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 Villa Springfield Rehabilitation And Healthcare Ce during CMS and state inspections, most recent first.
The facility failed to properly store food in the Memory Care Unit and another unit's utility room, risking foodborne illness for 91 of 93 residents. Observations revealed multiple unlabeled and undated food items, including health shakes, protein packs, and yogurt, among others. A CNA and an LPN verified these findings, which were against the facility's policies requiring proper labeling and dating of food items.
The facility failed to track employee call-offs related to personal illness and did not ensure annual TB screenings for employees, affecting infection control measures. Interviews confirmed the lack of tracking and documentation, despite policies requiring these actions.
The facility failed to notify residents' representatives and families of the COVID-19 status during an outbreak, as required by CMS guidelines. Despite placing residents in droplet isolation due to COVID-19, the facility did not inform families about the outbreak. An interview with the Administrator revealed a lack of awareness regarding the notification requirement, which mandates informing families by 5:00 P.M. the next calendar day following a confirmed infection or onset of symptoms.
The facility failed to conduct required care conferences for five residents, affecting their care planning and involvement. Residents with various diagnoses, including COPD, heart failure, and diabetes, did not receive the mandated interdisciplinary care conferences. Interviews confirmed the lack of compliance with the facility's policy, which requires regular care conferences to involve residents in their care planning.
The facility failed to properly store insulin vials, affecting four residents. Observations revealed that an opened insulin vial was not dated, and unopened vials were not refrigerated as required. The DON and an RN confirmed these findings, which were against the facility's medication storage policy.
The facility failed to notify physicians of significant weight loss in two residents, despite care plans requiring such notification. One resident lost weight from 132.1 to 110 pounds, and another from 204 to 161 pounds, without timely physician notification. The facility's policy required immediate or next-day notification, which was not followed.
The facility failed to develop baseline care plans within 48 hours of admission for two residents, as required by policy. One resident with multiple health issues and another with severe cognitive impairment experienced delays in the creation of their care plans, which were confirmed by the Social Service Director.
A resident with multiple health conditions did not receive showers as scheduled, receiving only one per week instead of the scheduled two. The resident confirmed the inconsistency, and the DON verified the lack of documentation for any refusals. The facility's policy on ADLs, which includes maintaining hygiene, was not followed.
The facility failed to monitor and address significant weight loss in two residents, leading to a deficiency in providing adequate nutrition. One resident experienced an 18-pound weight loss over three months without timely intervention, while another lost 21 percent of their body weight over six months. The facility did not follow its policy on weight monitoring and intervention, and communication lapses prevented timely action.
A resident with intact cognition and at risk for altered nutritional status was unable to consume a health shake due to it being frozen. The CNA confirmed that health shakes had been frozen for weeks, complicating consumption for residents. The facility's policy required evaluation of factors affecting nutritional intake, but this was not effectively implemented.
The facility failed to document meal intakes for three residents, affecting their nutritional monitoring. One resident with heart failure and diabetes required supervision with eating, while another with cirrhosis and depression needed setup assistance. A third resident with depression and cancer also had incomplete records. The DON confirmed the documentation issues.
Improper Food Storage in Facility Refrigerators
Penalty
Summary
The facility failed to ensure proper storage of food in the Memory Care Unit and another unit's utility room, which could potentially lead to the spread of foodborne illness affecting 91 of 93 residents. During an observation, several items in the Memory Care Unit refrigerator and freezer were found to be improperly stored. These included an opened health shake carton, a partially consumed protein pack, an insulated container with fruited gelatin, a bag of bacon bits, a pitcher of unidentified liquid, a brown bag from Subway, and an uncovered container of yogurt. None of these items were labeled or dated, and there was a brown streak of an unidentified substance on the refrigerator's back panel. A CNA verified these findings. In another unit's utility room, similar issues were observed. Items found included an insulated bowl with unidentifiable contents covered in a black and white fuzzy substance, a bowl of pudding, a pitcher of lemonade, a container of prune juice, a bottle of coke, a slice of pie, a carton of thickened water, and two pints of ice cream. These items were either not labeled, not dated, or both. An LPN confirmed these findings and acknowledged that the items should have been labeled and dated. The facility's policies require all food to be appropriately dated and labeled to ensure safe storage and prevent foodborne illness, but these were not followed in the observed instances.
Deficiencies in Infection Control and TB Screening
Penalty
Summary
The facility failed to track employee call-offs related to personal illness as part of its infection prevention and control program. This deficiency was identified through a review of the facility's infection control surveillance logs, which lacked documentation of employee call-offs due to personal illness. Interviews with the Human Resource Manager and the Administrator, along with the Director of Nursing, confirmed that the facility did not include this tracking in their infection control surveillance program. The facility's policy on infection prevention and control, dated September 2022, indicated that surveillance tools should be used to monitor employee infections, but this was not being implemented effectively. Additionally, the facility did not ensure that annual Tuberculosis (TB) screenings were completed for employees, affecting seven employees whose files were reviewed. The Director of Nursing confirmed that employees who had been employed for more than one year were required to have an annual TB screening, but the facility lacked documentation to support that these screenings were completed in 2024. The facility's TB plan, dated September 2021, stated that an annual assessment for symptoms should be completed for facilities categorized as low risk, but this was not adhered to, as evidenced by the missing documentation in the employee files.
