Inspection Reports for Springfield Skilled Care Center
2401 Grand St, Springfield, MO 65802, United States, MO, 65802
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
24.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
345% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
98 residents
Based on a February 2025 inspection.
Census over time
Inspection Report
Deficiencies: 1
Date: Apr 10, 2025
Visit Reason
The inspection was conducted to assess compliance with pharmaceutical service requirements, specifically to ensure the facility provides pharmaceutical services to meet the needs of each resident and employs or obtains the services of a licensed pharmacist.
Findings
The report identified a deficiency related to pharmaceutical services, noting a minimal level of harm or potential for actual harm affecting a few residents. The detailed deficiency text was not available.
Deficiencies (1)
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspection Report
Routine
Census: 98
Deficiencies: 4
Date: Feb 13, 2025
Visit Reason
The inspection was conducted to assess compliance with regulations related to medication self-administration, pressure ulcer care, catheter care, and medication management.
Findings
The facility failed to ensure residents only self-administer medications after proper assessment, failed to provide appropriate pressure ulcer care leading to infection and possible amputation, failed to maintain proper catheter care and documentation, and failed to prevent significant medication errors including failure to discontinue medications and monitor for adverse effects.
Deficiencies (4)
Failed to ensure residents only self-administer medications after assessment by interdisciplinary team.
Failed to provide appropriate pressure ulcer care and prevent new ulcers, resulting in infection and referral for possible amputation.
Failed to ensure catheter use was properly ordered, care planned, and catheter care provided as ordered.
Failed to provide a safe and effective medication system, including documentation of medication administration and monitoring for adverse effects, resulting in medication errors and hospitalization.
Report Facts
Facility census: 98
Medication administration documentation omissions: 10
Medication administration errors: 6
Wound measurements: 7
Wound measurements: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN D | Licensed Practical Nurse | Noted resident's altered mental status and contacted DON |
| DON | Director of Nursing | Assessed resident with altered mental status, instructed holding narcotics, and attempted to contact physician |
| CMT F | Certified Medication Technician | Documented medication administration when medications were not available |
| Medical Records Personnel | Certified Medication Technician | Entered physician orders into EMR and did not follow up on drug interaction warnings |
| Resident's Psychiatrist | Physician | Ordered medications and expected monitoring for adverse effects; was not notified of medication errors |
| Administrator | Facility Administrator | Stated expectations for medication error notification and follow-up |
Inspection Report
Routine
Census: 98
Deficiencies: 15
Date: Feb 13, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey of Springfield Skilled Care Center to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including medication administration, wound care, resident safety, call light system functionality, catheter care, respiratory care, bed rail safety, and quality assurance meeting attendance. Several residents had issues such as medication errors, untreated wounds, unsafe bed rails, and inadequate call light systems. The facility failed to maintain complete and accurate documentation and timely interventions in many cases.
Deficiencies (15)
Failed to ensure residents only self-administer medications after assessment and clinical indication, with one resident observed self-administering without assessment.
Failed to keep prior survey results current and accessible in a public location for residents and families.
Failed to provide required Medicare notices to residents whose Medicare services were ending or changed.
Failed to coordinate and maintain Level II PASRR for a resident with mental health diagnoses.
Failed to obtain physician order, care plan, and monitor use of a brace for one resident.
Failed to initiate a discharge summary for an anticipated discharge for one resident.
Failed to provide good grooming and personal hygiene and document bathing attempts for one dependent resident.
Failed to provide care per physician orders and professional standards for a resident with a burn, including timely assessments, treatment, and care plan updates, resulting in hospitalization and skin graft.
Failed to keep environment free from accident hazards by not completing timely investigation or assessment of a coffee spill burn and not updating care plan with interventions to prevent future burns.
Failed to have a working call light system in a resident room shared by two residents, resulting in continuous blinking call light and lack of alert at nurses' station.
Failed to provide respiratory care consistent with standards and care plans, including failure to change oxygen equipment per physician order and failure to include oxygen use on care plan.
