Springbrook Center

Inspectors wroteBased on record review and interviews, the facility failed to ensure that sling straps were properly connected to a hanger bar before transferring a resident using an electric mechanical lift. This resulted in a resident falling from the lift sling onto floor during the transfer from bed to wheelchair and sustaining fractured ribs, lacerated spleen, and a fractured left arm, for 1 of 3 residents reviewed for falls with major injury (#1).

Inspectors wroteBased on observations, record review, and interviews the facility failed to implement the care plan interventions for 1 of 7 residents reviewed for transfers using a mechanical lift. (Resident #7)

Inspectors wroteBased on record review and interviews, the facility failed to revise a care plan to reflect the correct size sling used for transfers with a mechanical lift for 1 of 3 residents reviewed for falls with major injury (#1).

Inspectors wroteBased on observation and interview, the facility failed to ensure that sterile technique was maintained during a pressure ulcer dressing change for 1 of 1 residents observed. (Resident #1) On 7/31/25 at 10:57 a.m., LPN #1 was observed performing a dressing change on Resident #1's stage 4 sacrococcygeal pressure ulcer with tunneling. After cleansing the wound, LPN #1 retrieved a piece of silver alginate dressing that had been resting on the outer wrapper of the product packaging, a surface that is not sterile, and inserted it into the tunneling wound using a sterile cotton-tipped applicator. At that time, the surveyor intervened and asked whether the outer surface of the packaging was sterile. LPN #1 acknowledged that it was not and agreed that this action could have contaminated the dressing. [...]

Inspectors wroteBased on the complaint intake form, clinical record reviews, interviews, and facility policy, the facility failed to identify the appropriate resident when passing medications resulting the CNA-M admisistering medications to the incorrect resident that resulted in a resident being transported to an Acute Care Emergency Department and later admitted to the hospital critical care unit for monitoring and treatment of low blood pressure. (Resident #1)

Inspectors wroteBased on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and sanitary conditions on 4 of 7 units (Wayside, Mayflower, Saccarappa and King), the clean utility room, the 3rd floor common area for 1 of 1 Environmental tours.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to develop care plans in the area of oxygen therapy for 4 of 5 residents reviewed for respiratory care (#17, #56, #72 and #310). In addition, the facility failed to implement a care plan in the area of Activities of Daily Living (ADL), nutrition and incontinence for 1 of 2 residents reviewed for ADL's (#53).

Inspectors wroteBased on record reviews, observations and interviews the facility failed to provide Activities of Daily Living (ADL) care in the area of showers/bathing for 1 of 33 residents reviewed (#18), and in the area of nutrition for 1 of 2 sampled residents during 2 of 5 days of survey. (#53).

Inspectors wroteBased on facility policy, record reviews, observations and interviews, the facility failed to maintain and implement an infection control program to help prevent the development and transmission of disease and infection related to Multidrug-Resistant Organisms (MDRO's) colonized in sputum and wound care for a 2 of 2 sampled residents (Resident #48 and #79) for 1 of 1 day of survey (9/23/24). This has the potential to affect all 21 residents on the Wayside Gardens unit.

Inspectors wroteBased on observation and interviews, the facility failed to ensure that a resident was treated with dignity and respect for 1 of 19 residents reviewed. (Resident #419)

Inspectors wroteBased on policy review, clinical record review, observations and interviews, the facility failed to notify the provider and obtained orders for 1 of 6 residents reviewed for respiratory care (#33) and 1 of 6 residents reviewed for pressure ulcers (#48). In addition, the facility failed to assess a resident after an unwitnessed fall and complete neurological assessments as per facility policy for 1 of 3 residents reviewed for falls (#407). 1. On 7/15/24 at 11:05 a.m., a surveyor observed Resident #33 asleep in his/her bed on the Wayside Unit. The surveyor observed oxygen delivered at 3.5 liters/minute via nasal cannula with 2 oxygen tubes connected to the wall unit and only 1 tube connected to Resident #33. At 11:14 a.m., the surveyor discussed with the charge nurse that the oxygen was running but one tube was not connected to the resident. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that staff maintained the appropriate competency and skill required to provide tracheostomy care for 1 of 2 residents with tracheostomies on the Wayside Unit (#48).

Inspectors wroteBased on observations, and interviews the facility failed to ensure that medications were stored properly by having an unlocked, unattended medication cart on 1 of 7 resident units in the facility. In addition, the facility failed by leaving a resident's medications unattended at a bedside, allowing residents and unauthorized persons access to medications. (#33) (Saccarappa House Unit, Wayside Unit).

Inspectors wroteBased on record review and interview the facility failed to follow through with a physician's order for a dental referral for 1 of 43 sampled residents (#29).

Inspectors wroteBased on observations, record reviews and interview, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 2 residents reviewed for Activities of Daily Living (ADL) (#53).

Inspectors wroteBased on record review, observations and interviews, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction (POC) for an identified deficiency from the Annual Long Term Care Survey Process for Federal Recertification dated 7/19/24, was followed and effective. The Federal citation F656 was cited again during the re-visit to the annual Long Term Care Recertification Survey.

Inspectors wroteBased on observation and interviews, the facility failed to ensure that a resident was treated with dignity and respect for 1 of 11 residents reviewed. (Resident #5)

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide an environment free of accident hazards and supervision for 2 out 3 floors observed for accident hazards.

Inspectors wroteBased on record reviews and interviews, the facility failed to follow the facility policy and failed to document adequate interventions taken to protect resident (Resident #7) from abuse following a resident-to-resident altercation for 1 of 2 residents reviewed for abuse allegations.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that the clinical records were complete and contained accurate documentation for 1 of 1 sampled residents ( #1).

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping, laundry, and maintenance services necessary to maintain the building in good repair and in a sanitary condition for 2 of 4 units observed (Wayside Gardens, Saccarappa House).

Inspectors wroteBased on record review and interview, the facility failed to revise a care plan to reflect the current needs for 2 of 3 residents reviewed for falls with injuries (#2, #3).

Inspectors wroteBased on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition for 7 of 7 Units. (Wayside Unit, Saccarappa Unit, [NAME] Hill Unit, [NAME] Unit, Valley Square Unit, Mayflower Unit & King Unit).

Inspectors wroteBased on record review, facility policy, and interviews the facility failed to ensure a resident was adequately prepared and safely discharged for 1 of 1 resident reviewed for discharge (Resident #2).

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 2 of 5 residents reviewed for new admissions (Resdients #2 and #30).

Inspectors wroteBased on record review, observations and interview, the facility's nursing staff failed to provide care in accordance with professional standards of quality by not following guidelines for the safe administration set management for 1 of 2 observations of intravenous (IV) medication administration.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide personal hygiene related to bathing for 1 of 3 residents reviewed for Activities of Daily Living (Resident #80).

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure that physician's orders were obtained and/or followed for 2 of 47 sampled residents (Residdent #70 and #312).

Inspectors wroteBased on observation and interviews, the facility failed to ensure expired medications were removed from the supply available for use in 1 of 2 medication rooms observed (Wayside House).

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and sanitary conditions on 6 of 7 units (Wayside, [NAME], Saccarappa, [NAME] Square, Mayflower, and King), the supply room, the kitchen hallway, and the Laundry Room for 2 of 2 Environmental tours.