Below 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 Springfield Villa during CMS and state inspections, most recent first.
Food Handling, Kitchen Hygiene, and Plumbing Deficiencies: Surveyors observed wet dishes stacked for storage, staff in the kitchen without required hair/beard restraints, a grease- and lint-covered hood over the stove, and drainpipes from the ice machine and sink with no air gap and visible slimy buildup. The DON, Dietary Manager, and Administrator acknowledged that dishes should be air dried, hairnets and beard coverings were required in the kitchen, and the hood and piping had not been maintained as expected.
No On-Site Emergency Water Supply: The facility failed to have a policy addressing the required quantity of emergency water to keep on-site and failed to maintain an on-site supply. The Dietary Manager was unsure where emergency water was stored, dietary staff reported they had never seen any, and the DON and Administrator confirmed the facility did not keep emergency water on-site and instead relied on vendor delivery contracts.
Broken room fixtures and exposed handrail edges were left unaddressed, affecting the resident environment. A resident’s window blind was damaged and would not fully close, another resident’s bedside stand had a broken drawer handle, and three handrails near the nursing desk were missing end caps with exposed plastic edges. A family member bumped an elbow on the handrail, and staff and leadership said broken items should be reported through maintenance logs or directly to maintenance, but the Maintenance Supervisor was unaware of the issues.
Missing CBC Documentation for CMT: The facility failed to maintain documentation of a CBC for one CMT. The facility policy required employee screening before residents were cared for, but the CMT’s personnel file had no CBC documentation. The Administrator said the CBC record could not be located, and the HR staff and DON stated HR was responsible for completing background checks before hire.
Failure to Provide Ongoing Activities for Memory Care Residents: Three residents with dementia-related diagnoses and documented activity preferences were not consistently offered or engaged in activities on the memory care unit. Records showed only limited participation in scheduled events, while observations found no visible activity schedule in the common area, no observed resident activities during multiple checks, and residents sitting unattended. Staff and family interviews described limited supplies, inconsistent activity delivery by aides, and no routine one-to-one activities unless specifically in the care plan.
Hot water temperatures in four resident rooms were observed above the expected range, with sink water measuring over 122 degrees F and the water heater set just below 130 degrees F. The facility also failed to secure a resident’s cigarettes and lighter, despite the resident being assessed for supervised smoking only; observations found the smoking materials left in the room, and staff gave inconsistent accounts of where cigarettes and lighters should be kept.
Medication carts and narcotic boxes were left unsecured while CMTs prepared and dispensed resident medications. One CMT opened the narcotic box without a key, dispensed narcotics, and walked away from the cart while it remained unlocked; another CMT only partially locked the cart, then left it out of sight and later opened it by pulling the lock out with fingers instead of using a key. Staff interviews confirmed carts should be locked when not in line of sight and narcotic boxes should be locked and double locked when not in use.
Food Served Tough, Bland, and Cold: Residents reported meat that was hard to cut, meals that were bland or overcooked, and food that was often cold when served. Observations showed staff struggling to cut a very tough pork chop without knives available on the memory care unit, and test trays with hot items below acceptable temperatures, including a hot dog, corn fritter, potatoes, and cabbage. Residents, a family member, dietary staff, and the DON all described trays sitting in the hall too long and meals arriving cold or unappetizing.
EBP was not consistently followed during wound care and catheter care for multiple residents with chronic wounds and indwelling catheters. Staff were observed using gloves but not gowns during wound care, incontinent care, and catheter care, and in one instance a CNA entered without hand hygiene before gloving. PPE was not available near some resident rooms, and care plans did not address EBP for the affected residents. Interviews showed inconsistent staff understanding of when gowns were required.
Kitchen cleaning and maintenance were not consistently completed, leaving vents, ceiling tiles, shelving, walls, and floors visibly dirty with cobweb/lint buildup, food splatters, grease, and grime. Staff gave conflicting accounts about who was responsible for higher-area cleaning and dishwashing-area upkeep, and several said cleaning schedules were not being used or were unavailable. The floor also had missing tiles and an unused outlet casing with buildup, while the DM and Admin stated these areas should be cleaned on a regular schedule.
A resident with severe dementia, mobility impairment, and frequent bowel and bladder incontinence was left in a wheelchair near the nurses’ station for hours without being checked for incontinence or taken to the bathroom. When staff finally assisted the resident to the toilet, the resident’s clothing and wheelchair pad were soaked with urine, and staff provided incomplete perineal care by not washing the front genital area and legs. Interviews confirmed staff expected incontinence checks at least every two hours and proper cleansing of all dirty areas.
