Inspection Reports for
Springfield Rehabilitation & Health Care Center
MO, 65807
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
9.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
75% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
83% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 121
Deficiencies: 1
Date: Jun 17, 2025
Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to implement an effective pain management program for residents, specifically addressing ongoing pain and behavioral indications of pain in two residents.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to provide safe, appropriate pain management for a resident who requires such services.
Report Facts
Facility census: 121
Pain level numeric scale: 10
Pain level numeric scale: 6
Pain level numeric scale: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide A | Certified Nurse Aide | Observed and reported resident pain behaviors and assisted with care |
| Certified Medication Technician B | Certified Medication Technician | Administered pain medications and assessed pain levels |
| Licensed Practical Nurse F | Licensed Practical Nurse | Provided observations on resident pain and medication administration |
| Registered Nurse C | Registered Nurse | Performed wound care without assessing resident pain |
| Registered Nurse G | Registered Nurse | Provided information on resident pain and medication management |
| Registered Nurse H | Registered Nurse | Discussed pain management and medication effectiveness |
| Director of Nursing | Director of Nursing | Discussed pain management interventions and physician communications |
| Administrator | Administrator | Discussed staff responsibilities for pain assessments and medication administration |
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 1
Date: Oct 24, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide physician-ordered respiratory care, specifically the failure to provide or maintain a bipap/CPAP machine and timely acquisition of necessary supplies for one resident.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failed to provide physician-ordered bipap/CPAP or timely acquire needed supplies for one resident, resulting in non-use of the machine for extended periods.
Report Facts
Facility census: 120
Days without CPAP use: 8
Days delay in ordering supplies: 22
Oxygen flow rates: 1
Oxygen flow rates: 2
Oxygen flow rates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN C | Registered Nurse | Named as the nurse working on obtaining bipap supplies and coordinating care |
| LPN B | Licensed Practical Nurse | Mentioned involvement in bipap care and communication with family |
| LPN D | Licensed Practical Nurse | Described procedures for handling broken CPAP/bipap and communication |
| RN E | Registered Nurse | Described steps taken when CPAP broken and communication with doctor and staff |
| DON | Director of Nursing | Provided detailed account of resident's bipap care issues and facility response |
| Administrator | Facility Administrator | Provided overview of facility awareness and response to bipap issues |
Inspection Report
Plan of Correction
Census: 120
Deficiencies: 2
Date: Oct 24, 2024
Visit Reason
The inspection was conducted to assess compliance with respiratory care regulations, specifically related to respiratory/tracheostomy care and suctioning, and to address deficiencies identified in the facility's provision of respiratory care.
Findings
The facility failed to provide respiratory care per professional standards, including failure to provide a physician-ordered BiPAP machine and timely acquisition of necessary supplies for a resident. Documentation and follow-up on the resident's respiratory care needs were inadequate, leading to noncompliance with regulatory requirements.
Deficiencies (2)
F695 Respiratory care was not provided according to professional standards, including failure to provide a physician-ordered BiPAP machine and timely acquisition of supplies for a resident. Documentation and follow-up on respiratory care needs were inadequate.
A4075 Nursing care per resident condition was not met as evidenced by failure to provide personal attention and nursing care consistent with current acceptable nursing practice. Refer to F695 for details.
Report Facts
Facility census: 120
Deficiency tags cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN C | Registered Nurse | Interviewed regarding respiratory care and BiPAP machine issues |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding respiratory care deficiencies and corrective actions |
| Administrator | Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Routine
Census: 115
Deficiencies: 16
Date: May 10, 2024
Visit Reason
Routine inspection of Springfield Rehabilitation & Health Care Center to assess compliance with healthcare regulations including resident rights, medication administration, infection control, and safety.
Findings
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.
Deficiencies (16)
Failure to provide dignity bags for catheter drainage bags for residents with indwelling urinary catheters.
Failure to determine clinical appropriateness for self-administration of medications when medications were left unattended at bedside.