Failed to ensure ongoing evaluation, safety checks, informed consent, and care planning for bed rail use for residents, including failure to address loose bed rails and lack of regular assessments.
Failed to provide a safe and effective medication system, including failure to document administration of scheduled medications, administration of unavailable medications, and failure to monitor for adverse effects of psychotropic medications.
Failed to maintain complete medical records including documentation of burn incident, assessments, and reason for follow-up hospitalization for one resident.
Failed to have required minimum of six staff members attend Quality Assessment Committee meetings.
Report Facts
Facility census: 98
Medication doses not documented: 5
Medication doses not documented: 4
Medication doses not documented: 3
Medication doses administered but not available: 4
Medication doses administered but not available: 1
Bed rail looseness: 1
QAA meetings missing required staff: 11
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 1
Date: Nov 20, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide a written discharge notice, including the reason for discharge and right to appeal, to a resident who was refused re-admission after hospitalization.
Complaint Details
The complaint investigation found that the facility did not provide a written discharge notice to Resident #1 when the resident was refused re-admission after hospitalization. The resident exhibited manic behavior, refused medications, and was placed on a 96-hour hold. Staff and administration acknowledged the lack of documentation and discharge notice issuance. The resident was transported back to the hospital via cab and refused to return to the facility.
Findings
The facility failed to provide a written discharge notice to Resident #1 upon discharge after hospitalization, despite the resident being refused re-admission due to behavioral issues. Staff did not document or issue any discharge notice, and the resident was sent back to the hospital on a 96-hour hold without proper notification.
Deficiencies (1)
Failure to provide timely notification to the resident, including reason for discharge and appeal rights, before transfer or discharge.
Report Facts
Facility census: 99
Resident admission date: May 13, 2019
Resident quarterly MDS date: Aug 21, 2024
Date of resident hospital events: Oct 18, 2024
96-hour hold: 96
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse A | Admissions Nurse | Interviewed regarding resident discharge and admission procedures |
| Licensed Practical Nurse C | Licensed Practical Nurse | Interviewed regarding resident discharge and facility policies |
| Social Service Director | Interviewed regarding resident discharge and interactions with resident and cab driver | |
| Administrator | Interviewed regarding resident discharge and facility policies |
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 3
Date: Oct 7, 2024
Visit Reason
The inspection was conducted due to complaints regarding staff treating residents disrespectfully, insufficient nursing staff to meet residents' needs, and malfunctioning call light systems.
Complaint Details
The complaint investigation was substantiated with findings that a staff member verbally abused a resident, the facility was understaffed leading to delayed responses to call lights, and the call light system was malfunctioning for some residents.
Findings
The facility failed to ensure residents were treated with dignity and respect, with one staff member verbally abusing a resident. There was insufficient nursing staff to respond to call lights timely, resulting in residents being left in soiled briefs and waiting long periods for assistance. Additionally, the call light system was found to be malfunctioning for some residents, causing delays in care.
Deficiencies (3)
Staff member (LPN F) raised voice and used inappropriate language towards a resident, threatening to revoke smoking privileges after a fall.
Insufficient nursing staff to timely answer call lights for four residents, leading to delays in care and residents being left in wet briefs.
Call light system malfunctioned for two residents, with call lights not lighting outside rooms though sounding at nurses' station, causing delayed response.
