Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Springfield Rehabilitation & Health Care Center during CMS and state inspections, most recent first.
A resident with chronic respiratory failure and COPD did not have access to a functional BiPAP/CPAP machine for over two months due to broken tubing and missing supplies. Despite physician orders and the resident's dependence on the machine for respiratory support, the facility failed to document timely steps to acquire the necessary parts. This resulted in the resident experiencing confusion and lethargy, highlighting a deficiency in the facility's provision of respiratory care.
The facility failed to ensure proper food safety practices by not allowing dishware to air dry before stacking and not separating dented cans from other canned goods. Observations and interviews revealed that some staff were not following the correct procedures, leading to potential contamination risks.
The facility failed to ensure the dignity of residents with indwelling urinary catheters by not providing dignity bags for their urine collection bags. Observations showed that the catheter bags of three residents were visible from the hallway and were not covered by dignity bags, compromising their dignity and privacy. Staff interviews confirmed that catheter drainage bags should always be covered with dignity bags, but this practice was not consistently followed.
The facility failed to provide scheduled showers for nine residents, leading to irregular shower provision and affecting residents' cleanliness and comfort. Staffing issues and inadequate documentation contributed to the deficiency, with residents often receiving fewer showers than scheduled.
The facility failed to notify residents and their representatives in writing of hospital transfers, including the reason, date, and destination. This deficiency was identified for three residents, with instances involving combative behavior, a drop in oxygen saturation, increased temperature, and a fall. Staff interviews revealed inconsistencies in the process for providing hospital transfer notices.
The facility failed to ensure proper catheter care for three residents, resulting in catheter drainage bags touching the floor, contrary to facility policy and CDC guidelines. This was observed in residents with severe cognitive deficits and chronic kidney disease, among other conditions. Staff interviews confirmed that catheter bags should not touch the floor and should be positioned below the level of the bladder.
The facility failed to ensure accurate documentation and storage for emergency kit medications, with lock tags on three out of five E-Kit boxes not matching the records. Staff interviews revealed a lack of clarity and responsibility for monitoring and reconciling the emergency kit lock tags and register documentation. The facility did not have a policy for emergency medication kits, leading to inconsistencies in documentation and storage practices.
The facility failed to ensure a medication error rate below 5%, as staff did not prime insulin pens before administration for three residents, resulting in a 10% error rate. Observations and interviews revealed a lack of awareness and training on the need to prime insulin pens.
The facility staff failed to ensure residents were free from significant medication errors by not priming insulin pens before administering insulin to three residents. This resulted in the potential for incorrect insulin doses. Interviews revealed a lack of awareness and training on the need to prime insulin pens.
The facility failed to ensure medications were stored safely and securely when staff left medication and treatment carts unlocked and unattended. Observations showed multiple instances where carts containing medications, including insulin, were left accessible without any authorized personnel present. Interviews confirmed that the facility's policy requires carts to be locked when unattended, but staff actions did not comply with this policy.
The facility failed to maintain effective infection control, as staff did not perform proper hand hygiene during incontinent and catheter care for two residents. Additionally, clean laundry was transported without protective covering, exposing it to potential contamination. Interviews confirmed staff awareness of proper protocols but revealed inconsistent adherence.
The facility failed to ensure that all bathrooms were adequately equipped with accessible call light systems. In multiple instances, call light pull cords were either wrapped around grab bars or missing entirely, preventing residents from easily accessing and activating the call light. This deficiency was observed in the bathrooms of eight residents, including those with significant medical conditions such as stroke, hemiplegia, diabetes, and dementia.
The facility failed to ensure safe self-administration of medications by a resident, leaving medications at the bedside without an assessment, physician's order, or care plan. Staff confirmed that medications should not be left unattended, yet observations showed otherwise.
The facility failed to notify and coordinate with the State-designated authority when a resident with major depressive disorder, generalized anxiety disorder, and unspecified dementia exhibited severe behavioral issues and threats. Despite significant changes, the facility did not refer the resident for a Level II PASARR review. Interviews revealed a lack of understanding and coordination regarding the PASARR process.
