Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Nhc Healthcare, Springfield during CMS and state inspections, most recent first.
Hazardous items were left unsecured in two residents’ rooms. One resident with COPD, AFib, HF, DM, and MDD had 7 disposable razors in a bowl on the over-bed table, and another resident with HF, MI, AFib, and cardiac arrest had disinfecting spray, hand sanitizer, disinfecting wipes, alcohol pads, and unused lancets on the nightstand. An LPN and the DON both stated these items should not be left out in the residents’ rooms.
Unsecured Medication Carts Left Unattended: The facility failed to ensure medications were properly stored and secured when an RN and an LPN left medication carts unsecured and unattended. During observations, the RN left a medication cart unlocked while entering a resident's room, and the LPN walked away from a cart and left it open and out of sight during a medication cart check. The DON stated that medication carts should not be left unsecured and unattended.
An LPN failed to wear a gown while administering medication through a resident’s gastrostomy tube even though the resident was on EBP for an indwelling medical device. The resident had severe cognitive impairment, aphasia, dysphagia, and a feeding tube, and the facility policy required gown and glove use for feeding tube care. The LPN acknowledged PPE should have been worn, and the DON confirmed staff should wear PPE in EBP rooms during enteral medication administration.
Multiple residents were subjected to sexual abuse, including one resident who was assaulted by another resident with cognitive impairment and another who was repeatedly abused by a visitor. Staff observed and intervened in the resident-to-resident incident, but there was a lack of immediate documentation, incomplete staff statements, and no timely reporting to authorities. The facility also failed to recognize and restrict a visitor who engaged in ongoing inappropriate sexual contact with a resident. These failures resulted in emotional harm and placed all residents at risk due to inadequate supervision, investigation, and enforcement of abuse prevention policies.
A resident with severe cognitive impairment and a history of falls was found on the floor in significant pain with an abnormally positioned leg. An LPN, without specialized training in managing fractures, repositioned the resident's leg before EMS arrived, causing the resident to scream in pain. Hospital evaluation confirmed a femur fracture with displacement. Staff interviews revealed concerns about the appropriateness of the LPN's actions and a lack of clear competency in handling such injuries, resulting in actual harm to the resident.
Two residents with cognitive impairments were involved in an incident where one was found on top of the other in bed, partially unclothed, requiring staff intervention. Although the event was witnessed and internally reported, the facility did not notify state authorities within the required two-hour timeframe, contrary to policy and regulatory requirements.
The facility did not thoroughly investigate or report an alleged abuse incident involving two residents, one with severe cognitive and physical impairments and another with moderate cognitive impairment and behavioral issues. The investigation lacked complete staff statements, physical assessments, and required documentation, and the incident was not reported to the state agency within the mandated timeframe.
The facility failed to store, prepare, and distribute food according to professional standards, risking foodborne illnesses for residents. Observations revealed unlabeled food, flying insects, and a malfunctioning dishwashing machine. Maintenance issues included peeling paint, food debris, and a lack of paper towels at the handwashing sink. Additionally, improperly labeled mighty shakes were found, with the FSS unable to confirm thawing dates. The Regional Dietician confirmed these findings.
The facility failed to provide adequate pharmaceutical services, resulting in deficiencies in medication administration and disposal. A resident did not receive timely delivery of medications, including insulin and pain medication, leading to unmanaged conditions. Another resident's medications were improperly administered via a G-Tube without checking placement. Additionally, insulin was administered without priming the pen, and discontinued medications were not disposed of properly, leading to unauthorized use by staff.
A resident's medication was misappropriated when an LPN took Zofran from the drug destruction bin and administered it to another LPN without a physician's order. The incident was discovered through facility gossip, and no formal investigation or disciplinary action was documented. The facility's failure to secure medications placed all residents at risk.
A facility failed to report the misappropriation of a resident's Zofran medication to the SSA. The medication was taken from the drug destruction box by a unit manager and administered to another unit manager without a physician's order. Despite the facility's knowledge of the incident, there was no documentation or evidence of reporting to the SSA, violating the facility's policy and placing residents at risk.
A facility failed to investigate the misappropriation of a resident's medication when a unit manager took Zofran from the drug destruction box and administered it to another unit manager without an order. Despite the incident being reported to the regional office, no disciplinary action or formal investigation was conducted, violating the facility's policy on handling such allegations.