Report Facts
Facility census: 106
Residents affected by staff disrespect: 1
Residents affected by insufficient staffing: 4
Residents affected by call light malfunction: 2
Number of sampled residents reviewed for staffing: 16
Call light response time: 41
Reported maximum wait time for call light: 210
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN F | Licensed Practical Nurse | Named in verbal abuse incident towards Resident #1 |
| CNA A | Certified Nurse Aide | Witnessed fall and verbal abuse incident; provided statements |
| CMT G | Certified Medication Technician | Witnessed verbal abuse incident; provided statement |
| CNA B | Certified Nurse Aide | Interviewed regarding staff cursing and call light response |
| CNA E | Certified Nurse Aide | Interviewed regarding staffing and call light response |
| CNA J | Certified Nurse Aide | Interviewed regarding call light response times |
| LPN K | Licensed Practical Nurse | Interviewed regarding reporting staff cursing |
| DON | Director of Nursing | Interviewed regarding expectations for reporting and call light response |
| Administrator | Facility Administrator | Interviewed regarding reporting concerns and call light response expectations |
| RN D | Registered Nurse | Interviewed regarding staffing and call light system issues |
| CMT C | Certified Medication Technician | Interviewed regarding call light response and staffing |
| CNA L | Certified Nurse Aide | Interviewed regarding staffing shortages and resident care delays |
| MDS Coordinator | MDS Coordinator | Interviewed regarding staffing schedule and improvements |
| Hospitality Aide M | Hospitality Aide | Interviewed regarding call light system issues |
| CMT I | Certified Medication Technician | Interviewed regarding call light repairs |
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 1
Date: Sep 12, 2024
Visit Reason
The inspection was conducted due to allegations of possible verbal and mental abuse by a Certified Nurse Aide (CNA A) reported anonymously to the facility's corporate office.
Complaint Details
The complaint involved allegations that CNA A smoked a weed pen while on duty and was verbally abusive to residents, calling them names and belittling non-verbal residents. The facility did not self-report these allegations to DHSS within the required timeframe.
Findings
The facility failed to report the anonymous allegation of verbal/mental abuse to the State Survey Agency within the required two-hour timeframe. The investigation showed no abuse, but the Administrator did not report the allegations from corporate as abuse to DHSS. Several staff interviews confirmed the reporting requirements and described the alleged behaviors of CNA A.
Deficiencies (1)
Failure to timely report suspected abuse allegations to the State Survey Agency within two hours.
Report Facts
Facility census: 110
Number of residents interviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Named in allegations of verbal and mental abuse and smoking while on duty |
| CNA B | Certified Nurse Aide | Interviewed regarding abuse reporting procedures |
| CMT C | Certified Medication Technician | Interviewed regarding abuse reporting and verbal abuse definitions |
| LPN D | Licensed Practical Nurse | Interviewed regarding abuse reporting and verbal abuse definitions |
| DON | Director of Nursing | Interviewed about abuse reporting and suspension of CNA A |
| Administrator | Facility Administrator | Interviewed about abuse reporting and investigation of allegations |
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 5
Date: Aug 30, 2024
Visit Reason
The inspection was conducted due to complaints regarding inadequate cleaning and maintenance of a resident's room, failure to update a resident's care plan with new communication needs, failure to provide necessary assistance with activities of daily living including bathing and changing clothes, failure to ensure call light accessibility for fall prevention, and failure to implement effective infection control measures.
Complaint Details
The visit was complaint-related due to allegations of inadequate cleaning, failure to update care plans, failure to assist with ADLs, call light accessibility issues, and infection control breaches. Substantiation status is not explicitly stated.
Findings
The facility failed to maintain a clean and homelike environment, failed to update a resident's care plan to reflect new communication needs, failed to provide adequate assistance with bathing and changing clothes for a resident, failed to ensure call lights were within reach for a resident at risk of falls, and failed to implement proper infection control practices including timely cleaning of urine spills and cleaning of medical equipment.
Deficiencies (5)
Failed to ensure a clean and homelike environment when staff failed to clean the floor and change soiled bedding for Resident #2.
Failed to maintain a comprehensive person-centered care plan by not updating it with new communication needs for Resident #2.
Failed to provide necessary assistance with activities of daily living including bathing and changing clothes for Resident #2.
Failed to ensure call light was within reach of Resident #1 as care planned for fall prevention.
Failed to implement effective infection control program including failure to clean urine spills timely, walking through facility with contaminated shoes, leaving resident's feet in urine, and failure to clean blood pressure monitor after contact with floor.