The facility failed to ensure that a resident who required assistance with showers received the necessary care. The resident, dependent on staff for grooming and bathing, experienced significant gaps between showers, resulting in unkempt and greasy hair, a dirty face, and crust buildup around the eyes. Staff interviews confirmed the absence of a set shower schedule and difficulties in providing the required two showers per week.
The facility failed to ensure staff followed physician orders and accurately documented the implementation of orders for a resident requiring tubi grips. Observations showed the resident was often without the tubi grips, and staff interviews revealed inconsistencies in application and documentation.
The facility failed to maintain a safe environment when two CNAs transferred a resident without using a gait belt, contrary to the facility's policy. The resident, who had severe cognitive impairment and required assistance for transfers, was lifted by the CNAs using improper techniques, leading to a deficiency in resident safety.
The facility failed to provide proper tracheostomy care for a resident, as the LPN did not follow aseptic techniques, failed to perform hand hygiene, and improperly handled contaminated items. The DON and Administrator confirmed that the expected procedures were not followed.
The facility failed to consistently honor a resident's meal preferences, resulting in the resident receiving meals that did not reflect their requests. Staff interviews revealed inconsistencies in the process of taking and fulfilling meal orders, and the facility lacked a policy regarding resident food preferences.
Failure to Provide Necessary Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care per standards of practice by not ensuring a resident had access to a physician-ordered BiPAP or CPAP machine. The resident, who had chronic respiratory failure, COPD, and was dependent on supplemental oxygen, was prescribed a CPAP to be used anytime they were in bed sleeping. However, the resident did not have access to a functional CPAP machine from late July through September due to broken tubing and missing supplies. Despite the resident's medical records indicating the need for consistent use of the BiPAP/CPAP, the facility did not document timely steps to acquire the necessary supplies to make the machine operable. The resident's medical records showed that the CPAP was not used from July 23 through the end of August because the machine lacked the needed supplies. The facility records indicated that a fax was sent to a home health agency for supplies on August 14, 22 days after the machine became inoperable. Interviews with staff revealed that there was confusion and a lack of communication regarding the responsibility for obtaining the necessary parts. The resident's family was involved in attempts to acquire the parts, but the facility did not successfully coordinate with suppliers to resolve the issue. Throughout this period, the resident experienced episodes of confusion and lethargy, which were noted in the progress notes. The facility's failure to ensure the resident had a functional BiPAP/CPAP machine, as ordered by the physician, resulted in the resident not receiving the prescribed respiratory support. The lack of documentation and follow-up actions by the facility staff contributed to the prolonged period during which the resident did not have access to the necessary respiratory care equipment.
Failure to Ensure Proper Food Safety Practices
Penalty
Summary
The facility failed to keep food safe from potential contamination by not allowing dishware to air dry before stacking them. Observations on multiple occasions showed various items, including metal pans, plastic bowls, coffee cups, and divided plates, left wet and stacked on top of one another, trapping water between the items. Interviews with dietary aides and the Regional Dietary Manager confirmed that some staff, particularly new employees, were not following the proper air-drying procedures, despite being aware of the correct protocol. The facility's policy clearly states that all items must be air-dried before stacking to prevent wet-nesting, which was not adhered to in these instances. Additionally, the facility failed to separate dented cans from other canned goods, which could potentially compromise food safety. Observations revealed several dented cans, including tomato paste, mixed sweet peas, navy beans, and grapefruit sections, stored alongside undamaged cans. Interviews with dietary staff indicated a lack of awareness regarding the presence of dented cans and the proper procedure for handling them. The facility's policy mandates that dented cans should be set aside and reviewed with a manager for appropriate credit, which was not consistently followed. The Administrator was aware of these issues through communication with the Regional Dietary Manager.