Failure to Notify Families During COVID-19 Outbreak
Penalty
Summary
The facility failed to notify residents' representatives and families of the COVID-19 status during an outbreak, as required by CMS guidelines. This deficiency was identified through a review of medical records, staff interviews, and CMS guidance. The facility had a census of 93 residents at the time of the survey. The review of the medical record for one resident revealed that the resident was admitted with multiple diagnoses, including COVID-19, and was placed in droplet isolation. Another resident, also with multiple diagnoses, was similarly placed in droplet isolation due to COVID-19. Despite these measures, the facility did not inform the residents' representatives and families about the outbreak. An interview with the Administrator revealed a lack of awareness regarding the requirement to notify residents' representatives and families during a COVID-19 outbreak, other than posting a sign on the front door. The facility did not comply with the CMS Quality Safety and Oversight Memorandum, which mandates informing residents, their representatives, and families by 5:00 P.M. the next calendar day following a confirmed COVID-19 infection or the onset of respiratory symptoms in multiple residents or staff. The facility's failure to provide timely notifications had the potential to affect all residents, as it did not adhere to the required communication protocols during the outbreak.
Failure to Conduct Required Care Conferences
Penalty
Summary
The facility failed to conduct required care conferences for five residents, affecting their care planning and involvement in their own care. Resident #15, with diagnoses including COPD, PVD, and congestive heart failure, had no documented quarterly care conferences since their admission care conference in 2014. Resident #20, diagnosed with heart failure and diabetes, did not receive any care conferences in the past 12 months. Resident #31, with cirrhosis and major depressive disorder, had only one care conference in the last year. Resident #33, with COPD and diabetes, also did not receive any care conferences in the past year. Resident #51, with multiple diagnoses including COPD and chronic kidney disease, had only one care conference documented in the past year. Interviews with the Social Service Director confirmed the lack of care conferences for these residents, which is a violation of the facility's policy requiring regular interdisciplinary care conferences. The policy, dated September 2021, mandates that each resident should be invited to participate in these conferences to ensure their involvement in the care planning process. The failure to conduct these conferences as required indicates a deficiency in the facility's adherence to its own policies and procedures for resident care planning.
Improper Storage of Insulin Vials
Penalty
Summary
The facility failed to ensure proper storage of insulin vials, affecting four residents who received insulin. During an observation of the Skilled One medication cart, it was found that a resident's insulin glargine vial was opened and not dated, while another resident's unopened insulin glargine vial was not stored in the refrigerator as required. The Director of Nursing confirmed these findings during the observation. Further observations of the Skilled Two medication cart revealed that a resident's unopened insulin Lispro vial was not refrigerated, and another resident's unopened Lantus SoloStar insulin pen-injector was stored correctly in the refrigerator. The Registered Nurse verified that the insulin vials and pen-injector should have been refrigerated since they were unopened. The facility's policy on medication storage mandates that medications requiring refrigeration must be stored in a secured refrigerator, and this policy was not adhered to in these instances.
Failure to Notify Physicians of Significant Weight Loss
Penalty
Summary
The facility failed to ensure timely notification of significant weight loss to the residents' physicians and/or providers, affecting two residents. Resident #31, who had diagnoses including cirrhosis of the liver and major depressive disorder, experienced a significant weight loss from 132.1 pounds to 110 pounds over a period from July to October 2024. Despite the care plan's directive to report significant weight changes to the physician, there was no documentation of such notification. Interviews confirmed that the Nurse Practitioner was not informed of the weight loss. Similarly, Resident #48, with diagnoses including depression and malignant neoplasm of the prostate, experienced a weight decrease from 204 pounds to 161 pounds between August 2024 and February 2025. The care plan also required notification of significant weight changes, but again, there was no documentation of physician notification. The Registered Dietician, responsible for notifying the physician, confirmed that no notification was made. The facility's policy required immediate or next-day notification of significant changes, which was not adhered to in these cases.
