Springfield Rehabilitation and Healthcare Center

Inspectors wroteBased on review of clinical records, facility documentation, and staff interview, it was determined that the facility failed to complete a thorough fall investigation, including obtaining witness statements from the resident and the resident's roommate for one of two residents reviewed for falls.

Inspectors wroteBased on observations, interview with staff and resident, and review of clinical record and facility's policy, it was determined that facility did not ensure to develop and implement a care plan related to assistive device and fall prevention measures for one of 18 residents reviewed (Resident R69)

Inspectors wroteBased on review of clinical records, facility documentation, and staff interviews, it was determined that the facility did not ensure development and implementation of a care plan related to the need for oxygen for 1 of 18 residents reviewed (Resident R10)

Inspectors wroteBased on resident interview, review of facility's policy and clinical record, it was determined that facility did not ensure hygiene care was provided as per resident's preference for one of 18 residents reviewed (Resident R86)

Inspectors wroteBased on review of clinical records, facility documentation, and resident representative and staff interview, it was determined that the facility failed to provide care and services in accordance with professional standards of practice for one of four residents reviewed (Residents R16).

Inspectors wroteBased on observations, interview with residents' and staff, review of policies and review of clinical records, it was determined that facility did not ensure residents' received adequate supervision and assistive device to prevent accidents for two of 18 residents reviewed. (Residents R69, R117)

Inspectors wroteBased on review of facility assessment and staff interview, it was determined that the facility failed to ensure the direct care staff and input from residents, resident representatives, and/or family members was included when conducting the facility assessment.

Inspectors wroteBased on review of clinical records, facility documentation, and staff interviews, it was determined that the facility did not ensure a dressing covering a central line was changed as ordered by the physician for one of one resident review with a central line. (Resident R106) Findings Include: Review of Resident R106's clinical record revealed that the resident was admitted to the facility on [DATE] with diagnoses including cutaneous abscess of right lower limb (usually caused by bacterial infection, a collection of pus within or under the skin), extended spectrum beta lactamase (ESBL) resistance (resistance of a specific type of microorganism to a particular type of antibiotics, which cause infection), and methicillin susceptible staphylococcus aureus infection (type of staph infection that can be treated with penicillin-related antibiotics). [...]

Inspectors wroteBased on review of clinical record, review of facility policy and interview with staff, it was determined that the facility failed to monitor and provide appropriate and timely intervention to prevent further weight loss for 1 of 3 residents reviewed. (Resident R1)

Inspectors wroteBased on the review of clinical record, facility investigation, review of policies and procedures, and interviews with staff, it was determined that the facility failed to ensure resident environment was free of accident hazard related to unlocked elevator providing access to a door that resident was able to leave the facility. (Resident R1). This deficiency was identified as past non-compliance. Findings Include:Review of facility policy Safety and Supervision of Residents, dated July 2017, revealed Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and facility- wide commitment to safety at all levels of the organization. [...]

Inspectors wroteBased on clinical record reviews, interviews with residents and staff and reviews of policies and procedures, it was determined that the facility failed to provide foot care and treatment for one of eight residents reviewed. (Resident R1)

Inspectors wroteBased on review of clinical records, and family member and staff interviews, it was determined that the facility failed to provide confidentiality of residents' personal health information during medication administration for two of three residents reviewed. (Residents R2 and R3).

Inspectors wroteBased on observations, interview with staff and residents and review of facility provided documentation, it was determined that facility did not ensure residents received the necessary services to maintain personal hygiene and mobility for five out of 18 residents reviewed (Resident R35, R40, R65, R233, R13)

Inspectors wroteBased on review of facility policy, review of clinical record, and staff interview, it was determined that the facility failed to ensure that appropriate pain management was provided to a resident consistent with standards of professional practice for four of 18 residents reviewed (Residents R79, R290, R292 and R293).

Inspectors wroteBased on review of facility provided documentation and interview with residents and staff, it was determined that facility did not ensure there is sufficient nursing staff available at all times to provide nursing and related services to meet the residents' needs based on 43 out of 50 grievances reviewed for months of March 2025, February 2025, January 2025, December 2024, October 2024.

Inspectors wroteBased on observations, review of clinical records, review of facility policy, interview with residents and staff, it was determined that facility did not ensure to implement enhanced barrier precautions for four residents (Residents R14, R5, R70, R77), ensure that infection control standards were maintained during wound care for one resident, (Residenr R22), and did not ensure that tuberculosis testing was administered on entry to the facility as required for one resident (Resident R190) out of 18 residents reviewed.

