Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Neighborhoods At Quail Creek, The during CMS and state inspections, most recent first.
The facility failed to ensure proper use of hairnets by kitchen staff, leading to potential food contamination. Observations showed staff either not wearing hairnets or wearing them improperly, exposing hair. Interviews confirmed the expectation for hairnets to cover all hair, but some staff admitted to non-compliance.
The facility failed to maintain a sanitary environment, with observations of unclean conditions in kitchen areas, including dirty ceiling vents, light fixtures with dead bugs, and unclean ice machines. Staff interviews revealed confusion over cleaning responsibilities, contributing to the unsanitary conditions. Despite having policies for cleanliness, the facility did not ensure compliance, leading to repeated observations of unclean conditions.
The facility failed to maintain safe hot water temperatures, with readings in resident and public bathrooms exceeding 120°F. Two residents with severe cognitive impairments and mobility issues were affected, with water temperatures in their bathrooms reaching up to 134.6°F. Maintenance staff did not include public bathrooms in routine checks, leading to unsafe conditions.
The facility failed to accurately reconcile controlled medications and did not properly destroy expired or unused medications. A CMT left a sticky note for a nurse to sign out a controlled medication later, contrary to policy. Additionally, expired medications and those belonging to deceased or discharged residents were found in storage, violating the facility's destruction policy. Staff interviews revealed a lack of adherence to these protocols.
The facility failed to properly store and label medications, with controlled substances not double-locked, medication carts left unlocked, and medications left at a resident's bedside without a physician's order. Prescription labels were also removed from medications for use on multiple residents, contrary to facility policy.
A long-term care facility failed to implement an effective infection control program, as staff did not consistently follow protocols for a resident with C. Diff, including proper use of PPE and hand hygiene. Additionally, staff did not adhere to hand hygiene standards during care and medication administration, and failed to properly disinfect glucometers, leading to potential cross-contamination.
A facility failed to conduct required EDL and NA Registry checks for an RN transferred from another state, nearly 20 months after hire. The oversight was due to a misunderstanding of state requirements and was acknowledged by the LPN responsible for checks, the DON, and the Administrator.
A resident with moderate cognitive impairment and at risk for malnutrition did not receive timely assistance with meals, leading to prolonged periods without eating. Observations showed the resident was left unattended with meals for extended times, and staff interviews revealed inconsistencies in understanding the resident's needs. The lack of a specific care plan for meal assistance contributed to the deficiency.
The facility failed to provide physician-ordered dietary supplements to two residents at risk for weight loss. One resident experienced significant weight loss without intervention in their care plan, and staff did not provide the prescribed supplements during meals. Another resident, identified as high risk for weight loss, did not consistently receive the ordered mighty shakes after meals, and the care plan lacked this intervention. Staff interviews revealed issues with communication and documentation, leading to the deficiency.
A resident with severe cognitive impairment accused staff of abuse, theft, and trespassing. Despite the facility's policy requiring immediate reporting of abuse allegations, the facility failed to report the incident to the State Survey Agency within the required two-hour timeframe. An investigation attributed the resident's claims to hallucinations, but a misunderstanding of reporting requirements led to the deficiency.
A CNA at a LTC facility asked a resident for money, claiming it was for their child's surgery, and received a $2,000 check from the resident. The incident was reported after the resident overheard the CNA speaking inappropriately about them. The facility's policy prohibits staff from accepting gifts over $25, and the CNA's actions violated this policy.
Improper Use of Hairnets in Kitchen
Penalty
Summary
The facility failed to maintain proper food safety standards by not ensuring that all staff wore hairnets correctly while working in the kitchen. Observations revealed that several staff members, including Homemaker Q, Baker D, Homemaker D, and Homemaker F, either did not wear hairnets at all or wore them improperly, allowing hair to be exposed. This was contrary to the facility's policy and the FDA 2013 Food Code, which require hair restraints to prevent hair from contacting food and potentially contaminating it. Interviews with staff, including Chef C, the Dietary Manager, and the Administrator, confirmed that the expectation was for all kitchen staff to wear hairnets covering all hair. However, some staff members admitted to forgetting to wear hairnets or acknowledged that the hairnets did not stay on well, leading to non-compliance with the facility's policy and food safety standards.
