Springtown Park Rehabilitation and Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys, for the medication cart located on 1 of 4 halls. 1. The medication cart was observed unlocked and unattended by LVN C on Hall 100 on 12/16/2025 at 9:31 AM.2. Resident #52 was observed walking in Hall 100 to the unlocked medication cart and leaned her arms and head on top of the cart on 12/16/2025 at 9:32 AM. This failure placed residents at risk for adverse reactions from accessing and ingesting medications that were not prescribed for them.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 5 residents (Resident #82) reviewed for medication administration on Hall 100. Resident #82's medications were in a paper medication cup on her overbed table on the morning of 12/16/2025 at 9:13 AM. This failure could place the resident at risk for adverse consequences from not taking her prescribed medications at the prescribed time.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure they followed professional standards of practice in accordance with physician orders and facility policy for care of midline for 3 (Residents #13, #349, #354) of 4 residents reviewed for parenteral and intravenous care. The facility failed to assess the midline intravenous catheter (an intravenous catheter that is suitable for long term infusion therapy) dressing on Resident #13. Dressing was observed as soiled and dislodged before flush being performed. The facility failed to change the midline intravenous catheter (an intravenous catheter that is suitable for long term infusion therapy) dressing on Resident #349 for more than 7 days. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were labeled properly in the refrigerator and the freezer. The facility failed to ensure food that had spoiled was discarded timely. The facility failed to ensure that staff performed hand hygiene while preparing food. These failures could place residents that eat out of the kitchen at risk for food borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 2 of 3 residents (Resident #60, and #98) reviewed for Medicare/Medicaid coverage. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 1 resident (Residents #12's) reviewed for respiratory care. 1. The facility failed to ensure Residents #12's nasal cannula was kept in a bag while not in use. These failures could place residents at risk for infections and transmission of communicable diseases.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were secured and stored in accordance with current accepted professional principles for 1 Treatment Cart observed for medication storage. The facility did not ensure the Treatment Cart was locked and secured. This failure could place the residents at risk of gaining access to unlocked medications not prescribed to them.

Inspectors wroteBased on interview and record review the facility failed to ensure before a resident transfers or discharges from the facility the notice of transfer or discharge required under this section was made by the facility at least 30 days before the resident was transferred or discharged for one of 2 residents (Resident #1) reviewed for discharge requirement. 1) The facility failed and refused to readmit Resident #1 from the hospital where she was transferred for evaluation and treatment. 2) The facility did not give Resident #1 or the representative a discharge notice when she was transferred to another facility from the hospital. 3) The facility did not permit Resident #1 to remain in the facility and failed to initiate a 30-day discharge based upon the facility's ability to meet the resident's needs and welfare. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #2) reviewed for infection control practice. LVN A failed to perform hand hygiene and change gloves while providing wound care to Resident #2. These failures could place residents at risk for the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were secured on 1 (Medication Cart 1) of 8 medication carts reviewed for pharmacy services. The facility did not ensure medication cart (Medication Cart 1) was secured and locked. This failure could place the residents at risk of gaining access to unlocked medications not prescribed to them.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases for 1 (Resident #1) of 2 residents reviewed for infection control practice. CNA A and CNA B failed to perform hand hygiene and change their gloves while providing incontinence care for Resident #1. These failures placed residents at risk for the spread of infection.

Inspectors wroteBased on, interview and record review the facility failed to develop a baseline care plan within 48 hours of admission for 2 of 5 residents reviewed for baseline care plans, (Resident #'s 1 and 2). Resident # 1 was admitted on [DATE] and did not have a baseline care plan. Resident #2's family did not receive a written summary of his baseline care plan. This failure could affect residents by the facility not having the minimum healthcare information necessary to properly care for the resident immediately upon their admission. Findings Included: Record review of Resident #1's face sheet revealed he was a [AGE] year-old, male with an admission date of 11/02/2023. Record review of Resident #1's Diagnosis list revealed the following diagnoses: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to complete an assessment that accurately reflected the resident's status for 2 of 23 residents (Residents #11 and #243) whose records were reviewed for MDS accuracy, in that: 1. Resident #11 had an order for the anti-platelet medication of Clopidogrel (Plavix). The resident's Comprehensive MDS Assessment documented the use of an anticoagulant medication. 2. Resident #243 had an admission medication order, dated 8/06/2023, for a pain patch to be applied one time a week every Monday. She received an order on 8/09/2023 for pain medication as needed. The resident's admission MDS Assessment, dated 8/09/23, documented the resident did not receive scheduled pain medication. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate care to maintain highest practical physical and psychosocial well-being for 1of 23 residents (Resident # 62) reviewed for ADL care, in that: The facility failed to ensure Resident #62's fingernails were cut This failure placed residents at risk of experiencing a decreased quality of life and an increased risk of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 23 residents (Resident #46) reviewed for resident care, in that: The facility failed to ensure Resident #46 was provided treatment for her edema. This failure could place residents at risk for a decline in health status.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 2 of 3 residents (Resident #'s 46 and #191) reviewed for respiratory care. 1. The facility failed to ensure oxygen tubing for Residents #46 was dated and kept in a bag when not in use. 2. The facility failed to ensure Resident #191's nebulizer tubing was dated and kept in a bag while not in use. These failures could place residents at risk for infections and transmission of communicable diseases.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs) to meet the needs for 2 of 6 residents (Residents #62 and #63) reviewed for pharmaceutical services, in that: 1. Medication Aide A left Resident #62's medication with her in a cup to take later. 2. Medication Aide B failed to reorder medication for Resident #63 before her supply was depleted. These failures could place residents who receive medications at risk for a decline in health and of not receiving the intended therapeutic benefit of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide each resident with an ongoing program of individual activities designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident for 1 of 1 resident (Resident #82) who was reviewed for individual in-room activity programs, in that: Resident #82 did not have an individualized activity program developed and implemented for in-room activity pursuits based on her past and current activity interests. This failure could place the residents at risk for social isolation, a decline in mental health status, and decreased feelings of well-being within their environment.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 1 resident (Resident #146) whose record was reviewed for accurate and complete documentation, in that: 1. Resident #146 was admitted to the facility on [DATE]. A copy of an existing Out of Hospital - Do Not Resuscitate Order form was provided to the to the facility and had been scanned into her electronic health record. A DNR order was entered into the Physician Order Summary on [DATE]. 2. The OOH-DNR Order form was signed by the resident's family member on [DATE], with her signature witnessed and notarized. The OOH-DNR Order form was not accurately completed and had not been signed by a physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the results of the most recent survey of the facility conducted by the State surveyors and the facility's plan of correction were posted in a place readily accessible to residents, family members and legal representatives of residents, and the public in 1 of 1 facility, in that: The most recent State survey results and intake investigation findings of non-compliance with the facility's plan of correction were not readily accessible to residents. This failure could place residents and their family members and representatives at risk for violation of the right to review the findings from State surveys and investigations conducted in the facility without asking to review the reports.