Failure to Provide Dignity Bags for Urinary Catheter Collection Bags
Penalty
Summary
The facility failed to ensure the dignity of residents with indwelling urinary catheters by not providing dignity bags for their urine collection bags. This deficiency was observed in three residents out of a sample of 29 in a facility with a census of 115. The facility's policy on urinary catheter care indicated that catheter bags should be covered with dignity bags, but this was not followed for Residents #29, #2, and #61. Observations over several days showed that the catheter bags were visible from the hallway and were not covered by dignity bags, compromising the residents' dignity and privacy. Resident #29, who had chronic kidney disease and an indwelling catheter, was observed multiple times with an uncovered catheter bag that was visible from the hallway. The resident's care plan did not include instructions for using a dignity bag. Similarly, Resident #2, who had a history of frequent urinary tract infections and neuromuscular dysfunction of the bladder, was also observed with an uncovered catheter bag visible from the hallway. The care plan for this resident also lacked instructions for using a dignity bag. Resident #61, who had chronic kidney disease and benign prostatic hyperplasia, was observed on multiple occasions with an uncovered catheter bag visible from the hallway. The care plan for this resident did not include the use of a dignity bag. Interviews with staff, including CNAs, an LPN, the Director of Nursing, and the Administrator, confirmed that catheter drainage bags should always be covered with dignity bags, but this practice was not consistently followed.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not providing showers as preferred and care planned for nine residents. The facility's policy on baths and showers did not address the scheduling of these activities, leading to inconsistencies in shower provision. Residents were scheduled for showers twice a week, but records and resident interviews revealed that they often received showers less frequently, sometimes only once a week or even less. This failure affected residents' cleanliness and comfort, as well as their dignity and self-esteem. Resident #9, who was cognitively intact and required moderate assistance, was scheduled for showers on Tuesdays and Fridays but received them irregularly, with gaps of up to eight days between showers. Resident #21, also cognitively intact and requiring moderate assistance, experienced similar issues, with gaps of up to 12 days between showers. Resident #23, who required substantial assistance, received only one shower in April and one in early May, despite being scheduled for two showers per week. Other residents, including Resident #55, Resident #108, Resident #33, Resident #8, Resident #15, and Resident #11, also reported receiving fewer showers than scheduled, feeling dirty, and being unsure of their shower schedules. Interviews with staff, including CNAs, LPNs, the DON, and the Administrator, revealed that the facility had staffing issues, with only one shower aide available at times instead of the usual two. This led to missed showers and inadequate documentation of shower provision. The facility's method of tracking showers was inconsistent, and there was a lack of communication between nurses and shower aides regarding new residents or transfers. The DON and Administrator acknowledged the problem and mentioned that a shower aide had been fired for not providing showers as reported, but the deficiency persisted, affecting residents' quality of life and self-determination.
Failure to Provide Hospital Transfer Notices
Penalty
Summary
The facility failed to notify residents and their representatives in writing of transfers or discharges to a hospital, including the reason for the transfer, date of transfer, and destination of transfer. This deficiency was identified for three residents out of a sample of 29. For Resident #100, there were two instances where the resident was transferred to the hospital without documented notification to the resident or their representative. The first instance involved the resident being combative and agitated, and the second instance involved a significant drop in oxygen saturation. In both cases, the medical records lacked documentation of a hospital transfer notice being provided to the resident or their representative. For Resident #5, the resident was transferred to the emergency room due to increased temperature, pale color, and poor intake, but there was no documentation of a hospital transfer notice being provided. Similarly, Resident #8 was transferred to the emergency room after a fall that resulted in a head injury and shoulder pain, but again, there was no documentation of a hospital transfer notice being provided. Interviews with various staff members, including the Social Service Director, LPNs, and the Director of Nursing, revealed inconsistencies and a lack of clarity regarding the process for providing hospital transfer notices to residents and their representatives.
