Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Masonic Community during CMS and state inspections, most recent first.
Dishwasher sanitation was not properly verified, and dietary staff were documenting wash and rinse temperatures even though the machine was using bleach sanitizer rather than high-temp sanitizing. A DFCNS test strip did not register sanitizer, the DRT confirmed the machine had been using bleach sanitizer for several months, and the facility policy required checking proper temperatures and/or chemical concentrations before use.
Torn carpet seams and bunching were observed throughout the 4th-floor hallways at Rickly Commons, including outside multiple room doorways, near the electrical panel, and by the biohazard storage room. An RN confirmed the damaged carpet in these areas.
Therapy staff did not follow physician orders and facility policy for Enhanced Barrier Precautions (EBP) for a resident with serious medical conditions and a wound who required extensive assistance with transfers. A Physical Therapy Assistant provided hands-on transfer assistance in a common area without wearing a gown or gloves, and therapy staff reported they do not use EBP in the therapy gym or hallways, even when providing close-contact care. Facility policy and CDC guidance required gown and glove use for high-contact activities such as transfers and mobility assistance in shared areas and the therapy gym for residents on EBP.
Failure to provide SNF ABN when Medicare Part A ended. A resident with CHF and intact cognition remained in the facility after Medicare Part A services ended, but there was no documentation that the SNF ABN was given to the resident or legal guardian when benefit days were not exhausted.
The facility failed to provide privacy during medical procedures for two residents. A resident with cognitive impairment had blood drawn while seated at a dining room table with other residents nearby, and another resident with severe cognitive impairment received two insulin pen injections in the abdomen while seated at a dining room table with other residents present. The LPN and DON confirmed these procedures should not have been performed in the dining room and that doing so violated residents' right to privacy.
Failure to Provide Individualized Activities and Encourage Participation: Three residents with dementia, cognitive impairment, and significant functional dependence were documented as having interests such as pet visits, social interaction, music, history, and campus activities, but records mainly showed room TV and brief staff visits. Observations found the residents staying in their rooms with little or no engagement, and CNA interview confirmed residents did not participate in activities and staff did not encourage participation.
Inadequate Admission Assessment of Pressure Ulcers: A resident with a hip fracture, DM, and Alzheimer’s disease was admitted with documented coccyx and right hip pressure injuries from the hospital, but the facility’s initial skin assessment did not accurately describe the wound in the crack of the buttocks or support that a coccyx PU was present on admission. The ADON confirmed the admission skin observation lacked enough detail to show whether the area was open, blanchable, or draining, and later documentation by the wound NP identified the coccyx wound as a Stage III PU present on admission.
Opened insulin pen-injectors were found without an opened date in medication carts. Two residents had insulin pens that were opened but not dated, and two RNs confirmed the issue during observation. Facility policy required the opened date to be documented on insulin vials or pens.
Hospice communication for a resident on hospice was incomplete because the binder at the nursing station contained only contact information, a CNA sign-in sheet, and a few shower sheets, but no hospice visit notes or hospice care plan. An LPN, CNA, and the DON acknowledged the binder had limited information and should have included additional hospice documentation.
Call Light Left Out of Reach: A resident with severe cognitive impairment, vascular dementia, and dependence for toileting and personal hygiene was repeatedly observed lying in bed with the call light on the floor and not within reach. The care plan included keeping the call light within reach, and an RN later confirmed it had been out of reach before placing it on the resident’s bed.
Delayed Weekend Mail Distribution: Residents did not receive mail delivered on Saturdays. Resident council members stated they do not get any mail on Saturdays, and the DLE and BOM confirmed that activity staff distribute mail and that weekend mail is held until Monday before being given to residents.
