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 June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Springfield Nursing & Independent Living during CMS and state inspections, most recent first.
Facility temperatures were repeatedly measured below the acceptable range, with residents and staff observed wearing coats, hats, and multiple layers to stay warm. An LPN, CNAs, and residents reported the building had been cold for days, while the heat system was blowing cold air and the Administrator said there was no plan of action. Temperature logs showed halls, nursing stations, and resident rooms in the 50s and low 60s, with one room later measured in the 40s.
Pest Control Program Not Effectively Implemented: Staff observations showed the facility cat interacting with and eating mice in the front lobby area, and a MT removed one mouse after it was seen near the front desk. A housekeeping supervisor confirmed the cat was eating another mouse and said she would mop and disinfect the area after the cat left. Review of the facility pest control policy stated the facility would maintain an effective program to eradicate common household pests and rodents.
The facility did not ensure a safe and clean environment, as evidenced by a shower room with damaged flooring, a hole in the drywall, debris, and stained ceiling tiles, as well as an employee entrance door that could not be secured. Staff confirmed these issues had persisted for months to over a year, affecting all residents who used the shower room and allowing potential unauthorized access through the unsecured entrance.
A resident with severe cognitive impairment and multiple medical conditions was moved to a different room without receiving written notification prior to the change. Staff interviews confirmed that neither the resident nor their representative was shown the new room or given written notice, and the facility did not follow its own policy requiring notification for room changes.
The facility did not conduct timely or thorough investigations into two separate allegations of abuse and neglect involving residents with severe cognitive impairment and dementia. In both cases, staff failed to document or conduct interviews with involved personnel or witnesses, and investigations were not initiated promptly, contrary to facility policy.
A resident experienced a major decline in cognitive and functional status after a stroke, becoming nonverbal, unable to make needs known, and fully dependent on staff for all ADLs, with all nutrition provided via tube feeding. Despite these significant changes, the facility did not complete a required significant change MDS assessment, as confirmed by staff interviews and medical record review.
A resident with multiple medical conditions, including diabetes, was not monitored for blood sugar levels according to the physician's order for twice-daily Accu-Chek testing. Instead, documentation showed that blood sugar checks were only completed once daily, a fact confirmed by the DON.
A resident with multiple medical conditions was readmitted from the hospital with a pressure ulcer and DTI, but the facility did not promptly assess, document, or initiate treatment for these wounds. Weekly wound evaluations were not completed, and physician orders for wound care were delayed. The DON confirmed the lack of timely documentation and treatment, and wound care was only provided after a significant delay, contrary to facility policy.
A resident with a history of stroke and dysphagia was readmitted on tube feedings and showed cognitive improvement, making them a candidate for SLP services to restore eating skills. However, the facility did not provide these services due to the absence of a speech therapist, resulting in a lack of care to help the resident regain oral intake abilities.
Two residents did not receive their prescribed medications as ordered, resulting in a medication error rate of 7.4%. A nurse administered the incorrect dosage of Verapamil to one resident and an insufficient dose of Metformin to another, contrary to physician orders and facility policy.
A resident with a history of stroke, dysphagia, and tube feeding was not offered or provided SLP services after readmission, despite hospital recommendations for ongoing evaluation and subsequent cognitive improvement. The facility lacked a Speech Therapist and did not document any SLP follow-up or treatment.
A resident with an unstageable sacral pressure ulcer did not receive proper infection control during wound care, as an LPN failed to don a gown and did not wash hands between glove changes. Enhanced Barrier Precautions (EBP) were not implemented as required, with no EBP signage posted and no physician order documented, despite facility policy mandating these measures for high-contact care activities.
The facility did not update or post current daily nurse staffing information at the front desk, as required, with staff and DON confirming that the information displayed was several days out of date. This issue was identified during a complaint investigation and had the potential to affect all residents.
A resident with a history of schizophrenia and bipolar disorder was re-admitted to the facility without the continuation of prescribed psychiatric medications, leading to increased verbal outbursts, manic behaviors, and hospitalization. The facility failed to follow its policy for medication reconciliation, resulting in actual harm to the resident.
The facility failed to follow the planned menu and did not inform residents of changes. On one occasion, residents were served a different meal than what was on the menu, and the Dietary Manager admitted to not notifying them. The Resident Council President also reported frequent menu deviations without prior notice, affecting all 61 residents.
The facility failed to store food properly and maintain a sanitary kitchen, affecting all 61 residents. Issues included undated and improperly stored food, a malfunctioning refrigerator, and unsanitary conditions confirmed by dietary staff and the maintenance director.
The facility failed to have the required members, including the medical director, at QAPI meetings, potentially affecting all 61 residents. Documentation for 2023 lacked sign-in sheets, and the medical director did not attend meetings in March and April 2024. The Administrator confirmed these deficiencies.