Inconsistent code status documentation: Two residents had conflicting records showing both DNR and full code across the chart, care plan, and door identifiers. One resident had a living will and DNR documents, yet the POS listed full code; another resident's face sheet and OHDNR showed DNR, but the POS listed full code. Staff interviews confirmed that code status should match throughout the record, but the documentation was not consistent.
Survey Results Binder Not Readily Accessible: The facility failed to keep the survey results binder in a readily accessible public location at all times. Although a sign at the front desk stated the binder was available there, observations found no binder visible at the desk, and staff gave conflicting accounts of its location and availability. The receptionist said it was kept behind the desk and locked after 4:00 P.M., while other staff, including the RN, CMT, MDS Coordinator, DON, and Administrator, were unsure or described different access arrangements.
The facility was cited under F684 for failing to provide treatment and care according to provider orders and in alignment with residents’ preferences and goals. Based on surveyor observation, interviews, and record review, this noncompliance was linked to complaints from multiple residents and initially rose to an Immediate Jeopardy level J before later being downgraded in severity. Specific clinical details about the affected residents or the exact orders and preferences not followed were not described, but the deficiency centered on not ensuring that residents received care and services as ordered and consistent with their individual goals.
A resident with chronic kidney disease and encephalopathy exhibited significant changes in mental status and behavior, which were reported by staff to an LPN. The LPN did not perform an assessment or document the change, and the resident was sent to dialysis without evaluation. At the dialysis clinic, the resident's condition worsened and she was sent to the hospital, where she was diagnosed with metabolic encephalopathy and hypoglycemia. Facility policy required prompt assessment and documentation of such changes, which did not occur in this instance.
A resident with multiple neurological and cognitive conditions developed significant bruising on the forehead and left finger that was not present at admission. Staff, including CNAs and LPNs, observed the bruising at different times but failed to consistently report, assess, or document the findings as required by facility policy. The care plan did not address the bruising, and there was no evidence of a timely or thorough investigation into the cause of the injuries.
Facility staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes, as identified during complaint investigations.
A resident and their physician and family were not promptly informed of important events, such as injury, decline, or room changes, that affected the resident, as identified during complaint investigations.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective measures to prevent new ulcers from developing. Surveyors found that necessary interventions, assessments, and monitoring were not consistently provided, resulting in the occurrence and worsening of pressure ulcers.
Gabapentin prescribed to three residents went missing while in the facility’s possession after a CMT was observed removing pills from medication cards and placing them in a personal backpack. Labels from the medication cards were found in the shred bin, and audits revealed significant discrepancies between the number of pills delivered and those available for use. The affected residents had documented needs for pain management, and only nurses and CMTs had access to the locked medications.
Staff did not promptly inform a resident, their physician, and a family member about important events such as injury, decline, or room changes, as required. This lapse in communication was identified during the survey.
A resident did not receive care and treatment in accordance with physician orders and their stated preferences and goals, as observed and documented by surveyors.
Several residents with significant cognitive and mobility impairments experienced repeated falls, but staff failed to consistently document fall events, update care plans, or implement new interventions as required by facility policy. In multiple cases, care plans were not revised after falls, assessments were incomplete, and preventive measures were not clearly documented, resulting in a failure to maintain a safe environment free from accident hazards.
Two residents who required assistance with bathing were not consistently offered or provided showers according to their care plans and preferences, with significant gaps in documentation and long intervals between showers. Staff interviews confirmed that showers were not always offered or documented as required, and there was confusion about responsibilities for residents on hospice. The facility also lacked a policy on showers or bathing.
Food Handling, Kitchen Hygiene, and Plumbing Deficiencies
Penalty
Summary
Food was not protected from possible contamination when dietary staff failed to ensure dishes were fully air dried before being stacked and stored. On 04/13/26 and again on 04/17/26, surveyors observed wet dishes stacked upside down on trays, including 30 clear juice cups and 69 white bowls on one observation and 19 plastic soup bowls and 30 clear juice cups on another, with no liner or air flow and water trapped inside the items. Facility staff interviewed after the observations acknowledged that dishes were not supposed to be stacked while still wet and that they should be completely air dried before being put away. The facility also failed to ensure that hair restraints and beard coverings were worn appropriately in the kitchen. On 04/13/26, the Administrator entered and walked through the kitchen without a hairnet or beard net while passing near the area where food was served. On 04/15/26, a dietary aide was observed putting away clean dishes without a beard covering. During interviews, the dietary aide stated he/she knew to wear a beard covering but forgot, and the Dietary Manager, DON, and Administrator all stated that anyone in the kitchen was required to wear hairnets and beard coverings. Surveyors also observed sanitation and plumbing issues in the kitchen and related food service areas. The hood over the gas stove was observed covered in thick greasy buildup mixed with cobwebs or lint, along with food splatters on the rim. In addition, drainpipes behind the ice machine and sink were observed with no air gap, with the drains lying directly on top of the drainpipe and covered in a black, slimy substance; in the vending machine room, an ice machine drainpipe sat directly in a drain pan containing stagnant water and touching the side of the pan. Staff interviews showed the Dietary Manager did not know about the required air gap, and the Administrator stated he/she had assumed the pipes were okay and was not aware of any potential problems.
