Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
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 Suites Rehab And Nursing during CMS and state inspections, most recent first.
Two residents experienced increased pain due to the facility's failure to ensure timely availability of prescribed pain medications. One resident went without Hydrocodone-Acetaminophen for several days due to prescription delays, while another faced a similar issue due to a prescription error. The facility's medication management processes were insufficient to prevent these occurrences.
A resident with a history of falls and fractures required assistance from two staff members for transfers, as documented in her care plan. However, she was assisted by only one CNA, resulting in a fall. A subsequent incident led to severe pain and hospitalization for a pulmonary embolism. Staff interviews revealed inconsistencies in understanding the resident's transfer needs.
Two residents experienced a lack of timely care and respect for dignity in an LTC facility. One resident faced prolonged pain due to delayed pain medication, while another was left in a saturated brief in front of visitors, causing embarrassment. The facility's policies on resident rights and call light response were not followed, leading to these deficiencies.
A resident with a left femur fracture and chronic pain syndrome experienced prolonged pain due to delayed administration of pain medication. Despite activating the call light, it took two hours for the resident to receive Oxycodone, during which their pain level increased significantly. The facility's pain management policy, which emphasizes timely assessment and self-reporting, was not effectively followed, as acknowledged by the DON.
The facility failed to post daily nursing staff hours, affecting all 58 residents. The survey team found the last update was several days old. The Administrator and Scheduler were unaware of the lapse, and there was no policy for posting staffing information.
The facility failed to properly prepare and store medications, as observed when an LPN administered medications from unlabeled cups without performing hand hygiene. Another LPN was seen with an unlabeled medicine cup and improperly stored medications, including a Tuberculin vial not refrigerated. Facility policies on medication storage and administration were not followed, potentially affecting all residents.
The facility failed to ensure proper food storage and hygiene practices in the kitchen, affecting all 58 residents. The Food and Beverage Manager did not wear a beard cover while preparing food, and several food items were found open, unsealed, and not dated or labeled. Additionally, the walk-in freezer had significant ice buildup and condensation issues, with condensation dripping onto food items. The facility's policy requires all open products to be sealed, labeled, and dated, and food should not be stored under leaking water lines or condensers.
The facility lacked a comprehensive QAPI policy and failed to sustain corrective actions for pharmacy services. The existing policy did not detail procedures for feedback, data collection, or monitoring concerns. An LPN was observed passing unlabeled medications, and the medication cart contained improperly stored items. Despite previous citations, the DON was unaware of ongoing issues, indicating insufficient oversight.
The facility failed to maintain an effective infection control program, with incomplete tracking of infections and outdated policies. The DON admitted to not tracking employee illnesses and the Administrator acknowledged the policies were old. Enhanced Barrier Precautions were not implemented, despite residents with medical devices at increased risk of infection. Specific instances included the absence of signage for precautions on residents' doors, and a nurse unaware of any residents requiring such measures.
The facility's infection control program was found deficient due to the Infection Preventionist's recent certification and lack of proactive measures, such as tracking employee illnesses and maintaining infection control logs. Two residents were on antibiotics without necessary tests, and Enhanced Barrier Precautions were not implemented for residents with indwelling devices. The facility also lacked a policy or job description for the IP role.
The facility failed to provide adequate incontinent care for several residents, leading to deficiencies in their care. A resident was found with a saturated brief and delayed assistance due to IV disconnection issues. Other residents received care with improper glove use, lack of drying, and inadequate cleaning, violating facility policies on incontinent care and hand hygiene.
The facility failed to develop comprehensive care plans for three residents, neglecting to address diagnoses such as major depressive disorder, anxiety, and dementia. One resident's care plan did not include interventions for a significant arm injury and subsequent skin graft. The facility's policy requires individualized care plans, which were not adequately implemented.
A resident at risk for falls due to dementia and impaired mobility fell after his wife left the room, closing the door and preventing staff from hearing the alarm. The facility failed to transfer the alarm from the bed to the chair and did not complete a Fall Risk Assessment after the incident, as required by their policy.