Failure to promote resident self-determination by not providing showers as preferred and care planned for nine residents.
Failure to notify residents and representatives in writing of hospital transfers including reason, date, and destination for three residents.
Failure to coordinate assessments with PASARR program and refer for Level II review after significant change for one resident.
Failure to provide care and assistance with showers and grooming for one resident dependent on staff.
Failure to maintain a safe environment by transferring a resident without use of gait belt.
Failure to provide appropriate catheter care and prevent urinary tract infections by allowing catheter drainage bags to touch the floor for three residents.
Failure to provide safe and appropriate tracheostomy care including aseptic technique and hand hygiene.
Failure to ensure pharmaceutical services with accurate documentation and storage for emergency medication kits; lock tags did not match register for three kits.
Failure to ensure residents receive food that accommodates preferences; one resident served meals not reflecting requested preferences.
Failure to keep food safe from contamination by stacking wet dishes and failing to separate dented cans from other canned goods.
Failure to ensure medication error rates below 5% when staff failed to prime insulin pens before administration for three residents.
Failure to ensure medication carts and treatment carts were locked when unattended by authorized personnel.
Failure to maintain effective infection control program including proper hand hygiene during incontinent care and catheter care, and failure to protect clean laundry from contamination.
Failure to ensure call light cords were accessible in resident bathrooms; cords were wrapped around grab bars or missing for eight residents.
Report Facts
Census: 115
Medication error rate: 10
Residents sampled: 29
Residents affected by dignity bag deficiency: 3
Residents affected by shower deficiency: 9
Residents affected by hospital transfer notification deficiency: 3
Residents affected by call light deficiency: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA J | Certified Nurse Aide | Named in catheter care and incontinent care deficiencies |
| CNA K | Certified Nurse Aide | Named in catheter care, incontinent care, and call light accessibility deficiencies |
| LPN C | Licensed Practical Nurse | Named in catheter care, transfer, and shower deficiencies |
| RN M | Registered Nurse | Named in insulin administration and medication cart security deficiencies |
| LPN G | Licensed Practical Nurse | Named in insulin administration and emergency kit deficiencies |
| CNA H | Certified Nursing Assistant | Named in incontinent care deficiency |
| NA I | Nursing Assistant | Named in incontinent care deficiency |
| LPN F | Licensed Practical Nurse | Named in medication cart security and emergency kit deficiencies |
| RN D | Registered Nurse | Named in medication cart security and emergency kit deficiencies |
| Administrator | Named in multiple interviews regarding facility policies and deficiencies | |
| Director of Nursing | Named in multiple interviews regarding facility policies and deficiencies | |
| Certified Medication Technician (CMT) Y | Certified Medication Technician | Named in emergency kit deficiencies |
| Dietary Aide AA | Dietary Aide | Named in food service and kitchen deficiencies |
| Regional Dietary Manager | Named in food service and kitchen deficiencies | |
| CNA X | Certified Nurse Aide | Named in shower scheduling deficiency |
| CNA B | Certified Nurse Aide | Named in call light accessibility deficiency |
| CNA O | Certified Nurse Aide | Named in call light accessibility deficiency |
| Laundry Staff P | Named in infection control and laundry delivery deficiency | |
| Housekeeping Staff Q | Named in infection control and laundry delivery deficiency |
Inspection Report
Life Safety
Census: 115
Capacity: 146
Deficiencies: 5
Date: May 7, 2024
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and related fire safety regulations at Springfield Rehabilitation & Health Care Center.
Findings
The facility failed to maintain the integrity of building construction, fire alarm system, sprinkler system, electrical systems, and generator testing as required by NFPA standards. Multiple deficiencies were identified that had the potential to affect residents, staff, and visitors.
