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 Arbors At Springfield during CMS and state inspections, most recent first.
A resident with multiple comorbidities developed an unstageable pressure wound and infection on the right foot after staff failed to monitor and assess skin integrity under a fracture boot. There were no documented orders for monitoring the device or the skin, and weekly skin assessments were missed. The wound progressed due to lack of timely intervention and incomplete adherence to wound care orders, resulting in actual harm.
A resident with severe cognitive impairment and a high risk for falls was found in bed with the bed left in a high position, contrary to the care plan's fall prevention interventions. Staff confirmed the bed was not lowered after a family member's visit, and no staff were present in the room at the time, resulting in a failure to follow established fall prevention protocols.
A nurse did not perform required hand hygiene between glove changes while providing wound care to a resident with multiple chronic conditions and ventilator dependence. The nurse confirmed the omission, and facility policy review showed that hand washing or sanitizing was required after glove removal and before donning new gloves during dressing changes.
A resident with severe cognitive impairment and high fall risk fell face-first to the floor during incontinent care due to improper positioning by staff. The resident, who required two-person assistance and was ventilator-dependent, suffered head injuries, including subdural and subgaleal hematomas. The facility failed to conduct a root cause analysis of the fall, highlighting deficiencies in care and safety protocols.
The facility failed to hold quarterly care conferences for nine residents, despite multiple MDS assessments being completed. Interviews with staff confirmed the lack of required care conferences, and the facility's policy mandates these meetings be attended by Social Services, Dietary, Activities, and Nursing.
The facility failed to follow physician orders for changing tube feeding equipment for two residents. One resident had an undated syringe and an outdated graduated cup, while another had a tube feed bag that had not been changed for several days. Staff confirmed the equipment was not replaced as required, despite having adequate supplies.
A resident on hospice care with a physician's order for Oxycodone was not administered the medication for four days due to a delay in obtaining the prescription. Despite the lapse, there were no documented concerns of pain. Interviews revealed the medication was not ordered in time, and the facility could not use the emergency box without a new prescription.
The facility failed to provide necessary podiatry services and adequate bathing assistance to two residents. One resident with diabetes and Alzheimer's had not received podiatry care since April 2022, resulting in long, thick toenails. Another resident, dependent on a ventilator, missed several scheduled showers and bed baths. The facility's policies on nail care and ADLs were not followed, leading to these deficiencies.
A resident with multiple health conditions continued to receive Prevacid DR despite orders to discontinue it. The pharmacy recommended stopping the medication because it should not be crushed, and the physician signed off on this recommendation. However, the medication was administered for over two months beyond the initial discontinuation order. The DON confirmed the oversight during an interview.
A facility failed to timely address a pharmacy recommendation, resulting in a resident receiving duplicate SSRI therapy for two months. The resident, who was cognitively intact and had multiple health conditions, continued this therapy despite a recommendation to discontinue one SSRI to prevent serotonin syndrome. The delay in addressing the recommendation was confirmed by the DON.
A facility failed to obtain necessary lab tests for a resident experiencing loose stools after antibiotic use. Despite a nurse practitioner's plan to order a stool test for C-diff, CBC, and BMP, no orders or results were found. The DON confirmed the tests were not ordered or obtained, as orders are entered directly into the lab's system by the practitioner, with no record in the electronic medical record.
A resident in a persistent vegetative state did not receive an IV antibiotic as ordered, with six doses remaining in storage. The error was discovered on the final day of the prescribed treatment. The DON confirmed the night shift nurse failed to administer the medication, but the resident did not experience negative outcomes.