A facility failed to follow its tube feeding protocol for a resident receiving enteral nutrition. Observations revealed that feeding bottles and water bags were undated and lacked time stamps, contrary to the facility's policy requiring replacement every 24 hours. The DON confirmed the requirement for dating and timing, which was not adhered to.
The facility failed to provide proper respiratory care for two residents requiring oxygen therapy. One resident received inconsistent oxygen administration, with the nasal cannula often not in use and the humidified water bottle undated. Another resident received an incorrect oxygen dose, despite being aware of the discrepancy. The facility did not follow its own oxygen administration policy, as confirmed by the DON and an LPN.
The facility failed to re-evaluate psychotropic medication orders for two residents, leading to a deficiency. A resident was prescribed alprazolam without an end date, and another resident on hospice care was prescribed lorazepam without an end date. The DON was aware of the 14-day re-evaluation requirement but not its applicability to hospice residents. The facility lacked a policy on unnecessary or psychotropic medications.
The facility failed to ensure proper antibiotic stewardship for three residents, leading to the administration of antibiotics without appropriate indications. One resident received antibiotics without a urine culture or symptoms of a UTI, while another was prescribed multiple antibiotics without clear documentation of a culture. A third resident's records lacked a culture and sensitivity report to confirm the causative organism for a UTI. The facility's infection control policy was outdated, and there was no evidence of adherence to antibiotic stewardship protocols.
The facility did not follow its vaccination policy for two residents. One resident did not receive the influenza vaccine, with no documentation of declination or contraindication, despite a physician's order. Another resident received both vaccines, but the facility's policy requires documentation of education and administration, which was not confirmed.
Pain Medication Availability Deficiency
Penalty
Summary
The facility failed to ensure that pain medications were readily available for administration, resulting in increased pain and discomfort for two residents. Resident R3, who suffers from arthritis and other medical conditions, did not receive her prescribed Hydrocodone-Acetaminophen for several days in December and February due to issues with obtaining a new prescription from her primary care provider. Despite multiple attempts by the facility to contact the physician's office and the on-call physician, the prescription was not filled in a timely manner, leading to R3 experiencing increased pain and difficulty functioning without her medication. Similarly, Resident R2, diagnosed with chronic pain syndrome and other conditions, did not receive her prescribed Hydrocodone-Acetaminophen for almost two days in March. The delay was caused by an error in the prescription sent to the pharmacy, which lacked the oral route specification. The facility contacted the physician and nurse practitioner to correct the script, but the medication was not delivered promptly, causing R2 to experience increased pain and inability to complete her therapy. The facility's policies on administering medication and pain management emphasize the importance of providing medications as ordered and ensuring residents do not experience unnecessary pain. However, the facility's inability to secure timely prescriptions and medication deliveries resulted in both residents experiencing increased pain and discomfort, highlighting a deficiency in the facility's medication management processes.
Inadequate Staffing for Resident Transfer Leads to Falls
Penalty
Summary
The facility failed to provide an appropriate number of staff to assist in a transfer for a resident, identified as R2, who was at risk for falls. R2 had a history of falls with fractures and required partial/moderate assistance with transfers. The care plan indicated that R2 needed assistance from two staff members for transfers due to an activities of daily living deficit. However, during an incident, R2 was assisted by only one CNA, resulting in R2's knees giving out and her sitting on the floor. This incident was documented in a progress note, and the physician was notified, but no new orders were given. A subsequent incident occurred when R2 fell again while being transferred off the toilet, resulting in severe pain and a large red spot on her hip and back. This time, R2 was sent to the hospital and admitted for a pulmonary embolism. The facility's fall event investigation documented that R2 fell due to increased weakness and loss of balance. Interviews with staff revealed inconsistencies in understanding R2's transfer needs, with some staff unsure of the required assistance level. The facility's fall policy aimed to prevent falls and minimize complications, but it was not effectively implemented in R2's case.
