Above average — CMS composite of the measures below.
The next survey window likely opens around October 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 Manor At Elfindale, The during CMS and state inspections, most recent first.
Food storage and kitchen sanitation deficiencies were identified when the DM and a culinary staff member did not consistently wear effective hair restraints, opened foods were left exposed or undated, a measuring cup was stored in an open thickener container, and the refrigerator fans and ice machine deflector shield were observed with visible soil. Staff interviews confirmed expectations for hair restraints, dating opened foods, and keeping food containers closed, but observations showed these practices were not consistently followed.
Kitchen Equipment Not Maintained in Sanitary Condition: Surveyors observed drips of a white substance on the outside of the ice machine, fuzzy lint on the ice machine vent, and a missing stove knob. Staff gave conflicting accounts about who was responsible for cleaning the ice machine and vents, and the cleaning schedule showed missed completion of the assigned wiping task. The stove knob had been missing for awhile, and staff reported the burner still functioned without it.
Failure to Complete Baseline Care Plans Within 48 Hours: The facility failed to complete baseline care plans within 48 hours for two cognitively intact residents and did not document that the resident or representative received a copy or summary of the plan. One resident had diagnoses including DM2, depression, and reduced mobility, while the other had a history of leg fracture, heart disease, and weakness. The baseline plans were completed several days after admission and did not include all relevant care needs, and staff interviews showed inconsistent access to resident information and uncertainty about where to find care needs in the EMR.
Incomplete Care Plans for Wound, Oxygen/CPAP, and Fracture: The facility failed to keep care plans current for three residents with significant changes in condition. One resident with CHF, CKD, and a stage 3 toe wound had wound treatments and serial wound measurements documented, but the care plan did not address the wound. Another resident with CHF and COPD had orders for O2 and CPAP and was noted with wheezing and low O2 saturation, but the care plan did not include O2 or CPAP use. A third resident with vascular dementia had a fall with severe hip/leg pain, a bad fracture on x-ray, and hospital transfer, but the care plan was not updated to reflect the fracture.
A resident with sleep apnea, respiratory failure with hypoxia and hypercapnia, CHF, and CKD was placed on oxygen after an SpO2 of 82% on room air, but the chart had no oxygen order and the care plan did not include oxygen use. Staff later observed the resident on O2 via NC at 3 lpm, and interviews showed staff understood oxygen should have been ordered and care planned.
Medication error rate exceeded the 5% threshold when surveyors found three errors in 31 opportunities. A resident received Allegra despite the MAR lacking a dosage, a scheduled B-complex dose was unavailable at the time of administration, and an LPN gave Humalog insulin without priming the pen. Staff interviews confirmed that medication orders should include dosage and that insulin pens should be primed before use.
Failure to Prime Insulin Pen Before Administration: An LPN administered Humalog to a resident with diabetes and dementia without priming the insulin pen first. The resident’s blood sugar was 232 mg/dL, and the ordered dose was 2 units, but the LPN initially dialed the pen incorrectly, then adjusted it and gave the injection without expelling air from the pen. Facility staff and the insulin pen instructions stated the pen should be primed before each injection, and staff identified not priming as a medication error.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards when kitchen staff did not consistently use effective hair restraints. The Dietary Manager was observed in the kitchen with facial hair on the chin while preparing mashed potatoes and without a hair net over the exposed hair. On another observation, the Dietary Manager again had facial hair exposed and was not wearing a hair net. A Culinary staff member was observed wearing a beard net that covered the beard, but the mustache was not covered while peeling potatoes. Staff interviews reflected that hair nets were expected in the kitchen and were supposed to cover all hair, including facial hair, beards, and mustaches. The facility also failed to consistently date opened foods and properly close frozen foods. A box of hamburger patties in the walk-in freezer was observed with the bag opened and the patties exposed, and some patties had a white substance on them. A large container of garlic was observed opened with approximately one-third remaining and no open date or use-by date. Staff interviews stated that opened food items should be resealed or placed in a new container and labeled with the open date so staff would know when to discard them. In addition, a measuring cup was stored inside an open container of thickening powder, and the container was not closed. The refrigerator holding milk products had two fans at the top with a black substance on the outside of both fans. The ice machine in the kitchen had five spots of a black substance and a brown substance on the deflector shield. Cleaning schedules showed the refrigerator and ice machine tasks were listed, but the observations documented that these areas were not clean at the time of survey. Staff interviews identified uncertainty about who cleaned some of the equipment, while the Maintenance Director stated he/she had not noticed the black spots on the ice machine deflector shield.