Failure to Monitor and Assess Skin Integrity Under Medical Device Resulting in Pressure Wound and Infection
Penalty
Summary
A deficiency occurred when a resident with multiple comorbidities, including a right lower leg fracture, chronic kidney disease, diabetes, and immunodeficiency, developed an unstageable pressure wound on the right foot that was not present upon admission. The resident had been fitted with a fracture boot and ace wrap following an orthopedic visit, but there was no documentation of orders for monitoring the boot or the skin under it from the time it was applied. Nursing staff did not remove the boot or ace wrap for approximately two weeks, and there was no evidence that the facility contacted the orthopedic office for guidance regarding care of the device or the resident’s skin integrity during this period. Weekly skin assessments were not consistently completed or documented, with gaps noted between assessments and missing records for several weeks. The facility’s policy required weekly skin evaluations for residents at risk for pressure injuries, but these were not performed as required. The lack of skin assessments and monitoring allowed the development and progression of a pressure wound on the dorsum of the resident’s right foot, which was first identified during a follow-up orthopedic appointment. At that time, significant skin breakdown, desquamation, and full-thickness dermis loss were observed, and the resident was subsequently ordered to receive daily wound care and antibiotics. Despite new orders for wound care, the resident later reported that dressing changes were not performed as frequently as prescribed, with the last change occurring two days prior to a follow-up visit. Upon examination, the wound had progressed to a necrotic, unstageable ulcer with malodorous, bloody, and purulent drainage, and there was concern for wet gangrene. The lack of timely and appropriate monitoring, assessment, and intervention contributed to the worsening of the pressure wound and the development of infection.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when staff failed to implement fall prevention interventions as outlined in the care plan for a resident with severe cognitive impairment, anoxic brain damage, and muscle weakness. The resident, who was dependent on staff for activities of daily living and identified as a fall risk, was observed lying in bed with an air mattress while the bed was in a high position, contrary to the care plan intervention requiring a low bed. No staff were present in the room at the time of observation. A CNA confirmed that the bed had been left in a high position after the resident's husband, who had previously raised the bed during visits, had left the facility, and the bed was not lowered as required. Facility policy required that fall risk interventions be initiated and monitored for effectiveness, but this was not followed in this instance.
Failure to Perform Hand Hygiene During Dressing Change
Penalty
Summary
A deficiency was identified when a nurse failed to perform proper hand hygiene during a dressing change for a resident. The resident, who was cognitively intact and dependent on staff for activities of daily living, had multiple diagnoses including COPD, chronic kidney disease stage four, ventilator dependence, and anxiety. The physician's order required wound care to the right lower abdomen, including cleansing with normal saline, application of collagen, and covering with a foam dressing. During observation, the nurse gathered supplies, prepared the area, and performed the dressing change, but did not wash or sanitize hands after removing soiled gloves and before donning clean gloves on four separate occasions throughout the procedure. Interview with the nurse confirmed that hand hygiene was not performed between glove changes, despite facility policy requiring hand washing or sanitizing after glove removal and before donning new gloves during dressing changes. Review of the facility's policy outlined specific steps for hand hygiene at multiple points during the dressing change process, which were not followed in this instance. The failure to adhere to these procedures was observed and verified through record review, observation, interview, and policy review.
Failure in Safe Bed Mobility and Fall Investigation
Penalty
Summary
The facility failed to ensure proper positioning techniques for safe bed mobility, resulting in a major fall with injury for a resident who was severely cognitively impaired and at high risk for falls. The resident, who was dependent on staff for turning and repositioning, fell to the floor face first while two staff members were providing incontinent care. The improper positioning technique during the care led to the resident's fall, causing actual harm. The resident involved had a complex medical history, including anoxic brain injury, morbid obesity, and was ventilator-dependent. She required two-person assistance for bed mobility and was at high risk for falls. During the incident, the resident was being rolled for care when the ventilator tubing disconnected, causing her to cough and slide off the bed. Despite attempts by the staff to prevent the fall, the resident hit her head on the floor, resulting in swelling and later diagnoses of subdural and subgaleal hematomas. The facility also failed to conduct a thorough fall investigation, including a root cause analysis. Although the Director of Nursing acknowledged the incident, there was no documentation of a root cause analysis in the records. The lack of a comprehensive investigation into the fall and the circumstances leading to it represents a significant deficiency in the facility's care and safety protocols.