Failure to Provide Timely Care and Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure timely care and respect for residents' dignity, resulting in negative experiences for two residents. One resident, identified as R117, experienced prolonged pain due to a delay in receiving pain medication. Despite activating the call light at 7:45 PM, the resident did not receive the medication until 9:15 PM, leading to feelings of insignificance and being chastised by a nurse for frequent use of the call light. The resident, who is cognitively intact, documented the times of the call light activation and medication administration, highlighting the delay in care. Another resident, R11, was found in a state that compromised his dignity. R11, who has a moderate cognitive impairment and requires assistance with activities of daily living, was left sitting in a recliner with a saturated incontinence brief while visitors, including his wife, were present. The resident's wife had activated the call light for assistance, but there was a delay in response due to the need for an RN to disconnect the IV. The resident's brief fell to the floor due to its saturation when he was eventually assisted to the restroom, causing embarrassment. The facility's policies on resident rights and call light response were not adhered to, as evidenced by the delayed response to call lights and the lack of timely care provided to the residents. The facility's Resident Rights Policy emphasizes the importance of treating residents with dignity and respect, while the Call Lights policy mandates prompt response to residents' needs. These policies were not followed, leading to the deficiencies observed in the care of R117 and R11.
Failure in Timely Pain Management for Resident
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident, identified as R117, who was experiencing significant pain due to a left femur fracture and chronic pain syndrome. R117 reported turning on his call light to request pain medication, but it took approximately two hours before he received it. During this time, his pain level increased from a 7 to a 9 on a 1-10 pain scale. The resident was on scheduled Oxycodone for pain management, which was changed to a PRN order shortly before the incident. The Medication Administration Record confirmed that R117 received his Oxycodone at 1:07 PM and again at 9:07 PM on the day in question. Interviews with facility staff, including the Minimum Data Set and Care Plan Coordinator and the Director of Nursing, revealed that the facility's pain management policy was not followed effectively. The policy emphasizes the importance of timely pain assessment and management, with self-reporting as the preferred indicator of pain. However, R117 stated that nurses occasionally asked him to rate his pain, but not consistently. The Director of Nursing acknowledged that the nurse should have addressed the resident's pain more promptly, indicating a lapse in adherence to the facility's pain management guidelines.
Failure to Post Daily Nursing Staff Hours
Penalty
Summary
The facility failed to post the daily nursing staff hours, which has the potential to affect all 58 residents residing in the facility. On 11/19/24, the survey team observed that the posted daily nursing staffing hours by the front entrance were dated 11/14/24. The Administrator, V1, acknowledged that the nursing department hours are supposed to be posted daily and was unaware of why they had not been updated since 11/14/24. V21, the Scheduler responsible for posting the hours, stated she did not know who was responsible for posting on weekends and was unsure why the last update was on 11/14/24. Additionally, both V1 and the Director of Nursing, V2, confirmed that the facility does not have a policy for posting staffing information.
Medication Preparation and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication preparation and storage protocols, as observed during a survey. An LPN was seen with five unlabeled medication cups containing multiple pills on top of a medication cart. The LPN admitted to not labeling the cups and administering medications in order by room number without performing hand hygiene before or after administering medications to residents. Additionally, the LPN did not document the medication administration immediately after giving the medications to the residents. Another LPN confirmed that pre-pouring medications is not the facility's procedure and emphasized the importance of hand hygiene and checking medications against the MAR. Further observations revealed that another LPN was seen administering medications to residents without performing hand hygiene before or after the process. This LPN also had an unlabeled medicine cup with pills in the medication cart, which was intended for a resident who had initially refused the medication. The LPN admitted to documenting the medication as given despite the resident's refusal. Additionally, a Basaglar Insulin pen without a name or date and a Tuberculin vial without an open date were found in the medication cart, with the latter not stored in the refrigerator as required. The facility's policies on medication storage and administration were not followed, as evidenced by the presence of unlabeled and improperly stored medications. The facility's policy requires drugs and biologicals to be stored in locked compartments under proper conditions and labeled correctly. The policy also mandates hand hygiene between residents during medication administration and documentation immediately after giving medications. The survey findings indicate a failure to comply with these policies, potentially affecting all residents in the facility.