No On-Site Emergency Water Supply
Penalty
Summary
The facility failed to have a policy in place that addressed the quantity of emergency water to be kept on-site and failed to have a supply of emergency water on-site. The census was 118. Review of the facility’s policies showed references to maintaining an emergency water supply, using outside vendors, and determining water amounts based on CDC and WHO guidance, but the records did not show a clear on-site quantity requirement being followed. The facility policy also stated that emergency water should be suitable and accessible and that water would be brought in and dispensed as needed during a shortage. During interviews, the Dietary Manager was unsure where emergency water was located and stated it may have been kept at a storage building for all facilities. Dietary Aides and another dietary staff member said they did not know where any emergency water might be kept and had never seen any. The Dietary Manager later said he/she was unsure whether the facility still had emergency water on-site or where it was located, and was uncertain how much was required. The DON and Administrator both stated the facility did not keep a supply of emergency water on-site and relied on contracts for delivery of emergency water.
Broken Room Fixtures and Exposed Handrail Edges
Penalty
Summary
The facility failed to ensure a clean, comfortable, and homelike environment when broken and damaged items were left unaddressed in resident and common areas. In one resident’s room, the window blind was only halfway up, the slats were bowed, one slat was missing, and a blind slat approximately 2 inches wide and five feet long was leaning against the wall near the bathroom. The resident said he/she wanted the blinds closed because it was frightening to look out at night and see a face in the window, and said he/she did not remember the last time the blinds were able to completely close. In another resident’s room, a 3-drawer bedside stand had a bottom drawer handle hanging toward the floor with only one screw present, and the resident said he/she did not know how long the handle had been broken and that the dresser was hard to open. In a common area near the nursing desk, three handrails were missing end caps and had exposed plastic edges; a resident’s family member bumped an elbow on the end of the handrail while sitting in a chair and expressed concern that a resident could bump the railing end and receive a bruise or skin tear. Staff and leadership stated that broken items and repairs should be entered in maintenance logbooks or reported to maintenance, and the Maintenance Supervisor said he/she was unaware of the broken blinds and missing handrail end caps.
Missing CBC Documentation for CMT
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after the facility failed to maintain documentation of a criminal background check (CBC) for one Certified Medication Technician (CMT N). The facility policy required screening of employees and volunteers before they worked with residents, including verification of references, certification and license, and a CBC through the Family Care Safety Registry or a contracted investigation company. Review of CMT N’s personnel file showed a hire date of 08/15/24, but no documentation that a CBC had been completed. During interview, the Receptionist/Human Resources staff stated he/she was responsible for completing background, EDL, and Nurse Aide Registry checks before hiring and said this duty had been taken over from the previous administrator after CMT N was hired. The DON stated the Receptionist/Human Resources staff was currently responsible for completing background checks before employees are hired. The Administrator stated the facility was unable to locate documentation for a CBC for CMT N, and orientation was not scheduled until CBC results were received.