Deficiencies (5)
K161 Building Construction Type and Height: The facility failed to maintain the rating of ceilings and walls due to unsealed penetrations in the drop ceiling and one wall, potentially affecting 22 residents. The facility lacked a policy regarding maintenance of walls and ceilings.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to maintain the fire alarm system according to NFPA standards, including magnetic holders on smoke barrier doors that remained disengaged during alarm activation, potentially affecting 25 residents. No policy was provided for fire alarm maintenance.
K353 Sprinkler System - Maintenance and Testing: The facility failed to inspect and maintain the sprinkler system quarterly as required, and sprinkler heads were found covered with debris, affecting all residents, staff, and visitors. No policy was provided for sprinkler system maintenance.
K918 Electrical Systems - Essential Electric System Maintenance and Testing: The facility failed to complete a required four-hour load test of generators in the past three years, potentially affecting all occupants during a power outage. No policy was provided for generator maintenance.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility allowed improper use of power taps and outlet extenders in resident rooms, posing a risk of fire or electrical injury to 25 residents. No policy was provided regarding power taps or outlet extenders.
Report Facts
Facility Capacity: 146
Census: 115
Residents potentially affected by K161 deficiency: 22
Residents potentially affected by K345 deficiency: 25
Residents potentially affected by K353 deficiency: all
Residents potentially affected by K918 deficiency: all
Residents potentially affected by K920 deficiency: 25
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 2
Date: Nov 14, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a staff member (Housekeeper G) yelling at a resident (Resident #3) in the dining room, and concerns about infection prevention practices related to hand hygiene and glove use during incontinent care for two residents (Resident #1 and Resident #2).
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failed to ensure all residents were treated with dignity and respect when a staff member yelled at a resident in the dining room.
Failed to maintain an effective infection prevention and control program when staff failed to complete appropriate hand hygiene and glove usage while providing incontinent care for two residents.
Report Facts
Census: 119
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper G | Housekeeper | Named in dignity violation for yelling at resident |
| Licensed Practical Nurse C | LPN | Documented incident and interviewed regarding dignity and infection prevention findings |
| Resident Assistant E | Resident Assistant | Witnessed housekeeper yelling at resident |
| Resident Assistant F | Resident Assistant | Witnessed housekeeper yelling and cursing at resident |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for staff to treat residents with dignity and perform infection prevention |
| Administrator | Administrator | Interviewed regarding expectations for staff to treat residents with dignity and use infection prevention measures |
| Certified Nursing Assistant A | CNA | Observed failing to perform proper hand hygiene and glove changes during incontinent care |
| Certified Nursing Assistant B | CNA | Observed failing to perform proper hand hygiene and glove changes during incontinent care |
| Licensed Practical Nurse D | LPN | Interviewed regarding infection prevention expectations |
Inspection Report
Annual Inspection
Census: 119
Deficiencies: 4
Date: Nov 14, 2023
Visit Reason
The inspection was an annual survey conducted to assess compliance with resident rights, infection prevention and control, and other regulatory requirements at Springfield Rehabilitation & Health Care Center.
Findings
The facility was found deficient in ensuring residents were treated with dignity and respect, as evidenced by an incident involving a housekeeper yelling at a resident. Additionally, the facility failed to maintain an effective infection prevention and control program, including proper hand hygiene and glove use during care.
Deficiencies (4)
F550 Resident Rights: The facility failed to ensure all residents were treated with dignity and respect, evidenced by a housekeeper yelling at a resident in the dining room.
F880 Infection Prevention & Control: The facility failed to maintain an effective infection prevention and control program, including inadequate hand hygiene and glove use by staff during incontinent care.
A4086 Infection Control/Communicable Disease: The facility did not meet requirements for infection control reporting and procedures as referenced in F880.
A8030 Dignity/Privacy: The facility failed to treat residents with full consideration, respect, and dignity as referenced in F550.