Food Storage and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure proper food storage and hygiene practices in the kitchen, which could potentially affect all 58 residents. During an initial tour, it was observed that the Food and Beverage Manager, who had a beard, was not wearing a beard cover while preparing food. Additionally, several food items in the dry storage area, walk-in refrigerator, and walk-in freezer were found open, unsealed, and not dated or labeled. This included bags of spaghetti noodles, dry cereals, flour, shredded cheese, barbeque sauce, chicken base paste, French fries, garden vegetables, and egg omelets. The facility's policy requires all open products to be sealed, labeled, and dated to ensure quality and prevent contamination. Furthermore, the walk-in freezer had significant issues with ice buildup and condensation. There was condensation dripping from a light fixture onto a box of chocolate shakes, and the pipes under the condenser fan were covered with ice. The freezer's light fixture was covered with icicles, and there was ice buildup on the floor and the bottom of the freezer door. Despite these observations, the Food and Beverage Manager denied any current issues with the freezer, attributing the ice formations to frequent and prolonged access by staff. The facility's policy states that food should not be stored under leaking water lines, sprinkler heads, or condensers, and all open products should be sealed, labeled, and dated.
Inadequate QAPI Policy and Medication Labeling Issues
Penalty
Summary
The facility failed to develop a comprehensive policy and procedure for its Quality Assurance Improvement Plan (QAPI) and did not ensure that corrective actions and performance improvements were sustained. The existing policy, dated 11/28/16, was a one-page document that outlined the committee's responsibilities but lacked detailed procedures for obtaining feedback from residents and staff, collecting and monitoring data, and identifying, reporting, tracking, and monitoring concerns. The administrator confirmed that this was the only policy available and acknowledged the absence of documentation regarding the process. Additionally, during a survey, it was observed that the facility had ongoing issues with pharmacy services, specifically related to the labeling and storage of medications. An LPN was found passing medications without labeling the cups with residents' names, and there were unlabeled medications and improperly stored items in the medication cart. Despite previous citations for similar issues, the facility's Director of Nursing was unaware of the current problems with pre-pouring and labeling medications, indicating a lack of sustained corrective action and oversight.
Inadequate Infection Control Program and Lack of Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of ongoing tracking and trending of infections among residents and employees. The Director of Nursing (DON) admitted that the infection control log for November 2024 was incomplete and that employee illnesses were not being tracked. Additionally, the facility's infection control policies were outdated and undated, with some policies dating back to 2001 and last revised in 2012. The Administrator acknowledged the policies were old and stated they would update them if issues arose. Furthermore, the facility did not implement Enhanced Barrier Precautions, despite the presence of residents who could benefit from such measures. Specific instances of non-compliance were observed, including the absence of signage for Enhanced Barrier Precautions on the doors of residents with medical devices that increased their risk of infection. One resident with a suprapubic catheter had no documentation of being on Enhanced Barrier Precautions, and the nurse on duty was unaware of any residents requiring such precautions. The facility's policies did not address Enhanced Barrier Precautions, which are recommended by the CDC to prevent the spread of multidrug-resistant organisms. These deficiencies have the potential to affect all 58 residents in the facility.
Deficiencies in Infection Control Program
Penalty
Summary
The facility was found to have deficiencies in its infection prevention and control program, primarily due to the lack of a fully qualified and proactive Infection Preventionist (IP). The Director of Nursing (DON), who also serves as the IP, had only recently obtained her certification and admitted to not tracking or trending employee illnesses as part of the infection control program. Additionally, there was no infection control log available for November 2024, and the process of maintaining such logs was described as a work in progress. The facility's administrator confirmed that the DON was in charge of infection control, despite the administrator having prior experience in this area during the COVID pandemic. Further deficiencies were noted in the management of residents receiving antibiotics. Two residents were on antibiotics for urinary tract infections without accompanying urinalysis or culture and sensitivity tests in their medical records. The IP admitted to not consistently following up with hospitals for such information when residents were admitted on antibiotics. Additionally, the facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices, despite the IP acknowledging awareness of the requirement. The facility lacked a policy or job description for the IP position, indicating a need for further development in their infection control protocols.
