Springfield Rehabilitation & Health Care Center

Inspectors wroteBased on interview and record review, the facility failed to complete the annual individual performance reviews or evaluations and failed to provide regular in-service education based on these reviews for three certified nurse aides (Certified Nurse Aide (CNA) K, CNA L, and CNA M), out of a sample of six CNAs. The facility census was 117. Review showed the facility did not provide a policy regarding annual individual performance reviews or education for CNAs.1. Review of CNA K's personnel records showed the following:-Hire date of 04/10/24;-Annual performance evaluation due on 04/10/25; -Staff did not document completion of the performance evaluation or education provided to CNA K based on an annual performance evaluation.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents were treated with dignity and respect when one staff member (Licensed Practical Nurse (LPN) A) spoke in a disrespectful tone and manner when interacting with one resident (Resident #70) resulting in the resident becoming upset. The facility census was 117. Review of the facility policy titled Patient Rights, undated, showed the following:-The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.-A facility must protect and promote the rights of each resident. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegation of possible abuse were reported immediately to facility management and to the Department of Health and Senior Services (DHSS) within the required two hour timeframe when staff one resident's (Resident #76) allegation of physical abuse. The facility census was 117. Review of the facility's policy titled Abuse Protection and Response Policy, showed the following:-Abuse, Neglect, and Misappropriation of Patient Property, as hereafter defined, will not be tolerated by anyone, including staff, patients, consultants, volunteers, family members or legal guardians, friends, visitors, or any other individual in this center;-Any patient event that is reported to any partner by patient, family, other partner or any other person will be considered an allegation of abuse if it meets any of the following criteria: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegations of abuse were investigate when staff failed to complete an investigation of an allegation of physical abuse made by one resident (Resident #76). The facility census was 117. Review of the facility's policy titled Abuse Protection and Response Policy, undated, showed the following:-Abuse, Neglect, and Misappropriation of Patient Property, as hereafter defined, will not be tolerated by anyone, including staff, patients, consultants, volunteers, family members or legal guardians, friends, visitors, or any other individual in this center;-All events reported as possible abuse, neglect, or misappropriation of patient property will be investigated to determine whether the alleged abuse, neglect, or misappropriation of patient property did or did not take place. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents received pain management consistent with standards of practice when staff failed to consistently administer pain medications in a timely manner to one resident (Resident #112). The facility census was 117. Review of a facility policy entitled Preparation and General Guidelines: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a pain management program that managed resident pain effectively when staff failed to address one resident's (Resident #1) on-going pain and when staff failed to address one resident's (Resident #2) behavioral indications of pain. The facility census was 121. Review of the facility policy Pain-Clinical Protocol, dated 2001, showed the following:-The physician and staff will identify individuals who have pain or who are at risk for having pain. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide respiratory care per standards of practice when the facility failed to provide a physician ordered bipap (noninvasive machine that helps people breathe by delivering pressurized air into their airways) or CPAP (a machine that treats breathing disorders by delivering pressurized air to the airways to keep them open while one sleeps) or document timely steps to acquire needed bipap supplies for one resident (Resident #1). Facility census is 120. Review of the facility policy titled, CPAP/Bipap (continuous positive airway pressure/bilevel positive airway pressure) Support, revised March 2015, showed the following: -Purpose of the machine was to provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep food safe from potential contamination when staff stacked clean dishware inside one another instead of air drying, which could potentially contaminate food served from those items, and failed to keep dented cans separate from other canned goods. The facility census was 115. 1. Review of the 2022 Food Code, issued by the Food and Drug Administration (FDA), showed the following information: -After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food; -Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. [...]

Inspectors wrote3. Review of Resident #2's face sheet showed the following: -admission date of 05/03/02; -Diagnoses included personal history of frequent urinary tract infections (UTI's), neuromuscular dysfunction of bladder (when the brain does not communicate with the bladder), and retention of urine (when one is unable to completely empty the bladder). Review of the resident's care plan, dated 06/11/22, showed the following: -Resident had an indwelling urinary catheter; -Staff are expected to maintain, clean, and position catheter tubing and bag below level of bladder and provide daily care. (Staff did not care plan the use of a dignity bag.) Review of the resident's annual MDS, dated [DATE], showed the following: -Resident required an indwelling urinary catheter; -Total dependence on staff for toileting needs. Observation on 05/09/24, at 4:05 P.M., showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote all residents' right for self-determination of schedule and cares when staff failed to provide showers as preferred and care planned for nine residents (Resident #9, #21, #23, #55, #108, #33, #8, #15, and #11) of 29 residents sampled. The facility census was 115. Review of the facility's policy titled, Bath, Shower/Tub, revised February 2018, showed the purpose of the procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of residents' skin. The policy did not address the scheduling of showers/baths. 1. Review of Resident #9's face sheet (a document that gives a resident's information at a quick glance) showed the following: -readmission date of 07/19/20; [...]