Failure to Maintain Proper Catheter Care
Penalty
Summary
The facility failed to ensure appropriate treatment and services to prevent possible urinary tract infections (UTIs) by not maintaining proper catheter care for three residents. Observations revealed that the catheter drainage bags of Residents #29, #2, and #61 were either touching or dragging on the floor. This is contrary to the facility's policy and the Centers for Disease Control and Prevention (CDC) guidelines, which state that catheter bags should not rest on the floor to prevent contamination and potential infections. Resident #29, who has severe cognitive deficits and chronic kidney disease, was observed with a catheter bag touching the floor on multiple occasions. Similarly, Resident #2, with a history of frequent UTIs and neuromuscular dysfunction of the bladder, had a catheter bag that touched the floor. Resident #61, who has severe cognitive impairment and chronic kidney disease, was also observed with a catheter bag touching the floor on two separate occasions. Interviews with staff, including a Certified Nurse Aide (CNA) and the Director of Nursing (DON), confirmed that catheter bags should not touch the floor and should be positioned below the level of the bladder. The Administrator also stated that staff are expected to follow the policy and procedure for catheter care, which includes ensuring that catheter drainage bags do not touch the floor.
Inaccurate Documentation and Storage of Emergency Kit Medications
Penalty
Summary
The facility failed to ensure accurate documentation and storage for the emergency kit (E-Kit) medications. During an observation, it was found that the lock tags on three out of five E-Kit boxes did not match the records in the All E-Kit Lock Registration form. Specifically, the A kit box had tag numbers 909 and 908, and the C kit box had tag numbers 953 and 954, which did not correspond to the documented numbers on the register form. Additionally, the rehab hall medication room had an A kit box with lock tag numbers 247 and 248, which also did not match the register form entries. The facility census was 115 at the time of the survey. The facility's policy on medication storage did not include specific guidelines for emergency kit boxes and logs, contributing to the discrepancy in documentation and storage practices. Interviews with staff, including LPNs, RNs, and the Director of Nursing (DON), revealed a lack of clarity and responsibility regarding the monitoring and reconciliation of the emergency kit lock tags and register documentation. Staff members were unsure who was responsible for ensuring the accuracy of the tag numbers and register documentation, and there was no designated staff member for this task. The DON and the Administrator confirmed that the pharmacy delivers the emergency kits every four weeks, and the first staff member to access the box should change the tag and document the information accurately. However, no facility staff audited the emergency kit locks and register, relying on the pharmacy to perform this task. The facility did not have a policy for emergency medication kits, leading to inconsistencies in documentation and storage practices.
Failure to Prime Insulin Pens Leads to Medication Errors
Penalty
Summary
The facility failed to ensure that the medication error rate was not 5 percent or greater, specifically when staff did not prime insulin pens before administration. This failure was observed in three residents out of 29 opportunities during a medication pass, resulting in a 10% error rate. The facility census was 115. The insulin pens for insulin lispro and NovoLog require priming to remove air bubbles and ensure accurate dosing, as per the manufacturer's instructions. However, staff did not follow these instructions, leading to potential underdosing or overdosing of insulin for the residents involved. Resident #220, who has diagnoses including type 2 diabetes mellitus and long-term use of insulin, was observed receiving insulin lispro without the pen being primed. The resident's blood sugar level was 183 mg/dL, requiring four units of insulin per the sliding scale order. The RN administered the insulin without priming the pen, which could affect the accuracy of the dose given. Similarly, Resident #215, also diagnosed with type 2 diabetes mellitus and long-term use of insulin, received 20 units of insulin lispro without the pen being primed. The RN did not follow the necessary steps to ensure the insulin pen was primed before administration. Resident #10, with moderately impaired cognition and a diagnosis of type 2 diabetes mellitus, was also administered 12 units of NovoLog insulin without the pen being primed. The RN admitted to usually priming the pen but forgot to do so on the day of observation. Interviews with staff revealed a lack of awareness and training on the need to prime insulin pens, contributing to the medication errors observed.