Report Facts
Facility census: 119
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Troy Lacey | Administrator | Signed the Statement of Deficiencies and Plan of Correction |
| Licensed Practical Nurse C | Licensed Practical Nurse | Documented resident progress notes and interviewed regarding incident |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for staff behavior and infection control |
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 3
Date: Jul 31, 2023
Visit Reason
The inspection was conducted due to concerns about the facility's failure to provide timely treatment and care for a resident's unstageable pressure ulcer, including lack of physician orders, missed wound clinic appointment transportation, and inadequate documentation.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failure to obtain a physician's order for treatment of the resident's right heel pressure ulcer for 10 days after admission.
Failure to assist the resident with transportation to a scheduled wound clinic appointment.
Failure to document pressure ulcer interventions in the resident's baseline (48 hour) care plan.
Report Facts
Facility census: 119
Pressure ulcer measurement: 2.8
Pressure ulcer measurement: 4
Pressure ulcer measurement: 0.2
Pressure ulcer measurement: 3
Pressure ulcer measurement: 5
Pressure ulcer measurement: 0.1
Treatment order date: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Wound Nurse | Completed wound assessments and treatments, but overlooked obtaining a physician's order for treatment. |
| LPN B | Licensed Practical Nurse | Discovered the pressure ulcer on 07/24/23, notified nurse practitioner, and performed treatment but failed to place a treatment order. |
| Director of Nursing | Director of Nursing (DON) | Provided information on wound care procedures and acknowledged deficiencies in assessment and documentation. |
| LPN C | Ward Clerk | Responsible for scheduling appointments and transportation but was unaware of the wound clinic appointment due to missing admission orders. |
| RN D | Registered Nurse | Worked on rehabilitation wing and completed skin treatments but was unaware of the resident's pressure ulcer and wound clinic appointment. |
| Administrator | Facility Administrator | Stated expectations for nurses to complete skin assessments and obtain treatment orders promptly. |
Inspection Report
Annual Inspection
Census: 119
Deficiencies: 2
Date: Jul 31, 2023
Visit Reason
Annual state survey inspection to assess compliance with regulations related to skin integrity and pressure ulcer prevention and treatment at Springfield Rehabilitation & Health Care Center.
Findings
The facility failed to ensure timely treatment and care for a resident with an unstageable pressure ulcer. Documentation and physician orders for treatment were lacking, and weekly skin assessments were not consistently completed as required.
Deficiencies (2)
F686 Skin Integrity: The facility failed to provide timely treatment and care for a resident with an unstageable pressure ulcer and did not document pressure ulcer interventions in the baseline care plan.
A4083 Pressure Sore Prevention/Treatment: The facility did not keep residents free from avoidable pressure sores and failed to provide adequate treatment as required.
Report Facts
Facility census: 119
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Troy Lacey | Administrator | Signed the statement of deficiencies and plan of correction |
| RN A | Registered Nurse | Performed wound care and provided interview statements regarding wound treatment |
| LPN B | Licensed Practical Nurse | Documented wound progress notes and provided interview statements |
| RN D | Registered Nurse | Provided interview statements regarding wound care treatments |
| Director of Nursing | DON | Provided interview statements regarding wound care policies and practices |
Inspection Report
Routine
Census: 116
Deficiencies: 3
Date: Jul 12, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food storage, preparation, and sanitation standards, including adherence to the Missouri Food Code and facility policies regarding food safety and contamination prevention.
Findings
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.
Deficiencies (3)
Failure to maintain food contact surfaces in a clean sanitary manner.
Failure to maintain the air conditioner located over a doorway in the kitchen, which was leaking and visibly dirty.
Failure to store food in sealed containers and failure to dispose of expired food items.
Report Facts
Facility census: 116
Expired hot dog buns: 5
Hot dogs in liquid: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Aide E | Dietary Aide | Interviewed regarding food storage, labeling, and kitchen practices |
| Dietary Aide F | Dietary Aide | Interviewed regarding food handling, labeling, and air conditioner maintenance |
| Dietary Aide G | Dietary Aide | Interviewed regarding leftover food handling and expired food removal |
| Dietary Manager | Dietary Manager | Interviewed regarding food safety practices, expired food removal, and air conditioner cleaning |
Inspection Report
Plan of Correction
Census: 116
Deficiencies: 4
Date: Jul 12, 2023
Visit Reason
The inspection was conducted to evaluate compliance with food safety requirements related to food procurement, storage, preparation, and sanitary conditions at Springfield Rehabilitation & Health Care Center.
