Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 The Waters Of Springfield Llc during CMS and state inspections, most recent first.
A resident with advanced liver disease, moderate cognitive impairment, and a documented full code status was found unresponsive on his knees slumped over a toilet, not breathing and without a pulse. A CNA who discovered the resident did not touch him and immediately sought an LPN, who briefly entered the room, then left and called 911 from the nurses’ station, inaccurately stating that CNAs were performing CPR. Video and staff interviews showed no CPR was initiated or maintained, the crash cart and AED were not promptly brought to the bedside, and the LPN later told 911 that CPR had been stopped and that there was “no point” in applying the AED. EMS arrived within minutes, found the resident dead without resuscitation efforts, and pronounced death, while facility policy and AHA BLS guidelines required immediate and continuous CPR for full-code residents until EMS assumed care.
The facility did not ensure sanitary food storage and preparation, with food items found unlabeled and undated, baking pans containing carbon build-up, and a grease trap under the stove filled with food debris. The walk-in cooler temperatures were consistently above the required range for an extended period, and food was not discarded promptly despite policy requirements. These deficiencies were confirmed by dietary management and the administrator, affecting meal service for most residents.
The facility did not ensure privacy for a resident group meeting, as non-participating staff and visitors entered the meeting space and interrupted the proceedings. An activity supervisor confirmed that such interruptions are a recurring problem, and the administrator acknowledged that meetings are supposed to be uninterrupted.
Two residents with cognitive impairments who required supervision during meals were observed feeding themselves in the dining room without any staff present to assist or supervise, contrary to facility policy.
Staff failed to follow hand hygiene protocols during medication administration, including not performing hand hygiene between glove changes and before or after administering medications to multiple residents. These lapses were observed among an RN and two LPNs, contrary to facility policy and as confirmed by the DON.
The facility failed to label and date food items in the walk-in refrigerator, contrary to its food safety policy. Surveyors found undated and unlabeled items such as salads, pears, pudding, and meat. Staff interviews confirmed the expectation for labeling and dating, highlighting a lapse in procedure that could impact all residents receiving food from the kitchen.
The facility failed to protect residents from physical abuse in three separate incidents involving residents with cognitive impairments. In one case, a resident struck another with a meal tray; in another, a resident pulled another's hair; and in the third, a resident was knocked out of their wheelchair. Staff intervened in each case by separating the residents and notifying administration.
A facility failed to provide the required SNFABN to a resident transitioning from Medicare to Medicaid, as staff believed it was unnecessary since the resident remained in the facility. Interviews revealed a lack of understanding and miscommunication among staff regarding the requirement to issue the SNFABN, and the facility lacked an official beneficiary notice policy.
A facility failed to report an allegation of abuse involving a resident to the State Survey Agency, as required by their policy. A family member reported that a man entered the resident's room, made inappropriate comments, and touched the resident. Although the resident initially confirmed the incident, they later recanted. The facility's policy mandates reporting all allegations, but the incident was not reported due to a misunderstanding of the requirements by the Administrator and DON.
A resident with a history of diabetes and hypertension was recommended for cataract evaluation by an optometrist, but the LTC facility failed to schedule a follow-up with an ophthalmologist. The Social Services Director was unaware of the recommendation due to a lack of communication with the vision provider. The Administrator and DON were also not informed, resulting in the resident not receiving the necessary evaluation and potential surgery.
Failure to Initiate and Maintain CPR for Full-Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide continuous basic life support/CPR to a resident with a documented full code status who was found unresponsive in the bathroom. Facility policy required that any resident suffering cardiac or respiratory arrest receive CPR unless a valid DNR order was in place, and that basic life support be initiated and maintained until ambulance arrival. AHA BLS guidance similarly required immediate CPR when no breathing and no pulse are present, continuing until advanced life support personnel take over. The resident’s care plan and medical record showed he had elected full code status, had moderate cognitive impairment, used a wheelchair, and required assistance with transfers and ambulation. He had been treated for cirrhosis and hepatic encephalopathy and had a recent PRN order for Zofran for nausea, which was administered the evening before the event without documented effectiveness. On the morning of the incident, the resident’s roommate activated the call light after the resident had been in the bathroom for an extended period without sound. A CNA entered the room around 6:07 AM, found the resident on his knees slumped over the toilet and unresponsive, did not touch him, and immediately went to get the nurse. Video footage showed the LPN and two CNAs entering the room briefly and exiting after approximately 11 seconds, which the Regional Director later acknowledged was not enough time for a proper assessment. The LPN then left the room area and was at the nurses’ station when she first called 911, reporting that the resident was not breathing and that CNAs were performing CPR, although both CNAs later stated they did not perform CPR and did not see CPR performed by the nurse or EMS. The 911 operator instructed the LPN to go to the resident’s room and to call back from a cell phone so that the resident’s status could be directly assessed. During the second 911 call, the LPN reported that the resident was “gone,” that CPR had been stopped once he was pulled off the toilet, and confirmed that CPR was not being done. She described the resident as cold to touch, blue in the face, bleeding from the head, and without a pulse. Facility video showed that the crash cart did not arrive outside the resident’s room until about 6:20 AM, and there was no evidence that the AED on the crash cart was applied. EMS and fire personnel arrived within minutes and documented that the resident was dead without resuscitation efforts, with significant lividity and jaw rigor mortis, and pronounced him deceased at 6:30 AM. Interviews with the nurse practitioner, DON, and staff confirmed that for a full-code resident found without vital signs, CPR should be initiated and not discontinued prior to EMS arrival, and that in this case CPR was not initiated or continuously performed despite the resident’s full code status and absence of a DNR order. The surveyors concluded that the facility failed to provide continuous CPR as required, resulting in an Immediate Jeopardy citation at F-678.
