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 August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Springbrook Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Two residents were found to be missing full cards of prescribed narcotic pain medications, along with the corresponding count sheets. Investigation revealed that a nurse had falsely documented the return of these medications to the pharmacy using fictitious prescription numbers, and the pharmacy confirmed no such returns were made. Despite audits and staff interviews, the missing narcotics and documentation were not recovered.
A resident with diabetes was admitted to a facility with incorrect insulin orders, omitting necessary sliding scale and blood glucose checks. The oversight by the admitting nurse led to the resident receiving insulin without proper monitoring, resulting in a severe hypoglycemic event. The resident was found unresponsive and later diagnosed with sepsis and hypoglycemia at the hospital.
A resident was verbally and physically abused by a family member during the discharge process. The family member threw cold tea and water on the resident, choked her, and pushed her onto the bed, resulting in a neck strain. The resident was sent to the ED for evaluation and returned the same day. The facility staff provided immediate support and notified the police, leading to the arrest of the family member.
Failure to Protect Residents from Misappropriation of Narcotic Medications
Penalty
Summary
The facility failed to protect two residents from the misappropriation of their narcotic medications. Both residents had physician orders for as-needed narcotic pain medications, with pharmacy records confirming delivery and receipt of the medications by two nurses. On a subsequent date, it was discovered that each resident was missing a full card of their prescribed narcotic medication, along with the corresponding medication count sheets. The missing medications were identified during a routine medication pass, and the nurse involved noted that the residents rarely requested their as-needed pain medications, making the disappearance of an entire card suspicious. An internal investigation revealed that a nurse had documented the removal and alleged return of the medications to the pharmacy, but failed to include required information such as the residents' names and reasons for return. Further inquiry with the pharmacy confirmed that the prescription numbers provided were fictitious and that no medications had been returned. Audits of all narcotic medications and count sheets were conducted, but the missing medications and documentation were not recovered. The nurse suspected of involvement could not be reached for an interview, and the staffing agency was notified to prevent her return to the facility. Interviews with other staff members confirmed that the facility's policy required two nurses to verify and sign for narcotic deliveries, and that no discrepancies had been noted prior to the incident. The pharmacist corroborated that the pharmacy had not received any returned narcotic medications for the affected residents. The administrator and other staff confirmed the sequence of events and the steps taken to investigate the missing medications, but the narcotics and associated documentation remained unaccounted for.
Failure to Follow Diabetic Care Orders Leads to Hypoglycemic Event
Penalty
Summary
The facility failed to follow the hospital physician's discharge orders for a resident with diabetes, which included sliding scale insulin administration and blood glucose checks before meals and at bedtime. Upon admission, the resident's orders were incorrectly entered into the electronic medical record by Nurse #4, omitting the sliding scale and blood glucose checks for both Lispro and Lantus insulin. This oversight led to the resident receiving insulin without the necessary blood glucose monitoring, which is critical for managing diabetes effectively. Nurse #4, who was responsible for admitting the resident, did not initiate the necessary features in the medication record to ensure blood glucose checks were performed before administering insulin. This was due to a lack of awareness of the system's features and the absence of clear directives from the physician regarding blood glucose monitoring. The resident's blood glucose was not checked as required, and the omission was not identified until after the resident experienced a severe hypoglycemic event. The resident was found unresponsive with a critically low blood glucose level, which was not immediately recognized as a potential cause of the resident's condition. The nursing staff, including Nurse #2, did not perform a blood glucose check during the emergency assessment, leading to a delay in identifying the hypoglycemia. The resident was eventually sent to the hospital, where they were diagnosed with sepsis and hypoglycemia, conditions that were not adequately managed due to the facility's failure to adhere to the prescribed diabetic care plan.
Resident Abused by Family Member During Discharge Process
Penalty
Summary
The facility failed to protect a cognitively intact resident from verbal and physical abuse by a family member. The incident involved a family member who threw cold tea and water onto the resident, put her hands around the resident's throat, threatened to kill her, and pushed her onto the bed. This resulted in redness to the resident's neck, and she was sent to the Emergency Department for evaluation, where she was diagnosed with a strain of the neck muscle. The resident appeared out of breath, nervous, and shocked following the incident. The incident occurred when the resident was scheduled to be discharged home. A family member arrived and made multiple excuses for not taking the resident home. After a discussion with the family member, the resident was found out of her room, drenched in tea and water, and reported the assault to the staff. The staff observed the resident's wet clothing and liquid on the chair and floor in her room. The resident was provided with oxygen and emotional support by the staff. The Director of Nursing and other staff members were informed of the incident, and the police were notified. The family member involved in the assault was arrested when she returned to the facility. The resident agreed to stay at the facility over the weekend to arrange a safe discharge. The facility had no prior indication that the family member would become physical with the resident.
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What surveyors actually found near you
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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 Clayton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clayton Rehabilitation And Healthcare Center | 1.5 mi | ★★★★★ | 19 | 1 |
| Barbour Court Nursing And Rehabilitation Center | 8.2 mi | ★★★★★ | 6 | 0 |
| Bellarose Nursing And Rehab | 9.1 mi | ★★★★★ | 0 | 0 |
| Smithfield Manor Rehabilitation And Healthcare Cen | 10.5 mi | ★★★★★ | 12 | 1 |
| Wellington Rehabilitation And Healthcare | 10.7 mi | ★★★★★ | 10 | 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 August 2026) and official state health department websites.