Springfield Nursing & Independent Living

In the surveyor’s words

From the most serious findings on record at Springfield Nursing & Independent Living, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 13, 2023

  Based on observation, interviews with facility staff and resident representatives, medical record review, review of a facility investigation, review of hospital records, and review of the facility policy on elopement, the facility failed to provide adequate supervision for Resident #60, who had severely impaired cognition and had a history of exit seeking behaviors. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death when Resident #60 displayed a change in condition, began having exit seeking behaviors identified by the facility staff on [DATE], and a physician order was requested for fifteen-minute checks related to Resident #60's newly identified behavior of pushing on exit doors and attempting to exit the facility unsupervised. […]

• Actual harm, isolatedF760May 22, 2024

  Based on medical record review, staff interview, and policy review, the facility failed to reconcile medications following a hospital re-admission. This resulted in Actual Harm when Resident #210 was admitted to the psychiatric hospital on 03/25/24 and upon return to the facility on [DATE], the facility failed to continue the psychiatric medications resulting in a change in condition and hospitalization . This affected one (Resident #210) of one resident reviewed for medication reconciliation. The facility census was 61. Findings include: Review of the medical record for Resident #210 revealed an admitted [DATE]. […]

• No harm, potential for more than minimal, widespreadF801Jun 4, 2026

  Based on record review and staff interview, the facility failed to have a qualified dietary manager. This had the potential to affect all of the residents residing in the facility with the exception of one facility identified (Resident #17) who did not receive food from the kitchen. The facility census was 61 residents. Findings include: Observation on 06/01/26 at 8:40 A.M. revealed there was no evidence posted indicating the facility Dietary Manager (DM) #343 or other kitchen staff met the minimum qualifications to serve as DM for the facility. Interview on 06/01/26 at 8:41 A.M. […]

• No harm, potential for more than minimal, widespreadF803Jun 4, 2026

  Based on menu review, observation, staff interview, and review of dietary spreadsheets, the facility failed to ensure menus were followed and a substitution log was maintained. This had the potential to affect all of the residents residing in the facility with the exception of one facility-identified (Resident #17) who did not receive food from the kitchen. The facility census was 61 residents. Findings include: 1. Review of the menu dated 06/01/26 revealed residents were to be served chicken, rice, and broccoli at the lunch meal. Observations on 06/01/26 between 11:30 A.M. and 1:00 P.M. made on both units and in the dining room revealed residents were served tuna casserole and peas. Interview on 06/01/26 at 8:40 A.M. […]

• No harm, potential for more than minimal, widespreadF812Jun 4, 2026

  Based on observation, staff interview, record review, and policy review, the facility failed to ensure food was stored in a manner to protect against the potential spread of foodborne illness, failed to maintain the kitchen in a clean and sanitary manner, failed to maintain accurate temperature and chemical logs, and failed to ensure proper chemical utilization for the dishwasher. This had the potential to affect all of the residents residing in the facility with the exception of one facility-identified (Resident #17) who did not receive food from the kitchen. The facility census was 61 residents. Findings include: 1. […]