Removal Plan
- Administrator and DON educated on BLS Standards, CPR Policy, and Facility Expectations during a Code Blue Response by the Regional Nurse
Failure to Maintain Sanitary Food Storage and Preparation Conditions
Penalty
Summary
The facility failed to store, handle, prepare, and serve food under sanitary conditions, as evidenced by multiple observations and documentation. Food items were found unlabeled and undated, including an open bag of white powder (thickening powder for drinks) left on top of a flour bin. Eight large rectangular baking pans were observed with carbon build-up, and a grease trap drawer under the stove was found with excessive tearing of aluminum foil, a black plastic lid, and a large amount of food debris. These conditions were confirmed by the Regional Certified Dietary Manager (CDM) and the CDM during interviews. Additionally, the walk-in cooler temperatures were consistently recorded above the acceptable range of 35 to 41 degrees Fahrenheit, with numerous documented instances of temperatures ranging from 42 to 58 degrees over a period of nearly two months. Despite facility policy requiring immediate reporting and action for unacceptable refrigerator temperatures, the elevated temperatures persisted, and the food in the cooler was not discarded until a new refrigerator was purchased. The Administrator confirmed being informed about the elevated temperatures only twice and acknowledged that the dietary staff had not reported the abnormal temperatures as required by policy. The census at the time was 37, with 34 residents receiving meal trays from the kitchen.
Failure to Provide Privacy for Resident Council Meeting
Penalty
Summary
The facility failed to provide a private and uninterrupted space for the Resident Council meeting, as required by its own policy and federal regulations. During the observed meeting, the Transportation Driver remained in the room while the meeting was in progress, and later allowed a family member to enter, who then interacted with a resident attending the meeting. Additionally, another resident entered the dining room to access the snack machine during the meeting. The Activity Supervisor confirmed that such interruptions are a recurring issue, and the Administrator acknowledged that Resident Council meetings are supposed to be uninterrupted. These actions and inactions resulted in the residents' right to organize and participate in private group meetings being compromised.
Failure to Provide Supervision During Dining
Penalty
Summary
The facility failed to provide required supervision and assistance during mealtime for two residents who needed such support. According to facility policy, there should be a process in place to ensure residents receive appropriate assistance and supervision during dining. Medical record reviews showed that one resident was severely cognitively impaired and required supervision with eating, while another was moderately cognitively impaired and also required supervision. During an observation in the dining room, both residents were seen feeding themselves without any staff present to supervise or assist. The administrator later confirmed that staff should have been present to supervise residents during meals.
Failure to Follow Hand Hygiene Protocols During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were followed during medication administration for three residents. Facility policy required hand hygiene before direct contact with residents, before applying gloves, and after removing gloves. However, observations revealed that staff did not consistently perform hand hygiene at the required times. Specifically, one LPN did not perform hand hygiene between glove changes while administering eye drops to a resident. Another RN failed to perform hand hygiene before and after administering medications and removing gloves. A third LPN did not perform hand hygiene before preparing medications, before and after glove changes, and after administering medications, including eye drops and an inhaler. Interviews with the Director of Nursing confirmed that staff were expected to perform hand hygiene as outlined in facility policy, including before preparing medications and between glove changes. The observed lapses in hand hygiene occurred during direct care and medication administration to residents, as documented by surveyors during their review and interviews.
