Complete Care at Springbrook

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure a safe, clean, and comfortable homelike environment for the residents. This was evident for multiple areas within the facility observed during the annual survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to complete a quarterly Minimum Data Set (MDS) assessment within 14 days after the assessment reference date. This was evident for 6 (Resident #22, # 41, #80, #47, #58, and #69 ) of 7 residents reviewed during the annual survey.

Inspectors wroteBased on review of Minimum Data Set (MDS) Assessment material and interview with facility staff, it was determined that the facility failed to transmit MDS assessments within 14 days of completion of the assessment. This was evident for 5 (Resident #22, #41, #80, #47 and #58 ) of 7 residents reviewed during the annual survey.

Inspectors wroteBased on observations, Resident and staff interviews and surveyor record reviews it was determined that the facility failed to code Minimum Data Set (MDS) Assessments accurately for Residents. This finding was found to be evident in 2 (Resident #13 and #23) out of 2 Residents reviewed for falls and continence.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure residents were served meals according to their meal ticket. This was evident for 11 (Resident #14, #19, #30, #39, #41, #51, #58, #66, #70, #87, and #92) of 83 trays observed during the lunch meal tray lineThe

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation and interview, it was determined that the facility failed to maintain residents dignity by staff knocking prior to entering their rooms. This was evident for 3 (Resident #48, #67, #73) of 24 residents screened during the initial pool process of the annual survey.

Inspectors wroteBased on observation, staff interviews and surveyor record reviews it was determined that the facility failed to develop/implement a comprehensive care plan for a Resident. This finding was found to be evident in 1 (Resident #13) out of 4 Residents reviewed for care plans.

Inspectors wroteBased on observation, interviews, and record review, it was determined that the facility failed to provide residents who are unable to carry out activities of daily living (ADLs) the necessary services to maintain personal hygiene. This was evident for 2 (Resident #54 and #109) of 3 residents reviewed for ADLs during the annual survey

Inspectors wroteBased on review of medical records and interview with staff, it was determined that the facility failed to respond to recommendations made by consulting pharmacists in a timely manner. This was evident for 1 (Residents #88) of 5 residents reviewed during the annual survey.

Inspectors wroteBased on observations, staff interviews and surveyor record reviews it was determined that the facility failed to ensure that physician medication orders had 1) appropriate indication for usage of the medications and 2) appropriate monitoring and documenting for side effects of medications for a Resident. This finding was found to be evident in 1 (Resident #111) out of 3 Residents reviewed for physician medication orders.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure food was stored to maintain food safety. This was evident during the initial observation of the kitchen upon survey entry.

Inspectors wroteBased on record review and interview, it was determined that the facility staff failed to ensure resident medical records were accurately documented and maintained according to professional standard of practice. This was evident for 3 (Resident #3 #78 and #13) of 7 residents reviewed for advance directives and medical records accuracy.

Inspectors wroteBased on record review and staff interview, it was the determined that the facility failed to report an incident involving a resident who had a serious injury of unknown source, where abuse or neglect had not been ruled out, to the Office of Health Care Quality (OHCQ) as required. This was evident for 1 (Resident #12) of 13 residents reviewed during a complaint survey.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to complete a thorough and timely investigation of an incident involving a resident who had a serious injury of unknown source. This was evident for 1 (Resident #12) of 13 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) discharge assessments were completed for a discharged resident. This was evident for 1 (Resident #2) of 13 residents reviewed during a complaint survey.

Inspectors wroteBased on record review, observations and staff interviews, it was determined that the facility failed to ensure implementation of care planned interventions necessary to prevent accidents for a resident identified as high risk for falls. This was evident for 1 (Resident #12) of 3 residents reviewed for accidents during the complaint survey.

Inspectors wroteBased on record review, resident, facility staff interviews, the facility failed to provide medication administration that meets professional standards for 5 of 8 sampled residents reviewed for medication administration. (Resident #27, Resident #23, Resident #28, Resident #29 and Resident #30). 1. Resident #27 was admitted to the facility on [DATE] with a diagnosis of diabetes. A review of the physician's orders dated 11/22/25 revealed Resident #27 was prescribed insulin lispro injection solution; inject as per sliding scale if 0 - 150 = 0 units; 151 - 200 = 2 units; 201 - 250 = 3 units; 251 - 300 = 4 units; 301 - 350 = 5 units; 351 - 400 = 6 units Blood sugar above 400, give 7 units. Repeat Blood Sugar in 15 minutes and call provider., subcutaneously before meals and at bedtime for diabetes. [...]

