ElderGrade

Inspection citations at Springbrook Center

30 citations on record, 2 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2025 5 2
2024 15 0
2023 9 0
2021 1 0
D October 28, 2025 Tag F0657 Complaint investigation Corrected Nov 2025

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

No actual harm, potential for more than minimal harm

D October 28, 2025 Tag F0656 Complaint investigation Corrected Dec 2025

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

G October 28, 2025 Tag F0689 Complaint investigation Corrected Dec 2025

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Actual harm to a resident

D July 31, 2025 Tag F0686 Complaint investigation Corrected Sep 2025

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

No actual harm, potential for more than minimal harm

G May 12, 2025 Tag F0760 Complaint investigation Corrected Jun 2025

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Actual harm to a resident

D July 19, 2024 Tag F0867 Corrected Oct 2024

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

No actual harm, potential for more than minimal harm

D July 19, 2024 Tag F0842 Corrected Sep 2024

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

No actual harm, potential for more than minimal harm

D July 19, 2024 Tag F0791 Corrected Sep 2024

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

No actual harm, potential for more than minimal harm

D July 19, 2024 Tag F0761 Corrected Sep 2024

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

No actual harm, potential for more than minimal harm

D July 19, 2024 Tag F0726 Corrected Sep 2024

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

No actual harm, potential for more than minimal harm

D July 19, 2024 Tag F0684 Complaint investigation Corrected Sep 2024

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D July 19, 2024 Tag F0557 Corrected Oct 2024

Resident Rights Deficiencies

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

No actual harm, potential for more than minimal harm

E July 19, 2024 Tag F0880 Corrected Oct 2024

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

E July 19, 2024 Tag F0677 Corrected Sep 2024

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

No actual harm, potential for more than minimal harm

E July 19, 2024 Tag F0656 Corrected Oct 2024

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

E July 19, 2024 Tag F0584 Corrected Sep 2024

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

No actual harm, potential for more than minimal harm

D April 25, 2024 Tag F0557 Complaint investigation Corrected May 2024

Resident Rights Deficiencies

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

No actual harm, potential for more than minimal harm

D February 28, 2024 Tag F0607 Complaint investigation Corrected Apr 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

No actual harm, potential for more than minimal harm

E February 28, 2024 Tag F0689 Complaint investigation Corrected Apr 2024

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

D January 18, 2024 Tag F0842 Complaint investigation Corrected Feb 2024

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

No actual harm, potential for more than minimal harm

E December 6, 2023 Tag F0657 Complaint investigation Corrected Jan 2024

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

No actual harm, potential for more than minimal harm

E December 6, 2023 Tag F0584 Complaint investigation Corrected Jan 2024

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

No actual harm, potential for more than minimal harm

E November 28, 2023 Tag F0584 Complaint investigation Corrected Jan 2024

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

No actual harm, potential for more than minimal harm

D April 27, 2023 Tag F0761 Corrected Jun 2023

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

No actual harm, potential for more than minimal harm

D April 27, 2023 Tag F0684 Corrected Jun 2023

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D April 27, 2023 Tag F0677 Corrected Jun 2023

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

No actual harm, potential for more than minimal harm

D April 27, 2023 Tag F0658 Corrected Jun 2023

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

No actual harm, potential for more than minimal harm

D April 27, 2023 Tag F0655 Corrected Jun 2023

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

No actual harm, potential for more than minimal harm

D April 27, 2023 Tag F0622 Corrected Jun 2023

Resident Rights Deficiencies

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

No actual harm, potential for more than minimal harm

E June 24, 2021 Tag F0584 Corrected Jul 2021

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.