Facility Fails to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain a sanitary environment for residents and staff, as evidenced by multiple observations of unclean conditions in various kitchen areas. Observations revealed that ceiling vents, light fixtures, and non-contact food surfaces were not properly cleaned. Specifically, the ice machine in the main kitchen had dark smear marks and lime build-up, while the ceiling vent above it was covered in lint. Additionally, light fixtures contained dead bugs, and the fronts of freezers and refrigerators were dirty with splatter stains and smear marks. Interviews with staff members, including homemakers and the dietary manager, indicated a lack of clarity regarding cleaning responsibilities. Homemakers reported that they no longer used checklists for cleaning and were unsure who was responsible for cleaning certain areas, such as ceiling vents and walls behind ice machines. The dietary manager stated that homemakers were expected to keep kitchens clean, but maintenance was responsible for ceiling vents and light fixtures. This confusion contributed to the ongoing unsanitary conditions observed during the survey. The facility's policies on cleanliness and sanitation were not effectively implemented, as evidenced by the repeated observations of unclean conditions over several days. Despite having policies in place that required routine cleaning and visual inspections by the food service manager, the facility failed to ensure compliance. The administrator confirmed that housekeeping was responsible for cleaning walls and ceiling vents, while homemakers were expected to clean most kitchen areas. This lack of coordination and adherence to cleaning protocols resulted in the facility's failure to provide a sanitary environment.
Failure to Maintain Safe Hot Water Temperatures
Penalty
Summary
The facility failed to maintain hot water temperatures at a safe level, with multiple resident access areas measuring in excess of 120 degrees Fahrenheit. Observations revealed that hot water temperatures in various hall/public bathrooms and resident bathrooms were significantly higher than the recommended maximum, with readings ranging from 122.0 to 134.6 degrees Fahrenheit. The facility's policy mandates that water temperatures should not exceed 120 degrees Fahrenheit, yet the maintenance staff did not include hall/public bathrooms in their routine temperature checks, leading to unsafe conditions. Two residents with severely impaired cognition and mobility issues were directly affected by this deficiency. One resident, diagnosed with metabolic encephalopathy, type 2 diabetes, and peripheral vascular disease, had a bathroom water temperature of 132.3 degrees Fahrenheit. Another resident with a hip fracture and late-onset Alzheimer's disease had a bathroom water temperature of 134.6 degrees Fahrenheit. The maintenance staff and director confirmed that they only checked water temperatures in two resident rooms per hall weekly, excluding hall/public bathrooms, which contributed to the oversight.
Medication Management Deficiencies in Controlled Substances and Expired Medications
Penalty
Summary
The facility failed to maintain an accurate reconciliation and accounting for controlled medications for a resident, leading to a discrepancy in the medication count. The issue arose when a Certified Medication Technician (CMT) believed that a night shift nurse had administered a controlled medication but failed to sign it out. Instead of resolving the discrepancy immediately, the CMT left a sticky note for the night shift nurse to sign the medication out later. This action was contrary to the facility's policy, which requires immediate reporting and resolution of any discrepancies in controlled medication counts. Additionally, the facility did not properly destroy expired or unused medications, as observed in two neighborhoods. Medications belonging to deceased or discharged residents, as well as expired medications, were found in the medication storage areas. These included controlled substances such as OxyContin and Percocet, as well as other medications like dexamethasone and ibuprofen. The facility's policy mandates that such medications be destroyed in accordance with their Destruction of Unused Drugs Policy, but this was not adhered to. Interviews with staff, including the Director of Nursing (DON), Registered Nurses (RN), and Licensed Practical Nurses (LPN), revealed a lack of awareness and adherence to the facility's policies regarding medication discrepancies and the destruction of expired or unused medications. Staff members acknowledged that discrepancies should be reported immediately and that expired or unused medications should be destroyed and not used. However, the observations indicated that these protocols were not consistently followed, leading to the deficiencies noted in the report.