The facility failed to have a developed water management plan, potentially affecting all 61 residents. The Administrator confirmed the absence of such a plan, and the Maintenance Director revealed that only hot water temperatures were checked. The facility's policy indicated that Legionella surveillance is part of the water management plan, but no plan was in place.
The facility failed to provide a homelike environment, with multiple observations of unclean and poorly maintained areas in the behavioral unit and residents' rooms. Issues included sticky and dusty window ledges, black substances on window sills, broken blinds, rust spots in showers, and stagnant water around a toilet. Interviews confirmed that these areas should have been cleaned better.
The facility failed to conduct quarterly care conferences for four residents, including those with chronic obstructive pulmonary disease and Parkinson's disease. Residents and their representatives were not adequately informed or involved in the care planning process, contrary to the facility's policy.
The facility failed to ensure timely administration of medications for four residents, with delays ranging from over two to four hours past the scheduled times. Interviews confirmed that the LPN declined assistance, and the DON verified the late administration of medications.
The facility failed to ensure that residents and staff were offered and/or administered the COVID-19 vaccine, as required by their policy. Medical record reviews for four residents and three staff members revealed no evidence of education, consent, or administration of the COVID-19 vaccine, and interviews confirmed the lack of vaccine offers.
A facility failed to ensure a resident with severe cognitive impairment and multiple diagnoses was treated with dignity and respect. An STNA was observed interacting with the resident in a loud and abrasive tone, which was confirmed by other staff members as unprofessional behavior. The facility's policy on resident dignity was not followed.
The facility failed to develop a comprehensive care plan for a resident with multiple diagnoses, omitting plans for smoking and activities. Despite the resident's severe cognitive impairment and smoking habit, the care plan lacked necessary measures, which was confirmed by the DON.
The facility failed to complete discharge summaries for two residents, leading to a deficiency in the communication of necessary information at the time of planned discharge. Both residents had multiple diagnoses and required various levels of assistance for daily activities. Despite being discharged, the assessments titled 'Discharge Instructions' and 'Discharge Summary' were not completed for either resident.
The facility failed to provide necessary ADL care, including bathing, beard trimming, and nail trimming, for a resident who was unable to perform these tasks independently. The resident, who was cognitively intact and required supervision for all ADLs, received inconsistent care, with only one shower given out of 12 opportunities. Staff interviews confirmed the lack of available shavers and incomplete shower and nail care.
The facility failed to assess enabler bars for entrapment risk, affecting a resident with severe cognitive impairment. Despite the resident denying issues, no safety assessments were conducted, and the facility's policy on bed rail use was not followed.
The facility failed to assess the use of side rails/enabler bars for two residents with cognitive impairments and multiple diagnoses. Interviews revealed that enabler bars were not assessed for proper fit or need upon admission or routinely thereafter, despite the facility's policy requiring such assessments.
The facility failed to ensure the activity department was overseen by a qualified professional. The Activity Director, hired and promoted within the facility, lacked certification and relevant employment experience. Both the Activity Director and the Administrator confirmed the absence of necessary qualifications, potentially affecting all 61 residents.
Facility Failed to Maintain Safe Indoor Temperatures
Penalty
Summary
The facility failed to maintain temperatures in a safe and comfortable range throughout multiple resident care areas. During observations on 01/27/26, residents in the East Hall and [NAME] Hall were seen in bed under multiple blankets, residents in the East TV room were wearing coats, and staff at the nurses station were wearing jackets, hats, and hooded sweatshirts. Residents in the dining room were also observed eating while dressed in sweatpants and hooded sweatshirts, and two random residents were seen wearing coats and hats. Resident #10 stated the facility was cold and said she was wearing two layers of pants, shirts, and socks just to stay warm. Temperature checks documented very low readings in resident rooms, halls, and nursing stations. On 01/27/26, the [NAME] Hall temperatures were recorded between 53.1 degrees F and 55.4 degrees F, the nurse station was 55.6 degrees F, and several resident rooms were in the 53.8 to 58.8 degrees F range. The East Hall temperatures were also below the facility’s stated acceptable range, with hall temperatures between 57.6 degrees F and 61 degrees F and resident rooms ranging from 58.6 degrees F to 70.5 degrees F. Staff interviews confirmed the facility had been cold after a recent cold snap, and LPN #100 stated efforts to fix the heating unit began when the cold temperatures were noticed. The maintenance technician reported the facility had recently installed a new heat system that began blowing cold air over the prior week, and the gas company, mechanical company, and installer had been notified, but the source of the heating issue had not been discovered at the time of interview. The Administrator stated there was no plan of action for the low temperatures and said she did not know what to do. The performance improvement action plan noted the issue had been identified on 01/23/26 and that residents were to be given extra blankets and clothing, while the maintenance director was responsible for twice-daily temperature checks until temperatures reached 71.0 degrees F to 81.0 degrees F. However, the maintenance director later stated he was not aware of the plan and had not taken the second set of temperatures. Additional observations and interviews showed residents and staff continued to experience cold conditions, portable heaters were delayed or not yet in place during the period described, and one resident room was later measured at 46.4 degrees F.
