NHC Healthcare, Springfield

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to provide an environment free of hazardous materials for 2 of 93 (Resident #3 and #96) sampled for accident hazards.

Inspectors wroteBased on policy review, observation and interview, the facility failed to ensure medications were properly stored and secured when 2 of 6 nurses (Registered Nurse (RN) B and Licensed Practical Nurse (LPN) C) left medication carts unsecured and unattended.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure proper infection control practices were followed when 1 of 6 (Licensed Practical Nurse (LPN) A) nurses failed to wear Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP) while administering medications through a Gastrostomy (surgically placed device used to give direct access to the stomach) tube.

Inspectors wroteBased on facility policy review, medical record review, observation and interview, the facility failed to protect the residents' right to be free from sexual abuse by another resident for 3 of 6 (Resident #1, Resident #6, and Resident #9) sampled residents reviewed for abuse. At an unknown date and time between [DATE] - [DATE], Resident #1 who was severely cognitively impaired was sexually assaulted by Resident #6. Resident #6 who was moderately cognitively impaired was found naked from the waist down and had climbed into his roommate's bed (Resident #1) and attempted sexual intercourse. Certified Nursing Assistant (CNA) C observed that the lights were off, the curtain was pulled between A and B bed, and Resident #6 was on top of Resident #1 (B bed). CNA C screamed for assistance. Licensed Practical Nurse (LPN) A and CNA K arrived to assist CNA C. [...]

Inspectors wroteBased on Facility Assessment review, employee file review, medical record review, observation, and interview, the facility failed to ensure all nursing staff possessed the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely for 1 of 10 (Resident #11) sampled residents. On 1/21/2025, Resident #11 was found in the floor of her room laying face down with her right lower extremity (RLE) next to her face and her left upper extremity (LUE) under her abdomen. Resident #11 was crying and moaning in pain. Licensed Practical Nurse (LPN) L documented that she gently repositioned Resident #11's RLE to baseline, which resulted in actual Harm to Resident #11. [...]

Inspectors wroteBased on facility policy review, medical record review, facility investigation review, and interview, the facility failed to ensure alleged violations involving abuse were reported immediately, but not later than 2 hours, after the allegation was made for 2 of 6 (Resident #1 and Resident #6) sampled residents reviewed for abuse.

Inspectors wroteBased on facility policy, medical record review, facility investigation review, and interviews, the facility failed to complete a thorough investigation and report the results of all investigations to the State Survey Agency, within 5 working days of the incident for 2 of 6 (Resident #1 and Resident #60) residents reviewed for abuse.

Inspectors wroteBased on observation, interview, and review of the facility's policy, the facility failed to ensure food was stored, prepared, and distributed in accordance with professional standards. The deficient practice has the potential to 80 of 82 residents who receive food by mouth and placed residents at risk for food borne illnesses.

Inspectors wroteBased on observation, interview, record review, review of manufacturer's instructions, and review of the facility's policy, the facility failed to ensure residents were provided and received pharmaceutical services to meet the needs of each resident for one of 30 sampled residents (Resident (R) 76) and for three of 15 supplemental residents (R123, R20, and R21). R123's medications were not delivered timely by the pharmacy and the resident was not administered her medications as ordered by her physician. Also, R20's medications were administered via the resident's gastronomy tube (G-Tube); however, the nurse did not check the resident's G-Tube placement prior to the administration of the medications. Additionally, the nurse failed to prime R21's insulin syringe per the manufacturer's instructions prior to administering the resident's insulin. [...]

Inspectors wroteBased on medical record review, facility policy review and interview, the facility failed to ensure nursing services followed orders for lab testing, followed facility protocol and considered each resident's diagnosis to determine appropriate treatment for 1 of 3 (Resident (R) #72) closed records reviewed. The facility admitted R72 on [DATE] at 5:00 PM with diagnoses including generalized epileptic syndrome, not intractable, without status epilepticus. R72 was to have a lab tests drawn at 2:00 AM on [DATE] which were not performed. Per physician's orders there was no documentation staff monitored and periodically documented the presence or absence of seizure activity for R72. [...]

Inspectors wroteBased on record review, interview, review of facility policies and procedures, the facility failed to ensure that the binding arbitration agreement signed by residents or legal representatives was understood by the residents for two of three residents (Resident (R) 224 and R226) reviewed for arbitration agreements. This failure placed the residents at risk of entering into an agreement they did not understand.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure Certified Nurse Aides (CNAs) performance evaluations/reviews were completed on a periodic basis, which may be annually for two of three CNAs (CNA1, CNA3) whose personnel files were reviewed. Due to this failure the facility was not able to develop and maintain an in-service training program for certified nurse aides as determined by the nurse aide performance evaluations/reviews.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to notify in writing the resident and the resident's representative regarding the resident's emergent transfer to the hospital for nine residents (Resident (R) 10, R17, R37, R47, R7, R62, R275, R72, and R59) of nine residents reviewed for hospitalization in a total sample of 31 residents. This failure had the possibility to affect every resident (current census of 82 Residents) that was transferred to the hospital during their stay at the facility by not being aware of their appeal rights.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure bed hold notifications were provided to residents and residents' responsible party for six residents (Resident (R) 10, R17, R37, R7, R62, and R275) of nine residents reviewed for bed hold notification. Due to this failure the residents and their responsible parties were not informed of the bed hold policy prior to or immediately following the residents' transfer to the hospital. This failure had the possibility to affect every resident (current census of 82 Residents) that was transferred to the hospital during their stay at the facility and placed the residents at risk for losing their bed.