SpringTree Healthcare: Diabetic Missed Insulin - VA
Resident 4 arrived at the facility on August 14 with physician orders for two essential medications: Oxycodone 5 mg every six hours for pain and Insulin Glargine 40 units at bedtime for diabetes. Both medications were ordered to start immediately upon admission.
The resident never received either drug that first night.
At 6:00 p.m., when staff attempted to administer the first dose of Oxycodone, they discovered the medication wasn't available. A progress note stated only that the "patient is a new admission, awaiting delivery from the pharmacy." The note failed to specify which medication was missing.
Five hours later, at 11:18 p.m., nursing staff tried to give the insulin injection. They couldn't. Another progress note documented: "Insulin Glargine unable to administer medication at this time as patient is a new admit and medication hasn't arrived from pharmacy at this time, medication unavailable in Omnicell."
Staff did notify the physician assistant about the missing insulin. But they took no further action.
The facility's own policies required immediate intervention. Policy titled "Medication Unavailability" stated that "a licensed nurse discovering a medication on order that is unavailable will initiate appropriate steps to ensure medical treatment is provided as ordered." If medications aren't available, nurses must "activate the backup pharmacy process and procedures."
Staff never activated backup pharmacy procedures for either medication.
The facility also maintained a "stat box" containing emergency medications for situations exactly like this. A review of the stat box inventory revealed that neither the insulin nor the Oxycodone would have been available there either.
Resident 4's care plan specifically identified diabetes as a focus area requiring medication administration as ordered. The patient was described as alert and oriented, meaning they likely understood they weren't receiving prescribed treatments.
The medication delays continued into the next day. Staff finally administered the insulin at 9:00 p.m. on August 15 — 24 hours after the original bedtime dose was due. The Oxycodone wasn't given until midnight on August 15, 30 hours after the first scheduled dose.
For a diabetic patient, missing insulin doses can cause dangerous blood sugar spikes. Long-acting insulin like Glargine is designed to provide steady glucose control over 24 hours. Skipping doses disrupts this carefully calibrated system.
The facility's admission policy required staff to "provide pharmacy notification, if applicable" when admitting new patients. Yet the pharmacy delays suggest this notification either didn't happen or occurred too late to ensure medication availability.
Federal inspectors discovered the medication failures five days later during a complaint investigation. On August 19, they notified the Director of Nursing and two Regional Directors of Clinical Services about Resident 4's missed medications.
The nursing home provided no additional information about the incident before inspectors completed their review.
Springfield Healthcare's medication management failures violated federal requirements for ensuring residents receive necessary care and services. The citation carried a determination of "minimal harm or potential for actual harm" affecting few residents.
But for Resident 4, the impact was immediate and personal. Their first night in the facility meant going without the insulin that controlled their diabetes and the pain medication that provided relief — not because the drugs weren't prescribed, but because staff failed to follow their own policies to obtain them.
The case illustrates a common problem in nursing home admissions: the gap between physician orders and actual medication availability. While facilities have policies to address these situations, implementation often falls short when patients need medications most.
Resident 4 eventually received both medications, but only after enduring more than a day without essential treatments that should have been available from the moment they arrived.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Springtree Healthcare & Rehab Center from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 5, 2026 · Our methodology
SPRINGTREE HEALTHCARE & REHAB CENTER in ROANOKE, VA was cited for violations during a health inspection on August 20, 2025.
Both medications were ordered to start immediately upon admission.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.