Inspectors wroteBased on interviews, observations and recorded reviews, the facility failed to provide a direct communication system which relays Resident(R) calls when assistance was needed to ensure appropriate response from staff members at a centralized staff working station for three Residents, R35, R36, and R37. The facility census was 78. Findings Include: Record review of the facility undated policy titled Call Lights, Accessibility and Timely Response documented, the purpose of the policy was to assure the facility equipped Residents with a call light at each Resident bedside, toilet and bathing area to allow Residents to call for assistance. Call lights will directly be relayed to staff member or centralized location to ensure appropriate response. Policy directed staff to ensure the call light was within reach and secured as needed. [...]

Inspectors wroteBased on interviews of observations and recorded reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for three Residents(R). R13, R33 and R34, when facility failed to replace a damaged and leaking commode toilet in R33 and R34s bathroom for several months and failed to provide a sanitary environment in R13s room. The census was 78. Findings Include: Record review of the facility undated policy titled Safe and Comfortable Environment dated 12/11/2024 and last reviewed on 2/11/2025 documented; in accordance with Residents rights, the facility will provide a safe, clean, comfortable and homelike environment. Housekeeping and maintenance services will be provided to maintain a sanitary, orderly, and comfortable environment. [...]

Inspectors wroteBased on record review, resident, facility and pharmacy staff interviews, the facility failed to administer medication as ordered by the physician to meet the resident's need of 3 of 8 sampled residents reviewed for pharmacy services. (Resident #23, Resident #29 and Resident #30). a. Resident #23 was admitted to the facility on [DATE] with a diagnosis of seizures adjustment disorder, hypertension, diabetes and dysarthria. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact. A review of the physician's orders dated 11/3/25 revealed Resident #23 was prescribed Biofreeze cool the pain external gel 4% (menthol topical analgesic) apply to right shoulder topically two times a day for pain. A medication administration observation was conducted on 12/16/25 at 9:22 am with Staff Nurse #5. [...]

Inspectors wroteBased on observations, record review , staff and pharmacist interviews, the facility failed to maintain a medication error rate of less than 5% as evidenced by 5 errors out of 43 opportunities observed. The medication error rate was 11%. 1. A review of the physician's orders dated 11/3/25 revealed Resident #23 was prescribed Biofreeze cool the pain external gel 4% (menthol topical analgesic) apply to right shoulder topically two times a day for pain. A medication administration observation was conducted on 12/16/25 at 9:22 am with Staff Nurse #5. Staff Nurse #5 was observed to not have administered the medication biofreeze cool the pain external gel 4%(menthol topical analgesic) to Resident #23 as per physician orders. During interview on 12/18/25 at 10:33 am, Staff Nurse #5 stated that she thought she administered the medication to Resident #23. 2. [...]

Inspectors wroteBased on observations, and staff and pharmacist interviews, the facility failed to label opened insulin pens with the patient name, physician name, date used for 1 insulin pens for 1 of 3 medication carts reviewed for medication storage (West Wing Medication Cart). The [NAME] Wing Medication Cart was observed on 12/16/25 at 11:49 am in the presence of Staff Nurse #6. The observation revealed 1 opened and used insulin pen of Humalog (insulin lispro) that was stored with no label indicating patient name, physician name and order. The facility insulin pens policy copyright 2025, provided by the Director of nursing , indicated that Insulin pens must be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency, and expiration date. [...]

Inspectors wroteBased on observations, record reviews, and staff interviews, it was determined that the facility failed to ensure medications were administered to a resident as ordered. This was evident for 6 (Resident #77, #7, #38, #48, #90 & #85) out 14 residents reviewed for medication regimen review and medication administration.

Inspectors wroteBased on interviews and record review it was determined that the facility failed to develop and implement a comprehensive care plan to meet the needs of a Resident. This was found evident of 1 (Resident #85) of 19 Residents reviewed for care planning during an annual and complaint survey.

Inspectors wroteBased on observation, meal ticket review and interview, it was determined that the facility staff failed to ensure the residents' food preferences were honored. This was found to be evident for 1(Resident #9) out of 38 residents reviewed for food/nutrition.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to report allegations of abuse within the required timeframe for 3 (Residents #13, #27, and #32) of 19 residents reviewed for abuse allegations.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to conduct a thorough investigation into an allegation of neglect by failing to conduct interviews with facility staff assigned to care for the resident. This affected 1 (Resident #13) of 19 residents reviewed for abuse and neglect.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure necessary treatment and services were provided to promote healing of pressure ulcers for 2 (Resident #3 and Resident #21) of 13 residents reviewed for pressure ulcers. Specifically, the facility failed to ensure weekly wound assessments were consistently completed and documented as per the care plan and to promptly consult with the attending physician or wound nurse practitioner (NP) regarding deterioration of a pressure ulcer for Resident #3. Additionally, the facility failed to provide wound treatments as ordered for Resident #21.