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, leading to several deficiencies. Controlled substances were not stored under two locks as required, with a cabinet containing narcotics left unlocked and accessible without a key. Additionally, medication carts were observed unlocked and unattended, contrary to the facility's policy that requires them to be locked when not in use. Staff interviews confirmed that these practices were not acceptable and did not align with the facility's standards. A resident was found with medications left on their bedside table without a physician's order or care plan allowing for self-administration. The resident, who had a history of emphysema, COPD, hypercapnia, and high blood pressure, had two inhalers and a bottle of echinacea on their bedside table over several days. Staff interviews revealed that leaving medications at the bedside without a physician's order was not acceptable, and there was no documentation supporting the resident's self-administration of these medications. Furthermore, prescription labels were removed from medications in the treatment and overflow cart, allowing for their use on multiple residents. This included medications such as Santyl, Diclofenac cream, Mometasone Furoate cream, and Ketoconazole. Staff interviews indicated that this practice was done to use medications for other residents as needed, which was acknowledged as unacceptable by the nursing staff and administration.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by multiple deficiencies in handling infection control practices. Staff did not consistently communicate or implement an infection control plan for a resident diagnosed with Clostridium difficile (C. Diff), a highly contagious infection. Observations revealed that staff did not adhere to contact precautions, such as wearing gowns and gloves, and failed to perform proper hand hygiene when providing care to this resident. Additionally, there was confusion among staff regarding the type of isolation required, with discrepancies between Enhanced Barrier Precautions (EBP) and contact isolation signage. Further deficiencies were noted in the facility's hand hygiene practices. Staff failed to perform hand hygiene according to standards when providing care to residents, including during incontinence care and when administering medications via a feeding tube. Observations showed that staff did not wash their hands before and after care, and in some instances, continued to wear contaminated gloves while performing multiple tasks, potentially spreading infection. The facility also failed to properly disinfect glucometers used for blood glucose monitoring. Staff did not follow the facility's policy for cleaning glucometers between uses, leading to potential cross-contamination. Observations showed that glucometers were not disinfected immediately after use and were placed on potentially contaminated surfaces. Additionally, staff mishandled clean items by placing them back with clean supplies after they had been dropped on the floor, further compromising infection control protocols.
Failure to Conduct Required Background Checks for Transferred RN
Penalty
Summary
The facility failed to adhere to its abuse and neglect policy by not conducting necessary background checks for a registered nurse (RN A) who was transferred from another state. The facility's policy mandates that all potential employees be checked against the Employee Disqualification List (EDL) and the Nurse Aide (NA) Registry before employment. However, RN A's EDL and NA Registry checks were only completed nearly 20 months after their hire date. This oversight occurred despite the facility's policy requiring these checks to be done prior to any employee having contact with residents. Interviews with staff revealed that the Licensed Practical Nurse (LPN B), responsible for conducting these checks, did not complete them for RN A due to a misunderstanding of the requirements when transferring from another state. The Director of Nursing (DON) and the Administrator acknowledged the oversight, attributing it to the differences in state requirements and the impact of the COVID-19 pandemic. The failure to perform these checks was identified as a deficiency in the facility's compliance with its own policies and state regulations.
Failure to Provide Timely Meal Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically during meal times, for a resident with moderate cognitive impairment and at risk for malnutrition. The resident, who was dependent on staff for eating, was observed on multiple occasions not receiving timely assistance with meals. On one occasion, the resident was left unattended with a meal for over an hour before receiving help, and on another, the resident struggled to eat a chicken leg without assistance for 28 minutes before a CNA intervened. Interviews with staff revealed inconsistencies in the understanding and execution of meal assistance for the resident. Some staff members indicated that the resident required immediate assistance, while others suggested that assistance could be delayed if staffing was insufficient. The MDS Coordinator and Clinical Dietary Nurse had differing views on the resident's risk for weight loss and the level of assistance needed, with the Dietary Nurse acknowledging the resident's risk for weight loss and the need for monitoring. The Director of Nursing also expressed that the resident should not wait longer than five to ten minutes for assistance, yet observations showed this standard was not met. The lack of a specific care plan addressing the resident's need for assistance with eating contributed to the deficiency, as staff did not consistently provide the necessary support to ensure the resident's nutritional needs were met.