Failure to Prime Insulin Pens Before Administration
Penalty
Summary
The facility staff failed to ensure that residents were free from significant medication errors when they did not prime insulin pens before administering insulin to three residents. The failure to prime the insulin pens, which is necessary to remove air from the needle and cartridge, resulted in the potential for administering incorrect doses of insulin. This deficiency was observed during insulin administration to three residents, all of whom had diagnoses of type 2 diabetes mellitus and were on long-term insulin therapy. For Resident #220, the Registered Nurse (RN) performed an accucheck and determined that the resident required four units of insulin lispro. However, the RN administered the insulin without priming the pen. Similarly, for Resident #215, the RN administered 20 units of insulin lispro without priming the pen. In the case of Resident #10, the RN administered 12 units of NovoLog insulin without priming the pen, despite the resident's blood sugar level indicating the need for insulin. Interviews with the RN and Licensed Practical Nurse (LPN) revealed a lack of awareness and training regarding the need to prime insulin pens. The Director of Nursing (DON) and the Administrator confirmed that the facility was in the process of switching from insulin vials to injectable pens and that an in-service training was scheduled but had not yet occurred. The staff's failure to follow the manufacturer's guidelines for insulin pen use led to the observed deficiencies.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
The facility failed to ensure medications were stored safely and securely when staff left medication and treatment carts unlocked and unattended. On multiple occasions, surveyors observed medication and treatment carts left unlocked and accessible without any certified medication technician (CMT) or nurse present. For instance, on one occasion, a CMT left a medication cart unlocked and unattended for three minutes. On another occasion, a treatment cart containing insulin, glucometers, prescription creams, and ointments was left unlocked and unattended multiple times by an RN, who also left an insulin vial on top of the cart while walking away to administer the medication to a resident. Interviews with staff, including an LPN, the Director of Nursing (DON), and the Administrator, confirmed that the facility's policy requires medication and treatment carts to be locked when unattended. Despite this policy, the observed actions of the staff did not align with the facility's procedures, leading to the deficiency. The facility had a census of 115 at the time of the survey, indicating a significant potential risk due to the unsecured medications and treatment supplies.
Infection Control Deficiencies in Hand Hygiene and Laundry Practices
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by improper hand hygiene practices during incontinent care for one resident and urinary catheter care for another. Certified Nursing Assistants (CNAs) were observed not performing hand hygiene before donning gloves, between glove changes, and after providing care. Specifically, during incontinent care, CNAs did not wash their hands before donning gloves, after removing soiled gloves, or before donning new gloves. Similarly, during catheter care, a CNA did not perform hand hygiene before donning gloves, between glove changes, or after completing care, leading to potential contamination and spread of infection. The report also highlighted the facility's failure to protect clean laundry from possible contamination. Laundry staff were observed carrying clean garments on hangers without any protective covering through the hallways. Additionally, clean laundry was transported using uncovered wire rolling carts, which exposed the garments to potential contamination. Interviews with staff confirmed that the facility did not have a policy for covering clean laundry during transport. Interviews with various staff members, including CNAs, Licensed Practical Nurses (LPNs), the Director of Nursing (DON), and the Administrator, revealed a lack of adherence to proper hand hygiene protocols. Staff acknowledged the correct procedures for hand hygiene but failed to implement them during care. The DON and Administrator confirmed that staff are expected to wash their hands before and after care, and before donning or doffing gloves, but these practices were not consistently followed, leading to deficiencies in infection control.
Inaccessible Call Light Systems in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that all bathrooms were adequately equipped with a full call light system. In multiple instances, call light pull cords were either wrapped around grab bars or missing entirely, preventing residents from easily accessing and activating the call light. This deficiency was observed in the bathrooms of eight residents, including those with significant medical conditions such as stroke, hemiplegia, diabetes, and dementia. These residents were at increased risk for falls and required assistance with toileting and transfers, making the accessibility of call lights crucial for their safety and well-being. For example, Resident #9, who had a history of stroke and hemiplegia, was observed to have a call light pull cord wrapped tightly around the grab bar in their shared bathroom, making it inaccessible. Similarly, Resident #21, who had diabetes and chronic kidney disease, also had a call light pull cord wrapped around the grab bar, preventing easy access. Resident #23, who had dementia and heart disease, was found to have a missing call light pull cord in their shared bathroom, further compromising their ability to call for assistance. Interviews with residents and staff revealed that the issue of inaccessible call lights was known but not consistently addressed. Some staff members admitted to wrapping the cords around grab bars to make them more accessible, while others reported the issue to maintenance without timely resolution. The Director of Nursing and the Administrator both acknowledged that call lights should always be within reach of residents, indicating a lapse in adherence to the facility's policy on call light accessibility.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that all residents who self-administered medications were clinically appropriate to do so. Specifically, staff left medications at the bedside for Resident #99 to self-administer without an assessment, physician's order, or care plan in place. The resident, who was cognitively intact and had diagnoses including PTSD, major depressive disorder, type 2 diabetes mellitus, and autoimmune hepatitis, was found with medications left unattended on two separate occasions. The facility's policy mandates that staff should not leave medications at the bedside unless specifically ordered by a prescriber and should remain with the resident while the medication is taken. However, this policy was not followed in the case of Resident #99. During interviews, multiple staff members, including LPNs, RNs, the DON, and the Administrator, confirmed that medications should not be left with residents to take later and that staff should observe residents taking their medications. Despite this, Resident #99 reported that staff left medications at the bedside, trusting the resident to take them later. Observations confirmed that medications were left unattended on the resident's bedside table. The facility did not have documentation of an assessment to determine if the resident could safely self-administer medications, nor was there a physician's order or care plan for self-administration in place.