A resident with epilepsy was admitted to the facility, and the staff failed to perform scheduled lab tests and document seizure activity as per protocol. The resident experienced multiple seizures, and the nurse on duty did not notify the physician promptly or administer necessary medication due to lack of training and orders. The resident was eventually sent to the hospital with status epilepticus and later passed away in hospice care.
The facility failed to ensure that two residents understood the binding arbitration agreements they signed, despite being cognitively intact. Both residents expressed confusion about the documents, and the Admissions Director admitted to not knowing that a legal representative should sign if the resident did not understand.
The facility failed to conduct timely performance evaluations for CNAs, as required by their policy. CNA1 had not received an evaluation for four years, and CNA3 had not received one for seven years. The Administrator confirmed the overdue evaluations, which are required annually according to the facility's Human Resources Policies and Procedures.
The facility failed to provide written notification to residents and their representatives regarding emergent hospital transfers, affecting several residents. The facility's policy did not specify the contents of the transfer notice, nor did it ensure that residents were informed about their appeal rights. Interviews revealed that while some documents were sent with residents, the SBAR form used did not include appeal rights information, indicating a systemic issue in the notification process.
The facility failed to provide bed hold notifications to residents and their representatives during hospital transfers, affecting six residents. The policy requires written notice of the bed hold policy, but documentation was lacking. The Director of Nursing confirmed the use of SBAR forms, which include bed hold information, but there was no evidence that this was communicated in writing, risking residents' bed security.
Hazardous Items Left Unsecured in Resident Rooms
Penalty
Summary
The facility failed to provide an environment free of hazardous materials for 2 of 93 residents sampled for accident hazards. The facility’s policy titled Environmental Services Toolkit, dated 8/2025, stated chemicals should be kept locked up away from patients when not in use, and the facility was unable to provide a policy regarding razors and hazardous sharps unsecured and unattended in a resident’s room. Resident #3 was admitted with diagnoses including COPD, atrial fibrillation, heart failure, diabetes, and major depressive disorder, and had a BIMS score of 15, indicating cognitive intactness. Observations in the resident’s room revealed 7 teal-colored disposable razors in a bowl on the over-bed table. Resident #96 was admitted with diagnoses including heart failure, myocardial infarction, atrial fibrillation, and cardiac arrest, and had a BIMS score of 9, indicating moderate cognitive impairment. Observations in the resident’s room revealed a can of disinfecting spray, a bottle of hand sanitizer, a container of disinfecting wipes, and a clear box containing unused lancets and alcohol pads on the nightstand. An LPN and the DON both stated these items should not be left unsecured and unattended in the residents’ rooms.
Unsecured Medication Carts Left Unattended
Penalty
Summary
The facility failed to ensure medications were properly stored and secured when 2 of 6 nurses left medication carts unsecured and unattended. The facility policy titled, Medication Storage in the Facility.Controlled Substance Storage, dated 2/25/2025, stated that Schedule II medications are stored in an affixed, double locked compartment separate from all other non-controlled medications or per state regulations. The facility was unable to provide a policy related to medication cart drug storage. During an observation and interview on the 14 Hall, RN B left the Medication Skilled Cart 3 unsecured and unattended when entering a resident's room without locking the cart. RN B stated that a medication cart should not be left unlocked when unattended. During an observation and interview on the 30 Hall, LPN C walked away from the 30 Hall Medication Cart and into a resident's room, leaving the unsecured cart out of sight while the surveyor was performing a medication cart check. LPN C stated that the cart should not have been left open and unsupervised. The DON later stated that a medication cart should not be left unsecured and unattended when staff are in a resident's room or when a surveyor is performing a medication cart check.
Failure to Use PPE During Enteral Medication Administration Under EBP
Penalty
Summary
The facility failed to ensure proper infection control practices were followed when an LPN did not wear PPE for Enhanced Barrier Precautions while administering medication through a resident’s gastrostomy tube. The facility policy titled, 706 Enhanced Barrier Precautions, dated 2/2025, stated that EBP is an infection control intervention designed to reduce transmission of multidrug-resistant organisms and requires targeted gown and glove use during high-contact patient care activities, including device care of a feeding tube. Resident #34 was admitted with diagnoses including hemiplegia and hemiparesis, aphasia, dysphagia, and gastrostomy. The quarterly MDS indicated the resident’s BIMS could not be completed and that the resident had severely impaired cognitive skills for daily decision making, with a feeding tube in place. Physician orders included simethicone 125 mg via gastric tube three times daily and EBP related to an indwelling medical device every shift. During observation, the LPN administered simethicone through the resident’s gastrostomy tube without donning a gown. When interviewed, the LPN stated a gown should have been worn because the resident was in EBP, and the DON stated staff should wear PPE in EBP rooms when performing enteral medication administration.