Delayed Creation of Baseline Care Plans
Penalty
Summary
The facility failed to ensure that baseline care plans were developed within 48 hours of admission for two residents, which is a requirement according to the facility's policy. Resident #15, who was admitted with multiple diagnoses including COPD, PVD, hyperlipidemia, ASHD, hypothyroidism, and congestive heart failure, did not have baseline care plans created until several days after admission. Although an IDT note indicated that the resident was given a copy of the baseline care plans on the day following admission, the actual creation of these plans was delayed, as confirmed by the Social Service Director. Similarly, Resident #53, who was admitted with severe cognitive impairment and required various levels of assistance, also experienced a delay in the creation of their baseline care plan. The care plan for this resident was not created until several days post-admission, despite the facility's policy mandating the development of such plans within 48 hours. The Social Service Director verified the delay and acknowledged that the baseline care plan should have been created within the specified timeframe.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that showers were provided as scheduled for a resident, affecting one of the four residents reviewed for showers/baths. The resident, who had diagnoses including chronic obstructive pulmonary disease, peripheral vascular disease, hyperlipidemia, atherosclerotic heart disease, hypothyroidism, and congestive heart failure, was admitted on an unspecified date. The Minimum Data Set assessment indicated that the resident had moderate cognitive impairment and required supervision with toilet hygiene and transfers, and partial/moderate assistance with bathing. The resident was scheduled to receive showers on Wednesdays and Saturdays between 7:00 A.M. and 3:00 P.M. However, documentation revealed that the resident received showers on specific dates in December 2024, January 2025, and February 2025, which did not align with the scheduled frequency of two showers per week. An interview with the resident confirmed that she did not receive showers as scheduled, stating she may only get one shower weekly. The Director of Nursing verified that the resident did not receive the scheduled showers and that there was no documentation to support any refusals of showers by the resident. The facility's policy on Activities of Daily Living stated that residents would be provided with necessary care to maintain or improve their ability to carry out activities of daily living, including hygiene, which was not adhered to in this case.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to adequately monitor and address significant weight loss in two residents, leading to a deficiency in providing sufficient food and fluids to maintain their health. Resident #31, who had diagnoses including cirrhosis of the liver and major depressive disorder, was not weighed in August and September 2024, resulting in an 18-pound weight loss by October 2024. Despite interventions such as ordering a super donut breakfast and health shakes, the resident continued to experience weight loss, and the facility did not implement timely monitoring or interventions. Resident #48, diagnosed with depression and malignant neoplasm of the prostate, experienced a significant weight loss of 21 percent over six months. The resident's weight was not recorded in October 2024, and despite being ordered health shakes, the resident's meal intake decreased significantly. The resident was also out to the hospital for a period, which may have contributed to the weight loss. The facility failed to monitor the resident's weight more frequently and did not notify the nurse practitioner of the significant weight changes. The facility's policy on weight assessment and intervention was not followed, as residents were not weighed monthly or more frequently when significant weight loss was identified. The registered dietician confirmed the lack of timely monitoring and intervention for both residents, and the nurse practitioner was unaware of the weight loss due to a lack of communication. This deficiency highlights the facility's failure to prevent, monitor, and intervene for undesirable weight loss as per their policy.
Inappropriate Serving of Nutritional Supplements
Penalty
Summary
The facility failed to ensure that nutritional supplements were served in a manner appropriate for consumption, affecting one resident out of 37 on supplements. Resident #48, who had intact cognition and required setup assistance with eating, was unable to consume a health shake due to it being frozen. This resident had a history of depression, malignant neoplasm of the prostate, and metabolic encephalopathy, and was at risk for altered nutritional status. The care plan included administering supplements as per physician orders and monitoring nutritional intake. On observation, a CNA reported that the health shake on Resident #48's lunch tray was frozen, making it impossible for the resident to drink. The CNA confirmed that the health shakes had been frozen for several weeks, complicating consumption for residents. The facility's policy required direct care staff, assisted by the clinical dietician, to evaluate factors affecting nutritional intake, but this was not effectively implemented, leading to the deficiency.
Inadequate Documentation of Meal Intakes
Penalty
Summary
The facility failed to maintain adequate documentation of meal intakes for three residents, affecting their nutritional monitoring and care. Resident #20, who was admitted with diagnoses including heart failure, type two diabetes mellitus, and cirrhosis of the liver, had missing meal intake documentation from November 2024 through February 2025. This resident, with moderate cognitive impairment, required supervision with eating. The Director of Nursing (DON) confirmed the incomplete documentation during an interview. Similarly, Resident #31, with diagnoses of cirrhosis of the liver and major depressive disorder, also had missing meal intake documentation for the same period. This resident, assessed with moderate cognitive impairment, required setup with eating and was at risk for altered nutritional status. The care plan included monitoring meal intake and reporting significant weight changes. Resident #48, with intact cognition and diagnoses including depression and prostate cancer, also had incomplete meal intake records. The DON verified the documentation issues for all three residents, indicating a systemic failure in maintaining accurate records.
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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) |
|---|---|---|---|---|
| Aventura At Oakwood Village | 0.7 mi | ★★★★★ | 8 | 0 |
| Allen View Healthcare Center | 0.8 mi | ★★★★★ | 3 | 0 |
| Northwood Skilled Nursing And Rehabilitation | 1.3 mi | ★★★★★ | 4 | 0 |
| Forest Glen Rehabilitation And Healthcare Center | 1.8 mi | ★★★★★ | 12 | 0 |
| Springfield Nursing & Independent Living | 2.1 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.