Failure to Provide Ongoing Activities for Memory Care Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet residents’ needs and preferences on the memory care unit. The deficiency was identified after observation, interview, and record review showed that three residents who had documented interests in activities were not consistently offered or engaged in activities, and staff did not document offering them other activities from the activity calendar. The facility policy stated that activities should be planned to meet individual resident needs, that all staff were responsible for assisting residents with activities of their choice, and that an individualized program should be implemented for residents unable to participate in or attend activities. Resident #94 had diagnoses including dementia, muscle weakness, and cerebrovascular disease, with severe cognitive impairment on the MDS. The resident’s preferences included books, magazines, music, animals, snacks between meals, news, group activities, fresh air, and religious services. The April 2026 activity record showed participation in a limited number of events such as Easter treats, snack cart, chapel services, movie with the meal, National Wear a Star Day, refreshments cart, hot cocoa bar, and another movie with the meal. During interview, the resident stated liking to be involved in activities when available, but said there were not many activities. Resident #11 had vascular dementia, repeated falls, and anxiety disorder, with moderate cognitive impairment on the MDS. The resident preferred snacks between meals, family involvement, reading, music, animals, group activities, favorite activities, time outdoors, and religious activities. The activity record showed participation in events such as assembling Easter eggs, chapel services, movie with the meal and hot cocoa bar, National Wear a Star Day, a movie with lunch, hot cocoa bar, and another movie with the meal. The resident’s family member said the resident liked to be involved in activities when available, there were not many activities provided, and they were unaware of staff providing one-to-one activities or conversations. Resident #115 had frontal temporal neurocognitive disorder, vascular dementia, and needed assistance with personal cares, with severe cognitive impairment on the MDS. The resident preferred reading, music, group activities, time outdoors, favorite activities, and religious activities. The activity record showed participation in Easter treats, therapy, music therapy, therapy and movie with the meal, National Wear a Star Day, a drive with family and movie with lunch, and another movie with the meal. The resident’s family said the resident liked to be involved in activities when available. Observations on the memory care unit showed no activity schedule posted in the common area, the schedule posted near the nurses’ desk and not visible to residents or visitors, no observed activities with residents during multiple observations, and residents seated without staff present during one observation. Staff interviews indicated that memory care staff were responsible for providing activities, that activities did not always occur because aides were busy with resident care, that there were limited supplies, and that one-on-one activities were not provided unless in the care plan.
Hot Water Temperatures and Smoking Materials Not Secured
Penalty
Summary
The facility failed to provide an environment free of accident hazards when hot water temperatures in resident rooms 100, 102, 103, and 106 were found above the expected range. The report states the facility did not provide a policy pertaining to water temperature range, while the Maintenance Director said he/she checked only two rooms per hall monthly and believed hot water should not be over 120 degrees F. The Administrator stated staff would expect hot water to be maintained between 105 and 120 degrees F. Observations on 04/14/26 and 04/15/26 showed sink hot water temperatures ranging from 122.9 to 124.5 degrees F in the affected rooms, and on 04/16/26 the hot water heater in the closet on the 100 hall was set just below 130 degrees F. The facility also failed to ensure smoking materials and lighters were secured for a resident identified as an independent smoker. The resident’s face sheet showed admission on 04/06/26 with diagnoses including lower spine and pelvis fractures, multiple rib fractures, traumatic pneumothorax, depression, anemia due to blood loss, anxiety, and postprocedural pain. The admission MDS showed the resident was cognitively intact, had functional limitations in range of motion and mobility, and used tobacco. The smoking risk assessment dated 04/06/26 documented cigarette use, intact memory, independent decision-making, understanding of smoking guidelines, and a recommendation for supervised smoking until further observation. The care plan stated the resident was not allowed to smoke in the room, could smoke only with staff supervision in the designated smoking area, and smoking safety assessments were to be completed per protocol. However, observations showed a pack of cigarettes and a lighter left on the vanity countertop and later on the sink in the resident’s room. During observation, the resident said he/she was a smoker but had not smoked since admission and had not been told anything about securing the cigarettes or lighter. Staff interviews showed inconsistent understanding of the smoking process, with some stating lighters should be kept at the nurses’ desk, others stating cigarettes could be kept in the room if assessed safe, and the DON and Administrator stating lighters or smoking materials should be kept at the nurses’ station.
Medication carts and narcotic boxes left unsecured
Penalty
Summary
Medication carts and narcotic storage were not kept secure while staff were preparing and dispensing resident medications. During observation, a CMT stood at a medication cart in the hall outside the main dining room, prepared medications, opened the narcotic box without using a key, dispensed a narcotic medication, and closed the box without engaging the lock. The CMT then walked away from the cart into the dining room and out of sight of the cart, returned, and again opened the cart and narcotic box without using a key to dispense another narcotic medication, leaving the cart unlocked each time. A second CMT was observed on the 100 hall closing the medication drawer and only pressing in slightly on the cart lock, which remained protruding with a visible red dot, then walking away from the cart and out of sight into a resident's room. When the CMT returned, the lock was pulled out with fingers rather than a key to open the cart, and the same partial locking occurred again before the CMT again left the cart unattended. During interview, staff including an RN, MDS Coordinator, LPN, ADON, DON, and the Administrator stated that medication carts should be locked when staff are away or not in line of sight and that the narcotic box should be locked and double locked when not in use; the DON and others also stated staff should not partially lock the carts.