Failure to Protect Residents from Sexual Abuse and Inadequate Investigation
Penalty
Summary
The facility failed to protect residents from sexual abuse, as evidenced by multiple incidents involving both resident-to-resident and visitor-to-resident abuse. In one incident, a severely cognitively impaired resident was found with another resident, who was moderately cognitively impaired, on top of him in bed, naked from the waist down and attempting sexual intercourse. Multiple staff members, including a CNA and LPNs, witnessed the event and had to physically remove the perpetrating resident, who was combative and had an erection. Despite the severity of the incident, there was no immediate documentation in the medical record, and the perpetrating resident remained in the facility without documented supervision until his discharge the following day. Staff interviews revealed confusion and disagreement about the nature of the incident, with some staff and administrators minimizing the sexual aspect, and others clearly identifying it as sexual abuse. The incident was not reported to law enforcement at the time, and statements from staff were either not collected or were delayed. Another incident involved a cognitively intact resident who reported to a family member that a frequent visitor had been inappropriately touching her during regular visits, including at facility activities such as bingo. The visitor admitted to the inappropriate sexual contact when confronted by a family friend. The facility's failure to recognize, evaluate, and restrict the visitor's access allowed the abuse to continue over an extended period. The resident expressed sadness, anxiety, and fear regarding the visitor's continued presence and the lack of intervention by the facility. The facility's policies required immediate investigation, documentation, and protective measures in response to allegations or suspicions of abuse. However, the investigation into the resident-to-resident incident was incomplete, with missing staff statements, lack of timely documentation, and no clear evidence of a thorough assessment of the victim. The abuse coordinator and administrator did not ensure that all required steps were taken, and there was a lack of communication and follow-up with staff and family members. The failure to implement adequate supervision and interventions for residents with known behavioral risks, as well as the failure to protect residents from abusive visitors, resulted in ongoing risk and emotional harm to vulnerable residents.
Failure to Ensure Nursing Staff Competency in Post-Fall Injury Response
Penalty
Summary
The facility failed to ensure that all nursing staff possessed the necessary competencies and skill sets to provide safe care for residents, as evidenced by an incident involving a resident with severe cognitive impairment and a history of falls. The resident, who was dependent on staff for toileting, dressing, bathing, and transfers, was found on the floor of her room after an unwitnessed fall from her wheelchair. She was discovered in significant distress, with her right lower extremity positioned abnormally near her face and her left upper extremity under her abdomen, crying and moaning in pain. Multiple staff members, including an LPN, responded to the scene. Despite the resident's obvious pain and abnormal limb positioning, the LPN on scene manipulated and repositioned the resident's right leg to what was perceived as a more natural alignment before emergency medical services arrived. This action was performed without a clear assessment of the injury's extent and without specialized training in managing potential fractures or dislocations. Several staff interviews confirmed that the LPN moved the resident's leg, which caused the resident to scream in pain. The LPN later stated that she acted to relieve the resident's pain, but acknowledged she was not trained to manipulate a potentially dislocated or fractured limb. Emergency medical personnel arrived and administered significant pain management interventions before attempting to move the resident, noting the severity of her pain and the obvious deformity of her leg. Hospital evaluation confirmed a right distal femur fracture with posterior displacement. Interviews with staff, including the DON and other nurses, revealed uncertainty and concern regarding the appropriateness of the LPN's actions, as well as a lack of clear guidance or competency in handling such situations. The incident resulted in actual harm to the resident, demonstrating a failure by the facility to ensure nursing staff were adequately trained and competent to respond appropriately to residents' needs following a fall with injury.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that alleged violations involving abuse were reported immediately, but not later than two hours after the allegation was made, for two of six sampled residents. Facility policy requires that any partner with direct or indirect knowledge of an event that might constitute abuse must report the event immediately, and not later than two hours after forming the suspicion, in accordance with federal and state law. Despite this, the facility did not report an incident involving two residents within the required timeframe. One resident, with diagnoses including dementia, delirium, and severe visual impairment, required substantial assistance with daily activities and had poor memory. Another resident, with diabetes, dementia, traumatic brain injury, and schizoaffective disorder, had moderate cognitive impairment and exhibited physical behaviors toward others. An incident occurred in which the second resident was found on top of the first resident in bed, partially unclothed and refusing to get off, requiring multiple staff members to intervene. The first resident was assessed and found to have no injuries, while the second resident was confused and required redirection. Staff interviews and written statements confirmed that the incident was witnessed and reported internally, but the required report to state authorities was not made within the mandated two-hour window. The Administrator acknowledged that the incident was not reported to the state agency and was not discussed in QAPI meetings, despite facility policy and regulatory requirements. The Director of Social Services also confirmed that such incidents should be reported within two hours and that a follow-up investigation is due on the fifth day.