ElderGrade

Inspection citations at Springfield Health & Rehab

77 citations on record, 18 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
2026 3 0
2025 47 15
2024 22 3
2023 5 0
E April 1, 2026 Tag F0887 Corrected May 2026

Infection Control Deficiencies

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

No actual harm, potential for more than minimal harm

E April 1, 2026 Tag F0584 Corrected May 2026

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 February 17, 2026 Tag F0609 Complaint investigation Corrected Mar 2026

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, potential for more than minimal harm

D December 9, 2025 Tag F0761 Complaint investigation Corrected Dec 2025

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 December 9, 2025 Tag F0561 Complaint investigation Corrected Dec 2025

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

No actual harm, potential for more than minimal harm

E December 9, 2025 Tag F0610 Complaint investigation Corrected Dec 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

No actual harm, potential for more than minimal harm

E December 9, 2025 Tag F0609 Complaint investigation Corrected Dec 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, potential for more than minimal harm

E December 9, 2025 Tag F0607 Complaint investigation Corrected Dec 2025

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

D November 19, 2025 Tag F0726 Complaint investigation Corrected Dec 2025

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 November 19, 2025 Tag F0580 Complaint investigation Corrected Dec 2025

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

No actual harm, potential for more than minimal harm

D November 19, 2025 Tag F0552 Complaint investigation Corrected Dec 2025

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

No actual harm, potential for more than minimal harm

H November 19, 2025 Tag F0760 Complaint investigation Corrected Dec 2025

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Actual harm to a resident

J November 19, 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.

Immediate jeopardy to resident health or safety

J November 19, 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.

Immediate jeopardy to resident health or safety

J November 19, 2025 Tag F0600 Complaint investigation Corrected Dec 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Immediate jeopardy to resident health or safety

K November 19, 2025 Tag F0635 Complaint investigation Corrected Dec 2025

Resident Assessment and Care Planning Deficiencies

Provide doctor's orders for the resident's immediate care at the time the resident was admitted.

Immediate jeopardy to resident health or safety

D March 27, 2025 Tag F0791 Corrected Apr 2025

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

No actual harm, potential for more than minimal harm

D March 27, 2025 Tag F0759 Corrected Apr 2025

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

No actual harm, potential for more than minimal harm

D March 27, 2025 Tag F0697 Corrected Apr 2025

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

No actual harm, potential for more than minimal harm

D March 27, 2025 Tag F0635 Corrected Apr 2025

Resident Assessment and Care Planning Deficiencies

Provide doctor's orders for the resident's immediate care at the time the resident was admitted.

No actual harm, potential for more than minimal harm

D March 27, 2025 Tag F0610 Corrected Apr 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

No actual harm, potential for more than minimal harm

D March 27, 2025 Tag F0552 Corrected Apr 2025

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

No actual harm, potential for more than minimal harm

E March 27, 2025 Tag F0847 Corrected Apr 2025

Administration Deficiencies

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

No actual harm, potential for more than minimal harm

E March 27, 2025 Tag F0812 Corrected Apr 2025

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

E March 27, 2025 Tag F0758 Complaint investigation Corrected Apr 2025

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

No actual harm, potential for more than minimal harm

E March 27, 2025 Tag F0757 Corrected Apr 2025

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

No actual harm, potential for more than minimal harm

E March 27, 2025 Tag F0711 Corrected Apr 2025

Nursing and Physician Services Deficiencies

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

No actual harm, potential for more than minimal harm

E March 27, 2025 Tag F0699 Corrected Apr 2025

Quality of Life and Care Deficiencies

Provide care or services that was trauma informed and/or culturally competent.

No actual harm, potential for more than minimal harm

E March 27, 2025 Tag F0625 Corrected Apr 2025

Resident Rights Deficiencies

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

No actual harm, potential for more than minimal harm

E March 27, 2025 Tag F0623 Corrected Apr 2025

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

No actual harm, potential for more than minimal harm

F March 27, 2025 Tag F0947 Corrected Apr 2025

Nursing and Physician Services Deficiencies

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

No actual harm, potential for more than minimal harm

F March 27, 2025 Tag F0756 Complaint investigation Corrected Apr 2025

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

No actual harm, potential for more than minimal harm

F March 27, 2025 Tag F0726 Corrected Apr 2025

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

F March 27, 2025 Tag F0585 Corrected Apr 2025

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

No actual harm, potential for more than minimal harm

D March 3, 2025 Tag F0684 Complaint investigation Corrected Apr 2025

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 March 3, 2025 Tag F0657 Complaint investigation Corrected Apr 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 March 3, 2025 Tag F0609 Complaint investigation Corrected Apr 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, potential for more than minimal harm

E March 3, 2025 Tag F0842 Complaint investigation Corrected Apr 2025

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 March 3, 2025 Tag F0760 Complaint investigation Corrected Apr 2025

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

No actual harm, potential for more than minimal harm

F March 3, 2025 Tag F0725 Complaint investigation Corrected Apr 2025

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

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.