Inspectors wroteBased on record review and interview, the facility failed to notify the resident and the resident's representative in writing of a transfer or discharge to a hospital that included the reason for the transfer, date of transfer, and destination of transfer for three residents (Resident #100, Resident #5 and Resident #8) out of 29 sampled residents. The facility census was 115. Review of the facility provided copy of Hospital Transfer Checklist, showed the following: -Fill out Interact Nursing Home to Hospital Transfer under observation, print and send with the resident. 1. Review of Resident #100's progress note, dated 01/23/24, showed the following: -The resident was reported to be combative, agitated, yelling, and cursing at staff and refusing cares; -Order received to send resident to hospital for evaluation and treatment; [...]

Inspectors wrote2. Review of Resident #2's face sheet showed the following: -admission date of 05/03/02; -Diagnoses included personal history of frequent urinary tract infections (UTI's), neuromuscular dysfunction of bladder (when the brain does not communicate with the bladder), and retention of urine (when one is unable to completely empty the bladder). Review of the resident's care plan, dated 06/11/22, showed the following: -Resident does use an indwelling catheter; -Staff are expected to maintain, clean, and position catheter tubing and bag below level of bladder and provide daily care. Review of the resident's annual MDS, dated [DATE], showed the following: -Resident required an indwelling catheter; -Toileting hygiene showed resident as totally dependent on staff for toileting needs. Observation on 05/09/24, at approximately 4:05 P.M., showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmaceutical services with accurate documentation and storage for the emergency kit (E-Kit - kits containing commonly prescribed medications for emergency use) when medication lock tags failed to match the form titled All E-Kit Lock Registration for three of five E-Kit boxes. The facility census was 115. Review of the facility policy titled Medication Storage in the Facility, dated 01/01/19, showed the following: -Medications and biologics are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications; [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure that the medication error rate was not 5 percent or greater, when staff failed to prime insulin pens (removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly; failure to do so may result in administering too much or too little insulin) for three residents (Residents #220, #215, and #10) of 29 opportunities observed during medication pass (10% error rate). The facility census was 115. Review of the Instructions for Using Insulin Lispro (rapid acting insulin) KwikPen, revised 07/2023, showed the pen needs to primed before each use. The pen should be primed by the following steps: -Turn dose knob to two units; -Hold pen with needle pointing up; -Tap the cartridge holder gently to collect air bubbles at the top; [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed ensure all residents were free from significant medication errors when staff failed to to prime (removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly; failure to do so may result in administering too much or too little insulin) the insulin pens before administering insulin to three residents (Residents #220 #215, and #10) of four residents observed during insulin administration. The facility census was 115. Review of the Instructions for Using Insulin Lispro (rapid acting insulin) KwikPen, revised 07/2023, showed the pen needs to primed before each use. The pen should be primed by the following steps: -Turn dose knob to two units; -Hold pen with needle pointing up; -Tap the cartridge holder gently to collect air bubbles at the top; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored safely and securely when staff failed to lock medication and treatment carts when unattended by authorized personnel. The facility had a census of 115. Review of the facility policy titled Medication Storage in the Facility, revised 01/01/19, showed the following information: -Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are permitted to access medications; -Medication rooms, carts, and medication supplies are to be locked when not attended by persons with authorized access. Review of the facility policy titled Specific Medication Administration Procedures, revised 01/01/19, showed the following information: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection control program to prevent the risk of contamination and spread of infection when staff failed to complete proper hand hygiene during incontinent care for one resident (Resident #81) and during urinary catheter (bag that collects urine from the tube that attaches to a catheter (tube) that is inside the bladder) care for one resident (Resident #61). The facility also failed to protect clean laundry from possible contamination. The facility census was 115. Review of the facility's policy titled Handwashing/Hand Hygiene, revised August 2015, showed the following information: -Hand hygiene is the primary means to prevent the spread of infections; [...]

Inspectors wrote5. Review of Resident #8's face sheet showed the following: -admission date of 06/22/23; -Diagnoses included Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), history of falling, Alzheimer's disease (progressive disease that destroys memory and other important mental functions), and generalized anxiety disorder. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Used walker and/or wheelchair for mobility; -Independent with toileting hygiene; -Independent with upper and lower body dressing; -Supervision with transferring from bed, chair, or toilet. Review of the resident's care plan, reviewed on 05/04/24, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to determine all residents who self-administered medications were clinically appropriate to do so when staff left medications at bedside for one resident (Resident #99) to administer to his/herself unattended without an assessment, order, or care plan to do so. The facility census was 115. Review of the facility policy titled Specific Medication Administration Procedures, revised 01/01/19, showed the following information: -Administer medication and remain with resident while medication is swallowed. Do not leave medications at bedside, unless specifically ordered by prescriber; -Chart medication administration on Medication Administration Record (MAR) immediately following each resident's medication administration. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify and coordinate with the State-designated authority when one resident (Resident #100), a previously identified by the Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals who have a mental disorder or intellectual disability are not inappropriately placed in nursing homes for long-term care. The PASARR requires that all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability and be offered the most appropriate integrated setting for their needs (in the community, a nursing facility, or acute care setting) and receive the services they need in those settings) as having a mental disorder, experienced a significant change. The facility census was 115. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who required assistance with showers received the necessary assistance with showers when the facility failed to ensure one resident (Residents #2), dependent on staff for grooming, received regular showers and appropriate grooming. The facility census was 115. Review of the facility's policy titled Bath, Shower/Tub, revised February 2018, showed the purpose of the procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin. Review showed the facility did not provide a policy pertaining to the scheduling of showers/bathing. 1. Review of Resident #2's face sheet showed the following: -admission date of 05/03/02; [...]

