Inspection Reports for Springfield Rehabilitation & Health Care Center

The complaint investigation found substantiated deficiencies related to inadequate pain management for two residents, including failure to assess pain indicators and ineffective pain relief measures.

The facility failed to adequately manage pain for Resident #1, who had chronic rheumatoid arthritis and reported moderate to severe pain despite scheduled and PRN medications, and Resident #2, who exhibited behavioral signs of pain that were not properly addressed. Staff did not consistently assess pain indicators or provide effective interventions, resulting in continued resident discomfort and pain.

The complaint investigation revealed substantiated issues with respiratory care for Resident #1, including failure to provide ordered bipap/CPAP and delays in obtaining supplies, contributing to resident harm such as confusion and lethargy.

The facility failed to provide appropriate respiratory care for Resident #1 by not providing the ordered bipap/CPAP or timely obtaining necessary supplies, resulting in the resident not using the machine for extended periods. Staff documentation regarding efforts to obtain supplies was lacking, and the resident experienced confusion and lethargy when not using the bipap. The facility was unaware of the resident's bipap use upon admission and faced challenges obtaining replacement parts due to supplier and order issues.

The facility had multiple deficiencies including failure to maintain resident dignity with catheter care, improper medication administration including insulin pen priming errors, inadequate shower assistance and scheduling, failure to notify residents of hospital transfers, improper infection control practices, unsecured medication carts, inaccurate emergency kit documentation, and inaccessible call lights in resident bathrooms.

The complaint involved Housekeeper G yelling and cursing at Resident #3 in the dining room, accusing the resident of having bad spirits. Several employees intervened, and the housekeeper was suspended and removed from the facility. Resident reported feeling safe with no complaints after the incident.

The facility failed to ensure residents were treated with dignity and respect when a housekeeper yelled and cursed at a resident, leading to the housekeeper's removal. Additionally, the facility failed to maintain an effective infection prevention program as staff did not perform proper hand hygiene and glove changes during incontinent care for two residents.

The investigation was complaint-related, focusing on the resident's unstageable pressure ulcer care. The complaint was substantiated as the facility failed to provide timely treatment, obtain physician orders, assist with wound clinic transportation, and document care plans appropriately.

The facility failed to ensure timely treatment for a resident's unstageable pressure ulcer present on admission, did not obtain a physician's order for 10 days, failed to assist with transportation to a wound clinic appointment, and did not document pressure ulcer interventions in the baseline care plan. Staff interviews revealed gaps in skin assessments and communication.

The facility failed to properly store, prepare, and serve food in a manner that protected it from contamination. Observations revealed multiple instances of food items without proper labeling or use-by dates, expired food items, unclean food contact surfaces, a leaking and dirty air conditioner in the kitchen, and personal items improperly placed near food preparation areas.

The complaint investigation found that the facility did not comply with Medicare notification requirements for residents whose Medicare Part A benefits were ending or exhausted. The facility was unaware of the proper issuance timing of SNFABN and NOMNC forms as confirmed by interviews with the Bookkeeper, Social Worker, and Administrator.

The facility failed to issue a CMS Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) Form 10055 for one resident who remained in the facility after Medicare benefits ended, and failed to issue a CMS Notice of Medicare Non-Coverage (NOMNC) Form 10123 at least two days before coverage ended for another resident. Interviews revealed staff were unaware of the proper timing for issuing these notices.

Complaint MO00156757 involved privacy violations during incontinent care, inadequate skin assessment and monitoring, insufficient nursing staff for bathing, and improper bed rail use documentation.

The facility failed to ensure privacy during incontinent care for two residents, failed to develop comprehensive care plans for residents with specific diagnoses, failed to complete and document skin assessments and monitoring for residents at risk of pressure ulcers, failed to provide sufficient nursing staff to meet resident needs including bathing, and failed to properly assess and document bed rail use and obtain consent.