Springfield Health & Rehab

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident was treated in a manner that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's right to be treated with dignity and respect, and to make choices, for 1 of 3 sampled residents (Resident #1).

Inspectors wroteBased on interview and record review, the facility failed to report an incident of alleged abuse for 1 of 3 sampled residents. This is a repeat deficiency for this facility, with the violation cited during two previous partial surveys dated 2/17/26 and 12/9/25.

Inspectors wroteBased on observation and interviews, the facility failed to provide a safe, clean, and homelike environment for the residents who reside on 2 of 2 units.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy related to Covid 19 vaccination and provide evidence that five out of five sampled staff members were offered a Covid 19 vaccination and consent obtained along with three out of five sampled residents (Resident #9, Resident #43, and Resident #53). Per review of the facility policy titled Coronavirus, Prevention, and Control dated 3/5/26, it states that all residents and staff members will be educated and offered a Covid 19 vaccine unless contraindicated or full immunization has been acquired. That both the staff and resident/resident representative will be educated on the benefits and the risks of the vaccination and that a vaccine will not be administered without written informed consent. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that a facility investigation of abuse was submitted to the state agency within the required five-day timeframe.

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property related to the screening of prospective employees 2 out of 5 sampled staff.

Inspectors wroteBased on interview and record review, the facility failed to report three allegations of abuse to the state for one of two sampled residents (Resident #3). This is a repeat deficiency for this facility, with the violation cited during a previous partial survey, dated 3/3/25.

Inspectors wroteBased on interview and record review, the facility failed to investigate two of four sampled allegations of abuse for Resident #3. This is a repeat deficiency for this facility, with the violation cited during the previous recertification survey, dated 3/27/25.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to honor residents' choices as outlined in their care plan for 1 of 3 sampled residents (Resident #3).

Inspectors wroteBased on observation and interview, the facility failed to store medications appropriately on one randomly observed medication cart, potentially impacting residents on 1 of 2 units.

Inspectors wroteBased on interview and record review, the facility failed to accurately reconcile physician orders needed to provide necessary care and services on admission, once the facility identified an issue with the admission orders, they failed to review the rest of the discharge summary for other potential missed orders for 1 of 3 residents in the sample (Resident #1). All residents admitting or readmitting to the facility are at risk for serious injury or death as a result of noncompliance. [...]

Inspectors wroteBased on interview and record review, the facility failed protect a resident's right to be free from neglect by failing to provide services to the resident that are necessary to avoid physical harm, pain, mental anguish and emotional distress for 1 of 5 residents in the applicable sample (Resident #1). This deficient practice rose to the immediate jeopardy level due to the facility's failure to provide necessary services, which resulted in antipsychotic medication withdrawal, repeated falls with major head injury, and death. This is a repeat deficiency for this facility, with the violation cited at immediate jeopardy during a partial survey dated 3/3/25.

Inspectors wroteThe facility failed to develop a care plan or implement interventions specific to the safety risks associated with narcolepsy with cataplexy (sudden weakness or limping of the muscles), risk factors for the use of antipsychotic medications, implement care plan interventions to monitor blood glucose 4 times daily and administer insulin on a sliding scale for a diabetic who was admitted with physician orders to do so, identify safety/fall risk related to complications of the diagnosis of a subdural hematoma for 1 of 3 residents in the sample (Resident #1). This deficient practice rose to the immediate jeopardy level due to the facility's failure to ensure care plans are developed and implemented, which resulted in Resident #1 experiencing a fall that resulted in a head injury with a subdural hematoma that worsened over time and resulted in death. [...]

Inspectors wroteBased on interview and record review the facility failed to effectively assess a resident's risks, implement, monitor, and modify interventions when necessary to prevent falls with major injury resulting in death. The facility also failed to provide necessary treatment of clinical conditions which put the resident at an increased risk of safety and accidents. The facility also failed identify and address potential accident hazards related to the resident's clinical condition. As a result, the resident experienced a recuring UTI, a decline in behavioral health, hyperglycemic episodes, medication withdrawal, and increased fall risk for 1 of 3 Residents in the sample (Resident #1). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 3 sampled residents (Resident #1). This deficient practice resulted in harm; Resident #1 had antipsychotic medication withdrawal, increased behavior health distress exhibited by hallucinations, resistive and combativeness with care, and medication refusals; unmonitored and untreated blood sugars; increased risk of urinary tract infection resulting in a hemolytic Strep Group B urinary tract infection, and increased risk for and repeated falls with major head injury, and death. This is a repeat deficiency for this facility, with the violation cited during two recent partial surveys dated 3/3/25 and 5/28/25.