Inadequate Incontinent Care and Hygiene Practices
Penalty
Summary
The facility failed to provide complete and timely incontinent care for several residents, leading to deficiencies in their care. Resident R11 was found sitting in a recliner with a saturated incontinence brief, which dropped to the floor due to its weight when he stood up. Despite his wife's attempts to get assistance, there was a delay in care because the CNA could not disconnect the IV, and the RN was not immediately available. Additionally, R11's chair alarm did not activate, and there was no proper cleaning of his anal area after using the toilet. Resident R48 received inadequate incontinent care when CNAs used soiled gloves to handle clean supplies, contaminating them. The CNAs failed to clean R48's penis properly, including retracting the foreskin, and did not change gloves between dirty and clean tasks. Similarly, R176's care was compromised as CNAs used the same gloves to clean different areas, did not dry the resident, and failed to apply barrier cream, despite the presence of a yeast infection. Resident R27's care was also deficient, as CNAs did not perform hand hygiene before and after care, failed to dry the resident's skin, and did not apply barrier cream to reddened areas. The facility's policies on incontinent care and hand hygiene were not followed, contributing to the inadequate care provided to these residents.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in addressing their medical needs. Resident 14, diagnosed with major depressive disorder and anxiety disorder, had physician orders for buspirone and citalopram, yet their care plan did not address these diagnoses or the need for prescribed psychotropic medication. Similarly, Resident 18, diagnosed with vascular dementia and altered mental status, exhibited agitation and noncompliance with CPAP and diet restrictions, but their care plan lacked documentation of care approaches for dementia. Resident 35, with a history of traumatic subdural hemorrhage, anemia, anxiety, and atherosclerotic heart disease, sustained an arm injury while propelling themselves in a wheelchair. Despite undergoing a skin graft procedure, the care plan did not document the arm injury or post-surgical care for the skin graft. Additionally, the facility failed to address the root cause of the injury or implement new interventions to prevent further skin impairments. The facility's care plan policy mandates individualized, person-centered care plans within seven days of assessment, but these requirements were not met for the residents in question.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement adequate safety measures to prevent a fall for a resident, identified as R11, who was at risk for falls due to multiple health conditions including dementia, Parkinson's disease, and impaired mobility. Despite having a care plan that included interventions such as a bed and chair alarm, the facility did not ensure these measures were consistently applied. On one occasion, R11 fell while attempting to self-transfer after his wife left the room and closed the door, preventing staff from hearing the alarm. The fall resulted in bleeding from his leg, and it was noted that the alarm was not transferred from the bed to the chair when R11 was moved, as it should have been. Additionally, the facility did not complete a Fall Risk Assessment after R11's fall, which is a requirement according to the facility's Falls Policy. The policy mandates that a licensed nurse complete a Fall Risk Assessment following any fall and implement relevant interventions to minimize serious consequences. Interviews with staff and R11's wife confirmed that the alarm was not consistently used as intended, and the Director of Nursing acknowledged that a Fall Risk Assessment should have been completed after the fall.
Failure to Follow Tube Feeding Protocol
Penalty
Summary
The facility failed to adhere to its policy regarding tube feeding administration for a resident receiving enteral tube feeding. During observations, it was noted that a bottle of enteral tube feeding and a bag of water were hanging without any indication of the date or time they were opened. This occurred on two separate occasions, with 200 milliliters of feeding and 100 milliliters of water remaining in the containers. The facility's protocol requires that containers, tubing, and syringes be replaced every 24 hours and that unused or open containers of feeding formula be discarded. The Director of Nursing confirmed that there should be a date and time to indicate when the tube feeding was opened, which was not followed in this instance.