Kitchen Equipment Not Maintained in Sanitary Condition
Penalty
Summary
The facility failed to maintain the kitchen area in a sanitary and comfortable condition when the outside of the ice machine had three drips of a white substance down the left side, the ice machine vent had fuzzy lint present, and one knob was missing from the stove. The facility did not provide a policy for cleaning the ice machine, and the September 2025 cleaning schedule showed the night shift was to wipe down the ice machine and ice reflector guard on Fridays, but no staff initialed completion of that task during the weeks of 09/01/25 and 09/08/25. During observations on 09/15/25 and 09/17/25, surveyors noted the drips on the side of the ice machine, the lint on the vent, and the missing knob on the stove. Staff interviews showed conflicting understanding about who was responsible for cleaning the outside of the ice machine and its vents, with responses identifying the dietary manager, kitchen staff, maintenance, or anyone on staff. The dietary manager stated kitchen staff were responsible and that this was on the cleaning schedule, while the administrator stated maintenance cleaned the outside of the ice machine and the maintenance director said kitchen staff could wipe it down and that he/she also did it when the machine was descaled. Staff also reported the stove knob had been missing for awhile, and the dietary manager said a replacement had not been located because the stove was older.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to complete baseline care plans within 48 hours of admission for two residents and failed to document that the resident or representative received a copy or summary of the baseline care plan. Resident #37 was admitted with diagnoses including history of head and face injury with fracture, type 2 diabetes, depression, and reduced mobility, and was cognitively intact. The resident’s baseline care plan was created several days after admission and addressed personal preferences and some prior history, but did not include other care needs such as diabetes or depression, and there was no resident or representative signature confirming receipt of the baseline care plan or summary. Resident #95 was admitted with diagnoses including history of leg fracture, heart disease, and weakness, and was cognitively intact. The resident’s baseline care plan was created several days after admission and addressed personal preferences, part of the resident’s history, and risk for poor nutrition, but did not include other care needs such as the leg fracture or weakness, and there was no resident or representative signature confirming receipt of the baseline care plan or summary. During interviews, staff described inconsistent access to resident information in the EMR, said newer resident needs often had to be learned from nurses or other staff, and stated that full care plans could take up to 21 days to complete, while baseline care plans should be completed immediately or within 24 hours.
Incomplete Care Plans for Wound, Oxygen/CPAP, and Fracture
Penalty
Summary
The facility failed to develop and implement complete comprehensive person-centered care plans for three residents with identified changes in condition. Review of the facility policy showed care plans were to be individualized, interdisciplinary, and include measurable goals and timeframes for resident needs identified in the comprehensive assessment. For one resident with CHF, CKD, and a facility-acquired stage 3 pressure wound to the left second toe, the record showed wound assessments and treatment orders for cleansing the area, applying skin prep, and leaving it open to air. The wound was documented as a scabbed area that measured 0.4 cm by 0.4 cm by 0.2 cm with scant bloody drainage, later 0.4 cm by 0.4 cm by 0.1 cm with scant yellow drainage, and later as a dry intact dark brown scab. The resident’s care plan, revised on 4/07/25, did not address the wound to the left toe. For another resident with CHF and COPD, the record showed orders for oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath to maintain oxygen saturation above 90% related to respiratory failure, and an order for CPAP to be applied and checked during the night. Progress notes documented audible wheezing with accessory muscle use and oxygen saturation of 91% on room air, followed by oxygen use at 2 liters per minute. The resident’s care plan addressed altered respiratory function related to COPD and asthma, but did not include oxygen or CPAP usage. For a third resident with vascular dementia, weakness, depression, anxiety, and a history of falls, a progress note documented a fall with severe left hip/leg pain, shortening and outward rotation of the leg, inability to sit or stand, x-ray findings described by the technician as a bad fracture, ambulance transport to the hospital, and hospital admission for orthopedic evaluation. The resident’s care plan, last updated 07/14/25, did not reflect the fall with fracture.
