ElderGrade

Inspection citations at Springfield Nursing & Independent Living

50 citations on record, 1 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 2 0
2025 11 0
2024 17 1
2023 3 0
2022 11 0
2019 6 0
F January 29, 2026 Tag F0925 Complaint investigation Corrected Feb 2026

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

No actual harm, potential for more than minimal harm

F January 29, 2026 Tag F0584 Complaint investigation Corrected Feb 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

C May 22, 2025 Tag F0732 Complaint investigation Corrected Jul 2025

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

No actual harm, minimal potential

D May 22, 2025 Tag F0880 Complaint investigation Corrected Jul 2025

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D May 22, 2025 Tag F0825 Complaint investigation Corrected Jul 2025

Quality of Life and Care Deficiencies

Provide or get specialized rehabilitative services as required for a resident.

No actual harm, potential for more than minimal harm

D May 22, 2025 Tag F0759 Complaint investigation Corrected Jul 2025

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

No actual harm, potential for more than minimal harm

D May 22, 2025 Tag F0693 Complaint investigation Corrected Jul 2025

Quality of Life and Care Deficiencies

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

No actual harm, potential for more than minimal harm

D May 22, 2025 Tag F0686 Complaint investigation Corrected Jul 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

D May 22, 2025 Tag F0684 Complaint investigation Corrected Jul 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 May 22, 2025 Tag F0637 Complaint investigation Corrected Jul 2025

Resident Assessment and Care Planning Deficiencies

Assess the resident when there is a significant change in condition

No actual harm, potential for more than minimal harm

D May 22, 2025 Tag F0610 Complaint investigation Corrected Jul 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

No actual harm, potential for more than minimal harm

D May 22, 2025 Tag F0559 Complaint investigation Corrected Jul 2025

Resident Rights Deficiencies

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

No actual harm, potential for more than minimal harm

F May 22, 2025 Tag F0921 Complaint investigation Corrected Jul 2025

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

No actual harm, potential for more than minimal harm

C May 22, 2024 Tag F0680 Corrected Jun 2024

Quality of Life and Care Deficiencies

Ensure the activities program is directed by a qualified professional.

No actual harm, minimal potential

D May 22, 2024 Tag F0909 Corrected Jun 2024

Environmental Deficiencies

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

No actual harm, potential for more than minimal harm

D May 22, 2024 Tag F0700 Corrected Jun 2024

Quality of Life and Care Deficiencies

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

No actual harm, potential for more than minimal harm

D May 22, 2024 Tag F0677 Corrected Jun 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

D May 22, 2024 Tag F0661 Corrected Jun 2024

Resident Assessment and Care Planning Deficiencies

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

No actual harm, potential for more than minimal harm

D May 22, 2024 Tag F0656 Corrected Jun 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

D May 22, 2024 Tag F0550 Corrected Jun 2024

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

No actual harm, potential for more than minimal harm

E May 22, 2024 Tag F0887 Corrected Jun 2024

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 May 22, 2024 Tag F0755 Corrected Jun 2024

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

No actual harm, potential for more than minimal harm

E May 22, 2024 Tag F0657 Corrected Jun 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 May 22, 2024 Tag F0584 Corrected Jun 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

F May 22, 2024 Tag F0880 Corrected Jun 2024

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

F May 22, 2024 Tag F0868 Corrected Jun 2024

Administration Deficiencies

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

No actual harm, potential for more than minimal harm

F May 22, 2024 Tag F0812 Corrected Jun 2024

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

F May 22, 2024 Tag F0803 Corrected Jun 2024

Nutrition and Dietary Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

No actual harm, potential for more than minimal harm

G May 22, 2024 Tag F0760 Corrected Jun 2024

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Actual harm to a resident

D January 16, 2024 Tag F0584 Complaint investigation Corrected Feb 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 September 27, 2023 Tag F0690 Complaint investigation Corrected Oct 2023

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

No actual harm, potential for more than minimal harm

D September 27, 2023 Tag F0609 Complaint investigation Corrected Oct 2023

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 September 27, 2023 Tag F0607 Complaint investigation Corrected Oct 2023

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 May 26, 2022 Tag F0700 Corrected Aug 2022

Quality of Life and Care Deficiencies

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

No actual harm, potential for more than minimal harm

D May 26, 2022 Tag F0689 Corrected Aug 2022

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 May 26, 2022 Tag F0657 Corrected Aug 2022

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 May 26, 2022 Tag F0656 Corrected Aug 2022

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

D May 26, 2022 Tag F0646 Corrected Aug 2022

Resident Assessment and Care Planning Deficiencies

Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.

No actual harm, potential for more than minimal harm

D May 26, 2022 Tag F0641 Corrected Aug 2022

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

No actual harm, potential for more than minimal harm

D May 26, 2022 Tag F0578 Corrected Aug 2022

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

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.