Springbrook Nursing and Rehabilitation Center

Inspectors wroteBased on observations, record reviews, staff and Pharmacist interviews, the facility failed to protect the resident's right to be free from misappropriation of narcotic medication for 2 of 2 residents reviewed for misappropriation of property (Residents #299 and #300).

Inspectors wroteBased on record review and interviews of the staff, physician, and family member, the facility failed to follow the resident's hospital physican order from the discharge summary for sliding scale insulin which included blood glucose checks (normal range 70 to 120) before meals and at bedtime and to check a resident with diabetes blood glucose as indicated in the standing orders when staff was unable to wake him for 1 of 9 residents reviewed for diabetic care (Resident #1).

Inspectors wroteBased on record review and resident and staff interviews, the facility failed to protect a cognitively intact resident from verbal and physical abuse by a family member when Family Member #1 threw cold tea and water onto Resident #1, put her hands around Resident #1's throat, threatened to kill her and pushed Resident #1 onto the bed. This resulted in redness to Resident #1's neck. Resident #1 was sent to the Emergency Department (ED) for evaluation and returned the same day with a diagnosis of the strain of the neck muscle. Staff reported the resident appeared out of breath, nervous, and shocked following the incident. A reasonable person would have experienced feelings such as fear, anxiety, and humiliation. This was for 1 of 4 residents reviewed for abuse.

Inspectors wroteBased on observations, record review and staff, Physician, and resident interviews the facility failed to prevent a significant medication error when Nurse #1 administered Resident #63 medications prescribed to Resident #340 to include carvedilol (a medication classified as a beta blocker used to lower the heart rate and high blood pressure) 25 milligram (mg), losartan (a medication to treat high blood pressure) 25 mg, hydralazine (a medication to treat high blood pressure) 100 mg, and apixaban (a medication to thin the blood) 5 mg on 01/14/24. Resident #63 had previously received her own prescribed carvedilol 25 mg and losartan 100 mg that morning prior to receiving Resident #340's medication which resulted in duplicate medication. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain a dumpster that was in good condition and free of leaks and to maintain the dumpster area free of debris for 1 of 1 dumpster. This practice had the potential to attract pests and rodents.

Inspectors wroteBased on observations, record review, resident, staff, Nurse Practitioner (NP) and Physician interviews the facility failed to obtain a physician's order for the use of supplemental oxygen (Residents #68 and #37), assess a resident receiving respiratory medications via nebulizer (Resident #8), change oxygen tubing and humidification bottles in accordance with the manufacturer's instructions (Residents #68 and #37), and administer oxygen in accordance with the Physician's order (Resident #30) for 4 of 5 residents reviewed for respiratory care.

Inspectors wroteBased on observations and staff interviews, the facility failed to don a clean pair of disposable gloves prior to the start of tray line, failed to ensure dietary staff had their hair restrained during food production and failed to serve a food item within safe temperature range. These practices had the potential to affect food served to residents.

Inspectors wroteBased on observations, record review and resident, staff, Nurse Practitioner (NP), and Physician interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the 3/9/21 complaint survey and the 8/20/21 and 9/22/22 recertification and complaint investigation surveys. This was for 7 deficiencies in the areas of F550 Dignity, F677 Activities of Daily Living, F684 Quality of Care/Professional Standards, F693 Tube Feeding, F695 Respiratory Care, F812 Food Preparation and Storage, and F842 Accuracy of Records. These deficiencies were recited on the current recertification and complaint investigation survey of 2/13/24. [...]

Inspectors wroteBased on observations, record review and staff interviews the facility failed to provide a dignified dining experience when Nurse Aide (NA) #4 stood at Resident #7's bedside while feeding Resident #7. This was for 1 of 2 residents reviewed for dignity. A reasonable person might feel a lack of dignity when NA #4 stood while feeding them.

Inspectors wroteBased on record review and interviews with the Responsible Party (RP) and staff, the facility failed to facilitate the inclusion of a cognitively intact resident and her RP in the care planning process for 1 of 1 resident reviewed for the care planning process (Resident #287).

Inspectors wroteBased on record review and staff interviewed, the facility failed to complete a recapitulation of stay for 1 of 1 resident reviewed for a planned discharge from the facility to home (Resident #137).

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to rinse soap from a resident's skin during a dependent resident's bed bath and to provide nail care for 1 of 9 residents reviewed for activities of daily living (Resident #57).