Failure to Label and Date Food Items in Refrigerator
Penalty
Summary
The facility failed to adhere to its food safety policy by not labeling and dating food items stored in the walk-in refrigerator. During a kitchen tour, surveyors observed several undated and unlabeled food items, including bowls of salad, pears, yellow pudding, pieces of meat identified as country fried steak, and bowls of tartar sauce. The facility's policy required that food items without a manufacturer's expiration date be labeled with a received and use-by date, which was not followed in this instance. Interviews with various staff members, including the Dietary Director, Registered Dietician, Director of Nursing, and the Administrator, confirmed that it was the facility's expectation for all opened food items to be labeled and dated. Despite this expectation, the observed food items in the refrigerator were not labeled or dated, indicating a lapse in following the established food safety procedures. This deficiency had the potential to affect all residents receiving food from the kitchen.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by other residents, as evidenced by three separate incidents involving residents with cognitive impairments. In the first incident, a resident with moderate cognitive impairment struck another resident with a meal tray after being told not to take an uneaten meal tray. The incident was witnessed by another resident and staff intervened by separating the residents and notifying the administration. The resident who was struck did not sustain any injuries and felt safe in the facility. In the second incident, a resident with moderate cognitive impairment and a history of schizophrenia struck another resident with severe cognitive impairment on the forearm and pulled their hair. The altercation occurred in the resident's bedroom and was witnessed by a roommate. Staff separated the residents and the aggressor was placed under one-to-one supervision. The resident who was attacked experienced some pain but no significant injuries were reported. The third incident involved a resident with severe cognitive impairment who struck another resident, causing them to fall out of their wheelchair. The altercation occurred during a smoke break when the aggressor attempted to take a lighter and was redirected by staff. The resident who was struck did not sustain any injuries. Staff intervened by separating the residents and the aggressor was sent for a psychiatric evaluation.
Failure to Provide Required SNFABN Notice
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to a resident who was reviewed for beneficiary notification. According to the facility's policy, the SNFABN should be issued prior to receiving non-covered care or upon termination of Medicare-covered skilled care needs. However, the facility did not provide the SNFABN to the resident, as they believed it was unnecessary since the resident remained in the facility and transitioned from Medicare to Medicaid. Interviews with various staff members, including the Business Office Manager, Social Services Director, MDS Coordinator, Administrator, and Director of Nursing, revealed a lack of understanding and miscommunication regarding the requirement to issue the SNFABN. The staff believed that the notice was not needed if the resident remained in the facility or had skilled days remaining. Additionally, the facility did not have an official beneficiary notice policy, and the staff were unsure of the specific requirements and timing for issuing the SNFABN.
Failure to Report Alleged Abuse to State Survey Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the State Survey Agency (SSA) as required by their policy. The policy, titled 'Abuse Prevention Program,' mandates that any suspected abuse or neglect be reported immediately to the appropriate authorities, including the State Licensing and Certification Agency. In this case, a family member of a resident reported to facility staff that a man had entered the resident's room, made inappropriate comments, and touched the resident. The staff informed the Administrator and Director of Nursing (DON) about the allegation, but the incident was not reported to the SSA. The resident involved had a medical history of mood disorder and malignant neoplasm of the right breast, with moderate cognitive impairment. The facility's investigation revealed that the resident initially confirmed the incident but later recanted the allegation within two hours. Despite this recantation, the facility's policy required that all allegations be reported, which was not done. Interviews with the Administrator and DON indicated a misunderstanding of the reporting requirements, as they believed the recantation negated the need to report the incident to the SSA.
Failure to Schedule Ophthalmologist Appointment for Cataract Evaluation
Penalty
Summary
The facility failed to arrange a follow-up appointment with an ophthalmologist for a resident who was recommended for cataract evaluation. The resident, who had a medical history of Type 2 Diabetes Mellitus, Hypertension, and Dry Eye Syndrome, was seen by an optometrist who noted significant cataracts in the left eye and recommended a follow-up with an ophthalmologist. Despite this recommendation, there was no evidence in the resident's progress notes or order summary report that such an appointment was scheduled or conducted. The Social Services Director (SSD) was unaware of the need for a follow-up appointment and had not seen any recent notes from the vision provider regarding the resident's condition. The SSD stated that she had to contact the vision provider to obtain records from the resident's most recent eye appointment and was not informed about the need for cataract surgery. The SSD acknowledged that there was a lack of communication between the vision provider and the facility, which led to the oversight. The facility's Administrator and Director of Nursing (DON) were also unaware of the resident's need for cataract surgery. The Administrator mentioned that the vision provider's documentation should have been emailed to the SSD, and the DON noted issues with the previous social worker not scheduling necessary appointments timely. This lack of communication and follow-up resulted in the resident not receiving the recommended ophthalmological evaluation and potential surgery.
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What surveyors actually found near you
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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) |
|---|---|---|---|---|
| Nhc Healthcare, Springfield | 0.3 mi | ★★★★★ | 10 | 1 |
| Stoneridge Health Care, Llc | 9.5 mi | ★★★★★ | 9 | 0 |
| White House Health Care Inc | 10.6 mi | ★★★★★ | 11 | 0 |
| Alta Heights Post Acute | 16.4 mi | ★★★★★ | 0 | 0 |
| Whites Creek Wellness And Rehabilitation Center | 18.9 mi | ★★★★★ | 3 | 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.