Below 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 Springfield Villa during CMS and state inspections, most recent first.
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.
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 140 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 | ★★★★★ | 1 | 0 |
| Spring Valley Health & Rehabilitation Center | 0.6 mi | ★★★★★ | 33 | 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 | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.