Inspection Reports for
Springfield Rehabilitation & Health Care Center

19 CSR 30-85.042(66) Nursing Care per Res Condition: See the deficiency cited at F695.

19 CSR 30-85.022(10)(B) Fire Alarm System-Test/Maintain: Please refer to K345.

19 CSR 30-85.022(11)(C) Sprinkler System-Test/Maintain: Please refer to K353.

19 CSR 30-85.032(2) Substantially Constructed/Maintained: Please refer to K161.

19 CSR 30-85.032(37) Extension Cords/Duplex Receptacles: Please refer to K920.

19 CSR 30-85.042(77) Infection Control/Communicable Disease: Please refer to F880.

19 CSR 30-88.010(29) Dignity/Privacy: Please refer to F550.

19 CSR 30-85.042(74) Pressure Sore Prevention/Treatment: Please refer to F686.

19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Please refer to F812.

19 CSR 30-87.030(14) Food-Clean Containers, Storage, Covers: Please refer to F812.

19 CSR 30-87.030(65) Nonfood Contact Surfaces,Cleaned as Needed: Please refer to F812.

19 CSR 30-85.042(102) Clinical Records Accurate/Accessible: Please refer to F842.

19 CSR 30-88.010(23) Develop/Implement A/N Policies: Please refer to F609 and F610.

19 CSR 30-88.010(8) Informed Services/Charges - Alz Disclosure: Refer to F582.

19 CSR 30-85.022(5) Combustible Materials, Unnecessary: See K 753.

19 CSR 30-85.032(37) Extension Cords/Duplex Receptacles: See K 920.

19 CSR 30-88.020(2) Resident Fund Use: See the deficiency cited at F550.

19 CSR 30-85.042(37) Nursing Staff Sufficient/Qualified: Please refer to F725.

19 CSR 30-85.042(67) Nursing Care per Res Condition: Please refer to F700.

19 CSR 30-85.042(75) Pressure Sore Prevention/Treatment: Please refer to F686.

19 CSR 30-85.052(1) Nutritional Needs Met, Assess Res, Inform Dr: Please refer to F692.

19 CSR 30-88.010(29) Dignity/Privacy: Please refer to F583.

19 CSR 30-85.022(11)(C) Sprinkler System-Test/Maintain: Refer to K-353.

19 CSR 30-85.042(67) Nursing Care per Res Condition: Please refer to F689.

Failure to provide safe, appropriate pain management for a resident who requires such services.

F695 Respiratory/Tracheostomy Care and Suctioning: Based on interview and record review, the facility failed to provide physician-ordered BiPAP/CPAP supplies and consistent respiratory care for one resident, resulting in the resident not using the CPAP/BiPAP and reliance on supplemental oxygen.

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.

K161 Building Construction Type and Height: The facility failed to maintain the integrity of building construction by leaving unsealed penetrations in a drop ceiling and a wall, creating unsealed openings that could affect residents.

K345 Fire Alarm System - Testing and Maintenance: The facility failed to maintain the fire alarm system in accordance with NFPA standards when sets of smoke barrier doors had magnetic holders that remained disengaged while the fire alarm was activated, potentially affecting residents and lacking a maintenance policy.

K353 Sprinkler System - Maintenance and Testing: The facility failed to inspect and maintain the sprinkler system per NFPA standards, including lack of documented quarterly inspections for 2023 and sprinkler heads obstructed by lint/debris, risking failure to operate properly.

K918 Electrical Systems - Essential Electric System Maintenance and Testing: The facility failed to complete a required four-hour load test of the generators in the past three years and did not provide documentation of the required testing, risking generator performance during an outage.

K920 Electrical Equipment - Power Cords and Extension Cords: The facility allowed improper use of power taps/strip outlets and outlet extenders in resident rooms (examples noted in resident rooms), creating potential electrical hazards for residents.

F550 Resident Rights/Exercise of Rights: Based on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect when a housekeeper yelled at Resident #3 in the dining room.

