Springtree Healthcare & Rehab: Medication Delays - VA
The resident, identified in inspection records only as Resident 4, had an order for Insulin Glargine, 40 units subcutaneously at bedtime, starting that same day. They also had an order for oxycodone. When the medications weren't available, nursing staff marked both as a 9 on the medication administration record. On that MAR, a 9 means "other, see progress notes."
The progress notes told the story in pieces. At 6:00 p.m., a nurse wrote that the patient was a new admission and the facility was awaiting delivery from the pharmacy. The note didn't name which medication was missing. At 11:18 p.m., a second note was more specific: Insulin Glargine could not be administered because the patient was a new admit and the medication hadn't arrived from the pharmacy. It wasn't in the Omnicell automated dispensing cabinet either. A physician assistant was made aware, the note said.
That was the end of the documented response.
Inspectors reviewed the facility's stat box, a supply of emergency medications kept on hand for situations exactly like this. Insulin Glargine wasn't on the list. There was no backup available.
The facility had two written policies that applied directly to what happened that night. The first, titled Medication Unavailability, stated that a licensed nurse discovering an unavailable medication would initiate appropriate steps to ensure medical treatment is provided as ordered, and would activate the backup pharmacy process if an alternate medication wasn't available. The second policy, titled Admitting a Patient, included a procedure step to provide pharmacy notification if applicable.
Neither policy appears to have been followed on the night of August 14.
Resident 4 received the insulin the following evening, August 15, at 9:00 p.m., roughly 24 hours after the missed bedtime dose. The oxycodone came at midnight on August 15.
Inspectors raised the issue with the Director of Nursing, a Regional Director of Clinical Services, and a second regional clinical director on August 19, five days after the missed medications. The inspection report notes that no further information regarding this issue was provided to the survey team before the exit conference. The facility offered nothing to explain why the backup pharmacy process wasn't activated, why the admissions procedure didn't trigger a pharmacy notification, or what, if anything, had been done to prevent a repeat.
The level of harm was cited as minimal harm or potential for actual harm, the lower end of the federal scale. A small number of residents were affected.
What the record shows is a resident who came through the door sick enough to need both a long-acting insulin and an opioid pain medication, and spent their first night in the building without either. Staff knew both medications were missing. A physician assistant was told about the insulin. Someone wrote it down. And then, as far as the inspection record shows, nothing happened until a federal surveyor brought it up five days later.
Resident 4 got their insulin the next evening. Whether the gap in their diabetes management caused any measurable harm, the inspection report doesn't say. The facility didn't say either.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
SPRINGTREE HEALTHCARE & REHAB CENTER in ROANOKE, VA was cited for violations during a health inspection on August 20, 2025.
They also had an order for oxycodone.
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.