Failure to Obtain Oxygen Order and Care Plan Oxygen Use
Penalty
Summary
Safe and appropriate respiratory care was not provided for a resident with sleep apnea, respiratory failure with hypoxia and hypercapnia, CHF, and chronic kidney disease when staff applied oxygen without first obtaining an order and without care planning the oxygen use. The resident’s face sheet, MDS, and current POS showed no oxygen order, and the care plan updated before the event did not address oxygen use. On 09/12/25, the resident’s oxygen saturation was 82% on room air, and staff applied oxygen at 3 lpm to raise the saturation to 90%; the note documented hospice notification and a hospice visit, but did not document physician notification or an order for oxygen. After oxygen was started, progress notes and observations showed the resident wearing oxygen via nasal cannula at 3 lpm on multiple dates, including being observed asleep in a recliner and later in bed with oxygen in place. Staff interviews indicated they understood oxygen should have been ordered and included on the care plan, and several staff stated they had observed the resident using oxygen. The MDS Coordinator and nursing leadership stated oxygen should be on the care plan and that oxygen required an order, while the Administrator said there should be an order for oxygen if a resident was using it and expected care plans to be updated.
Medication Error Rate Exceeded Due to Incomplete Order, Missed Dose, and Unprimed Insulin Pen
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5% when surveyors identified three errors out of 31 opportunities, resulting in a 9.67% error rate. During medication pass observations, staff failed to administer one ordered medication to a resident and administered another medication to the same resident even though the order and MAR did not list a dosage. Staff also failed to prime an insulin pen before administering insulin to another resident. The facility procedure titled Safe Administration Practiced, Long-Term Care stated daily, weekly, and monthly medications should be administered within two hours of the scheduled time and that safe medication administration documentation should include the medication name, strength, and dose. For Resident #47, the face sheet listed diagnoses of high blood pressure and pulmonary fibrosis. The resident’s POS included an order for B-Complex tablet once daily for vitamin B deficiency, an order for Allegra allergy tablet once daily with no dosage listed, and an order for fexofenadine HCl 180 mg as needed for allergies. The September 2025 MAR showed Allegra documented as administered 17 days in the month without a listed dosage. During observation of the medication pass, the CMT prepared Allegra from the cart, where the card showed 180 mg and a PRN sticker, and placed it in the medication cup for administration even though the MAR order did not list a dosage. The B-complex vitamin was not in the medication cart and was unavailable at the ordered time. The CMT stated the facility was waiting for the medication to be delivered from the pharmacy and indicated a note stating the medication was not available in the MAR. For Resident #52, the face sheet listed diagnoses of diabetes and dementia. The resident had an order for Humalog sliding scale insulin with 2 units ordered for a blood glucose reading of 232 mg/dL. During observation, the LPN returned to the medication cart after obtaining the blood sugar, dialed the insulin pen incorrectly at first, then adjusted it to 2 units, and administered the insulin without priming the pen. The facility’s insulin pen procedure required priming the pen until a drop appeared, and the Humalog packet insert stated the pen should be primed before each injection. Interviews with nursing staff and administration confirmed that medication orders should include dosage, that medications should not be given without a listed dose, and that insulin pens should be primed before administration.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when staff did not prime an insulin pen before administering Humalog to a resident with diabetes and dementia. Resident #52 had an order for Humalog sliding-scale insulin with meals, and during observation the LPN obtained the resident’s blood sugar of 232 mg/dL, determined 2 units were needed, and prepared the insulin pen. The LPN initially dialed the pen to a line between 2 and 4 units, then adjusted it to 2 units after questioning the setting, but did not prime the pen before leaving the medication cart area and administering the medication in the resident’s room. The facility’s insulin pen procedure required priming the pen before use, and the Humalog KwikPen insert stated the pen should be primed before each injection and that failure to prime may result in too much or too little insulin. During interviews, multiple nurses and the ADON stated the pen should be primed with 2 units before dialing the ordered dose and that failure to prime would be a medication error because air could be administered instead of insulin. The Administrator stated staff should follow professional standards when administering insulin.
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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) |
|---|---|---|---|---|
| Magnolia Square Nursing And Rehab | 1.2 mi | ★★★★★ | 1 | 0 |
| Springfield Rehabilitation & Health Care Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Maples Health And Rehabilitation, The | 1.5 mi | ★★★★★ | 0 | 0 |
| Wilson's Creek Nursing & Rehab | 2.2 mi | ★★★★★ | 4 | 0 |
| Brookhaven Nursing & Rehab | 2.3 mi | ★★★★★ | 4 | 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.