Inspectors wroteBased on interview and record review the facility failed to inform in advance of the risks and benefits of the proposed care, the treatment alternatives or other options for 1 of 5 sampled residents (Resident #1). This is a repeat deficiency for this facility, with the violation cited during a recertification survey dated 3/27/25.

Inspectors wroteBased on interview and record review the facility failed to notify the resident representative of a change in condition related to laboratory results and treatment options for one of three residents in the sample (Resident #1). This is a repeat deficiency for this facility, with the violation cited during a partial survey dated 3/3/25.

Inspectors wroteBased on interview and record review the facility failed to ensure that one of five nurses, an agency nurse in the applicable sample had received training and competencies needed to provide care for the residents who reside in the facility. This is a repeat deficiency for this facility, with the violation cited during a recertification survey dated 3/27/25.

Inspectors wroteBased on observation, interview, and record review of facility policy, the facility failed to establish a grievance policy that contains the correct information to support the residents' rights to file a grievance for seven of the seven residents in the sample (Resident #62, #15, #51, #19, #30, #46, and #35). This has the potential to affect all residents in the facility.

Inspectors wroteBased on the interview and staff education record review, the facility failed to ensure that 2 of 3 sampled licensed nursing assistants (LNAs) were assessed for the competency and skill sets needed to provide care and respond to each resident's individualized needs. This is a repeat deficiency for this facility, with violations cited during a previous complaint survey, dated 4/16/24, and has the potential to affect all residents.

Inspectors wroteBased on the record review and staff interview, the facility failed to ensure that monthly pharmacist drug regimen reviews, recommendations, and attending physician responses were completed and documented in the resident record Medication Regimen Review (MRR) process for 10 of 10 Residents in the applicable sample (Residents #12, #13, #20 #22 #23# 26#29 #54 #61, and #64). This is a repeat deficiency for this facility, with violations cited during the previous recertification survey, dated 1/10/24.

Inspectors wroteBased on interview and review of employee training records, the facility failed to develop a system to document the minimum 12 hours of nurse aide training per year required to ensure the continuing competence of the LNAs ( Licensed Nursing Assistants).

Inspectors wroteBased on interviews and record review, the facility failed to notify residents and/or their representative in writing of a transfer/discharge for 3 out 3 sampled residents (Residents #14, #22, and #26).

Inspectors wroteBased on interviews and record review, the facility failed to notify residents and/or their representative in writing of the bed-hold and returns policy for 3 out 3 sampled residents (Residents #14, #22, and #26).

Inspectors wroteBased on interview and record review the facility failed to ensure that residents are effectively assessed for past trauma experiences and address the needs of trauma survivors by identifying and minimizing triggers and/or re-traumatization and developing an idevidualized care plan related to trauma for 4 of 4 residents in the applicable sample (Resident #22, #26, #28, and #51).

Inspectors wroteBased on staff interview, and record review the physician failed to ensure that the onsite review of the resident's total program of care included necessary lab testing, treatment, and medication orders for 3 of 27 residents sampled (Resident #13, #26, and Resident #322).

Inspectors wroteBased on interview and record review, the facility failed to ensure that 2 out of 10 applicable residents (Resident #20, #23) remained free from unnecessary medications.

Inspectors wroteBased on interview and record review the facility failed to ensure that residents were free from unnecessary psychotropic medications for 5 of 10 Residents in the sample (Resident #12, #20, #29, #54, and #61). The facility also failed to implement 14 day stop dates on prescribed as needed (PRN) psychotropic medications for 3 of the 5 residents in the sample (Residents #12, #20, #54).

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean kitchen environment, which has the potential to impact all residents in the facility.

Inspectors wroteBased on interviews and record review the facility failed to ensure that the binding arbitration agreement was explained in a form or manner the resident or resident's representative acknowledges that he/she understands for 2 out of 3 residents sampled, (Resident #31 and Resident #43).