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to complete a thorough investigation and report the results of all investigations to the State Survey Agency within five working days of the incident for two residents reviewed for abuse. According to facility policy, any allegation of abuse must be reported immediately and investigated promptly, with results completed within five working days. However, in the case involving two residents, the facility did not follow these procedures after an incident where one resident was found on top of another in bed, which was considered an allegation of sexual abuse. Medical record reviews revealed that one resident had severe cognitive and physical impairments, including dementia, delirium, and blindness, while the other had moderate cognitive impairment and a history of physical behaviors toward others. The incident was reported to the Administrator and Director of Social Services, who responded after the residents were separated. The investigation conducted by the facility was incomplete, containing only one written staff statement and lacking documentation of a physical assessment for the resident involved, as well as missing incident reports for both residents. Further review showed that there was no documentation in the progress notes by the Abuse Coordinator regarding the incident, nor any follow-up note explaining the room change for the affected resident. Interviews with facility staff confirmed that the investigation did not include statements from all staff who witnessed the event, and the incident was not reported to the state agency as required. The lack of a comprehensive investigation and timely reporting constituted a failure to comply with both facility policy and federal regulations.
Food Storage and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to ensure food was stored, prepared, and distributed in accordance with professional standards, placing residents at risk for foodborne illnesses. Observations revealed unlabeled and undated food items, such as bacon bits and a Styrofoam container with spareribs, macaroni and cheese, and potato salad, in the main kitchen's cooler. Additionally, numerous small, dark-colored flying insects were observed near the reach-in coolers, the three-compartment sink, and the floor drain. The Food Service Supervisor (FSS) confirmed the presence of these issues and was unable to provide documentation of pest control treatments. Further observations indicated that the dishwashing machine was not dispensing sanitizing solution during its cycles, with the FSS verifying the issue and subsequently attaching a new container of sanitizer. A large red spill in the walk-in freezer was noted on consecutive days, indicating it had not been cleaned promptly. The kitchen also had peeling paint above the food preparation area, food debris on electrical outlets, and food splashes on walls and ceilings. The FSS acknowledged these maintenance issues but could not produce maintenance requests. Additional deficiencies included a lack of paper towels at the handwashing sink, leading staff to air dry their hands. The FSS was unaware of who was responsible for replenishing paper towels on weekends. Observations also revealed improperly labeled and thawed mighty shakes, with the FSS unable to confirm thawing dates. The Regional Dietician confirmed these findings and mentioned plans for kitchen remodeling and maintenance staff involvement.
Pharmaceutical Service Deficiencies in Medication Administration and Disposal
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of several residents, leading to significant deficiencies. One resident, identified as R123, did not receive timely delivery of medications, including insulin, pain medication, and eye ointment, as ordered by the physician. The delay in medication delivery resulted in the resident experiencing elevated blood sugar levels and unmanaged pain. The facility's policy required medications to be obtained from the emergency box or through alternative means if not available, but this was not followed, and the resident's needs were not met. Another deficiency involved the improper administration of medications via a gastronomy tube for resident R20. The nurse failed to check the G-Tube placement before administering medications, which is a critical step to ensure safe and effective medication delivery. The facility's policy and training emphasized the importance of checking gastric residuals before administering medications, but the nurse did not adhere to these guidelines, potentially compromising the resident's safety. Additionally, the facility did not follow proper procedures for insulin administration for resident R21. The nurse did not prime the insulin pen before administering the dose, contrary to the manufacturer's instructions and facility policy. This oversight could lead to incorrect dosing of insulin, affecting the resident's blood glucose management. Furthermore, the facility failed to dispose of discontinued medications properly, as evidenced by the unauthorized use of medication from the destruction box by staff members, which was not documented or reported according to policy.