Food Served Tough, Bland, and Cold
Penalty
Summary
The facility failed to ensure food served was palatable and at an appetizing temperature. During the Resident Council Meeting, a resident said the meat was hard as a rock and the food was not very good, while other residents said the food was stone-cold and that meals delivered to rooms were cold. Observation of the memory care dining room showed meal trays served with pork chop, onion rings, mixed vegetables, bread, and pears, and staff struggled to cut the meat into bite-size pieces using only a fork and spoon because the pork chop was very tough. A CNA stated the kitchen does not send knives to the memory care unit, and an LPN was also observed having difficulty cutting the meat for a resident requesting assistance. Meal observations and interviews also showed food that was not at the expected temperature and lacked seasoning. A lunch test tray from hall service included ham and beans that were mostly broth, diced fried potatoes at 118.2 degrees F and undercooked, and cabbage at 115.5 degrees F and not seasoned. Another lunch test tray showed chili that was bland, a hot dog on a bun at 115.8 degrees F, and a corn fritter at 119.9 degrees F. Residents and a family member reported that food was plain, never seasoned, almost always overcooked, and often cold when delivered. Dietary staff and management stated that trays were made up ahead of time, sat in the halls for an hour or longer, and that trays were not passed fast enough, resulting in food becoming cold.
EBP Not Followed During Wound and Catheter Care
Penalty
Summary
The facility failed to implement a complete and effective infection prevention and control program when staff did not follow Enhanced Barrier Precautions (EBP) during wound care and catheter care. The report states that EBP requires gown and glove use during high-contact resident care activities for residents with wounds or indwelling medical devices, and that PPE should be available near the resident room. The facility policy also stated that residents with wounds or indwelling devices require EBP for the duration of the wound or device use, and that gowns and gloves are required for wound care and other high-contact care activities. For one resident with multiple chronic wounds, including a stage 3 pressure ulcer and diabetic foot ulcers, the wound nurse provided wound care without donning a gown. A CNA entered the room, put on gloves without washing or sanitizing hands, and also did not wear a gown. The two staff members then provided incontinent care and applied barrier cream. The resident’s care plan did not address EBP, and no protective gowns were located outside or inside the room. For another resident with an indwelling urinary catheter and pressure ulcer, staff were observed providing wound care while washing hands and donning gloves but not wearing gowns. The resident’s care plan also did not address EBP, although signage on the door indicated the need for EBP. For a third resident with an indwelling catheter and severe cognitive impairment, staff provided catheter and incontinent care with gloves but without a gown, and there was no EBP sign or PPE available near the room. For a fourth resident with stage 2 pressure ulcers, staff provided incontinent care and wound care in the shower room while wearing gloves but not gowns. Interviews with nursing staff and the DON showed differing understanding of when gowns were required, while the DON and Administrator stated that gowns and gloves should be worn for residents with chronic wounds, catheters, and other devices during direct care.
Kitchen Cleaning and Maintenance Lapses
Penalty
Summary
The kitchen was not kept clean and sanitary in non-food contact areas because the ceilings, shelving, walls, and floors were not maintained in good repair and were visibly dirty. Survey observation on 04/13/26 found vents coming out of the ceiling above the dishwasher with no covering, wall surfaces behind the stove, grill, deep fryer, dishwashing machine drain area, and three-bin sink discolored and covered with cobweb/lint buildup, food splatters, and stains, and the air conditioning unit in the dishwashing room discolored with cobweb/lint buildup. Ceiling tiles above the metal shelving were discolored and broken, exit signs above the back door were covered in cobweb/lint buildup, and the metal shelving next to the kitchen entrance and the cabinet over the hand washing sink were also covered with cobweb/lint buildup. Staff interviews showed inconsistent understanding of who was responsible for cleaning these areas. A Dietary Aide said he/she tried to clean while working but there were not enough hours or enough people helping, that there were supposed to be two staff doing dishes, and that he/she did not know who was responsible for cleaning higher areas. Another Dietary Aide said he/she kept food surface areas clean and that there was a list for chores, but no one used it. A staff member said whoever was doing the dishes would clean the dishwashing area, that there used to be a cleaning schedule but it was not available, and that deep-cleaning was not getting done because there were not enough staff and no one knew what their job was. The floor in the kitchen and dishwashing area was also dirty and not maintained. Observation found an unused electrical outlet and large metal casing coming out of the floor with cobweb/lint buildup and food splatters, missing tiles under the dishwasher, and grime and grease buildup under and around the stove, grill, and deep fryer. The Dietary Manager stated the floors were listed on a cleaning schedule but it had not been used in a while, and that floors should be swept and mopped every day following every meal. The Maintenance Director and Administrator both stated that higher areas such as vents, ceiling tiles, and other elevated surfaces should be cleaned on a regular schedule, but staff interviews indicated those tasks were not being consistently assigned or completed.