Pest Control Program Not Effectively Implemented
Penalty
Summary
The facility failed to implement an effective pest control program for the eradication of pests and rodents. During observation on 01/28/26 at 8:19 A.M., the facility cat was seen on the west side of the front desk playing with a mouse, and Maintenance Technician #103 and Maintenance Director #104 were observed nearby. The mouse was lying still, and MT #103 bent down, picked up the mouse, and walked off to dispose of it; MD #104 verified the mouse had been in the facility. During observation on 01/29/26 at 9:20 A.M., a resident was overheard saying, "the cat got another one," and the same cat was seen in the east side of the front lobby hunched over in a corner eating a mouse. Housekeeping Supervisor #111 confirmed the observation and stated she would mop and disinfect the area after the cat ran off. Review of the facility's Pest Control Program revised 2025 stated the facility would maintain an effective pest control program to eradicate common household pests and rodents.
Failure to Maintain Safe and Clean Environment in Resident and Staff Areas
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, staff, and the public. Observations revealed that the shower room on the [NAME] Hall had significant maintenance issues, including peeled flooring along the walls, a hole in the drywall near the baseboard, protruding drywall, and drywall debris on the floor. Additionally, two ceiling tiles in the shower room were stained with large, brownish marks. Staff interviews confirmed that these issues had persisted for several months, and all residents on the [NAME] Hall used this shower room. Further observations and interviews identified that the employee entrance door in the basement did not fit the doorframe and could not be closed, leaving the entrance open at all times. Maintenance staff confirmed that this issue had existed for quite some time and that residents could access the basement via the elevator. It was also confirmed that individuals from the community could enter the facility through this unsecured door. The facility had sought an estimate for repairs to the shower room but had not yet received a quote. These deficiencies were investigated under multiple complaint numbers and had the potential to affect all 63 residents in the facility.
Failure to Provide Written Notice Prior to Resident Room Change
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple complex medical diagnoses, including cerebral infarction with left hemiplegia, aphasia, ischemic cardiomyopathy, obesity, congestive heart failure, and chronic kidney disease, was moved to a different room without receiving written notification prior to the change. The resident, who was dependent on staff for all activities of daily living and received nutrition via tube feeding, was moved in April 2025 as part of a facility effort to consolidate beds. The medical record review confirmed there was no evidence of written notification provided to the resident or their representative before the room change. Interviews with staff revealed that the resident was unhappy with the new room assignment, particularly because the new bed placement did not allow the resident to look out the window as before. Admissions staff confirmed that neither the resident nor their representative was shown the new room or given written notice prior to the move, and acknowledged that the facility did not provide written notice for room changes. Review of the facility's policy indicated that notification is required for changes such as room or roommate changes, but this procedure was not followed in this instance.
Failure to Timely and Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly and timely investigate allegations of abuse and neglect for two residents. In the first case, a resident with severe cognitive impairment, hemiplegia, and dependent on staff for all activities of daily living experienced a change in condition, including shaking and lack of eye contact, which was reported by a CNA to an LPN. The LPN assessed the resident and found no immediate concerns, but the resident was later sent to the hospital for stroke symptoms. The facility's self-reported incident (SRI) investigation was not initiated until ten days after the event, and there was no documentation of staff or resident interviews related to the neglect allegation. Both CNAs involved confirmed they were not interviewed or asked to provide witness statements regarding the incident. In the second case, a resident with dementia and delusions reported to a CNA that she had been raped by a man who entered her room. The nurse was notified, an assessment was completed, and the DON was informed. The resident was sent to the hospital for examination, which yielded negative results. The SRI investigation documented that resident interviews were conducted, but there was no evidence that staff interviews or witness statements were obtained. The nurse on duty confirmed she was not interviewed about the allegation, and the administrator acknowledged the lack of documentation for staff interviews in both cases. The facility's policy requires immediate and thorough investigation of abuse, neglect, or exploitation allegations, including identifying and interviewing all relevant persons and providing complete documentation. However, in both incidents, the facility did not follow its policy, as there was a lack of timely initiation of investigations and insufficient documentation of interviews with staff and witnesses.
