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
- View all inspection reports for Springtree Healthcare & Rehab Center
- Browse all VA nursing home inspections
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: June 15, 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.
Frequently Asked Questions
- What happened at SPRINGTREE HEALTHCARE & REHAB CENTER?
- Both medications were ordered to start immediately upon admission.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in ROANOKE, VA, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from SPRINGTREE HEALTHCARE & REHAB CENTER or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 495378.
- Has this facility had violations before?
- To check SPRINGTREE HEALTHCARE & REHAB CENTER's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.