Misappropriation of Resident's Medication by LPNs
Penalty
Summary
The facility failed to protect a resident's medication from misappropriation, specifically involving the unauthorized use of Zofran, an antiemetic medication. A Licensed Practical Nurse (LPN) took the medication from the facility's drug destruction bin and administered it intramuscularly to another LPN without a physician's order. This incident was reported as a practice that had been previously tolerated, and no disciplinary action was initially taken. The incident involved Resident 76, whose medication was misappropriated. The facility's records indicated that Resident 76 had been admitted and later discharged, but the exact dates were not specified. The unauthorized use of the medication was discovered through facility gossip, and it was confirmed that the medication was taken from the drug destruction bin, which was not properly secured or documented. Interviews with various staff members, including the Administrator, Director of Nursing, and Consultant Pharmacist, revealed a lack of formal investigation and documentation regarding the incident. The facility's policy on abuse, neglect, and misappropriation of property was signed by the involved LPNs, but there was no evidence of reprimands or corrective actions documented in their personnel files. The facility's failure to safeguard medications placed all residents at risk for similar incidents.
Failure to Report Misappropriation of Resident Medication
Penalty
Summary
The facility failed to report the misappropriation of a resident's medication to the State Survey Agency (SSA), which is a requirement under federal and state law. The incident involved the misappropriation of Zofran, an antiemetic medication, which was taken from the drug destruction box by a unit manager and administered intramuscularly to another unit manager without a physician's order. This practice was admitted by the involved staff members, who claimed it was a common practice. Despite the facility's knowledge of the incident, there was no documentation or evidence that the misappropriation was reported to the SSA, as required by the facility's policy. The investigation revealed that two residents had physician orders for the medication, but one had been discharged, leaving only one resident, R76, whose medication was misappropriated. Interviews with staff, including the Director of Nursing and the Administrator, confirmed the lack of documentation and reporting of the incident. The facility's policy mandates immediate reporting of such incidents to the SSA and other relevant authorities, but this was not adhered to, placing all residents at risk of unreported misappropriation of their personal property.
Failure to Investigate Misappropriation of Resident Medication
Penalty
Summary
The facility failed to thoroughly investigate allegations of misappropriation of resident property, specifically involving Resident 76's medication. The incident involved a unit manager taking Zofran, an antiemetic medication, from the drug destruction box and administering it intramuscularly to another unit manager without a medical order. This practice was reportedly acknowledged by both unit managers as something they had always been able to do. Despite the Director of Nursing notifying the regional office about the incident, no disciplinary action was taken, and the facility did not conduct a formal investigation. Interviews conducted during the investigation revealed that one LPN admitted to taking Resident 76's Zofran from the destruction box and administering it to another LPN. The second LPN confirmed receiving the injection but was unaware of the medication's origin. The facility's policy on patient protection and response to allegations of misappropriation clearly defines such actions as the wrongful use of a patient's belongings without consent and mandates immediate assessment and investigation of such allegations. However, the facility did not adhere to this policy, leaving all residents at risk for uninvestigated misappropriation allegations.
Failure to Follow Seizure Protocol and Lab Orders
Penalty
Summary
The facility failed to ensure that nursing services followed orders for lab testing and adhered to the facility's Seizure and Epilepsy Clinical Protocol for a resident with a history of epilepsy. The resident was admitted with diagnoses including generalized epileptic syndrome and post-stroke epilepsy. A lab test scheduled for 2:00 AM was not performed, and there was no documentation of seizure monitoring as per the physician's orders. The staff did not document the resident's seizure activity in detail, including onset time, duration, and intervals between seizures, nor did they notify the physician immediately when the resident experienced status epilepticus. The medical record review revealed that the resident had four seizures in 20 minutes, starting at 4:55 AM. The nurse on duty increased the resident's oxygen and attempted to contact the physician, but there was no answer. The nurse called 911 after the second seizure, but the resident continued to have seizures while waiting for emergency services. The nurse did not have an order for a benzodiazepine and was not trained on the seizure protocol. The resident was eventually sent to the hospital, where they were admitted with status epilepticus and other complications. Interviews with the staff and the Medical Director highlighted that the nurse did not follow the expected protocol of notifying the physician after the first seizure to obtain necessary medication orders. The Medical Director confirmed that timely documentation and treatment were crucial, and the facility lacked an alternate provider to contact in the absence of the Medical Director. The resident was later transferred to inpatient hospice and passed away, with the facility acknowledging the lack of proper documentation and response during the seizure episodes.