Findings
The facility failed to maintain proper food safety standards, including improper storage and labeling of food items, failure to maintain a clean air conditioner in the kitchen, and inadequate protection of food from contamination. Several food items were found without use-by dates or proper packaging, and the air conditioner showed signs of leakage and dirt accumulation.
Deficiencies (4)
F812 Food safety requirements were not met as the facility failed to store, prepare, and serve food in a manner that protected it from contamination. Observations included improperly labeled and stored food items and a dirty, leaking air conditioner in the kitchen.
A7015 Food must be protected from potential contamination including dust, insects, and overhead leakage. This regulation was not met, resulting in a Class II violation.
A7016 Food containers must be clean and covered except during preparation or service. This regulation was not met, resulting in a Class III violation.
A7067 Nonfood contact surfaces must be cleaned as often as necessary to prevent accumulation of dirt and debris. This regulation was not met, resulting in a Class III violation.
Report Facts
Facility census: 116
Deficiencies cited: 4
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 5
Date: Dec 1, 2022
Visit Reason
The inspection was conducted in response to allegations of abuse and neglect involving two residents at Springfield Rehabilitation & Health Care Center.
Complaint Details
The complaint investigation was substantiated. The facility failed to report and investigate allegations of abuse between two residents in a timely manner and did not maintain accurate resident records.
Findings
The facility failed to report allegations of possible abuse involving two residents to the State Survey Agency within the required timeframe. The investigation into the alleged abuse was not initiated promptly, and resident records were not accurately documented.
Deficiencies (5)
F609: The facility failed to report allegations of possible abuse involving two residents to the State Survey Agency within two hours of staff awareness.
F610: The facility failed to begin an immediate investigation of an allegation of abuse between two residents as soon as staff were aware of the allegation.
F842: The facility failed to ensure resident records were accurate and complete when staff did not accurately document in one resident's record regarding contact with another resident.
A4116: The facility failed to maintain clinical records that were complete, accurately documented, readily accessible, and systematically organized.
A8023: The facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of any resident and require reporting to the department.
Report Facts
Facility census: 103
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Witnessed and reported the alleged inappropriate contact between residents |
| RN F | Registered Nurse | Received report from LPN A about the incident |
| DON | Director of Nursing | Involved in the investigation and reporting process |
| SSA | Social Service Assistant | Interviewed regarding the incident and reporting |
| SSD | Social Service Director | Directed the SSA to report the incident |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 2
Date: Jan 27, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to issue required Medicare notices to residents when Medicare benefits were not exhausted or coverage was ending.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failure to issue CMS Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) Form 10055 for one resident when Medicare benefits were not exhausted.
Failure to issue CMS Notice of Medicare Non-Coverage (NOMNC) Form 10123 at least two days prior to coverage ending for one resident.
Report Facts
Residents sampled: 19
Facility census: 93
Residents affected: 2
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jan 27, 2022
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance for Springfield Rehabilitation & Health Care Center following a survey completed on 01/27/2022.
Findings
The facility failed to issue required Medicare notices to residents regarding coverage and non-coverage of services, including the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) and Notice of Medicare Non-Coverage (NOMNC). The facility also did not fully inform residents or their representatives about services and charges as required by regulations.
Deficiencies (2)
F582 Medicaid/Medicare Coverage/Liability Notice: The facility failed to issue required Medicare notices (SNFABN and NOMNC) timely to residents, and did not properly inform residents about services and charges as required.
A8008 19 CSR 30-88.010(8) Informed Services/Charges - Alz Disclosure: The facility did not fully inform residents or their representatives in writing about services available and related charges, including those not covered by the facility's basic per diem rate.