Failure to Provide Timely Incontinence Checks and Complete Perineal Care
Penalty
Summary
The facility failed to provide timely and complete urinary incontinence care for a resident who was dependent on staff for toileting hygiene and personal hygiene. The resident had severe vascular dementia, gait and mobility impairment, generalized muscle weakness, type 2 diabetes, and candidiasis. The resident’s assessments and care plan identified frequent bowel and bladder incontinence, dependence on staff for toileting and hygiene, and a need for frequent checks, perineal care after incontinent episodes, assistance to the restroom as appropriate, and help maintaining personal hygiene and clean clothing. On observation, the resident remained in a wheelchair near the nurses’ station for extended periods without being taken to the bathroom or to the room. The resident was observed sitting in the wheelchair from late morning through the evening, including during meals and while staff passed by or provided care to other residents. Staff did not take the resident to the bathroom or room during these periods, and the resident was later assisted to the bathroom after more than eight and one-half hours without an incontinence check. When the resident was finally assisted to the toilet, the shirt, pants, brief, and wheelchair pad were soaked with urine. During the toileting episode, staff provided incomplete perineal care. The resident’s bottom was noted to be dark red and purple, non-blanchable, and intact, and barrier cream was applied. However, the resident’s front genital area and legs were not washed, and the resident’s dirty clothing was placed in a trash bag for laundry. Staff interviews confirmed that incontinence care should include checking briefs every two hours, before and after meals, cleaning all dirty areas from front to back, washing skin folds, and changing clothing as needed. The DON and Administrator stated they expected staff to check residents frequently, provide proper incontinent care, and perform care at least every two hours.
Inconsistent Code Status Documentation
Penalty
Summary
The facility failed to ensure a system was in place that clearly and consistently represented each resident's code status throughout the medical record. Surveyors found that two residents had conflicting code status information in different parts of their charts, with physician orders showing full code while other documents and identifiers showed DNR. The facility policy stated that advance directive information should be displayed prominently in the medical record, but the records reviewed did not consistently reflect the residents' choices. One resident had diagnoses including metabolic encephalopathy, dementia with anxiety, a history of TIA, and cerebral infarction without residual deficits. The resident's Health Care Declaration/Living Will directed providers to withhold or withdraw life-sustaining treatment, and the baseline care plan and OHDNR form showed DNR. However, the Physician's Order Sheet contained an order for full code. The resident was also observed with a red tag by the door indicating DNR. A second resident had diagnoses including a cancerous brain tumor, stroke with right-sided weakness, muscle wasting and weakness, repeated falls, dysphagia, speech disturbances, pain, depression, hypertension, and hypothyroidism. The resident's face sheet showed DNR and the OHDNR form was signed by the resident's representative and physician, but the Physician's Order Sheet listed full code. The care plan did not address code status, and the resident's name plate was observed on red paper indicating DNR. Staff interviews showed that code status should match throughout the chart and on the door tags, but multiple staff members described different roles for admissions, MDS, social services, and nursing in documenting and auditing code status.
Survey Results Binder Not Readily Accessible
Penalty
Summary
The facility failed to ensure that survey results were kept in a readily accessible public location at all times of the day for residents, family members, and visitors. Observations on 04/13/26 at 8:15 A.M., 04/14/26 at 10:40 A.M., and 04/16/26 at 8:30 A.M. showed a sign at the front entry desk stating the survey binder was available at the front desk, but no survey binder was located or visible there during any of those observations. The facility census was 118, and no policy regarding survey results accessibility was provided during record review. During interviews on 04/17/26, staff gave conflicting information about where the survey book was kept and when it was available. RN C said it was located at the front desk and should be available for anyone to view at any time. The receptionist said it was kept in a cupboard behind the receptionist's desk and locked in the reception area after 4:00 P.M., and that a visitor had requested to see it a couple of months earlier. CMT D did not know where the survey book was located, and Resident #6 said he/she did not know where the book was or when it was available. The MDS Coordinator was unsure whether it was still at the front desk, while the DON and Administrator stated it was at the front desk but was locked behind the receptionist's desk when the receptionist left for the day because they did not want it stolen.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders and in alignment with residents’ preferences and goals. Surveyors, through observation, interview, and record review, identified that this failure rose to the level of Immediate Jeopardy beginning on 01/23/26. The issues were cited under F684, indicating noncompliance with requirements to ensure that residents receive necessary care and services as ordered and consistent with their individual goals and preferences. The deficiency was associated with complaints #2727145 and #2728765 and was initially determined to be at the immediate and serious jeopardy level J during an abbreviated survey. The Administrator was notified of the Immediate Jeopardy on 01/29/26 at 5:29 P.M., and the situation was later reassessed, with the severity of the deficiency ultimately lowered to a D level at the time of survey exit. The report does not provide specific clinical details about individual residents, their diagnoses, or the exact nature of the orders or preferences that were not followed, but it clearly attributes the cited noncompliance to failures in delivering care and treatment as ordered and as aligned with residents’ stated goals and preferences.