Dishwasher sanitation levels not properly verified
Penalty
Summary
The facility failed to ensure dishwashers reached proper sanitation levels and failed to ensure dietary staff were knowledgeable about checking dishwasher sanitation. Review of dishwasher logs for December 2025, January 2026, and February 2026 showed wash and rinse temperatures were documented, with wash temperatures ranging from 140 F to 174 F and rinse temperatures ranging from 120 F to 185 F, but sanitizer levels were not documented on any of the logs. Observation of the dishwasher revealed the wash temperature reached 140 F and the rinse temperature reached 115 F, and a bottle of sodium hypochlorite sanitizer was present on top of the machine with a tube running into it. During interview, the ADDS stated the dishwasher was high temperature sanitizing and the bleach sanitizer was only a back-up if the temperature did not go high enough. However, the DFCNS ran a sanitizer test strip through the full wash and rinse cycle and it did not register a sanitizer level, and a later re-check showed sanitizer remained below the required level. The DRT confirmed the dishwasher used bleach sanitizer and was not using high temperatures to sanitize, and had been using bleach sanitizer for several months. The DFCNS also confirmed the dishwasher had not been serviced or changed from a high temperature machine since she had worked there, and that dietary staff were completing logs with water temperature readings that the dishwasher was not currently capable of reaching. The DON stated all residents of the facility receive food from the kitchen, and the facility policy required verification of proper temperatures and/or chemical concentrations before use.
Torn Carpet Seams in Fourth-Floor Hallways
Penalty
Summary
The facility failed to ensure the carpet was in safe and comfortable condition on the fourth floor of Rickly Commons. During observation and staff interview, multiple tears were found in the carpet seams in the hallway between rooms RC428 to RC415 and in the hallway between rooms RC410 to RC402. Tears in the hallway carpet seams were also observed outside the doorways to rooms RC402, RC404, RC405, RC408, RC407, RC410, RC420, RC422, RC423, and RC424. Additional torn carpet seams with bunching of carpet material were observed beneath the handrail by the electrical panel, outside room RC416, which was identified as the biohazard storage room, and outside room RC413. RN #773 confirmed the torn carpet seams in these locations.
Failure to Follow Enhanced Barrier Precautions During Therapy Sessions
Penalty
Summary
The facility failed to ensure therapy staff followed physician orders and facility policy for Enhanced Barrier Precautions (EBP) for residents receiving therapy outside their rooms. A resident admitted with diagnoses including sepsis, multiple myeloma, congestive heart failure, and other bacterial infections had an order for EBP, and the admission MDS showed the resident was cognitively intact but required substantial to maximum assistance with transfers and bed mobility and was dependent on staff for toilet hygiene and bathing. During an observation, a Physical Therapy Assistant (PTA) provided hands-on assistance to this resident for a transfer from a wheelchair to a set of steps in a common area without wearing a gown or gloves, despite the resident being on EBP due to a wound. In interviews, the PTA confirmed he provided hands-on assistance without donning a gown or gloves and acknowledged the resident was on EBP. An Occupational Therapist stated that therapy staff follow EBP when treating residents in their rooms but not in the therapy gym when providing hands-on assistance. The Director of Rehabilitation confirmed that therapy staff do not follow EBP when providing treatment for residents with EBP orders in the therapy gym. Review of the facility’s EBP policy showed that EBP is to be implemented to prevent transmission of multidrug-resistant organisms and that gowns and gloves should be used during high-contact care activities, including transfers and mobility assistance in shared/common areas and the therapy gym. CDC guidance reviewed by surveyors similarly described EBP as targeted gown and glove use during high-contact resident care activities and indicated EBP may be needed for residents with wounds or indwelling medical devices.
Failure to Provide SNF ABN When Medicare Part A Ended
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) to Resident #24 when Medicare Part A benefits ended and the resident remained in the facility. Resident #24 was admitted with diagnoses including congestive heart failure, and the MDS 3.0 assessment identified the resident as cognitively intact. Review of the Notice of Medicare Non-Coverage showed that Medicare Part A services ended on 12/15/25, but the facility initiated discharge from Medicare Part A services when benefit days were not exhausted and the resident continued to stay in the facility. There was no documentation that the SNF ABN was provided to the resident or legal guardian, and the Social Services Director confirmed the notice was not given when Medicare Part A services ended.