Report Facts
Facility census: 93
Sampled residents: 19
Residents with findings: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator interviewed and signed the plan of correction | |
| Bookkeeper and Social Worker | Interviewed regarding Medicare notice procedures |
Inspection Report
Life Safety
Census: 93
Deficiencies: 3
Date: Jan 27, 2022
Visit Reason
The inspection was conducted as an Emergency Preparedness Survey and Life Safety Code survey to assess compliance with fire safety regulations and related requirements.
Findings
The facility was found non-compliant with the 2012 Life Safety Code due to combustible decorations, use of portable space heaters, and improper use of extension cords and power strips. No deficiencies were cited for the Emergency Preparedness Survey.
Deficiencies (3)
K753 Combustible decorations were found in multiple locations including the Director of Nursing office, assisted dining room, and beauty shop, creating a fire hazard. The facility census was 93 at the time of observation.
K781 Portable space heaters were observed in the activity office and dietary office, which is prohibited in healthcare occupancies. The facility census was 93.
K920 Extension cords and power strips were used improperly in patient care areas, including the activity office, dining room, dietary office, and office behind the fish tank. The facility census was 93.
Report Facts
Facility census: 93
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 22, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 (b)(6) and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 2, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted as a complaint investigation.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 22, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted as a complaint investigation to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Routine
Deficiencies: 0
Date: Dec 1, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Sep 21, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 2, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted as a complaint investigation to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and infection control. No deficiencies were cited during this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 29, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Routine
Deficiencies: 0
Date: Jun 3, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 2
Date: Oct 29, 2019
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to protect a resident's rights, specifically related to interference, coercion, discrimination, and reprisal in exercising their rights and misuse of the resident's Durable Power of Attorney (DPOA).
Complaint Details
The complaint investigation substantiated that staff interfered with Resident #1's rights and misused the resident's funds by acting as the resident's Durable Power of Attorney without proper authorization. The facility was unaware of these actions until the resident discovered unauthorized use of their bank account.
Findings
The facility failed to protect Resident #1's rights to be free from interference, coercion, discrimination, and reprisal. Staff improperly used the resident's funds and acted as the resident's DPOA without proper authorization, violating resident rights and financial protections.
Deficiencies (2)
F550 Resident Rights: The facility failed to protect Resident #1's right to be free from interference, coercion, discrimination, and reprisal in exercising their rights. Staff acted as the resident's Durable Power of Attorney without proper authorization and misused the resident's funds.
A9002 Resident Fund Use: The operator failed to use the resident's personal funds exclusively for the resident's use as authorized. Staff acted improperly in managing Resident #1's funds without proper authorization.
Report Facts
Facility census: 111
Monetary transactions: 2337.68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker C | Social Worker | Named in findings related to acting as Durable Power of Attorney and misuse of resident funds |
Inspection Report
Life Safety
Deficiencies: 0
Date: Jul 15, 2019
Visit Reason
The inspection was conducted as an Emergency Preparedness Survey and Licensure Inspection to assess compliance with the Life Safety Code and state licensure requirements.
Findings
No deficiencies were cited as a result of the Emergency Preparedness Survey or the Licensure Inspection. The facility met the applicable provisions of the 2012 edition of the Life Safety Code.
Inspection Report
Complaint Investigation
Census: 122
Deficiencies: 5
Date: Jul 15, 2019
Visit Reason
The inspection was conducted based on a complaint investigation regarding privacy violations during incontinent care and other care deficiencies.
Complaint Details
Complaint MO00156757 involved privacy violations during incontinent care, inadequate skin assessment and monitoring, insufficient nursing staff for bathing, and improper bed rail use documentation.
Findings
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.
Deficiencies (5)
Failed to ensure privacy of residents during incontinent care.
Failed to develop and maintain a comprehensive person-centered care plan for residents with neck and spine diagnoses.