Failure to Coordinate PASARR for Resident with Significant Change
Penalty
Summary
The facility failed to notify and coordinate with the State-designated authority when a resident, previously identified by the Preadmission Screening and Resident Review (PASARR) as having a mental disorder, experienced a significant change. The resident, who had diagnoses including major depressive disorder, generalized anxiety disorder, and unspecified dementia with other behavioral disturbances, exhibited severe behavioral issues and threats towards staff and other residents. Despite these significant changes, the facility did not refer the resident for a Level II PASARR review as required by their policy. The resident's progress notes detailed multiple incidents of aggressive and threatening behavior, including cursing at staff, refusing care, and making threats to harm themselves and others. The resident was eventually sent to a geriatric psychiatric facility following these incidents. Interviews with the Social Service Director, Long Term Care Social Worker, Rehabilitation Social Worker, Director of Nursing, and the Administrator revealed a lack of understanding and coordination regarding the PASARR process, particularly the need for a Level II screening after significant changes in the resident's condition.
Failure to Provide Regular Showers and Grooming Assistance
Penalty
Summary
The facility failed to ensure that a resident who required assistance with showers received the necessary assistance. The resident, who had diagnoses including heart failure and a Stage IV pressure ulcer, was dependent on staff for grooming and bathing. The resident's care plan indicated the need for extensive assistance with activities of daily living and specified that the resident should be offered and encouraged to take two showers a week. However, a review of the resident's shower records for April and May 2024 showed significant gaps between showers, with one instance of 14 days between showers. Observations on multiple occasions revealed the resident with unkempt and greasy hair, a dirty face, and crust buildup around the eyes. The resident reported not receiving showers regularly and could not recall the last time they had a shower. Interviews with staff, including CNAs, CMTs, the DON, and the Administrator, confirmed that there was no set shower schedule, and staff often struggled to provide the required two showers per week. The DON mentioned that there were designated shower aides for different halls and that staff tried to use Wednesdays as a catch-up day. Despite these efforts, the facility did not consistently meet the resident's grooming and bathing needs, leading to the observed deficiency.