Failure to Complete Significant Change MDS Assessment After Major Resident Decline
Penalty
Summary
The facility failed to complete a significant change in status assessment (SCSA) as required for a resident who experienced a major decline in condition. The resident, admitted with multiple diagnoses including cerebral infarction with left hemiplegia, aphasia, ischemic cardiomyopathy, obesity, congestive heart failure, and chronic kidney disease, was discharged to the hospital and later readmitted following a stroke. Prior to the stroke, the resident was cognitively intact, able to communicate, and required only set-up assistance for eating, consuming a regular diet by mouth. After the stroke, the resident became nonverbal, unable to make needs known, developed severe cognitive impairment, and became fully dependent on staff for all activities of daily living, receiving all nutrition via gastrostomy tube feedings. Despite these significant changes in the resident's cognitive and functional status, the facility did not complete a significant change MDS assessment within the required timeframe. Staff interviews confirmed the resident's marked decline in cognition, communication, and nutritional intake following the stroke. The facility's MDS coordinator stated she did not believe the criteria for a significant change assessment were met, despite clear evidence of major declines in multiple areas of the resident's health status. This failure was identified through medical record review, staff interviews, and review of facility policy and the RAI manual.
Failure to Monitor Blood Sugar Levels as Ordered
Penalty
Summary
The facility failed to monitor a resident's blood sugar levels as ordered by the physician. The resident, who had diagnoses including atrial fibrillation, hypertension, diabetes mellitus, and congestive heart failure, was admitted with an order for Accu-Chek (fingerstick blood sugar monitoring) to be performed two times daily. Documentation in the medical record showed that Accu-Chek was only completed once daily, rather than the twice-daily frequency specified in the physician's order. This was confirmed by the Director of Nursing during an interview, who acknowledged that the monitoring was not performed as ordered.
Failure to Timely Assess and Treat Pressure Ulcers
Penalty
Summary
The facility failed to properly assess, document, and initiate timely treatment for pressure ulcers in a resident with multiple medical conditions, including failure to thrive, dementia, right hemiplegia, and paranoid schizophrenia. Upon readmission from the hospital, the resident was documented to have a pressure ulcer on the right buttock and a deep tissue injury (DTI) to the coccyx, as well as a surgical incision on the right knee. Initial assessments by facility staff noted these wounds, but there was no evidence that appropriate treatments were ordered or initiated for the DTI to the coccyx or the open area to the right gluteal fold at that time. Further review of the medical record revealed a lack of weekly wound evaluations for the DTI to the coccyx and the right gluteal fold area between the initial assessment and a later evaluation, which did not occur until several weeks after the wounds were first identified. Physician orders for wound care to the sacrum were not placed until weeks after the wounds were observed, and there was no documentation of Enhanced Barrier Precautions or other interventions for the pressure ulcers during this period. Treatment records confirmed that only the surgical site on the right knee received timely care as ordered, while the pressure ulcers did not receive documented treatment until much later. Interviews with the DON confirmed that the facility did not have documentation to support timely initiation of treatments or completion of weekly wound measurements for the pressure ulcers. Observations of wound care performed by an LPN showed that wound care was eventually provided as ordered, but this occurred after a significant delay. Review of facility policy indicated that prompt assessment and treatment of pressure ulcers was required, but this was not followed in the case of this resident.
Failure to Provide Rehabilitative Services for Eating Skills Restoration
Penalty
Summary
The facility failed to provide appropriate rehabilitative services to restore eating skills for a resident who had recently experienced a stroke and was readmitted to the facility with new orders for NPO status and tube feedings due to dysphagia. Prior to the stroke, the resident was cognitively intact, able to make needs known, and required only set-up assistance with eating. Upon readmission, the resident's cognition was initially impaired, but improved after the first week, making the resident a candidate for speech/language pathology (SLP) services to address swallowing and eating skills. However, the facility did not provide SLP services because there had been no speech therapist on staff since October 2024. Medical record review showed that the resident had a history of cerebral infarction with left hemiplegia, aphasia, and other significant comorbidities. Hospital documentation recommended ongoing SLP evaluation and treatment, but there was no evidence of such services being provided after the resident's return to the facility. The Director of Rehab confirmed that although the resident could have benefited from SLP services after cognitive improvement, these services were not offered due to the absence of a speech therapist. This resulted in a lack of care and services aimed at restoring the resident's eating skills.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 7.4%, which exceeds the acceptable threshold of 5%. Specifically, two medication errors were identified out of 27 medication opportunities during observation of medication administration. One resident with a history of hypertension and transient cerebral ischemic attack was ordered to receive Verapamil HCL Extended Release 240 mg, but instead was given Verapamil HCL 120 mg two tablets. Another resident with type two diabetes and hypertension was ordered Metformin HCL 1,000 mg twice daily, but only received Metformin HCL 500 mg once during the observed medication pass. The errors were confirmed through medical record review, direct observation, and staff interview. The nurse responsible for medication administration acknowledged the errors, stating she was unaware of the new Verapamil 240 mg ER order and confirmed the incorrect dosage of Metformin was given. Facility policy required medications to be administered as ordered, ensuring all rights of medication administration were followed, but these protocols were not adhered to in these instances.
