used EBP for certain wounds and ports but not for residents with indwelling catheters or feeding tubes, and said there were no residents who required EBP. Other nursing staff stated that residents with feeding tubes, catheters, PICC lines, and certain wounds should have EBP, and specifically said the resident should have been on EBP. The RN director later stated she was not familiar with EBP procedures, while the administrator said staff should wear appropriate PPE for residents with PICC lines, catheters, and wounds.
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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 Springfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Springfield Villa | 0.4 mi | ★★★★★ | 25 | 1 |
| Spring Valley Health & Rehabilitation Center | 0.8 mi | ★★★★★ | 5 | 0 |
| Birch Pointe Health And Rehabilitation | 0.8 mi | ★★★★★ | 0 | 0 |
| Maples Health And Rehabilitation, The | 1.6 mi | ★★★★★ | 0 | 0 |
| Sunterra Springs Springfield | 1.9 mi | ★★★★★ | 0 | 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 August 2026) and official state health department websites.