Failure to Provide Privacy During Blood Draws and Insulin Injections
Penalty
Summary
The facility failed to provide privacy during medical procedures for two residents. Resident #7 had diagnoses including Parkinson's disease, psychotic disturbance, bipolar disorder, and dementia, and a quarterly MDS assessment showed moderate cognitive impairment. During observation, a laboratory technician drew blood from Resident #7's left arm while he was sitting at a table in the dining room, with another resident seated across from him and other residents nearby. The laboratory technician confirmed the blood sample was obtained while Resident #7 was seated in the dining room, and the DON confirmed residents should not have blood samples drawn in the dining room and that this violated their right to privacy. Resident #82 had diagnoses including long-term use of insulin, type 2 diabetes mellitus, cerebral infarction with residual effects, vascular dementia, and psychotic disturbances. An annual MDS assessment showed severe cognitive impairment and that she received insulin injections. During observation, an LPN administered two insulin pen injections to Resident #82 in the abdomen while she was sitting at a dining room table, after raising her shirt, with other residents seated at the same table and throughout the dining room. The LPN confirmed the injections were given while Resident #82 was seated in the dining room, and the DON confirmed insulin injections should not be given in the dining room and that this violated residents' right to privacy.
Failure to Provide Individualized Activities and Encourage Participation
Penalty
Summary
The facility failed to provide activities of interest and failed to encourage participation for three residents reviewed for activities. Resident #78 had diagnoses including Alzheimer’s disease, epilepsy, diabetes, blindness in one eye, muscle weakness, cerebrovascular disease, vascular dementia, and a history of traumatic brain injury. The resident’s record showed cognitive impairment and dependence on staff for bed mobility and transfers. The care plan identified dependence on staff for emotional, intellectual, physical, and social needs, with interventions to introduce the resident to others with similar backgrounds, invite the resident to scheduled activities, and provide a program of activities of interest. For Resident #78, the quarterly assessment documented interests such as visiting with staff about time overseas, watching television in the room, pet visits, and talking with other residents. However, the activity participation documentation for January and February 2026 showed repeated room television and staff room visits, and did not show that the resident was offered opportunities to talk with other residents or receive pet visits. Observations on multiple days showed the resident sitting in the room, not observed out of the room, and no interactions with other residents. During continuous observation, the resident remained in the room with the television on, and no staff entered to discuss mail, lunch choices, or daily activities. Resident #10 had diagnoses including respiratory failure with hypoxia, vascular dementia, muscle weakness, dysphagia, psychotic disorder with delusions, and epileptic disorder. The care plan identified dependence on staff for emotional, intellectual, physical, and social needs and included interventions for scheduled activities, monthly music therapy, and a program of activities of interest. The quarterly assessment documented that the resident was very social and enjoyed staff and resident visits, one-to-one visits, the activity cart, pet visits, television, happy hours, and other campus activities. Yet the activity participation documentation showed repeated room television and staff room visits without documentation of group activities, the activity cart, pet visits, happy hours, or other campus activities. Observations showed the resident in the room sleeping or sitting with only the television on, with no observed participation in activities and no staff encouraging participation. Resident #34 had diagnoses including hemiplegia and hemiparesis, heart disease, vascular dementia, dysphagia, and muscle weakness. The resident’s MDS showed severe cognitive impairment and dependence on staff for bed mobility and transfers. The care plan identified dependence on staff for emotional, intellectual, physical, and social needs and included interventions to introduce the resident to others with similar backgrounds, invite the resident to scheduled activities, and provide a program of activities of interest. The quarterly assessments documented interests in family and staff visits, music, ice cream, going outside on sunny days, and reading about history. However, the activity participation documentation showed room television and staff room visits without documentation of music, ice cream, or history-related activities. Observations showed the resident sitting in the room without television or music playing, not observed out of the room, and no interactions with other residents. Staff interviews confirmed residents did not participate in activities and that staff did not encourage residents to participate.
Inadequate Admission Assessment of Pressure Ulcers
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met when the facility failed to accurately assess a resident’s wound upon admission. Resident #100 was admitted with diagnoses including left hip fracture, diabetes mellitus, and Alzheimer’s disease, and the hospital record documented an unstageable pressure ulcer to the coccyx measuring 1.5 cm by 2.0 cm by 0.1 cm and a deep tissue injury to the right hip measuring 4.0 cm by 3.5 cm by 0.1 cm. The admission assessment showed severely impaired cognition and need for staff assistance with activities of daily living, and the Braden scale identified the resident as high risk for skin breakdown. The facility’s skin observation evaluation on admission documented a right hip pressure ulcer, a surgical site to the left hip, bruising, dry spots and scabbing, a skin tear, and an area from moisture in the crack of the buttocks measuring 0.5 cm by 0.5 cm with no depth, but it did not include enough description to show whether that area was pressure related or to support a coccyx pressure ulcer present on admission. The physician orders included treatment for coccyx and right hip wounds, and a later skin observation and wound nurse practitioner note identified an unstageable right hip pressure ulcer and a Stage III coccyx pressure ulcer as present upon admission. The ADON confirmed the initial skin observation did not document enough detail to support that the coccyx pressure ulcer was present on admission and stated the coccyx Stage III pressure ulcer was the same area previously documented as moisture in the crack of the buttocks.
