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 Wooded Glen during CMS and state inspections, most recent first.
Surveyors found that expired IV solution bags were not removed from medication storage, with the DON confirming twelve expired bags remained in the IV cart. The DON believed the pharmacy was responsible for removing expired solutions, contrary to facility policy requiring immediate removal. A resident was receiving IV solution at the time.
A resident with severe cognitive impairment and multiple medical conditions experienced two falls in one day due to the facility's failure to consistently implement physician-ordered fall prevention interventions, such as placing fall mats and keeping the bed in the lowest position. Staff confirmed that required interventions were not in place at the time of the second fall, and documentation and communication procedures were not followed according to facility policy.
A resident with diabetes mellitus received an insulin injection from an LPN who failed to date the insulin vial upon opening, contrary to facility policy. The LPN was unsure if the insulin had expired, highlighting a lapse in medication labeling and storage procedures.
A facility failed to follow infection control practices during medication administration. A resident with a complex medical history received medication from an RN who dropped a tablet, picked it up with bare hands, and administered it without performing hand hygiene. This action violated the facility's policy requiring hand hygiene and glove use during medication handling.
Two residents in an LTC facility experienced significant medication errors. One resident did not receive a prescribed IV antibiotic for two days due to an omission, while another continued to receive a diuretic despite an order to discontinue it due to hyperkalemia. The errors were confirmed by the DON and involved lapses in following the facility's medication administration policy.
Expired IV Solutions Not Removed from Medication Storage
Penalty
Summary
Surveyors observed that the facility failed to remove expired intravenous (IV) solution bags from medication storage, as required by pharmacy labels and manufacturer expiration dates. During an inspection of the IV cart in the 400-hall, the Director of Nursing (DON) confirmed the presence of twelve expired IV solution bags, including Dextrose, Sodium Chloride, and Lactated Ringers, some of which were past their 'do not use beyond' dates. The DON stated she believed the pharmacy representative was responsible for reviewing and removing expired IV solutions. Facility policy requires that outdated medications be immediately pulled from active inventory and segregated to prevent unintentional use. At the time of the survey, one resident was identified as receiving IV solution.
Failure to Implement Fall Prevention Interventions as Ordered
Penalty
Summary
The facility failed to implement fall prevention interventions in accordance with physician orders for a resident with multiple complex medical diagnoses, including encephalopathy, acute respiratory failure with hypoxia, congestive heart failure, acute kidney failure, and chronic obstructive pulmonary disease. The resident was assessed as having severely impaired cognition and required varying levels of assistance for activities of daily living. The care plan identified the resident as being at risk for falls and included interventions such as encouraging slow standing, ensuring the floor was free of hazards, keeping items within reach, providing non-skid footwear, and assisting with transfers as needed. Despite these interventions, the resident experienced two falls on the same day. After the first fall, new interventions, including placing the bed in the lowest position and adding a mat next to the bed, were documented. However, during the second fall later that day, it was observed that fall mats were not present on the floor as ordered. Staff interviews confirmed that fall mats were not in place at the time of the second fall, and documentation showed that the intervention was not consistently implemented. The facility's policy required updating the care plan and communicating new interventions during shift reports, but these steps were not effectively carried out.
Failure to Properly Label Insulin Vials
Penalty
Summary
The facility failed to ensure proper labeling of insulin vials, which affected a resident with multiple medical diagnoses including diabetes mellitus. The resident required supervision and staff assistance with activities of daily living due to moderate cognitive impairment. A physician's order was in place for the resident to receive Humalog insulin injections three times per day. During an observation, an LPN prepared and administered the insulin injection without the vial being dated upon opening. The LPN confirmed that the insulin had not been dated and was unsure if it had expired. The facility's policy requires that multiple dose injectable vials be dated upon opening to ensure medication purity and potency, which was not followed in this instance.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection control practices during medication administration, specifically affecting one resident. The resident, who was cognitively intact and required assistance with activities of daily living, had a medical history that included sepsis, clostridium difficile, colitis, hypertensive heart disease, and congestive heart failure. On a specific date, a registered nurse (RN) was observed preparing the resident's medications. During this process, the RN dropped a hydralazine tablet on the medication cart, picked it up with bare hands, and placed it into a pill cup without performing hand hygiene at any point. The RN confirmed during an interview that she touched the tablet with her bare hands and administered it to the resident without performing hand hygiene before, during, or after the medication administration. A review of the facility's medication administration policy, revised in November 2018, indicated that hand hygiene should be performed before beginning medication pass, prior to handling medications, and after direct contact with a resident. The policy also required the use of examination gloves to prevent direct contact with tablets. The RN's actions were inconsistent with these established infection control practices.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. Resident #197, who was admitted with conditions including orthostatic hypotension and MRSA bacteremia, was supposed to receive daptomycin IV daily for an infection. However, the medication was not administered on the first two days following admission due to an error of omission. The Director of Nursing confirmed that the hospital discharge summary included the order for the medication, but it was not ordered or administered until two days later. This oversight was identified when a Licensed Practical Nurse, upon receiving a verbal report, reviewed the resident's medical record and discovered the omission. Resident #04, admitted with diagnoses such as hypertensive heart disease and COPD, was supposed to have Aldactone discontinued due to hyperkalemia as per a nurse practitioner's note. However, the medication continued to be administered for nearly two weeks beyond the intended discontinuation date. The Director of Nursing confirmed that the medication was administered in error during this period. The facility's policy on medication administration, which requires adherence to prescriber's written orders, was not followed in these instances.
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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) |
|---|---|---|---|---|
| Arbors At Springfield | 0.7 mi | ★★★★★ | 3 | 0 |
| Springfield Nursing & Independent Living | 1.8 mi | ★★★★★ | 4 | 0 |
| Springfield Masonic Community | 2 mi | ★★★★★ | 16 | 0 |
| Allen View Healthcare Center | 2.7 mi | ★★★★★ | 3 | 0 |
| Villa Springfield Rehabilitation And Healthcare Ce | 2.8 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 July 2026) and official state health department websites.