Springfield Suites Rehab and Nursing

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store medication and label insulin vials for 4 of 6 residents in a sample of 37 residents residing in the facility.

Inspectors wroteBased on interviews, observations, and record reviews the facility failed to complete hand hygiene prior to conducting resident care, prior to and after donning gloves, and failed to apply a gown for enhanced barrier precautions for 5 of 8 residents (R14, R60, R57, R44 and R67); reviewed for infection control in a sample of 37.

Inspectors wroteBased on observation, interview and record review, the facility failed to check residual, for 1 of 1 (R67) resident, reviewed for enteral gastrostomy tube maintenance, in a sample of 37.

Inspectors wroteBased on observation, interview and record review the facility failed to check food temperature of all food items prior to serving and provide food at the correct temperature. This has the potential to affect all 65 residents residing at the facility.

Inspectors wroteBased on interview and record review, the Facility failed to ensure pain medications were readily available for administration in order to prevent increasing pain/discomfort for 2 of 4 (R2, R3) residents reviewed for pain medications in the sample of 4.

Inspectors wroteBased on interview and record review, the facility failed to provide an appropriate number of staff to assist in a transfer in 1 of 5 residents (R2), reviewed for falls in the sample of 7.

Inspectors wroteBased on interview and record review, the Facility failed to ensure residents are treated with dignity and respect by providing timely care which promotes quality of life for 2 of 24 residents (R117, R11) reviewed for dignity, in the sample of 44. This failure resulted in R117 experiencing prolonged pain and feeling undignified, and R11 feeling embarrassed.

Inspectors wroteBased on interview and record review, the Facility failed to ensure residents pain was addressed, assessed and medication provided in a timely fashion for 1 of 24 residents (R117) reviewed for pain management, in the sample of 44. This failure resulted in R117 experiencing prolonged, unrelieved pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to post the daily nursing staff hours daily. This failure has the potential to affect all 58 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely prepare medication, properly store medication, and to date medication bottles when opened, the Tuberculin (TB) vial was opened and undated and is used for all staff and residents. This has the potential to affect all residents living at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored in a manner that prevents potential contamination and failed to ensure required kitchen staff wear beard coverings. This has the potential to affect all 58 residents living in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive policy and procedure for Quality Assurance Improvement Plan and failed to ensure corrective actions/performance improvement is sustained. This has the potential to affect all 58 residents living in the facility.

Inspectors wroteBased on observation, interview, and record review, failed to provide ongoing tracking and trending of residents' and employees' infections, failed to update infection control policies, failed to implement infection control precautions, and failed to provide hand-hygiene during medication administration and resident care to prevent the spread of infections. This has the potential to affect all 58 residents in the facility.

Inspectors wroteBased on interview and record review, the facility must have an Infection Preventionist (IP) who has completed professional training before becoming the IP in the facility and implements infection control procedures which is applicable with standards of practice. This has the potential to affect all 58 residents living in the facility.

Inspectors wroteBased on Interview, Observation, and Record Review, the facility failed to provide complete and timely incontinent care for 4 of 5 residents (R11, R48, R176, R27) reviewed for incontinent care in the sample of 44.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan for 3 of 15 residents (R14, R18, R35) reviewed for care plans in a sample of 44.

Inspectors wroteBased on Interview, Observation, and Record Review, the facility failed to provide and implement safety measures to prevent a resident from falling, failed to complete a Fall Risk Assessment after a fall for 1 of 8 residents (R11) reviewed for falls in the sample of 44.

Inspectors wroteBased on observation, interview and record review, the Facility failed to follow their Facility Policy regarding tube feeding administration for 1 of 2 residents (R31) reviewed for enteral tube feeding, in the sample of 44.

Inspectors wroteThe facility failed to provide Oxygen (O2) to a resident requiring O2 to maintain an O2 Saturation above 92%, to administer the correct O2 dose per physician order, and to change and date the humidified water bottle for 2 of 3 residents (R170, R175), reviewed for respiratory care in the sample of 44.

Inspectors wroteBased on interview and record review, the Facility failed to re-evaluate the need for psychotropic medications for 2 or 6 residents (R19 and R6) reviewed for unnecessary medications, in the sample of 44.

Inspectors wrote[NAME] Based on interview and record review, the facility failed to ensure that residents do not receive antibiotics without indication for use for three of three residents (R119, R6, R318) reviewed for antibiotic stewardship in the sample of 44.

Inspectors wroteBased on interview and record review, the Facility failed to follow their influenza/pneumococcal vaccines policy for for 2 of 5 residents (R6, R31) reviewed for influenza/pneumococcal vaccines per their Facility Policy, in the sample of 44.

Inspectors wroteBased on observations and interview the facility failed to date multi use vials of medications when accessed, failed to date an open insulin pen, failed to date eye drops and left medications unattended at bedside. This failure has the potential to affect all 64 residents in the facility.

Inspectors wroteBased on observations and interview, the facility failed to remove expired food from the shelves and for resident use. This has the potential to affect all 64 residents in this facility.

Inspectors wroteBased on observations, interviews and record review the facility failed to provide, assess and provide supervision if needed for smoking, failed to utilize safe transfer techniques, failed to assess residents after falls and implement applicable interventions for 5 of 6 residents (R216, R154, R157, R1, R167) reviewed for supervision to prevent accidents in a sample of 34.

Inspectors wroteBased on observation, interview and record review the facility failed to provide complete incontinent care for 4 of 4 (R1, R7, R160, R253,) residents reviewed for incontinence care in a sample of 34.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide hand hygiene/glove changes during incontinent care and cleanse and store respirator equipment to prevent the spread of infection for 4 of 6 residents (R1, R3, R7, R160) reviewed for infection control in a sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents have services to provide a safe discharge from facility to home for 1 of 3 (R3) reviewed for orientation for discharge in the sample of 4. This failure resulted in R3 being discharged to home alone although the facility had assessed her as needing 24-hour care. This resulted in R3 having the inability to administer her medications as needed, having multiple falls requiring Emergency Medical Care, hospital admission, and subsequent readmission to facility on 10/17/23.