Opened Insulin Pen-Injectors Were Not Dated
Penalty
Summary
Drugs and biologicals were not labeled in accordance with accepted professional principles when opened insulin pen-injectors were found without an opened date documented. During observation and interview, medication cart two on the 400 Hall contained Resident #59’s Lantus pen-injector that was opened but had no date showing when it was opened, and RN #643 confirmed this. A second observation and interview of medication cart two on the 300 Hall found Resident #105’s Toujeo pen-injector opened without a date indicating when it was opened, and RN #557 confirmed this. The facility policy titled Medication Administration stated staff are to ensure the opened date is documented on insulin vial or pen.
Hospice Communication Binder Missing Care Plan and Visit Documentation
Penalty
Summary
The facility failed to establish a communication system with hospice and failed to ensure the hospice plan of care was readily available for staff review for one resident receiving hospice services. Resident #78 was admitted to the facility on 12/28/23 and had diagnoses including Alzheimer's disease, epilepsy, diabetes mellitus, cerebrovascular disease, and vascular dementia. The MDS assessment showed cognitive impairment and dependence on staff for bed mobility and transfers. A physician order dated 02/11/26 showed the resident was admitted to hospice on 02/11/26 for cerebrovascular disease. Review of the hospice communication binder on 03/04/26 showed it contained only the names and contact information for hospice staff, along with a sign-in sheet completed only by the hospice CNA and a few shower sheets. It did not include visit notes, the hospice care plan, or other hospice documents. During interview, LPN #626, CNA #710, and the DON acknowledged the binder had limited information and should have included additional hospice documentation such as visit notes and the hospice care plan. The facility policy stated the hospice shall maintain the hospice care plan and the facility shall maintain its own comprehensive care plan.
Call Light Left Out of Reach
Penalty
Summary
The facility failed to ensure that Resident #79’s call system was within reach when the resident was lying in bed. Resident #79 was admitted on 10/03/24 and had diagnoses including vascular dementia, metabolic encephalopathy, and cognitive communication deficit. The MDS assessment indicated severe cognitive impairment. The care plan dated 01/12/26 stated the resident was dependent on staff for toileting and personal hygiene, required substantial assistance with repositioning and transfers, and included interventions to ensure the call light was within reach, encourage use of it for assistance, and provide prompt response to requests for help. During multiple observations on 03/02/26, Resident #79 was seen lying in bed with the call light on the floor by the left side of the bed and not within reach. At one observation, the resident was asking for ice cream while the call light remained out of reach. Later observations again showed the resident resting in bed with the call light on the floor. When the RN entered the room, the RN picked up the call light and placed it on the resident’s bed within reach, and confirmed that the call light had been on the floor and not within the resident’s reach. The facility call light procedure dated 03/05/25 stated call lights will be within reach of the resident when in the resident room.
Delayed Weekend Mail Distribution
Penalty
Summary
The facility failed to ensure residents had reasonable access to and privacy in their use of communication methods when residents did not receive delivered mail on Saturdays. During interview, Resident Council Members #48, #59, #85, and #88 stated they do not receive any mail on Saturdays and that activity staff distribute mail at the facility. The Director of Life Enrichment stated activity staff distribute mail and that mail received on weekends is distributed to residents on Monday. The Business Office Manager stated mail is dropped off by post office staff in the mail room, but mail delivered on weekends is not given to residents until Monday, so residents do not receive Saturday mail until the following week.
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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 | 2 mi | ★★★★★ | 1 | 0 |
| Southbrook Healthcare Center | 2.3 mi | ★★★★★ | 1 | 0 |
| Arbors At Springfield | 2.6 mi | ★★★★★ | 3 | 0 |
| Springfield Nursing & Independent Living | 3.2 mi | ★★★★★ | 4 | 0 |
| Allen View Healthcare Center | 4.6 mi | ★★★★★ | 3 | 0 |
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