Inspectors wroteBased on interview and record review, the facility failed to ensure that the 1 of 27 residents in the sample (Resident #23) or his/her representative was informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment alternatives or treatment options, and to choose the alternative or option he or she prefers.

Inspectors wroteBased upon interview and record review, the facility failed to assure that further potential abuse, neglect, exploitation, or mistreatment did not occur after an allegation of abuse for 1 resident [Resident #324] of one sampled resident regarding abuse allegations.

Inspectors wroteBased on staff interview and record review, the facility failed to obtain accurate physician orders to provide necessary care and services on admission for 1 of 27 sampled residents (Resident #322).

Inspectors wroteBased on interview and record review, the facility failed to ensure pain management was provided for 1 of 27 sampled residents (Resident #28). This is a repeat deficiency for this facility, with violations cited during a previous complaint survey, dated 10/18/24.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medication error rates were not 5% or greater. The total error rate for all observations was calculated at 12%. There were 25 observations and three medication errors.

Inspectors wroteBased on interview and record review, the facility failed to promptly provide routine and emergency dental services to meet the residents' needs related to dental pain for one of 16 residents in the applicable sample (Resident #61).

Inspectors wroteBased on observation, interview, and record review, the facility was not administered in a manner that enables it to maintain the physical well-being of each resident, whereby actions and decisions by the facility's leadership team directly contributed to multiple deficiencies that resulted in harm and immediate jeopardy by failing to ensure that the physician was notified of changes, residents were free from abuse, care plans were implemented, pressure ulcer care and prevention was provided, adequate supervision of residents, residents' care is supervised by a physician, the responsibilities of the Medical Director were met, implement an effective infection prevention program, and have a qualified infection preventionist.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement an infection prevention and control program that follows the accepted national standards regarding preventing, identifying and controlling communicable diseases. Specifically, the facility failed to follow the CDC (Centers of Disease Control) and state health department recommendations for outbreak management, related to testing and other mitigation strategies including containment and personal protective equipment (PPE) use. The deficient practices associated with the lack of infection control measures led to the determination that the residents in the facility were in immediate jeopardy of serious harm and/or death. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure consultation with the attending physician during a COVID-19 outbreak, and failed to notify the physician of positive COVID-19 results for 3 of 11 residents who tested positive for COVID-19 (Residents #6, #7, and #12). The facility also failed to notify the physician after a resident physically assaulted another resident causing injury (Resident #1 and #4), and at the time of significant changes in condition regarding development of pressure ulcers (Resident #9). This citation is at the immediate jeopardy level due to the lack of notification and consultation with the physician during a COVID-19 outbreak and with significant changes in resident statuses puts all residents at risk for serious injury or death because of the noncompliance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to prevent 1 of 3 sampled residents (Resident #6) from gaining access to an alarmed stairwell and falling down a flight of 8 stairs, sustaining a head injury. The facility failed to ensure resident safety by not responding timely to a door alarm that is used to alert staff of potential resident elopement. The facility also failed to provide adequate supervision of 2 residents in the applicable sample (Resident #1 and Resident #4) to prevent a resident-to-resident assault that resulted in fear and injury to Resident #4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medical care of each resident is supervised by a physician for 3 of 15 sampled residents (Resident #7, #1, #4). As a result Resident #7 who was positive for COVID, did not receive specific monitoring or treatment for the COVID infection, and died of COVID, Resident #1's violent behaviors continued to put other residents at risk, and Resident #4 suffered injury that was not immediately assessed or treated. This citation is at the immediate jeopardy level due to medical care not being supervised by the physician resulting in residents not being treated for COVID, aggressive behaviors, and failure to assess resident with suspected injury to his/her head.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for 1 of 3 residents in the sample (Resident #4). As a result, Resident #4 suffered injury and persistent fear that s/he would be physically assaulted again.