Inspectors wroteBased on review of facility policy, review of clinical record, observations, and staff interviews, it was determined that the facility failed to develop comprehensive care plan for one of eighteen residents reviewed related to weight changes, and one resident related to long-term antibiotic use (Residents R2 and R43). Findings Include: Review of clinical documentation for Resident R2 revealed that she was admitted to the facility on [DATE], and had diagnoses which included, infection and inflammatory reaction due to unspecified internal joint prosthesis. Further review revealed a physician order for an antibiotic which read Bactrim DS Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth two times a day for joint infection chronic- no stop date. [...]

Inspectors wroteBased on clinical record review and interview with staff, it was determined that the facility did not ensure that care plans were revised in a timely manner for one of 18 records reviewed (Resident R81).

Inspectors wroteBased on clinical record review, and interviews with staff, it was determined that the facility did not ensure that standards of practice for pressure ulcer treatment were followed related to a physician not being informed of a missed wound treatment for one of 18 records reviewed (Resident R59).

Inspectors wroteBased on review of facility provided documentation and interview with staff, it was determined that facility did not ensure annual performance evaluation was completed for one nurse aide out of five nurse aides trainings reviewed (Employee E7)

Inspectors wroteBased on interview with resident and staff, and review of clinical record and facility provided documentation, it was determined facility did not ensure residents were free from significant medication errors for two out of 18 residents reviewed (Resident R235, R288)

Inspectors wroteBased on clinical record review and interview with staff, it was determined that the facility did not ensure that laboratory study results were communicated to the physician in a timely manner for one of 18 records reviewed (Resident R2).

Inspectors wroteBased on interviews with residents and staff, and clinical record reviews, it was determined that the facility failed to provide as needed dental services for one of eighteen residents reviewed. (Resident R43)

Inspectors wroteBased on review of facility provided documentation and interview with staff, it was determined that facility did not ensure one Performance Improvement Project was completed as required.

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that laboratory studies were promptly obtained as ordered by the physician for one of three clinical records reviewed (Resident R1).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for 1 of 4 residents reviewed (Residents R1).

Inspectors wroteBased on review of clinical records, facility documentation and policy, and interviews with staff, it was determined the facility failed to provide adequate supervision to Resident R1 with a history of wandering, and at risk for elopement. This failure resulted in an Immediate Jeopardy situation to Resident R1 who eloped from the facility, crossed a high traffic street and was found by a member of the community in a lot across from the facility entrance, for one of four residents reviewed at risk for elopement (Resident R1). The deficiency was identified as Immediate Jeopardy past non-compliance.

Inspectors wroteBased on interviews with staff and review of facility documentation determined the facility failed to notify a representative of the Office of the State Long-Term Care Ombudsman of residents' transfers and/or discharges in writing for 2 of 2 months reviewed (July and August 2024).

Inspectors wroteBased on review of clinical records, facility policy, and interviews with resident and staff , it was determined that the facility failed to provide a reasonable accommodation of needs for one of nine sampled residents. (Resident R7)

Inspectors wroteBased on review of facility policies, facility documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that residents remained free from significant medication errors for one of nine residents reviewed (Resident R9).

Inspectors wroteBased on clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure that residents received assistance with bathing for three of seven residents reviewed (Residents R1, R2 and R4).

Inspectors wroteBased on observation, review of facility policies, review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that water temperatures in resident bathroom hand sinks were maintained at a safe temperature for one of two nursing units. This failure placed residents on the North Side nursing unit exposed to unsafe hot water temperature and at risk of serious injury from a burn. This failure resulted in an Immediate Jeopardy situation. (North side nursing unit)

Inspectors wroteBased on observation, a review of facility documentation and interviews with staff, it was determined that the Nursing Home Administrator failed to effectively manage the facility related to hot water temperatures in one of two nursing units which resulted in an immediate jeopardy situation. (North Side Nursing Unit) Findings Include: Review of the job description for the Nursing Home Administrator (NHA) revealed the Nursing Home Administrator (NHA) primary purpose of the job position is to direct the day-to-day functions of the Center in accordance with current federal, state and local standards, guidelines, and regulations that govern nursing Centers to assure that the highest degree of quality care can be provided to our residents at all times. [...]

Inspectors wroteBased on on the review of clinical records and facility documentation, observations, interview with residents and staff, it was determined that the facility did not ensure an environment was free of potential hazards related to medications left at bedside, a fall incident, and no railing around the loading dock for three of 30 residents' records reviewed (Rooms R326, R328, R329).

Inspectors wroteBased on observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Inspectors wroteBased on a review of facility documents and resident clinical records and interviews with staff and residents, it was determined that the facility failed to ensure that residents had the capacity to understand the terms of a binding arbitration agreement for three of nine residents reviewed (Resident R226, R227 and Resident R228).

Inspectors wroteBased on observation, review of facility policy and procedure, and interviews with staff, it was determined that the facility failed to maintain an effective infection control program, related with linen transportation, and personal protective equipment disposal for one of one resident observed during trancheotomy care. (Resident R56).

