Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sunterra Springs Springfield during CMS and state inspections, most recent first.
A resident admitted after knee replacement surgery experienced moderate pain that was not addressed in a timely manner due to delays in obtaining and administering prescribed pain medications. Staff failed to document administration of pain medication and did not notify the physician when pain increased, despite ongoing pain assessments and facility policies requiring prompt pain management.
A resident with multiple comorbidities was admitted with existing pressure ulcers, but staff failed to complete a full wound assessment, did not transcribe or implement all hospital wound care orders, and did not update the care plan or consistently document wound care provided. Wound treatments were not always recorded, and additional wounds were not promptly identified or addressed, resulting in a lack of compliance with professional standards for pressure ulcer care.
A resident alleged abuse by two nurses, claiming inappropriate touching during a skin assessment. Despite the facility's policy requiring immediate reporting of such allegations, the incident was not reported to the state agency until seven days later. Interviews revealed that staff did not perceive the situation as abuse due to the presence of two staff members during the assessment, leading to a delay in reporting.
The facility failed to provide adequate pressure ulcer care for two residents, resulting in deficiencies in documentation, treatment, and care planning. Upon admission, staff did not conduct full assessments of wounds, and care plans were not updated. Treatment orders were not followed correctly, and there was a delay in obtaining treatment for a resident's pressure injury. Interviews revealed inconsistencies in wound assessment practices, contributing to inadequate care.
Failure to Provide Timely and Documented Pain Management After Surgery
Penalty
Summary
A deficiency occurred when staff failed to provide and document timely and appropriate pain management for a resident admitted after knee replacement surgery. The resident, who had a history of osteoarthritis, fibromyalgia, neuropathy, and recent joint replacement, was at risk for acute pain and had physician orders for both non-pharmacological and pharmacological pain interventions, including acetaminophen, hydromorphone, and tramadol. Despite these orders, there was no documentation that pain medication was administered to address the resident's pain during the initial period after admission, even though pain assessments indicated moderate pain levels. Multiple staff interviews revealed delays in obtaining and administering prescribed pain medications, particularly narcotics, due to issues with receiving signed physician orders and pharmacy delivery schedules. Staff reported that medications, especially controlled substances, were not always available upon admission, and there were delays in entering orders into the electronic medical record system. The resident expressed pain and frustration about not receiving pain medication, and staff acknowledged the expectation that pain medications should be available and administered in a timely manner, especially for post-surgical residents. Documentation in the medical record showed repeated moderate pain scores and limited participation in therapy and activities due to pain. There was also a lack of timely notification to the physician when the resident's pain increased. The facility's policies required prompt assessment and management of pain, but these were not consistently followed, resulting in the resident experiencing unaddressed pain and delays in receiving appropriate pain relief.
Failure to Provide and Document Pressure Ulcer Care per Standards
Penalty
Summary
Facility staff failed to provide pressure ulcer care in accordance with professional standards for one resident, resulting in multiple deficiencies. Upon admission, staff did not complete a full assessment of the resident's wounds, omitting detailed descriptions and measurements, and failed to identify all wounds present as documented in the hospital discharge summary. The initial admission assessment did not reflect the presence of buttock wounds, and there was no documentation of current treatment orders. Additionally, staff did not transcribe the hospital's wound treatment orders or the order to float the resident's heels into the facility's physician order sheet on the day of admission. Throughout the resident's stay, there was a lack of documentation regarding wound care and treatment in both the progress notes and the treatment administration record (TAR). Staff did not consistently document the completion of ordered wound treatments for the sacrum and buttocks, nor did they provide shower sheets for the resident during the entire admission period. The care plan was not updated to reflect newly identified wounds or changes in treatment, despite the resident's wounds worsening and additional interventions being ordered. Interviews with staff confirmed that wound assessments, documentation, and care planning were not performed as required by facility policy. The resident in question had significant medical conditions, including malignant neoplasm of the spinal cord, severe protein-calorie malnutrition, and diabetes, and was admitted with existing wounds to the sacrum and both buttocks. Despite these risk factors and the presence of hospital orders for wound care, the facility did not ensure timely and complete assessment, documentation, or implementation of wound care interventions. Staff interviews revealed inconsistent practices regarding wound identification, notification, and documentation, further contributing to the deficiency.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the state survey agency within the required two-hour timeframe. The incident involved a resident who was admitted with diagnoses including a left arm fracture, depression, and generalized anxiety disorder. The resident, who was cognitively intact, reported to the Social Services Director (SSD) that two nurses humiliated them by pulling down their pants and inappropriately touching them. Despite the resident's clear allegation, the facility did not document reporting this to the Department of Health and Senior Services (DHSS) until seven days later. Interviews with staff revealed that the resident did not make any allegations of abuse during the initial skin assessment conducted by an LPN and a CNA. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) were informed of the resident's concerns, but they did not perceive the situation as abuse due to the presence of two staff members during the assessment. The Administrator was informed of the resident's allegation by a night shift nurse but was uncertain about reporting it to the state due to the lack of immediate evidence of abuse. The facility's policy required immediate reporting of abuse allegations within two hours if they involved abuse or resulted in serious bodily injury. However, the Administrator did not report the incident to DHSS within the required timeframe, despite being aware of the resident's allegations. This delay in reporting constitutes a failure to comply with federal requirements for timely reporting of abuse allegations.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to deficiencies in documentation, treatment, and care planning. Upon admission, the staff did not conduct a full assessment of wounds, particularly for a resident with a deep tissue injury (DTI) on the coccyx. The staff failed to document a complete assessment of the DTI, and the care plan was not updated to address this condition. Additionally, the treatment orders for the DTI were not followed correctly, as the staff applied a dressing that was not part of the physician's order. Another resident was admitted with a deep tissue pressure injury on the left buttock, but the staff did not document a full description of the wound upon admission. There was a delay in obtaining treatment orders, and the care plan was not updated with new interventions for the pressure ulcer. The staff's failure to document and follow proper procedures for wound assessment and treatment contributed to the decline in the resident's condition. Interviews with staff revealed inconsistencies in wound assessment and documentation practices. The facility's wound nurse was responsible for weekly assessments, but there was a lack of communication and coordination with other nursing staff. The Director of Nursing acknowledged that nurses were not measuring or describing wounds adequately upon admission, relying instead on the wound nurse for assessments. This lack of adherence to professional standards and facility policies resulted in inadequate care for residents with pressure ulcers.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Springfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Birch Pointe Health And Rehabilitation | 1.7 mi | ★★★★★ | 0 | 0 |
| Cox Medical Centers Meyer Orthopedic And Surgical | 1.9 mi | ★★★★★ | 1 | 0 |
| Neighborhoods At Quail Creek, The | 2.1 mi | ★★★★★ | 0 | 0 |
| Springfield Villa | 2.3 mi | ★★★★★ | 10 | 1 |
| Spring Valley Health & Rehabilitation Center | 2.6 mi | ★★★★★ | 33 | 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.