Inspectors wroteBased on interview, record review, and observation, the facility failed to ensure staff followed physician orders and accurately documented the implementation of physician orders when staff failed to apply tubi grips (an elasticated tubular bandage designed to provide support for sprains, strains, and swelling) as ordered for one resident (Resident #59). A sample of 29 residents was selected for review. The facility census was 115. Review of the facility's policy titled, Physician Orders Policy, undated, showed the following information: -Orders will be received by licensed nursing staff; -Orders will be reviewed and if there are questions, clarification will be obtained from the physician; -If no questions or questions are clarified, orders will be implemented. 1. Review of Resident #59's face sheet showed the following information: -readmission date of 03/25/24; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an environment as free of accident hazards as possible when staff transferred one resident (Resident #61) without the use of the gait belt. The facility census was 115. Review of the facility's policy titled, Safe Lifting and Movement of Residents, dated 07/17, showed the following information: -In order to protect the safety and well-being of staff and residents, and promote quality care, this facility uses appropriate techniques and devices to lift and move residents; -Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents; -Manual lifting of residents shall be eliminated when feasible; -Staff will document resident transferring and lifting needs in the care plan; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe (trachea) where then a tube is placed into the hole to keep it open for breathing) care following professional standards of practice for one resident (Resident #59). The facility census was 115. Review of the facility's policy titled Tracheostomy Care Procedure, undated, showed the following information: -The purpose of the procedure was to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas; -Aseptic technique (method used to prevent contamination in procedures where a sterile field is required) must be used; -Gloves must be used on both hands during any or all manipulation of the tracheostomy; -Sterile gloves must be used during aseptic procedures, a mask and eyewear must be worn; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an effective system in place to ensure accommodation of residents' meal preferences when staff served one resident (Resident #84) meals that did not reflect the resident's requested food preferences. The facility census was 115. Review showed the facility did not provide a policy regarding resident food preferences. 1. Review of the Resident #84's face sheet (a document showing the resident's information at a quick glance) showed the following information: -readmission date of 04/26/24; -Diagnoses included congestive heart failure (a condition in which the heart doesn't pump blood as it should), respiratory failure with hypoxia (a condition where one does not have enough oxygen in the tissues of the body), type two diabetes, and dysphagia (difficulty swallowing). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents were treated with dignity/respect when one staff member (Housekeeper G) yelled at one resident (Resident # 3) in the dining room of the facility. A sample of seven residents selected for review in a facility with a census of 119. Review of the facility policy titled Quality of Life - Dignity, undated, showed the following information: -Residents shall be treated with dignity and respect at all times; -Residents shall be assisted in maintaining and enhancing his/her self-esteem and self-worth; -Staff shall speak respectfully to residents at all times. 1. Review of Resident # 3's face sheet (brief resident profile sheet) showed the following information: -admission date of 10/17/22; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection prevent and conrol program when staff failed complete appropriate hand hygiene and glove usage while providing incontinent care for two residents (Resident # 1 and Resident # 2). The facility census was 119. Review of the facility policy, titled Handwashing/Hand Hygiene, undated, showed the following: -The facility considers hand hygiene the primary means to prevent the spread of infections; -Wash hands with soap and water when hands are visibly soiled and after contact with a resident with infectious diarrhea; -Use an alcohol-based hand rub before and after direct contact with residents; -Use an alcohol-based hand rub before donning gloves; -Use an alcohol-based hand rub before moving from a contaminated body site to a clean body site during resident care; [...]

Inspectors wroteBased on interview and record review, the facility failed to issue a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advance Beneficiary Notice (SNFABN: Medicare requires SNFs to issue a SNFABN to beneficiaries prior to providing care that Medicare usually covers, but may not pay for because the care is not medically reasonable and necessary or considered custodial) Form 10055 for one resident (Resident #20) out of 19 sampled residents who remained in the facility when benefits were not exhausted, and failed to issue a CMS Notice of Medicare Non-Coverage (NOMNC: Medicare requires SNFs to issue a NOMNC to beneficiaries no later than two days before covered services end) Form 10123 at least two days before coverage ended for one resident (Resident #187) outside the sample. The facility's census was 93. 1. [...]