Failure to Promptly Assess and Document Change in Resident Condition
Penalty
Summary
Staff failed to provide care according to standards of practice when they did not promptly assess a resident after a noticeable change in condition. The resident, who had chronic kidney disease stage 5, encephalopathy, and a mood disorder, was observed by multiple staff members to be acting differently from her baseline. On the morning in question, the resident was incoherent, mumbling, dropping her toothbrush repeatedly, unable to lean forward to spit, and was hallucinating. These changes were reported by a CNA and a Certified Medication Tech to the LPN on duty, who was informed that the resident was not acting like herself and was talking to someone not present. Despite these reports, the LPN did not perform a face-to-face assessment of the resident. The LPN had a CNA check the resident's vital signs, which were within normal limits for the resident, but did not further evaluate the resident or document the change in condition. The LPN instructed staff to proceed with transporting the resident to her scheduled dialysis appointment, stating that dialysis staff would address the issue if it was serious. Upon arrival at the dialysis clinic, the resident's condition had further deteriorated, with slurred speech, and she was immediately sent to the hospital, where she was diagnosed with metabolic encephalopathy and hypoglycemia. Facility policy required that any change in a resident's condition be promptly assessed, documented, and reported to the physician and resident representative. The policy also required completion of an event report and documentation in the resident's chart. In this case, there was no documentation of the change in condition or the transfer to the hospital in the resident's records. Interviews with staff, including the LPN, DON, ADON, and the resident's physician and nurse practitioner, confirmed that an assessment should have been performed and documented when the change in condition was reported.
Failure to Identify, Assess, and Document Unexplained Bruising
Penalty
Summary
Staff failed to identify, assess, investigate, and document bruising of unknown origin for a resident with significant medical history, including cerebral infarction, hemiplegia, hemiparesis, muscle weakness, cognitive communication deficit, dementia, anxiety disorder, and aphasia. Upon admission and during initial assessments, no new skin issues were noted, but subsequent observations revealed scattered bruising, particularly on the right arm, and later, significant bruising on the resident's forehead and left ring finger. The bruising was not present prior to admission, according to the resident's family, and was first noticed by family members and staff on different occasions. Multiple staff members, including CNAs and LPNs, observed the bruising at various times but failed to consistently report, assess, or document the findings as required by facility policy. Some CNAs did not report the bruising to nurses, assuming it was either pre-existing or that the nurse was already aware. LPNs who noticed the bruising did not always assess or document it, and in some cases, did not consider the bruising significant enough to warrant further action. There was also a lack of communication between shifts, with no documentation or handoff information regarding the bruising. Facility policy required thorough investigation and documentation of all marks, discolorations, and injuries of unknown origin, including assessment, notification of the DON and physician, and completion of an event report. However, these procedures were not followed for the resident's bruising. The care plan did not address the bruising, and there was no evidence of a timely or comprehensive investigation into the cause of the injuries. Interviews with staff and administration confirmed that the required steps for assessment, documentation, and reporting were not consistently implemented.
Failure to Notify Resident, Physician, and Family of Significant Changes
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This deficiency was identified during the investigation of complaints #2572449 and #2586807, as referenced in event ID HP9H-H2. The report specifically notes the lack of timely communication regarding significant events impacting the resident's condition or environment.
Failure to Notify Resident, Physician, and Family of Significant Changes
Penalty
Summary
The facility failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This deficiency was identified during the investigation of complaints #2572449 and #2586807, as referenced in event ID HP9H-H2. The report specifically notes the lack of timely communication regarding significant events impacting the resident's condition or environment.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents were not consistently receiving necessary interventions to manage existing pressure ulcers or to prevent new ones from forming. The lack of proper assessment, monitoring, and timely intervention contributed to the occurrence and worsening of pressure ulcers among residents.