Report Facts
Facility census: 110
Shower refusal days: 11
Shower refusal days: 16
Shower refusal days: 30
Shower refusal days: 13
Shower refusal days: 6
Shower refusal days: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Named in findings related to failure to maintain cleanliness, failure to assist with ADLs, call light accessibility, and infection control breaches |
| LPN C | Licensed Practical Nurse | Named in findings related to failure to maintain cleanliness, call light accessibility, and infection control breaches |
| CNA A | Certified Nurse Assistant | Named in findings related to failure to maintain cleanliness, failure to assist with ADLs, and infection control breaches |
| CNA F | Certified Nursing Assistant | Named in findings related to failure to maintain cleanliness and failure to assist with ADLs |
| CMT G | Certified Medication Technician | Named in findings related to failure to maintain cleanliness and failure to update care plan |
| DON | Director of Nursing | Named in findings related to failure to maintain cleanliness, failure to update care plan, call light accessibility, and infection control breaches |
| Administrator | Named in findings related to failure to maintain cleanliness, failure to update care plan, call light accessibility, and infection control breaches | |
| MDS Coordinator | Named in findings related to failure to update care plan and ADL documentation | |
| Admissions Coordinator | Named in findings related to failure to update care plan and ADL documentation | |
| SSD | Social Service Director | Named in findings related to failure to update care plan |
Inspection Report
Annual Inspection
Census: 110
Deficiencies: 6
Date: Jul 29, 2024
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements for Springfield Skilled Care Center.
Findings
The facility was found deficient in multiple areas including maintaining a clean and homelike environment, updating comprehensive care plans, providing necessary personal care, ensuring accident hazard prevention, pharmaceutical services management, and infection prevention and control. Deficiencies involved failure to clean resident rooms timely, incomplete care plans, inadequate personal hygiene assistance, failure to place call lights within reach, improper medication destruction and documentation, and lapses in infection control practices.
Deficiencies (6)
Failed to ensure a clean and homelike environment when staff failed to clean the floor and change soiled bedding for one resident.
Failed to maintain a comprehensive person-centered care plan by not updating care plan for one resident and not ensuring staff awareness.
Failed to provide necessary services for dependent residents to maintain grooming and personal hygiene for one resident.
Failed to ensure environment free from accident hazards by not placing call light within reach of one resident as planned.
Failed to maintain ongoing monitoring, documentation, and timely destruction of expired or unusable medications for eleven residents and failed to develop proper medication destruction policy.
Failed to implement an effective infection control program by not cleaning urine on floor timely, walking through facility with contaminated shoes, leaving resident's feet in urine, and not cleaning blood pressure monitor between uses.
Report Facts
Facility census: 110
Facility census: 105
Number of residents affected: 11
Number of discontinued pills on counter: 200
Number of discontinued pills in tote: 600
Number of controlled substances in drawer: 200
Inspection Report
Routine
Census: 110
Deficiencies: 6
Date: Jul 12, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, environment, medication administration, infection control, and care planning at Springfield Skilled Care Center.
Findings
The facility failed to maintain a clean and homelike environment, ensure comprehensive and updated care plans, provide adequate assistance with activities of daily living, maintain call light accessibility, prevent medication administration errors, and implement effective infection control practices. Specific deficiencies included unclean resident rooms, failure to update care plans with new communication needs, inadequate bathing and clothing changes for a resident, call light not within reach, frequent medication documentation errors, and failure to clean urine spills and medical equipment properly.
Deficiencies (6)
Failed to ensure a clean and homelike environment; staff failed to clean resident room floor and change soiled bedding timely for Resident #2.
Failed to maintain a comprehensive person-centered care plan for Resident #2, not updating care plan with new communication needs after hospital discharge.
Failed to provide necessary assistance with activities of daily living for Resident #2, including bathing and changing urine-soaked clothing.
Failed to ensure call light was within reach of Resident #1 as care planned for fall intervention.
Failed to ensure residents were free from significant medication errors; frequent documentation of two doses administered at or near the same time and medication administered outside scheduled time frames for Resident #1.
Failed to implement an effective infection control program; staff failed to clean urine spills timely, walked through facility with contaminated shoes, left resident's bare feet in urine puddle, and failed to clean blood pressure monitor after floor contact for Resident #1.