Inspectors wroteBased on record review and staff and physician interviews the facility failed to obtain daily weights as ordered by the physician for 1 of 6 residents (Resident #30) reviewed for respiratory care.

Inspectors wroteBased on observation, record review, staff and physician interviews, the facility failed to: 1) obtain a written physician's order for the use of a urinary catheter (Resident #30 and #57) and 2) ensure the consulting physician's recommendation for the urinary catheter changes were entered into the medical record (Resident #30). This was for 2 of 4 residents reviewed for urinary catheter.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to change a tube feeding syringe daily or store a tube feeding syringe with the plunger separated from the barrel for 1 of 1 resident reviewed for enteral feeding management (Resident #57).

Inspectors wroteBased on observations, record review, and resident and staff interviews the facility failed to maintain accurate documentation of the administration of oxygen (O2) (Resident #30) and the completion of wound treatments (Resident #75). This was for 2 of 21 residents reviewed for accurate documentation.

Inspectors wroteBased on observations and staff interviews the facility failed to maintain walls in good repair for 1 of 23 rooms reviewed for the provision of a safe, clean, homelike environment (room [ROOM NUMBER]).

Inspectors wroteBased on observations and interviews the facility failed to serve food in sanitary conditions by a staff not covering their hair while preparing and serving food in 1 of 4 kitchenettes observed (Hall 300/400 Kitchenette) and failed to dry plate covers individually for 1 of 1 dishwashing observations in the main kitchen.

Inspectors wroteBased on observation, record review, and interviews with resident, physician, Pharmacy Consultant, and staff, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the 10/19/2019 complaint survey, 12/19/2019 recertification/complaint survey, 3/9/2021 complaint survey, and 8/20/2021 recertification/complaint survey. This was for 7 deficiencies cited on the current recertification/complaint survey of 9/22/22: 3 deficiencies were cited on 12/19/2019 and 8/20/2021 in the areas of F582 Medicaid/Medicare Coverage Liability Notice, F758 Free From Unnecessary Psychotropic Medication, and F812 Food Storage; 1 deficiency was cited on 10/19/2019 and 8/20/2021 in the area of F550 Dignity; [...]

Inspectors wroteBased on record review, and staff interviews the facility failed to provide required dementia management and/or abuse prevention training for 3 of 3 current nursing staff (Nurse Aide (NA) #2, NA #3, NA #4) reviewed for education requirements.

Inspectors wroteBased on observations, record review, and resident and staff interviews the facility failed to provide incontinence care causing the resident to feel not good but there was nothing she could do about it for 1 of 6 residents reviewed for activities of daily living care. (Resident #31)

Inspectors wroteBased on record review, resident and staff interviews the facility failed to ensure the advanced directive code status information maintained in the electronic record and the hard copy chart matched. This was for 1 of 1 resident (Resident #76) reviewed for advanced directives.

Inspectors wroteBased on observations, record review, and resident, staff and physician interviews the facility failed to provide incontinence care ( Resident #31) and failed to rinse soap from a resident's skin per manufacturer's directions during a bath ( Resident #7) for 2 of 6 residents reviewed for activities of daily living care.

Inspectors wroteBased on record review, staff interviews, Physician interview and family interview, the facility failed to provide the resident's tube feeding according to the Physician's orders for 1 of 1 resident (Resident #249) reviewed for tube feeding.

Inspectors wroteBased on record review, staff and physician interviews, the facility failed to notify the Physician of the Pulmonologist consult recommendations for Resident #11. This was for 1 of 2 residents reviewed for respiratory.

Inspectors wroteBased on record review, staff and physician interviews, the facility failed to arrange a follow-up pulmonary appointment for 1 of 1 resident reviewed for respiratory care (Resident #11).

Inspectors wroteBased on record review, staff, Pharmacy consultant, and Physician interviews, the facility failed to ensure Physician's orders for an as needed (PRN) psychotropic medication (drug that effects the mental state) were time limited in duration for 2 of 5 residents (Resident #1 and Resident #24) reviewed for unnecessary medications.

Inspectors wroteBased on record review and staff interviews the facility failed to include documentation in the resident's medical record to reflect education was provided regarding the benefits and potential side effects of receiving the pneumococcal vaccine and failed to include why vaccines were not administered for 3 of 5 residents reviewed for immunizations (Residents #11, #70, and #88).