Inspectors wroteBased on observations, review of facility policy, and interviews with staff and residents, it was determined that the facility did not ensure that residents were treated with dignity and respect for two of two residents reviewed. (Residents R13 and R47) Findings Include: Review of the Resident Rights policy with a revision date of October 2010 states, Purpose-To provide general guidelines for resident rights while caring for the resident. Preparation 1. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on resident rights, including: a. Preventing, recognizing and reporting resident abuse; b. Resident dignity and respect; c. Resident notification of rights, services, and health/medical condition; d. Protection of resident funds and personal property; e. Confidentiality of protected health information; f. [...]

Inspectors wroteBased on observation, it was determined that the facility failed to maintain a safe, clean, comfortable and homelike environment for 16 out of 21 residents reviewed. (Residents R42, R44, R28, R4, R63, R43, R329, R52, R35, R51, R19, R7, R44, R58, R30 and R34). Findings Include: An initial tour was taken on May 14, 2024 at 10:00 a.m. of n the East and North units revealed the following: Observation of Resident R35's room revealed an air conditioning unit that had liquid spilled on top of it. Observation of Resident R51's room at 10:04 a.m. revealed her call bell hanging on the wall and not within reach of her, this was confirmed by licensed nurse, Employee E6 at 10:08 a.m. A tour of Resident R42's room revealed trash on the floor and linens that were dirty. An interview with the resident revealed the facility phone in his room doesn't work. [...]

Inspectors wroteBased on review of clinical records, interviews with staff and review of facility policy, it was determined that the facility failed to develop a comprehensive person-centered care plan for three of 21 resident reviewed (Residents R32, R46 and Resident 48).

Inspectors wroteBased on observations and interviews with residents and staff it was determined the facility did not ensure physicians order were followed related to medication administration and care to a pleurax catheter for two of 21 residents reviewed. (Residents R326 and R329) Findings Include: During Resident Council held on May 15, 2024 at 2:00 p.m. Resident R326 stated during medication administration this morning, she dropped a pill, told the nurse, the nurse did not come back with a replacement pill, and she still hadn't gotten it for the day. The resident was asked by the surveyor if she knew what pill it was and she stated, No, but I have it still I saved it in my room At the end of Resident Council, the surveyor approached licensed nurse, Employee E5 and stated what Resident R326 had said during Resident Council. [...]

Inspectors wroteBased on observations, review of facility policy, review of clinical records, and interviews with staff it was determined that the facility failed to monitor a resident's needs to maintain acceptable parameters of nutritional status for one of 21 residents reviewed for nutritional status. (Resident R13). Findings Include: Review of the facilities policy titled, Weight Assessment and Intervention with a revision dated on March 2022 state, Resident weights are monitored for undesirable and unintended weight loss or gain. Review of Resident R13's clinical record revealed the diagnoses of muscle wasting and atrophy, hyperlipidemia, hypothyroidism, diverticulitis of large intestine without perforation or abscess without bleeding, unspecified hearing loss, abnormalities of gait and mobility, dysphagia, and cognitive communication deficit. [...]

Inspectors wroteBased on resident council interviews, review of the established meal time schedule, and clinical record review, it was determined that the facility failed to ensure a nourishing snack was provided when in between meals for five of 21 residents reviewed. (Residents R275, R22, R326, R14, and R13). Findings Include: Resident Council was held on May 15, 2024 at 2:00 p.m. When asked if the resident's receive snacks in the evening four out of five residents stated that they have never received a snack in the evening. Review of Resident R275's evening snack record revealed, no snack was given on May 14, 2024. Review of Resident R22's evening snack record revealed, no snack was given on April 20, April 26. May 1, May 2, May 4, May 5, May 14, 2024. Review of Resident R326's evening snack record revealed, no snack was given on May 11, May 14, and May 16, 2024. [...]

Inspectors wroteBased on observations and an interview with staff, it was determined that the facility did not ensure that garbage and refuse was disposed of properly.

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to ensure that the loading dock was in safe conditions.

Inspectors wroteBased on observation, review of facility policy and procedure, and interviews with staff, it was determined that the facility failed to handle and transport linens to prevent the spread of infection on one of two nursing units. (East wing)

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to developed a baseline care plan for one of six residents reviewed related to a community-acquired infectious disease (Resident R1).

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to follow acceptable infection control practices related to the admission to the facility of a resident with a community-acquired infectious disease for one of six residents reviewed (Resident R1).

Inspectors wroteBased on a review of clinical records, facility policies and procedures, and interviews with residents and staff, it was determined that the facility failed to ensure an alleged allegation involving suspected abuse was reported, as required, to the Department of Health for one of eight residents reviewed (Residents R8).