Inspectors wroteBased on interview and record review the facility failed to implement care plan interventions related to skin and wound assessments for 1 of 15 residents in the sample (Resident #9). As a result of the failure to follow care plan interventions Resident #9's pressure ulcers worsened.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that 1 of 3 residents in the applicable sample (Resident #9) received necessary treatment and services consistent with professional standards of practice to promote healing by not obtaining physician's orders for treatment, not following care plan interventions, and not performing accurate skin and wound assessments. This deficient practice caused Resident #9's wounds to deteriorate, and caused him/her to develop additional pressure ulcers. This is a repeat deficiency for this facility, with violations cited during the previous recertification survey, dated 1/10/25.

Inspectors wroteBased on interview and record review the facility failed to ensure that the medical director fulfilled her responsibilities to effectively implement resident care policies and coordinate medical care for residents in the facility regarding the surveillance of, and development of policies that reflect current professional standards of practice to prevent the spread of potential COVID-19 infection, and coordinate care of residents. This deficient practice resulted in ineffective COVID-19 mitigation, death of a resident from COVID-19, and resident abuse with injury. 1. Per review of the facility documented COVID-19 outbreak line list revealed that 11 Residents and 15 staff members tested positive for COVID-19 between [DATE] and [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the staff member designated as the facility's Infection Preventions (IP) had obtained specialized Infection Prevention and Control training beyond initial professional training. This is a repeat deficiency for this facility, with violations cited during the previous two recertification surveys, dated [DATE] and [DATE]. As a result the facility failed to prevent spread of COVID-19 through mitigation strategies that would be directed by an infection preventionist, and 1 resident died from COVID-19 (Resident #7). The failure to designate a qualified infection preventionist has the potential to impact all residents who reside in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that there was sufficient staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population. This deficient practice had the potential to impact all residents who reside in the facility. This is a repeat deficiency for this facility, with violations cited during a partial survey, dated 4/16/24.

Inspectors wroteBased on interview and record review the facility failed to ensure that residents were free from significant medication errors for 2 of 3 residents in the applicable sample (Resident #10 and #11).

Inspectors wroteBased on interview and record review the facility failed to ensure that resident's medical records contained nurse progress notes, complete and accurate assessments, and wound care consultant notes to provide a picture of the resident's progress, including his/her response to treatments and/or services, and changes in his/her condition for 2 of 15 sampled residents (Resident #9 and #7). This is a repeat deficiency for this facility, with violations cited during a partial survey, dated 6/12/24, and the previous recertification surveys, dated 1/10/24.

Inspectors wroteBased on record review and interview, the facility failed to ensure that an allegation of resident to resident abuse was reported to the State Licensing Agency for 1 of 3 sampled residents (Resident #4) within 2 hours of the incident and failed to submit an investigation of the findings to the State Agency within 5 days.

Inspectors wroteBased on observation, interview, and record review the facility failed to revise the care plan for 1 of 15 residents in the sample (Resident #4) related to resident to resident physical abuse and wounds.

Inspectors wroteBased on observation, interview and record review the facility failed to provide quality care to 1 out of 15 residents in the sample (Resident #4) related to wound care that is not pressure.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 2 residents in the sample were free from physical abuse (Resident #3).

Inspectors wroteBased on interview and record review, the facility failed to provide pain management that met professional standards for 4 of 7 sampled residents by not recognizing pain or evaluating existing pain and the causes (Resident #1) and revise a resident's care plan to address and manage pain (Residents #1, #3, #5, and #6). As a result, Resident #1 had a pattern of significant, untreated pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents remained as free from accidents as possible related to falls for 1 of 6 sampled residents (Resident #1) by failing to provide adequate supervision and implement care plan interventions that would reduce potential serious consequences if a fall did occur. As a result, Resident #1 suffered a fall that resulted in a hip fracture and significant pain.

Inspectors wroteBased on interviews and record review, the facility failed to identify a resident at risk for impaired hydration status, address risk factors for impaired hydration status, and ensure that a resident receive sufficient fluid intake to maintain proper hydration and health for 5 of 7 sampled residents (Residents #1, #2, #3, #4, and #5). As a result, Resident #1 was admitted to the hospital with dehydration, a urinary tract infection (UTI), and developed a stage 2 pressure ulcer.

Inspectors wrotePer interview and record review the facility failed to revise the comprehensive care plan related to a resident elopement from the facility for one sampled resident [Res.#1].