Failure to Protect Residents from Misappropriation of Medications
Penalty
Summary
The facility failed to protect residents from misappropriation of their medications when gabapentin prescribed to three residents went missing and was unaccounted for while in the facility’s possession. The missing medications were discovered after a nurse reported suspicious behavior by a certified medication technician (CMT), who was observed popping pills out of medication cards, tearing off the tops, and placing the pills in a personal backpack. Labels from the medication cards for three residents were later found in the shred bin, and audits revealed significant discrepancies in the number of gabapentin pills that should have been available for each resident compared to what was actually present. The residents affected had documented needs for pain management, with physician orders and care plans specifying regular administration of gabapentin for conditions such as neuralgia, neuritis, generalized muscle weakness, and chronic pain syndrome. Medication administration records and pharmacy delivery slips confirmed that the medications had been delivered and should have been available, but audits showed that large quantities were missing. For example, one resident was in the hospital at the time the medication went missing, yet their supply of gabapentin could not be located, while two other residents had far fewer pills available than expected based on recent pharmacy deliveries and administration records. Interviews with staff confirmed that only nurses and CMTs had access to resident medications, which were kept locked in medication carts or rooms. Staff described the process for disposing of medication labels and the protocol for reporting suspected misappropriation. The incident was reported to the Director of Nursing (DON) and the Administrator, and the Department of Health and Senior Services (DHSS) was notified. The deficiency centers on the facility’s failure to ensure the security and proper accounting of resident medications, resulting in the wrongful use or misappropriation of residents’ property.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the failure to promptly inform all required parties when significant events impacting the resident occurred, as required by regulation.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of records, which indicated that care provided did not align with the documented orders or the expressed wishes and care goals of the resident involved.
Failure to Document Falls and Update Care Plans for At-Risk Residents
Penalty
Summary
The facility failed to ensure that residents were free from accident hazards and did not provide adequate supervision to prevent accidents, as evidenced by repeated failures to document fall events and investigations, update or develop accurate care plans, and implement new interventions for residents with a history of falls. Multiple residents with significant medical histories, including cerebrovascular disease, hemiplegia, cognitive impairment, and mobility limitations, experienced repeated falls. Despite these incidents, staff did not consistently update care plans with new interventions or document the effectiveness of existing measures, as required by facility policy. For example, one resident with a history of cerebrovascular disease and repeated falls experienced several unwitnessed falls, some resulting in injury, including a laceration to the head that required hospital evaluation. In each case, documentation was incomplete: staff failed to update the care plan with new interventions, did not always review the care plan after falls, and sometimes omitted required assessments such as neurological checks. Similar patterns were observed with other residents, including those with severe cognitive impairment and dependence on staff for mobility, who also experienced multiple falls without corresponding updates to their care plans or implementation of new preventive strategies. The facility's fall prevention policy required identification and assessment of residents at risk for falls, regular reassessment, thorough investigation of each fall, and documentation of interventions and their effectiveness. However, the report details numerous instances where these steps were not followed. Fall logs and care plans were not consistently updated, immediate and preventive interventions were often left blank or not described, and staff failed to document or implement new strategies after repeated incidents. These deficiencies were observed across several residents, indicating a systemic failure to adhere to established protocols for fall prevention and accident hazard mitigation.
Failure to Promote Resident Self-Determination in Bathing Preferences
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not consistently offering or providing showers/bathing according to resident preferences and care plans for two residents. Both residents were cognitively intact and required partial to moderate assistance with bathing. Their care plans specified that they should be offered at least two showers per week, with the option to refuse or request additional showers. However, review of shower records revealed significant gaps, with showers not being offered or documented as required, and in some cases, long intervals between showers. One resident reported only receiving one to two showers per week and expressed a desire for more frequent showers, while the other stated they had not had a shower in about two weeks and that scheduled showers were sometimes not offered. Staff interviews confirmed that showers were supposed to be offered at least twice weekly, with refusals and completions documented on shower sheets and in the electronic medical record. However, multiple staff members, including CNAs, LPNs, RNs, MDS Coordinators, the ADON, and the DON, acknowledged that showers were not always being offered or documented as required. There was also confusion regarding the responsibility for providing showers to residents on hospice, with some staff unaware that the facility should offer showers in addition to those provided by hospice staff. Additionally, the facility did not provide a policy regarding showers or bathing when requested. The lack of consistent documentation and adherence to resident preferences and care plans resulted in residents not receiving showers as scheduled or requested, directly impacting their right to self-determination and personal hygiene.
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 145 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
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) |
|---|---|---|---|---|
| Cox Medical Centers Meyer Orthopedic And Surgical | 0.4 mi | ★★★★★ | 6 | 0 |
| Spring Valley Health & Rehabilitation Center | 0.6 mi | ★★★★★ | 5 | 0 |
| Birch Pointe Health And Rehabilitation | 0.9 mi | ★★★★★ | 0 | 0 |
| Maples Health And Rehabilitation, The | 1.2 mi | ★★★★★ | 0 | 0 |
| Springfield Rehabilitation & Health Care Center | 1.6 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Springfield Villa.
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 August 2026) and official state health department websites.