Report Facts
Facility census: 110
Medication doses documented at same time: 6
Medication doses documented late: 10
Shower refusals: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Named in findings related to Resident #2's room condition, call light placement, and infection control issues |
| LPN C | Licensed Practical Nurse | Named in findings related to Resident #1's care and infection control |
| CNA A | Certified Nurse Assistant | Named in findings related to Resident #1's care and infection control |
| CNA F | Certified Nursing Assistant | Named in interviews regarding cleaning responsibilities and resident care |
| DON | Director of Nursing | Named in interviews regarding care plan responsibilities, infection control, and medication administration |
| Administrator | Named in interviews regarding facility policies and staff responsibilities |
Inspection Report
Routine
Census: 104
Deficiencies: 2
Date: Jan 31, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations regarding the maintenance of a safe, clean, and homelike environment and infection prevention and control practices, including proper use of PPE in isolation rooms for residents with influenza A.
Findings
The facility failed to maintain a clean environment by not addressing black substance growth in a resident's room and lacked a maintenance policy. Additionally, the facility failed to maintain an effective infection control program, with staff not properly donning PPE, performing hand hygiene, or disposing of contaminated PPE when caring for residents on droplet isolation for influenza A.
Deficiencies (2)
Failed to provide a clean and homelike environment due to black substance on walls and closet ceiling in a resident's room.
Failed to maintain an effective infection control program with improper use of PPE and hand hygiene in isolation rooms for residents with influenza A.
Report Facts
Facility census: 104
Residents affected: Few
Residents affected: Some
Isolation duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant E | Certified Nursing Assistant | Interviewed regarding black substance in resident's room and infection control practices |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed about maintenance responsibilities and policies |
| Housekeeper G | Housekeeper | Interviewed about reporting black substances |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed about notification procedures for black substances |
| Director of Nursing | Director of Nursing (DON) | Interviewed about maintenance inspections and infection control policies |
| Administrator | Administrator | Interviewed about maintenance inspections and infection control policies |
| Certified Nurse Aide A | Certified Nurse Aide | Observed and interviewed regarding failure to don PPE in isolation rooms |
| Nurse Aide C | Nurse Aide | Interviewed regarding knowledge of isolation precautions |
| Certified Medication Technician F | Certified Medication Technician | Observed and interviewed regarding PPE use in isolation rooms |
| Registered Nurse B | Registered Nurse | Interviewed about proper PPE use and infection control |
| License Practical Nurse G | Licensed Practical Nurse | Interviewed about infection control practices |
| Infection Control Preventionist | Infection Control Preventionist | Interviewed about isolation practices and facility policies |
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 4
Date: Jan 24, 2024
Visit Reason
The inspection was conducted due to concerns about the facility's dialysis care services for residents requiring dialysis, specifically regarding failure to obtain physician orders, missed dialysis sessions, lack of documentation, and failure to notify the dialysis clinic and physician.
Complaint Details
The investigation was complaint-related, focusing on Resident #1 who missed three dialysis appointments due to transportation issues and staff failures. The resident reported concerns about the driver and refusal to ride with him. Staff and administration interviews revealed lack of documentation and inconsistent notification to the physician and dialysis clinic.
Findings
The facility failed to ensure safe and appropriate dialysis care for a resident who required dialysis, including missing physician orders for dialysis, failure to ensure the resident received scheduled dialysis, lack of documentation of monitoring after missed dialysis, and failure to notify the dialysis clinic and physician of missed dialysis appointments. The resident missed three dialysis sessions in a row, and staff did not document reasons or physician notifications consistently.
Deficiencies (4)
Failure to obtain physician orders related to dialysis services for Resident #1.
Failure to ensure the resident received scheduled dialysis services.
Failure to document monitoring due to missed dialysis services.
Failure to notify the dialysis clinic and physician of missed dialysis services.