Inspectors wroteBased on observation, interview, record review, facility document review, and facility policy review, the facility failed to ensure a physician-ordered intervention for bed rails was consistently implemented to assist the resident with safe bed mobility and minimize the risk of falls out of bed for 1 (Resident #4) of 5 residents reviewed for falls.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the complete medical record was retained for a minimum of five years from the date of the residents' discharge for 2 (Resident #33 and Resident #34) of 45 residents whose medical records were reviewed.

Inspectors wroteBased on observation and staff interview, it was determined that the facility staff failed to label drugs and biologicals in accordance with accepted professional standards. This was evident for 1 of 1 medication storage room selected for medication storage inspection during the survey.

Inspectors wroteBased on surveyor observation, review of clinical records, facility policy and procedures and interview with facility staff, it was determined that the facility staff failed to ensure infection control practices to prevent development and transmission of communicable disease and infections for residents. This finding was evident for 3 of 25 residents reviewed during annual survey (Resident #16, #67, and #281).

Inspectors wroteBased on review of medical records, interviews and observations, the facility failed to safeguard the disclosure of medical information. This was evident for 1 resident of 25 residents reviewed during the survey (Resident #63).

Inspectors wroteBased on record review, facility staff and resident interviews, it was determined that the facility staff failed to assist residents to file a grievance on a missing personal belonging. It was evident for 1 of 1 resident selected for the personal property review (Resident #74).

Inspectors wroteBased on resident record review and staff interviews, it was determined that the facility staff failed to meet professional standards of care. This finding was evident for 1 of 25 residents reviewed for standards of care during the survey (Resident #2).

Inspectors wroteBased on resident record review and staff interviews, it was determined that the facility staff failed to follow physician order to provide resident care. This finding was evident for 1 of 25 residents reviewed for quality of care during the survey (Resident #278).

Inspectors wroteBased on surveyor observation, review of the clinical records and facility staff interview, it was determined that the facility staff failed to ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This finding was evident for 1 of 5 residents selected for review of range of motion during the survey (Resident #5).

Inspectors wroteBased on surveyor review of the clinical record, surveyor observation and interview with a resident and facility staff, it was determined that the facility failed to ensure that a current physician's order was in place for the use and assessment for oxygen use by residents. This finding was evident for 2 of 3 residents selected for the Respiratory Care review. (#37,#55)

Inspectors wroteBased on record review and interview with facility staff, it was determined that the facility failed to develop a complete baseline care plan. This finding was evident for 1 of 25 residents selected for review during the survey. (#9)

Inspectors wroteBased on surveyor review of the clinical record and facility staff interview, it was determined that the facility staff failed to develop a comprehensive resident centered care plan to meet residents' medical condition. This finding was evident in 1 of 25 residents selected for review during the survey. (#61)

Inspectors wroteBased on surveyor review of the clinical record, interview with facility staff and with residents' court appointed guardian, it was determined that the facility staff failed to ensure that interdisciplinary care plan conferences were conducted timely after each resident's MDS assessment. This finding was evident for 3 of 25 residents selected during the survey. (#55, #20,#21)

Inspectors wroteBased on surveyor review of the clinical record, surveyor observation of medication pass and interview with facility staff, it was determined that the facility staff failed to ensure nursing standards of practice for residents. This finding was evident for 2 of 25 residents selected for review during the survey. (#23 and #68)

Inspectors wroteBased on surveyor review of the clinical record and facility staff interview, it was determined that the facility staff failed to follow physician's orders. This finding was evident in 1 of 5 residents selected for unnecessary medication review during the survey. (#72)

Inspectors wroteBased on surveyor review of the clinical record, review of the Beneficiary Protection Notifications and interview with facility staff, it was determined that the facility failed to provide resident #23's responsible party with the NOMNC (Notice of Medicare Non-Coverage) and SNFABN (Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage) in a timely manner. This finding was evident for 1 (#23) of 3 residents selected for the Beneficiary Protection Notification review.

Inspectors wroteBased on record review and interview with facility staff, it was determined that the facility failed to accurately document a resident's responsible party on the face sheet. This finding was evident for 1 of 25 residents selected for review during the survey. (#28)