Failure to Provide Required Speech/Language Pathology Services
Penalty
Summary
The facility failed to provide or offer Speech/Language Pathology (SLP) services as required for a resident with significant medical needs. A resident with a history of cerebral infarction with left hemiplegia, aphasia, ischemic cardiomyopathy, obesity, congestive heart failure, and chronic kidney disease was readmitted to the facility after a hospital stay for a stroke. Upon readmission, the resident had orders for NPO status and continuous tube feedings due to dysphagia, and had previously received SLP services in the hospital, including recommendations for ongoing SLP evaluation. Despite these recommendations and the resident's subsequent improvement in cognition, the facility did not provide SLP services because they had not had a Speech Therapist on staff since October 2024. The Director of Rehab confirmed that although the resident would have benefited from SLP services after cognitive improvement, no such services were offered or provided. The facility's practice in cases of swallowing concerns was to obtain a modified barium swallow evaluation and follow dietary recommendations, but no ongoing SLP evaluation or treatment was documented for this resident.
Failure to Follow Infection Control Procedures During Wound Care
Penalty
Summary
A deficiency was identified when a resident with multiple medical diagnoses, including adult failure to thrive, dementia, right hemiplegia, and paranoid schizophrenia, was not provided appropriate infection control measures during wound care. The resident had an unstageable pressure ulcer to the sacrum, as documented in weekly wound evaluations. During an observed dressing change, the LPN performed the procedure without donning a gown and failed to wash hands between glove changes, both of which are required infection control practices according to facility policy for Enhanced Barrier Precautions (EBP). Additionally, the resident did not have an EBP sign posted in the room or on the door, and there was no physician order for EBP documented in the medical record. The LPN confirmed during interview that the resident should have been under EBP and acknowledged not following the required procedures. Facility policy specifies that EBP, including the use of gown and gloves during high-contact care activities such as wound care, is necessary to prevent the transmission of multidrug-resistant organisms (MDRO), but these protocols were not followed in this instance.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nursing staffing information was posted as required, potentially affecting all 63 residents in the facility. Multiple observations on different days revealed that the staffing information displayed at the front receptionist desk was outdated, consistently showing the date 05/12/25 instead of the current date. Staff interviews with both the receptionist and the Director of Nursing confirmed that the posted staffing information had not been updated. This deficiency was identified during the course of a complaint investigation.
Failure to Reconcile Medications Post-Hospital Re-admission
Penalty
Summary
The facility failed to reconcile medications for Resident #210 following a re-admission from a psychiatric hospital. Resident #210, who had a history of schizophrenia, bipolar disorder, and other significant medical conditions, was readmitted to the facility without the continuation of prescribed psychiatric medications. This oversight led to an increase in verbal outbursts, religious ideations, manic behaviors, and ultimately, the resident's hospitalization. The medical record review revealed that the discharge medication list from the psychiatric hospital included several critical medications for managing the resident's mental health conditions, which were not entered into the electronic health record upon re-admission to the facility. The Director of Nursing confirmed that the medications were not reconciled and continued upon re-admission, leading to a deterioration in the resident's condition. The progress notes indicated that Resident #210 exhibited significant behavioral changes, including verbal outbursts and self-harm, after the failure to administer the necessary medications. Despite attempts to manage the behaviors through redirection and other interventions, the resident's condition worsened, necessitating transfer to the emergency room and subsequent admission to a psychiatric hospital. The facility's policy required the attending physician to authenticate orders and the nurse to verify and transcribe these orders, which was not followed in this case. This lapse in medication reconciliation directly contributed to the resident's adverse change in condition and subsequent hospitalization.
Failure to Follow Menu and Notify Residents of Changes
Penalty
Summary
The facility failed to ensure the menu was followed and did not inform residents of menu changes. On 05/19/24, the planned menu included apple pork chop, onion roasted potatoes, dilled carrots, roll, and pumpkin crisp. However, during the lunch meal observation on the same day, residents were served apple pork chop, mashed potatoes and gravy, dilled carrots, roll, and a brownie. The Dietary Manager confirmed the menu change and admitted to not informing the residents due to a lack of awareness about the requirement to notify them. Additionally, the substitution list did not reflect any changes for that date. An interview with the Resident Council President revealed that the dietary department frequently did not follow the menu and failed to notify residents of changes. The Resident Council President mentioned an instance two nights prior when she expected the meal on the menu but received cheeseburgers instead. The facility's policy on meal substitutions, dated 01/01/24, stated that menu changes should only occur in emergency situations and that residents should be notified in advance when possible. However, this policy was not adhered to, affecting all 61 residents in the facility.