Failure to Follow Physician Orders for Tubi Grips
Penalty
Summary
The facility failed to ensure staff followed physician orders and accurately documented the implementation of physician orders for a resident who required tubi grips for bilateral lower extremities. Despite the physician's order to apply the tubi grips in the morning and remove them in the evening, observations on multiple occasions revealed that the resident was not wearing the tubi grips. The resident reported that staff did not apply the tubi grips unless specifically asked, and sometimes the tubi grips caused pain due to neuropathy, which might have led to staff not offering them proactively. Interviews with staff, including CNAs and LPNs, indicated a lack of consistent application and documentation of the tubi grips. Some staff were unaware of the need for the tubi grips, while others mentioned that the resident often put them on themselves or requested assistance. The Director of Nursing and the Administrator both acknowledged that staff should follow physician orders and document any refusals or issues, but there was no evidence of consistent documentation or communication with the physician regarding the resident's refusal or inability to wear the tubi grips.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to maintain an environment as free of accident hazards as possible when staff transferred a resident without the use of a gait belt. The resident, who had severe cognitive impairment and was dependent on staff for activities of daily living, including transfers, was assisted by two CNAs who did not apply a gait belt during the transfer. Instead, the CNAs lifted the resident by placing their arms underneath the resident's arms and holding onto the resident's pants, which is against the facility's policy for safe lifting and movement of residents. The facility's policy requires the use of gait belts for transfers to ensure resident safety and prevent accidents. Interviews with staff, including CNAs and the LPN, revealed that staff were aware of the requirement to use gait belts for transfers, especially for residents needing two-person assistance. The Director of Nursing and the Administrator confirmed that staff are expected to use gait belts and should not lift residents by their arms or pants. Despite this, the CNAs involved in the incident did not follow the proper procedure, leading to a deficiency in maintaining a safe environment for the resident.
Failure to Provide Proper Tracheostomy Care
Penalty
Summary
The facility failed to provide tracheostomy care following professional standards of practice for one resident. The Licensed Practical Nurse (LPN) did not adhere to aseptic techniques during the tracheostomy care procedure. The LPN picked up a suction catheter that had fallen on the floor, did not perform hand hygiene after removing gloves, and used a broken glove during the procedure. Additionally, the LPN touched the suction catheter with both gloved hands, and the catheter touched the resident's shirt, further contaminating it. The LPN also failed to have sterile water ready for flushing the catheter and used water from the bathroom sink instead, without completing hand hygiene before and after handling the water container. The LPN did not change gloves or perform hand hygiene after removing the old pad around the stoma and before placing a new pad around the tracheostomy site. The LPN also disposed of the suction canister contents improperly, contaminating the resident's bathroom floor and cleaning it with a paper towel without changing gloves or performing hand hygiene afterward. The LPN then organized the resident's tracheostomy supplies and exited the room after using hand sanitizer. During interviews, the LPN, Director of Nursing (DON), and Administrator acknowledged the correct procedures for tracheostomy care, including the need for sterile techniques and proper hand hygiene. However, the LPN admitted to performing the process out of order and not following the correct procedures. The DON and Administrator confirmed that the expected procedures were not followed, leading to the deficiency in tracheostomy care for the resident.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to ensure that Resident #84's meal preferences were consistently honored, leading to the resident receiving meals that did not reflect their requested food preferences. Resident #84, who was cognitively intact and could eat independently, had specific dietary needs and preferences documented in their care plan. Despite this, the resident did not receive gravy with their beef pot roast and was served breakfast without the requested oatmeal on one occasion and without brown sugar on another occasion. Interviews with various staff members, including CNAs, LPNs, RAs, the Clinical Dietician/Dietary Manager, the DON, and the Administrator, revealed inconsistencies in the process of taking and fulfilling meal orders. Staff members acknowledged that residents sometimes did not receive the meals they requested and that there were issues with communication and verification of meal tickets. The process involved RAs collecting meal preferences, kitchen staff preparing the meals based on these preferences, and CNAs and RAs serving the meals, but there were lapses in ensuring accuracy at each step. The facility did not have a policy in place regarding resident food preferences, contributing to the inconsistency in meal service. Staff interviews indicated that while there were multiple checkpoints intended to ensure residents received the correct meals, these were not always effectively implemented. The lack of a structured and reliable system led to repeated instances where Resident #84's meal preferences were not met, highlighting a deficiency in the facility's food service process.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Springfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Magnolia Square Nursing And Rehab | 0.3 mi | ★★★★★ | 1 | 0 |
| Maples Health And Rehabilitation, The | 0.5 mi | ★★★★★ | 0 | 0 |
| Manor At Elfindale, The | 1.5 mi | ★★★★★ | 10 | 0 |
| Birch Pointe Health And Rehabilitation | 1.5 mi | ★★★★★ | 0 | 0 |
| Springfield Villa | 1.6 mi | ★★★★★ | 10 | 1 |
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