F880 Infection Prevention & Control: Based on observation, interview, and record review, staff failed to perform appropriate hand hygiene and glove use during incontinent care for two residents, resulting in a failure to maintain an effective infection prevention and control program.

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer: Based on observation, interview, and record review, the facility failed to ensure one resident received timely treatment and care for an unstageable pressure ulcer. Staff failed to obtain a physician's order for treatment for 10 days, failed to assist the resident with transportation to a scheduled wound clinic appointment, and failed to document pressure ulcer interventions in the resident's baseline care plan.

F812 Food Procurement,Store/Prepare/Serve-Sanitary: The facility failed to store, prepare, and serve food in a manner that protected it from contamination; surveyor observed multiple uncovered or improperly stored or labeled food items, expired or undated items, and a leaking/dirty air conditioner above the kitchen doorway.

F609 Reporting of Alleged Violations: Based on interview and record review, the facility failed to report allegations of possible abuse involving two residents to the State Survey Agency (DHSS) within two hours of staff becoming aware of an allegation of abuse.

F610 Investigate/Prevent/Correct Alleged Violation: Based on interview and record review, the facility failed to begin an immediate investigation of an allegation of abuse between two residents as soon as staff were aware and failed to thoroughly interview multiple staff members.

F842 Resident Records - Identifiable Information: Based on record review and interview, the facility failed to ensure resident records were accurate and complete when staff did not accurately document an incident regarding contact that occurred with another resident.

F582 Medicaid/Medicare Coverage/Liability Notice: The facility failed to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) for one sampled resident and failed to issue a Medicare Notice of Non-Coverage at least two days before coverage ended for another resident.

K 753 Combustible Decorations: Based on observation and interview the facility failed to prohibit the use of flammable decorations, including candles, creating a fire hazard that affected residents, staff and occupants.

K 781 Portable Space Heaters: Observations showed portable space-heating devices in non-allowed areas and the facility failed to prohibit their use.

K 920 Electrical Equipment - Power Cords and Extension Cords: Observations showed power strips and extension cords in use in multiple locations and the facility failed to maintain the facility free of temporary wiring.

F550 Resident Rights/Exercise of Rights: The facility failed to protect a resident's right to be free from interference, coercion and reprisal when a staff member (Social Worker C) became appointed as the resident's Durable Power of Attorney and had placed their name on the resident's bank account and accessed funds without the resident's permission.

F583 Personal Privacy/Confidentiality of Records: Based on observation, interview, and record review, staff provided incontinent care with hall doors and privacy curtains left open, exposing residents to view and failing to ensure privacy during care.

F656 Develop/Implement Comprehensive Care Plan: The facility failed to develop and maintain comprehensive person-centered care plans addressing identified neck and spine diagnoses and needed interventions for resident #5 and did not include specific care planning information in the resident's plan.

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer: The facility failed to ensure complete skin assessments, monitoring, repositioning, and appropriate pressure-relieving devices and documentation for multiple residents at risk for pressure ulcers.

F692 Nutrition/Hydration Status Maintenance: The facility failed to monitor, assess, and initiate timely interventions for a resident with significant/unexplained weight loss and did not document or follow orders related to the resident's wounds, edema, or weight changes.

F700 Bedrails: The facility failed to document attempts at alternatives, complete resident-specific assessments for entrapment risk, obtain informed consent, and properly measure and document side rail configurations for several residents.

F725 Sufficient Nursing Staff: The facility failed to maintain sufficient nursing staff to meet resident needs, resulting in staff failing to provide preferred baths/showers and other care for multiple residents.

K 353 Sprinkler System - Maintenance and Testing: The facility failed to maintain the fire sprinkler system by allowing paint and plaster to remain on fire sprinkler heads in some resident rooms, which could delay activation.

F 689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure the resident environment remained free of accident hazards when one resident received a burn from hot coffee delivered by staff in a Styrofoam cup; staff did not document an assessment of the resident's ability to drink hot beverages safely, did not promptly notify the resident's next of kin and physician, and did not obtain orders prior to treatment.