Failed to complete and document weekly skin assessments and monitoring for residents at risk for pressure ulcers.
Failed to provide sufficient nursing staff to meet resident needs, resulting in inadequate bathing and showering.
Failed to properly assess, document, and obtain consent for bed rail use, and failed to document alternatives attempted prior to installation.
Report Facts
Facility census: 122
Sample size: 25
Weight loss percentage: 12.42
Weight loss percentage: 13.04
Pressure ulcer risk score: 17
Pressure ulcer risk score: 13
Pressure ulcer risk score: 12
Pressure ulcer risk score: 18
Weight: 227
Weight: 198.9
Weight loss: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA E | Certified Nursing Assistant | Named in privacy violation during incontinent care. |
| LPN R | Licensed Practical Nurse | Provided statements regarding privacy and care practices. |
| CNA Q | Certified Nursing Assistant | Provided statements regarding privacy and care practices. |
| DON | Director of Nursing | Provided statements regarding privacy, care plans, and staffing. |
| ADON | Assistant Director of Nursing | Provided statements regarding privacy, care plans, and staffing. |
| LTC UM | Long Term Care Unit Manager | Provided statements regarding care planning and privacy. |
| Rehab UM | Rehabilitation Unit Manager | Provided statements regarding care planning and bed rail use. |
| RN D | Registered Nurse | Provided statements regarding weight loss and nutritional monitoring. |
| DM | Dietary Manager | Provided statements regarding weight loss and meal provision. |
| NP | Nurse Practitioner | Provided statements regarding weight loss significance and monitoring. |
| CNA S | Certified Nursing Assistant | Provided statements regarding bathing and resident monitoring. |
| LPN K | Licensed Practical Nurse | Provided statements regarding bathing, side rails, and resident care. |
| CNA M | Certified Nursing Assistant | Provided statements regarding meal provision and resident monitoring. |
| Housekeeping Staff U | Housekeeping Staff | Provided statements regarding mattress changes. |
| Housekeeping Staff V | Housekeeping Staff | Provided statements regarding mattress changes and siderail presence. |
| CMT W | Certified Medication Technician | Provided statements regarding mattress changes. |
Inspection Report
Complaint Investigation
Census: 122
Deficiencies: 11
Date: Jul 15, 2019
Visit Reason
The inspection was conducted as a complaint investigation related to privacy breaches, care planning, skin integrity, nutrition, and staffing issues at Springfield Rehabilitation & Health Care Center.
Complaint Details
Complaint MO00156757 was substantiated with findings related to privacy breaches, inadequate care planning, skin integrity issues, nutritional deficiencies, and insufficient nursing staff.
Findings
The facility was found noncompliant with multiple federal regulations including failure to ensure resident privacy during care, incomplete comprehensive care plans, inadequate skin assessments and pressure ulcer prevention, insufficient nutrition and hydration monitoring, and inadequate nursing staff to meet resident needs.
Deficiencies (11)
F583 Privacy and Confidentiality. The facility failed to ensure privacy during incontinent care for two residents, with doors and curtains left open exposing residents to others.
F656 Comprehensive Care Plan. The facility failed to develop and maintain comprehensive person-centered care plans for residents, including measurable objectives and timely updates.
F686 Skin Integrity. The facility failed to ensure complete skin assessments and monitoring for residents at risk for pressure ulcers, including documentation and appropriate interventions.
F692 Nutrition/Hydration. The facility failed to monitor, assess, and intervene appropriately for residents with weight loss and nutritional needs, including documentation and care planning.
F700 Bedrails. The facility failed to properly assess, document, and obtain consent for use of bed rails for residents, and failed to ensure safe installation and maintenance.
F725 Sufficient Nursing Staff. The facility failed to maintain sufficient nursing staff to meet resident needs, resulting in missed showers, inadequate skin care, and insufficient supervision.
A4044 Nursing Staff. The facility failed to employ sufficient qualified nursing personnel to meet resident care needs.