Failure to Hold Quarterly Care Conferences
Penalty
Summary
The facility failed to hold care conferences for nine residents, as required by their policy, which mandates that comprehensive care conferences be scheduled after the completion of the comprehensive care plan and quarterly thereafter. The residents affected by this deficiency were identified as Residents #3, #8, #10, #12, #14, #17, #27, #28, and #34. The review of medical records revealed that these residents had multiple Minimum Data Set (MDS) assessments completed, but subsequent care conferences were not held as required. For instance, Resident #8 had MDS assessments completed on several occasions, but only one care conference was documented. Similarly, Resident #10 had multiple MDS assessments, but only one care conference was held. Interviews with facility staff, including the Social Services Designee (SSD) and the Director of Nursing (DON), confirmed the lack of quarterly care conferences. The SSD verified that care conferences were not held quarterly for the affected residents, and the DON confirmed that care conferences should be held quarterly. Additionally, the SSD was unaware that a care conference should be held quarterly even if a resident's guardian did not want to attend, as was the case with Resident #12. The facility's policy, dated March 2024, clearly states that care conferences should be attended by Social Services, Dietary, Activities, and Nursing, and the outcomes should be documented in the progress notes.
Failure to Change Tube Feeding Equipment as Ordered
Penalty
Summary
The facility failed to adhere to physician orders regarding the maintenance and replacement of tube feeding equipment for two residents. Resident #34, who was admitted with severe cognitive impairment and required enteral nutrition, had a tube feeding syringe that was not dated or stored properly, and a graduated cup that had not been changed since 10/06/24. During an observation, a Med Tech confirmed the syringe was not dated or in a plastic sleeve and was supposed to be changed daily on the night shift. Similarly, Resident #191, also severely cognitively impaired and dependent on enteral nutrition, had a tube feed bag that had not been changed since 10/16/24. A visitor reported being told that the facility ran out of bags, but Central Supply Staff later confirmed that there was an adequate supply. An LPN verified the outdated bag and stated that the bags were supposed to be changed daily on the night shift. These observations indicate a failure to follow physician orders for the timely replacement of tube feeding equipment.
Failure to Administer Oxycodone Timely to Hospice Resident
Penalty
Summary
The facility failed to ensure timely administration of a narcotic medication, Oxycodone, to a resident on hospice care. The resident, who was admitted with diagnoses including unilateral primary osteoarthritis, diabetes, and Alzheimer's disease, had a physician's order for Oxycodone to be administered twice daily for pain. However, the medication was not given for four consecutive days due to a delay in obtaining the prescription from hospice and the pharmacy. The resident's care plan emphasized the importance of administering medications as ordered and monitoring for pain, yet the facility did not have the medication available from 10/09/24 to 10/12/24. Interviews with the Director of Nursing and a Registered Nurse revealed that the medication was not ordered in time, and the facility could not use the emergency box without a new prescription. Despite the lapse in medication administration, there were no documented concerns about the resident experiencing pain during this period. The facility's pain management policy, which mandates providing pain management services consistent with professional standards and the resident's care plan, was not adhered to in this instance.
Failure to Provide Podiatry and Bathing Services
Penalty
Summary
The facility failed to provide necessary podiatry services and adequate bathing assistance to residents, affecting two out of three residents reviewed for activities of daily living. Resident #13, who has medical diagnoses including osteoarthritis, diabetes, and Alzheimer's disease, had not received podiatry services since April 2022. Despite being on a 'Do Not Treat' list, there were no notes explaining this status in the resident's record. Observations revealed that Resident #13 had long, thick, yellow toenails, and the Director of Nursing confirmed the facility's responsibility to manage nail care, acknowledging the oversight. Resident #3, with diagnoses including respiratory failure and tracheostomy status, required assistance for bathing due to an ADL self-care deficit. The care plan specified shower days, but documentation showed missed showers and bed baths on multiple occasions in September and October 2024. Interviews with Resident #3 and the Director of Nursing confirmed the lack of documentation and inconsistency in providing scheduled bathing services. The facility's policies on nail care and ADLs were not adhered to, leading to these deficiencies.