Failure to Provide Physician-Ordered Dietary Supplements
Penalty
Summary
The facility failed to provide physician-ordered dietary supplements to two residents, Resident #54 and Resident #67, who were either experiencing weight loss or at risk for it. Resident #54, diagnosed with Parkinson's disease, dysthymic disorder, chronic kidney disease, and high blood pressure, experienced a significant weight loss of 9.8 pounds over three months and an additional 5 pounds over two months. Despite this, the resident's care plan did not address the weight loss or include new interventions. Observations showed that staff did not provide the resident with the prescribed mighty shake or ice cream during meals, and the Medication Administration Records (MAR) lacked documentation of the nutritional supplement being provided. Resident #67, diagnosed with anorexia, dementia, abnormal weight loss, and hypothyroidism, was identified as high risk for weight loss with a low body mass index. The resident was supposed to receive mighty shakes after meals, as per the physician's order. However, the care plan did not include this intervention, and the MAR did not have a place to document the administration of the mighty shake. Observations confirmed that staff did not consistently provide or offer the mighty shake to the resident during meals. Interviews with various staff members, including registered nurses, dietary consultants, and the Director of Nursing, revealed a lack of communication and documentation regarding the dietary supplements. The Dietary Consultant Nurse acknowledged that the order for supplements was entered incorrectly into the electronic medical record, preventing it from populating on the MAR. Consequently, staff were unaware of the need to provide the supplements, leading to the deficiency in care for both residents.
Failure to Report Alleged Abuse in Required Timeframe
Penalty
Summary
The facility failed to report an allegation of possible physical abuse within the required timeframe to the State Survey Agency. A resident with severe cognitive impairment, including dementia and delusional disorder, accused staff of physical abuse, theft, and trespassing. Despite the resident's history of anxiety, hallucinations, and intermittent confusion, the facility's policy mandates that all allegations of abuse be reported immediately, but not later than two hours after the allegation is made. On the day of the incident, the resident exhibited behaviors and made accusations against staff, including being pinched on purpose. The Registered Nurse (RN) on duty reported the allegations to the Administrator, and an investigation was conducted. The investigation, which included a skin assessment and interviews with staff and family, concluded that the allegations were unsubstantiated and attributed the resident's claims to hallucinations. However, the facility did not report the allegations to the Department of Health and Senior Services (DHSS) within the required two-hour window. Interviews with various staff members, including RNs, LPNs, CNAs, and the Director of Nursing (DON), revealed a misunderstanding of the reporting requirements. The Administrator believed that if an allegation could be disproven within two hours, it did not need to be reported to DHSS. This misinterpretation led to the failure to report the resident's allegations, resulting in a deficiency in the facility's compliance with abuse reporting regulations.
Misappropriation of Resident's Money by CNA
Penalty
Summary
The facility failed to protect a resident from misappropriation of their belongings when a Certified Nurse Aide (CNA) asked for and took money from the resident. The resident, who was cognitively intact and responsible for themselves, was approached by CNA A, who claimed their child needed surgery. The CNA brought their child to the facility to show the resident, which led the resident to agree to give $2,000 to the CNA. The resident signed a check for this amount, which was cashed by CNA A. The incident came to light when the resident overheard CNA A speaking about them inappropriately during a phone call that was accidentally merged. The resident reported feeling that the CNA was trying to manipulate the situation to make it appear as though the resident was trying to buy the CNA's affection. This prompted the resident to report the incident to a Registered Nurse (RN) and subsequently to the Administrator. Interviews with other staff members, including CNAs and the Director of Nursing (DON), confirmed that it is against policy for staff to accept money from residents. The facility's policy prohibits staff from accepting gifts over $25, and the actions of CNA A were in direct violation of this policy. The CNA initially claimed the money was for someone else but later admitted to cashing the check, which was against the facility's Code of Business Conduct and Ethics.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 142 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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) |
|---|---|---|---|---|
| Birch Pointe Health And Rehabilitation | 1.4 mi | ★★★★★ | 0 | 0 |
| Springfield Rehabilitation & Health Care Center | 1.9 mi | ★★★★★ | 0 | 0 |
| Sunterra Springs Springfield | 2.1 mi | ★★★★★ | 0 | 0 |
| Magnolia Square Nursing And Rehab | 2.1 mi | ★★★★★ | 1 | 0 |
| Maples Health And Rehabilitation, The | 2.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Neighborhoods At Quail Creek, The.
100% money-back within 48 hours.
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.