Failure to Ensure Understanding of Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents or their legal representatives understood the binding arbitration agreements they signed. This deficiency was identified for two residents, R224 and R226, who were both assessed to be cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Despite this, R224 did not recall signing the agreement and stated she did not understand it. Similarly, R226, whose agreement was signed by a friend, expressed confusion about the documents she signed, indicating she did not understand their meaning. The facility's policy on arbitration and financial agreements emphasized the importance of explaining the information and the circumstances under which it was provided. However, during interviews, the Admissions Director admitted to not being aware that a legal representative needed to sign if the resident did not understand the agreement. The director claimed to have explained the document to both residents and their friends, but it was apparent that the explanation was insufficient, as neither resident comprehended the agreement they were involved in.
Failure to Conduct Timely CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received performance evaluations on a periodic basis, which may be annually, as required by their policy. This deficiency was identified for two out of three CNAs whose personnel files were reviewed. Specifically, CNA1, hired on January 17, 2017, had not received a performance evaluation for a four-year period, with the last evaluation dated February 27, 2020. Similarly, CNA3, hired on August 7, 2000, had not received a performance evaluation for a seven-year period, with the last evaluation dated December 10, 2008. During an interview, the Administrator confirmed that the performance evaluations for CNA1 and CNA3 were overdue. The facility's policy, titled Human Resources Policies and Procedures, dated October 6, 2023, requires supervisors to complete a timely performance appraisal for every partner at least annually, with the possibility of more frequent appraisals if deemed necessary by supervisors.
Failure to Notify Residents of Hospital Transfers and Appeal Rights
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding emergent transfers to the hospital, affecting nine residents reviewed for hospitalization. The facility's policy on transfers and discharges did not specify the contents of the transfer notice, nor did it ensure that residents and their representatives were informed in writing about the transfer or discharge and the reasons for the move in a language and manner they could understand. This oversight potentially affected all residents transferred to the hospital, as they were not made aware of their appeal rights. The report details specific instances where residents were transferred to the hospital without proper documentation or notification. For example, Resident 10 was transferred to the emergency room due to respiratory distress, but there was no evidence of written notification to the resident or their representative. Similarly, Resident 37 was sent to the emergency department for shortness of breath, and Resident 17 was discharged to the hospital without documentation of the Situation, Background, Assessment, and Recommendations (SBAR) being provided to the resident or their representative. Interviews with facility staff, including the Director of Nursing, revealed that while certain documents like the face sheet and physician orders were sent with residents during transfers, the SBAR form used did not include information about the residents' appeal rights. This lack of documentation and communication was confirmed for multiple residents, indicating a systemic issue in the facility's handling of hospital transfers and the notification process.
Failure to Provide Bed Hold Notifications During Hospital Transfers
Penalty
Summary
The facility failed to provide bed hold notifications to residents and their representatives for six out of nine residents reviewed, which is a requirement when residents are transferred to a hospital or take therapeutic leave. This deficiency was identified through interviews, record reviews, and policy reviews. The facility's policy on bed hold notifications, revised in 2016, mandates that the social services department contact the legal representative to discuss the bed hold policy and ascertain the plans to reserve the bed. However, the policy did not ensure that written notice was provided to the resident or their representative in a language and manner they understand. This oversight was evident in the cases of six residents who were transferred to the hospital without receiving the required bed hold policy notification. The report details specific instances where residents were transferred to the hospital without proper documentation of the bed hold policy being provided. For example, one resident was sent to the emergency room due to respiratory distress, and another was transferred for shortness of breath, yet neither had documentation of the bed hold policy being communicated. The Director of Nursing confirmed that the Situation-Background-Assessment-Recommendation (SBAR) form, which includes bed hold information, was used during transfers, but there was no evidence that this information was provided in writing to the residents or their representatives. This lack of documentation and communication placed residents at risk of losing their beds during hospital transfers.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 88 citations issued within 25 miles in the last 12 months — including the 2 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.
Illustrative
A prioritized, do-first checklist
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Illustrative
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) |
|---|---|---|---|---|
| The Waters Of Springfield Llc | 0.3 mi | ★★★★★ | 1 | 1 |
| Stoneridge Health Care, Llc | 9.5 mi | ★★★★★ | 9 | 0 |
| White House Health Care Inc | 10.7 mi | ★★★★★ | 11 | 0 |
| Alta Heights Post Acute | 16.3 mi | ★★★★★ | 0 | 0 |
| Whites Creek Wellness And Rehabilitation Center | 18.8 mi | ★★★★★ | 3 | 0 |
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