A4074 Nursing Care per Resident Condition. The facility failed to provide personal attention and nursing care consistent with resident conditions and nursing practice standards.
A4082 Pressure Sore Prevention/Treatment. The facility failed to keep residents free from avoidable pressure sores by inadequate assessment and treatment.
A5001 Nutritional Needs Met. The facility failed to serve nutritious food and adequately assess and meet residents' nutritional needs.
A8030 Dignity/Privacy. The facility failed to treat residents with consideration, respect, and full recognition of their dignity and privacy.
Report Facts
Facility census: 122
Deficiencies cited: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA E | Certified Nursing Assistant | Named in privacy breach observation during incontinent care. |
| LPN R | Licensed Practical Nurse | Interviewed regarding privacy curtain use and resident care. |
| CNA S | Certified Nursing Assistant | Involved in skin care and pressure ulcer findings. |
| LPN K | Licensed Practical Nurse | Interviewed regarding resident pressure ulcer risk and care. |
| DON | Director of Nursing | Named in multiple findings including privacy, care planning, and staffing. |
| ADON | Assistant Director of Nursing | Named in care planning and staffing findings. |
| Rehab Unit Manager | Named in care planning and skin integrity findings. | |
| Clinical Supervisor | Named in care planning and staffing findings. | |
| Dietary Manager | Named in nutrition and weight loss findings. | |
| Registered Dietitian | RD | Named in nutrition and weight loss findings. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 17, 2018
Visit Reason
This document is a plan of correction submitted by Springfield Rehabilitation & Health Care Center following a health facility survey and a licensure inspection.
Findings
No health facility survey deficiencies or state licensure deficiencies were cited during the inspections.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie J. Count | Administrator | Signed as the provider/supplier representative on the plan of correction documents. |
Inspection Report
Life Safety
Census: 107
Capacity: 146
Deficiencies: 2
Date: Aug 17, 2018
Visit Reason
The inspection was conducted as an annual recertification survey focusing on compliance with the Life Safety Code of the National Fire Protection Association.
Findings
The facility failed to maintain the fire sprinkler system by allowing paint and plaster to remain on fire sprinkler heads in several resident rooms, which could delay activation in the event of a fire. The deficiency was related to improper maintenance and testing of the sprinkler system.
Deficiencies (2)
42 CFR 483.90(a) and NFPA 101: The facility failed to maintain the fire sprinkler system by allowing paint and plaster to remain on fire sprinkler heads in resident rooms C3, C5, C6, C10, A6, and A7, potentially delaying activation during a fire.
19 CSR 30-85.022(11)(C): Facilities with sprinkler systems installed prior to August 28, 2007, must inspect, maintain, and test these systems. This requirement was not met as referenced in deficiency K-353.
Report Facts
Facility capacity: 146
Census: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denise J. Convit | Administrator | Signed the inspection report and plan of correction |
Inspection Report
Plan of Correction
Census: 110
Deficiencies: 2
Date: Jun 5, 2018
Visit Reason
The inspection was conducted to investigate and document deficiencies related to accident hazards and supervision at Springfield Rehabilitation & Health Care Center, specifically concerning a resident burn incident.
Findings
The facility failed to ensure the resident environment was free of accident hazards, resulting in a resident burn from hot coffee served in a Styrofoam cup without a lid. The facility lacked a policy addressing maximum temperatures for hot liquids and failed to properly notify family and physician or obtain treatment orders promptly.
Deficiencies (2)
F 689: The facility failed to maintain a resident environment free of accident hazards, evidenced by a resident receiving a burn from hot coffee served in a Styrofoam cup without a lid. Staff did not document assessment of the resident's ability to drink hot beverages safely or notify the resident's next of kin and physician promptly.
A4074: The facility failed to provide personal attention and nursing care consistent with current acceptable nursing practice, referencing the deficiency at F689.
Report Facts
Facility census: 110
Coffee temperature: 165
Date of survey: Jun 5, 2018
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