Improper Food Storage and Sanitation in Kitchen
Penalty
Summary
The facility failed to store food properly and maintain a sanitary kitchen, which had the potential to affect all 61 residents. Observations revealed multiple issues, including undated and improperly stored food items such as cereal, hamburger patties, and bacon. Additionally, the ice machine had various stains, and a bucket in the dry storage area was collecting water from the boiler system. These observations were confirmed by dietary staff and the maintenance director, who acknowledged the issues but had not yet resolved them. Further observations showed that the walk-in refrigerator was not maintaining the required temperature of 41 degrees Fahrenheit, with items such as milk, cheese, condiments, and vegetables being stored at 45 degrees Fahrenheit. Dust was also found on the light fixture above the tray line area and on the wall near the plate warmer. The facility's policies on date marking and sanitation were not being followed, as confirmed by the dietary manager and staff. These deficiencies were observed over multiple days and confirmed by various staff members.
Failure to Include Required Members in QAPI Meetings
Penalty
Summary
The facility failed to have the required members at the Quality Assurance and Performance Improvement (QAPI) meetings, which had the potential to affect all 61 residents residing in the facility. Review of QAPI documentation for January, March, June, July, and October 2023 revealed no sign-in sheets for the meetings. Sign-in sheets were only found for March and April 2024, but there was no documentation of the medical director attending the meetings in those months. An interview with the Administrator confirmed the absence of sign-in sheets for 2023 and the medical director's absence in March and April 2024. The facility's QAPI committee, as per policy, should include the medical director, who is responsible for ensuring compliance with federal and state requirements and continuous improvement in quality of care and resident satisfaction.
Lack of Water Management Plan
Penalty
Summary
The facility failed to have a developed water management plan in place, which had the potential to affect all 61 residents residing in the facility. During a review of the facility's water management binder, it was found that there was no water management plan, including a description and diagram of the water system or control measures to prevent Legionella. The Administrator confirmed the absence of a water management plan. Additionally, the Maintenance Director revealed that they only checked hot water temperatures and had no water management plan to follow. The facility's policy titled 'Legionella Surveillance' indicated that Legionella surveillance is a component of the water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water system, but no such plan was in place.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for its residents, as evidenced by multiple observations of unclean and poorly maintained areas. In the behavioral unit's activity room, window ledges were found to be sticky and dusty, with window sills covered in a black substance and blinds coated with a sticky yellow substance. The floor under the heaters and the baseboards also had a thick black substance. Additionally, several lights in the west hall had missing coverings and burned-out bulbs, and ceiling tiles were missing at the end of the hall. The shower room in the behavioral unit had a windowsill with a black substance and dead bugs, and the blind was covered with a sticky yellow substance. Resident #21's room had similar issues, with a broken blind, sticky window ledge, and a windowsill with black substance and bugs. The shower in this room also had rust spots. Resident #18's room had a sticky window ledge with a built-up yellow substance, a windowsill full of black substance and bugs, and a blind with a sticky yellow substance. Interviews with the maintenance man and housekeeping supervisor confirmed these findings and acknowledged that the areas should have been cleaned better during deep cleaning. Resident #31's bathroom had stagnant water around the base of the toilet, which the resident reported had been leaking for days without being fixed. Observations over several days confirmed the presence of stagnant water, which was later identified by the maintenance director as urine rather than water. The maintenance director stated that the area had not been cleaned properly and that the wax seal on the toilet was changed as a precaution. Subsequent observations confirmed that the issue was resolved after cleaning and changing the wax seal. The facility's policy on providing a safe and homelike environment was reviewed, revealing that the facility failed to adhere to its own standards in maintaining cleanliness and safety for the residents.
