Springtree Healthcare & Rehab Center
SPRINGTREE HEALTHCARE & REHAB CENTER in ROANOKE, VA — inspection on August 20, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
record dated 08/19/25.
The subject of this in-service was admissions/new.
The facility staff also
with attending physician for the patient's immediate care.No further information regarding this issue
495378 08/20/2025
Springtree Healthcare & Rehab Center 3433 Springtree Drive Roanoke, VA 24012
Insulin Glargine inject 40 units subcutaneously at bedtime for diabetes.
The order date and start date
facility staff documented a 9.
For the medication Oxycodone on 08/14/25 at 6:00 p.m. the facility
Resident #4's clinical record included the following progress notes.08/14/25 at 6:00 p.m. patient is a new admission, awaiting delivery from the pharmacy.
This progress note did not identify what medication was not available. 08/14/25 at 11:18 p.m., 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.
Physician Assistant made aware. A review of the facility stat box list revealed this medication would not have been available in the stat box for administration.
The facility staff provided the surveyor with copies of two policies.
Policy #1 was titled, Medication Unavailability.
This policy read in part, A licensed nurse discovering a medication on order that is unavailable will initiate appropriate steps to ensure medical treatment is provided as ordered.If alternate medication is ordered and is not available, the licensed nurse will activate the backup pharmacy process and procedures.
Policy #2 was titled, Admitting a Patient and read in part, PROCEDURE.Provide pharmacy notification, if applicable.Further review of Resident #4's MAR revealed the nursing staff had administered this resident's insulin on 08/15/25 at 9:00 p.m. and Oxycodone at midnight on 08/15/25. On 08/19/25 at 1:15 p.m. the Director of Nursing (DON), Regional Director of Clinical Services (RDCS) #1 and #2 were notified that Resident #4's insulin and Oxycodone were not available for administration on 08/14/25. No further information regarding this issue was provided to the survey team prior to the exit conference.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.