Inspectors wroteBased on interview and record review the facility failed to provide a discharge plan for a resident who attempted to leave against medical advice for 1 sampled resident [Resident #1].

Inspectors wroteBased upon interview and record review, the facility failed to ensure that each resident receives adequate supervision to maintain safety and prevent accidents regarding elopement and leaving the facility Against Medical Advice for 1 sampled resident [Res.#1].

Inspectors wroteBased upon interview and record review, the facility failed to maintain medical records on each resident that are complete and accurately documented for 1 sampled resident [Res.#1].

Inspectors wroteBased on resident interview, staff interview, and record review, the facility failed to ensure that there are a sufficient number of skilled nurse aides to provide care and services to attain the highest practicable well-being for each resident and in accordance with each resident's plan of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure that licensed nurses have the specific competencies necessary to care for Residents' needs as identified through resident assessments and the plan of care.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that Residents with colostomies receive care and services consistent with professional standards of practice and the comprehensive care plan for 2 of 2 sampled residents (Residents #1 and #2).

Inspectors wroteBased on interviews and record review, the facility failed to treat the resident with respect and dignity and failed to provide an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 5 (Resident # 334).

Inspectors wroteBased on interview and record review the facility failed to ensure that a Resident's choice regarding life sustaining treatment was updated on their COLST (clinician's order or orders for treatment or limitation of treatment such as intubation (insertion of a tube through a person's mouth or nose, then down into their trachea to open the airway and allow passage of air), mechanical ventilation (a machine that takes over the work of breathing when a person is unable to breath on their own), transfer to hospital, antibiotics, artificially administered nutrition, or other medical intervention) for one of 23 residents (resident #9). Per record review Resident #9 has a COLST that was signed on 12/13/2022 that reflects that Resident #9 would want a trial course in intubation and ventilation treatment if s/he were in respiratory distress. [...]

Inspectors wroteBased upon observation, interview, and record review, the facility failed to provide a comfortable and homelike environment for 1 resident [Res.#40] of 32 sampled residents.

Inspectors wroteBased on observations, interview, and record review the facility failed to develop a comprehensive care plan related to the communication needs of one hearing impaired resident (Resident #6) in the sample.

Inspectors wroteBased upon observation, interview, and record review, the facility failed to provide appropriate activities per the resident's plan of care for 1 resident [Res. #40] of 32 sampled residents.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure that irregularities noted during monthly pharmacist medication regimen reviews are documented in a written report for one of 5 sampled Residents (Resident #5). The facility also failed to ensure that the attending physician reviewing the report documents a rationale for not changing the medication according to the pharmacist's recommendations for one of 5 sampled Residents (Resident #5).

Inspectors wroteBased on staff interview and record review, the facility failed to ensure that residents who use psychotropic drugs receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue the drugs for one of 5 sampled residents (Resident #5).

Inspectors wroteBased on staff interview and record review, the facility failed to ensure that required documentation and medical records are readily accessible.

Inspectors wroteBased upon observation and interview, the facility failed to post nurse staffing data on a daily basis in a prominent place readily accessible to residents and visitors as required by federal regulation.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure that the individual who has completed the specialized training in infection prevention and control oversees the facility's infection prevention and control program.

Inspectors wroteBased upon interview and record review, the facility failed to maintain documentation related to staff COVID-19 vaccination that includes at a minimum, the following: (A) That staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine; (B) Staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine; and (C) The COVID-19 vaccine status of staff and related information as indicated by the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to ensure residents have a clean and comfortable environment as evidenced by a dirty and unsanitary resident environment.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure that care plans were reviewed by the interdisciplinary team within 7 days after completion of the comprehensive assessment for two of three sampled residents (Resident #1 and #2).

Inspectors wroteBased on observation and staff interview, the facility failed to make information on how to file a grievance available to residents as evidenced by a lack of posted procedures on resident units.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure that residents are seen by a physician once every 30 days for the first 90 days after admission and at least once every 60 days thereafter, with non-physician practitioners providing no more than every other required visit after the initial visit for 2 of 3 sampled residents (Resident #1 and #2).

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to implement a system for reporting and controlling communicable diseases as evidenced by insufficient reporting of new COVID-19 cases and insufficient transmission-based precautions for the care of residents with COVID-19.