Failure to Conduct Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure care conferences were provided quarterly for four residents. Resident #39, diagnosed with chronic obstructive pulmonary disease, was cognitively intact and required minimal assistance for daily activities. However, he only had one care conference since his admission, and he was unaware of what a care conference was. Similarly, Resident #21, diagnosed with Parkinson's disease and requiring substantial assistance for daily activities, had care conferences that were not held quarterly as required. He also reported not having any care conferences, which was confirmed by the Social Services Designee (SSD). Resident #32, also diagnosed with chronic obstructive pulmonary disease and cognitively intact, had only one care conference since admission, and the SSD confirmed this. Resident #33, with severe cognitive impairment and multiple diagnoses, had care conferences that did not include his son, who was the emergency contact, despite the facility's policy requiring notification and participation of the resident's representative. The facility's policy, revised on 01/01/24, mandates that care conferences be held regularly and involve the resident and/or their representative. However, the facility did not adhere to this policy, resulting in missed quarterly care conferences for the residents reviewed. Interviews with the residents and their representatives revealed a lack of awareness and participation in care conferences, highlighting the facility's failure to ensure proper communication and involvement in the care planning process. The Administrator acknowledged the oversight, particularly in notifying Resident #33's son, who lives out of state, and confirmed that care conferences were not held as frequently as required.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to ensure medications were administered in a timely manner and according to physician instructions, affecting four residents. Resident #13, who had severe cognitive impairment and multiple diagnoses including epilepsy and bipolar disorder, did not receive their 8:00 A.M. medications until 12:00 P.M. on one occasion and 10:44 A.M. on another. Resident #30, who was cognitively intact but required assistance for ADLs, received their 8:00 A.M. medications at 11:12 A.M. on one occasion and confirmed receiving medications late on multiple occasions. Resident #31, with diagnoses including schizoaffective disorder and type two diabetes, received their 8:00 A.M. medications at 11:20 A.M. and their 2:00 P.M. medication at 5:28 P.M. on the same day, and confirmed receiving medications late in the mornings recently. Resident #33, with severe cognitive impairment and multiple diagnoses including major depressive disorder and type two diabetes, received their 8:00 A.M. medications at 11:09 A.M. on one occasion. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed that they offered assistance to the LPN responsible for the medication pass, who declined the help. The DON confirmed the late administration of medications and verified that the nursing staff have a one-hour window before and after the scheduled time to administer medications. The facility's policy on medication administration, revised on 01/01/24, states that medications should be administered within 60 minutes prior to or after the scheduled time unless otherwise ordered by a physician.
Failure to Offer and Document COVID-19 Vaccinations
Penalty
Summary
The facility failed to ensure that residents and staff were offered and/or administered the COVID-19 vaccine, as required by their policy. Medical record reviews for four residents revealed no evidence of education, consent, or administration of the COVID-19 vaccine from 07/01/23 through 05/19/24. These residents included individuals with chronic obstructive pulmonary disease, schizoaffective disorder, human immunodeficiency virus (HIV), and respiratory failure. Interviews with the residents confirmed that they had not been offered the COVID-19 vaccination in a long time, and the Director of Nursing (DON) confirmed the lack of documentation regarding the vaccine offer and administration for these residents. Additionally, the facility failed to document the offering of the COVID-19 vaccine to staff members, including an Activity Aide and two Registered Nurses. The facility's policy, dated 01/01/24, mandates the education and offering of the COVID-19 vaccine to minimize the risk of acquiring, transmitting, or experiencing complications from COVID-19. However, the review of staff records showed no documentation of the vaccine being offered, indicating a failure to adhere to the established policy.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to ensure all residents were treated with dignity and respect, specifically affecting one resident with severe cognitive impairment and multiple diagnoses including unspecified psychosis, bipolar disorder, schizoaffective disorder, and dementia. The resident required maximal assistance for various activities of daily living and was non-verbal. During an observation, a staff member was noted to interact with the resident in a loud and abrasive tone, instructing the resident to sit down in an unprofessional manner. This interaction was overheard by housekeeping staff who confirmed the unprofessional behavior. The facility's policy on promoting and maintaining resident dignity, dated 01/01/24, was reviewed and it was found that the staff member's actions were not in alignment with the policy. The staff member, identified as a State tested Nursing Assistant (STNA), claimed to be hard of hearing and denied any unprofessional interaction. However, the observations and interviews with other staff members confirmed the deficiency in treating the resident with dignity and respect.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, specifically omitting plans for smoking and activities. The resident, who had multiple diagnoses including unspecified dementia, anxiety disorder, heart failure, and major depressive disorder, was admitted on an unspecified date. Despite being assessed as a smoker and having severely impaired cognition, the care plan did not include any measures related to smoking. Additionally, the care plan for activities was incomplete, with no specified preferred activities listed, even though the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs due to cognitive deficits. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the absence of a smoking care plan and the incomplete activities care plan. The facility's policies required that all safe smoking measures be documented in the care plan and that a comprehensive person-centered care plan be developed and implemented for each resident. However, these policies were not followed for this resident, leading to the identified deficiencies.
Failure to Complete Discharge Summaries for Residents
Penalty
Summary
The facility failed to complete discharge summaries for two residents, leading to a deficiency in the communication of necessary information at the time of planned discharge. Resident #57, who had multiple diagnoses including malignant neoplasm, COPD, anxiety disorder, PTSD, major depressive disorder, dementia, and hypokalemia, was discharged home without a completed discharge summary or discharge instructions. The resident had moderately impaired cognition and required various levels of assistance for daily activities. Despite being discharged on 05/09/24, the assessments titled 'Discharge Instructions' and 'Discharge Summary' dated 05/06/24 were not completed for this resident. Similarly, Resident #59, who had diagnoses including COPD, epilepsy, chronic kidney disease, type two diabetes mellitus, emphysema, hyperlipidemia, and major depressive disorder, was discharged to an assisted living facility without a completed discharge summary or discharge instructions. This resident had intact cognition and required setup assistance for several daily activities. The assessments titled 'Discharge Instructions' and 'Discharge Summary' were not completed for this resident either, despite the discharge occurring on 03/06/24. Social Services Staff confirmed the lack of completed discharge summaries for both residents, which was in violation of the facility's policy on transfer and discharge reviewed on 01/01/24.