Failure to Discontinue Medication as Ordered
Penalty
Summary
The facility failed to discontinue a medication as ordered for Resident #8, who was admitted with diagnoses including bronchopneumonia, anxiety disorder, obstructive sleep apnea, acute and chronic respiratory failure, and dependence on a ventilator. A pharmacy recommendation dated 05/10/24 advised discontinuing Prevacid DR capsule because it should not be crushed. The resident's physician signed the recommendation on 05/22/24 to discontinue the medication. However, a subsequent pharmacy recommendation on 07/06/24 again advised discontinuing Prevacid DR, as it had not been discontinued in May. The physician signed this second recommendation on 07/25/24. Despite these orders, the medication administration records showed that Resident #8 continued to receive Prevacid DR 30 mg twice daily from 05/22/24 to 07/25/24. During an interview on 10/22/24, the Director of Nursing confirmed that the medication was not discontinued as ordered. This deficiency was investigated under Complaint Number OH00158346.
Delayed Response to Pharmacy Recommendation Leads to Duplicate SSRI Therapy
Penalty
Summary
The facility failed to address pharmacy recommendations in a timely manner, resulting in extended duplicate therapy with selective serotonin reuptake inhibitors (SSRIs) for a resident. The resident, who was cognitively intact, had multiple diagnoses including congestive heart failure, type 1 diabetes, and anxiety disorder. A pharmacy recommendation dated August 7, 2024, advised discontinuing one of the two SSRI medications to reduce the risk of serotonin syndrome. However, this recommendation was not reviewed and signed by the physician until October 8, 2024. Consequently, the resident continued to receive duplicate SSRI therapy for two months. The Director of Nursing confirmed during an interview that the pharmacy recommendation was not addressed in a timely manner.
Failure to Obtain Laboratory Tests as Ordered
Penalty
Summary
The facility failed to obtain necessary laboratory values as planned by the practitioner for a resident who was under review for unnecessary medications. The resident, who had been admitted with chronic respiratory failure, dependence on a ventilator, pneumonia, and cerebral infarction, was experiencing loose stools following recent antibiotic use. On a specific date, a nurse practitioner noted the need for a stool test for clostridium difficile (C-diff), a complete blood count (CBC), and a basic metabolic panel (BMP). However, there were no corresponding physician orders or lab results for these tests. During an interview, the Director of Nursing confirmed that the tests had not been ordered or obtained, as the orders are typically entered directly into the lab's computer system by the practitioner, and nothing was recorded in the electronic medical record. This deficiency was investigated under a specific complaint number.
Failure to Administer IV Medication as Ordered
Penalty
Summary
The facility failed to ensure that an intravenous (IV) medication was administered as ordered for a resident who was in a persistent vegetative state and dependent on staff for all activities of daily living. The resident had been discharged from the hospital with orders for Avycaz, an antibiotic, to be administered every eight hours for a total of eight doses. However, it was discovered that the resident did not receive the medication as ordered, as six doses remained in the medication storage room. This error was identified on the day the resident was supposed to complete the antibiotic course. The Director of Nursing (DON) confirmed that the night shift nurse had not administered the IV medication as ordered, which led to the medication error. The resident had been readmitted from the hospital with diagnoses including chronic respiratory failure and pneumonia, and the medication was critical for their treatment. Despite the error, the resident did not sustain any negative outcomes from the missed doses. The incident was documented in the facility's incident report, and the DON acknowledged the failure in medication administration.
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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) |
|---|---|---|---|---|
| Wooded Glen | 0.7 mi | ★★★★★ | 1 | 0 |
| Springfield Nursing & Independent Living | 1.3 mi | ★★★★★ | 4 | 0 |
| Allen View Healthcare Center | 2.1 mi | ★★★★★ | 3 | 0 |
| Villa Springfield Rehabilitation And Healthcare Ce | 2.2 mi | ★★★★★ | 0 | 0 |
| Springfield Masonic Community | 2.6 mi | ★★★★★ | 16 | 0 |
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