Inadequate Respiratory Care for Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, R170 and R175, who required oxygen therapy. R170, who was admitted with multiple diagnoses including congestive heart failure and esophageal cancer, was observed with inconsistent oxygen administration. The resident's care plan did not mention the need for oxygen, and observations showed that the oxygen nasal cannula was often not in use, with the humidified water bottle undated and not changed as per physician orders. The resident's oxygen saturation was recorded below the required level, and the oxygen flow was not adjusted accordingly. Similarly, R175, who had diagnoses including pneumonia and COPD, was found receiving an incorrect oxygen dose of 4 liters per minute, despite the physician's order for 2 liters per minute. The resident was aware of the discrepancy but continued to receive the incorrect dose. Additionally, there was no signage indicating oxygen use in the rooms of either resident, and the facility's policy on oxygen administration was not followed, as confirmed by the Director of Nursing and an LPN. The facility's failure to adhere to physician orders and its own policies resulted in inadequate respiratory care for these residents.
Failure to Re-evaluate Psychotropic Medication Orders
Penalty
Summary
The facility failed to re-evaluate the need for psychotropic medications for two residents, leading to a deficiency in medication management. Resident 19 was prescribed alprazolam 0.5 mg twice a day as needed, starting on 10/18/2024, without an end date. Similarly, Resident 6, who requires hospice care due to senile degeneration of the brain, was prescribed lorazepam 0.5 mg every four hours as needed, starting on 3/21/2024, also without an end date. The Director of Nursing acknowledged awareness of the requirement for psychotropic medication orders to be re-evaluated and re-written every 14 days but was unaware that the same rules apply to hospice residents. As of 11/25/2024, the facility had not provided a policy addressing unnecessary or psychotropic medications.
Failure in Antibiotic Stewardship and Documentation
Penalty
Summary
The facility failed to ensure proper antibiotic stewardship for three residents, leading to the administration of antibiotics without appropriate indications. For one resident, the Director of Nursing (DON) admitted that a urine culture was not completed before prescribing antibiotics for a suspected urinary tract infection (UTI), and the resident did not exhibit any symptoms of a UTI. Another resident was prescribed multiple antibiotics over a short period without clear documentation of a urine culture to justify the treatment. The DON acknowledged that when residents are hospitalized, culture results are not always obtained, and there was no policy in place for antibiotic stewardship. A third resident was admitted with a diagnosis of sepsis and a UTI, but the facility records did not include a culture and sensitivity report to confirm the causative organism. The facility's infection control log failed to document whether the criteria for antibiotic use were met. Additionally, the facility's infection control policy, last revised in 2012, required the review of culture reports, but there was no evidence that this was being done. The lack of documentation and adherence to antibiotic stewardship protocols contributed to the inappropriate use of antibiotics.
Failure to Follow Vaccination Policy for Two Residents
Penalty
Summary
The facility failed to adhere to its influenza and pneumococcal vaccination policy for two residents. For one resident, the physician's order indicated that the influenza vaccine should be administered annually unless contraindicated. However, the resident did not receive the vaccine, and there was no documentation of declination or contraindication. The administrator suggested that the resident, who was under hospice care, might have opted out, but there was no proof of this decision. The resident's records showed that the flu vaccine was not up to date since 2022. Another resident received both the influenza and pneumococcal vaccines, as documented in their progress notes. However, the facility's policy requires that the resident's clinical record reflect education provided about the benefits and potential side effects of the vaccines, as well as documentation of administration, contraindication, or refusal. The report does not confirm whether this documentation was completed as per the policy.
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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) |
|---|---|---|---|---|
| Arc At Sangamon Valley | 1 mi | — | 4 | 0 |
| Concordia Village Care Center | 1.5 mi | — | 3 | 0 |
| Regency Care | 1.6 mi | — | 1 | 0 |
| Arcadia Care On The Hill | 3.1 mi | — | 30 | 2 |
| Avenues At Springfield | 4.5 mi | — | 0 | 0 |
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