Failure to Provide Necessary ADL Care
Penalty
Summary
The facility failed to ensure that a resident who could not perform Activities of Daily Living (ADL) independently was provided with necessary care such as bathing, beard trimming, and nail trimming. This deficiency affected one resident who was cognitively intact and required supervision for all ADLs but occasionally needed hands-on assistance. The resident used a powered wheelchair and had a history of refusing showers at times. However, out of 12 opportunities for showers, the resident only received one and refused two, indicating a lack of consistent care. Observations revealed that the resident's beard was long and unkempt, and his fingernails were long, which he stated were not trimmed unless he specifically asked for it. He also mentioned that he had requested a beard trim on the day of the observation, but it had not been done yet. Interviews with staff confirmed the lack of available shavers and incomplete shower and nail care for the resident. The Director of Nursing (DON) acknowledged that the shavers for residents had become old and were discarded, resulting in residents not getting shaved. The DON also admitted that the showers and nail care for the resident were not completed and described the situation as a work in progress. The facility's policy on Activities of Daily Living, dated January 1, 2024, stated that care and services would be provided for bathing, dressing, grooming, and oral care, and that residents unable to carry out ADLs would receive the necessary services to maintain grooming and personal care. Despite this policy, the facility failed to meet the grooming and personal care needs of the resident in question.
Failure to Assess Enabler Bars for Entrapment Risk
Penalty
Summary
The facility failed to assess side rails and/or enabler bars for entrapment risk, affecting one resident. Resident #33, who had severe cognitive impairment and required extensive assistance for activities of daily living, was observed with an enabler bar on their bed that had a gap of approximately three and a half to four inches between the bar and the mattress. Despite the resident denying any issues with the enabler bar, no assessments were completed to ensure the safety and proper fit of the enabler bar for the bed. Interviews with the Maintenance Director, Assistant Director of Nursing (ADON), and Director of Nursing (DON) confirmed that no assessments were conducted for Resident #33 or other residents using enabler bars. The facility's policy on the proper use of bed rails, which mandates correct installation, use, and maintenance, was not followed. The DON acknowledged that the assessments were on the list of things that needed to be addressed throughout the facility.
Failure to Assess Side Rails/Enabler Bars
Penalty
Summary
The facility failed to assess the use of side rails/enabler bars for two residents, leading to a deficiency. Resident #33, who had severe cognitive impairment and required extensive assistance for activities of daily living, was admitted with multiple diagnoses including dementia with behavioral disturbance. The care plan for Resident #33 included a mobility bar to assist with mobility, but no assessments for side rails or enabler bars were completed. Similarly, Resident #58, who had moderate cognitive impairment and was dependent on staff for activities of daily living, had a care plan that included a mobility bar, but no assessments were conducted for side rails or enabler bars. Interviews with the Maintenance Director and Assistant Director of Nursing revealed that enabler bars were not assessed for proper fit or need upon admission or routinely thereafter. The Director of Nursing confirmed that no assessments had been completed for any residents with enabler bars or side rails, despite the facility's policy requiring such assessments at least quarterly or upon significant changes in status. The lack of assessments for side rails and enabler bars was acknowledged as an issue that needed to be addressed throughout the facility.
Unqualified Activity Director
Penalty
Summary
The facility failed to ensure the activity department was overseen by a qualified activity professional. The personnel file for the Activity Director, who was hired on 03/15/23 and promoted on 06/12/23, revealed no certification or employment experience qualifying them for the role. During an interview, the Activity Director confirmed they were currently enrolled in a course to become certified. The Administrator also confirmed that the Activity Director was not certified and lacked the necessary previous employment experience to oversee the activity department. This deficiency had the potential to affect all 61 residents residing in the facility.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 277 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — 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.
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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) |
|---|---|---|---|---|
| Arbors At Springfield | 1.3 mi | ★★★★★ | 3 | 0 |
| Allen View Healthcare Center | 1.5 mi | ★★★★★ | 3 | 0 |
| Wooded Glen | 1.8 mi | ★★★★★ | 1 | 0 |
| Good Shepherd Village | 1.9 mi | ★★★★★ | 0 | 0 |
| Villa Springfield Rehabilitation And Healthcare Ce | 2.1 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 June 2026) and official state health department websites.