Report Facts
Resident weight: 267
Resident weight: 285
Missed dialysis appointments: 3
Facility census: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide C | Certified Nurse Aide (CNA) | Interviewed regarding dialysis appointment preparation and communication |
| Licensed Practical Nurse A | Licensed Practical Nurse (LPN) | Interviewed regarding dialysis orders, missed appointments, and documentation |
| Certified Medication Tech D | Certified Medication Tech (CMT) | Interviewed regarding transportation and appointment lists |
| Licensed Practical Nurse B | Licensed Practical Nurse (LPN) | Interviewed regarding dialysis orders, missed appointments, and documentation |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding dialysis communication, staff responsibilities, and missed appointments |
| Administrator | Administrator | Interviewed regarding dialysis orders, communication, and facility procedures |
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 1
Date: Dec 6, 2023
Visit Reason
The inspection was conducted due to complaints regarding the failure of the facility's call light system in multiple resident halls, impacting residents' ability to summon assistance.
Complaint Details
The investigation was complaint-driven, triggered by reports of non-functional call lights in halls 100, 200, 300, and part of 400. Residents expressed distress and difficulty obtaining timely assistance. Staff confirmed call lights had not worked for weeks to months, with intermittent repairs attempted. The complaint was substantiated by observations, interviews, and record reviews.
Findings
The facility failed to maintain a fully functional call light system since August 2023 across several resident halls. Multiple residents and staff reported call lights not working, causing delays in assistance and resident distress. The facility replaced circuit boards and conducted repairs, but issues persisted with wiring and intermittent functionality. No formal policy on call light maintenance was provided.
Deficiencies (1)
Failure to have a fully functional call light system in resident bathrooms and bathing areas since August 2023.
Report Facts
Facility census: 111
Dates of call light system issues: 3
Dates of repairs: 2
Resident admission dates: Multiple residents' admission dates listed but not summarized numerically
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 1
Date: Nov 21, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding misappropriation of narcotic medications for multiple residents at the facility.
Complaint Details
The complaint investigation revealed that narcotic medications for multiple residents went missing on 11/06/23. The facility suspended involved certified medication technicians, notified law enforcement and other authorities, and conducted a thorough investigation. The investigation found that CMT A and CMT B may have diverted as many as 54 narcotic tablets. The facility corrected the noncompliance by 11/10/23.
Findings
The facility failed to protect residents from misappropriation of narcotic medications, with multiple medication technicians suspected of diverting as many as 54 narcotic tablets. The facility conducted an investigation, suspended involved staff, notified authorities, and implemented system changes to restrict narcotic access to nurses only. The issue was corrected by 11/10/2023.
Deficiencies (1)
Failed to protect residents from misappropriation of narcotic medications resulting in missing narcotics.
Report Facts
Census: 108
Number of diverted narcotic tablets: 54
Number of residents with as needed narcotics: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Named in medication diversion investigation as having pulled narcotics and not documented them. |
| CMT B | Certified Medication Technician | Named in medication diversion investigation as having pulled narcotics and not documented them. |
| CMT C | Certified Medication Technician | Involved in narcotic count and investigation; suspended pending outcome. |
| CMT D | Certified Medication Technician | Involved in narcotic count and investigation; suspended pending outcome. |
| LPN F | Licensed Practical Nurse | Interviewed regarding medication administration and missing medications. |
| Administrator | Facility Administrator | Notified of the issue, involved in investigation and corrective actions. |
| Director of Nursing | Director of Nursing (DON) | Led the investigation and implemented corrective actions. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Reported missing narcotics and involved in investigation. |
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 3
Date: Aug 8, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to document physician notification of medication refusals for one resident and failure to notify next of kin following falls for another resident.
Complaint Details
The complaint investigation revealed that the facility failed to notify the physician in residents' medical records about medication refusals and failed to notify next of kin following falls. The facility also failed to properly implement neurological checks after falls involving head injuries.
Findings
The facility failed to document physician notification regarding medication refusals for Resident #1 and failed to notify next of kin following multiple falls for Resident #2. Additionally, the facility did not ensure neurological checks were properly completed after multiple falls involving head strikes for Resident #2.
Deficiencies (3)
Failure to document physician notification of medication refusals for Resident #1.
Failure to notify next of kin following falls for Resident #2.
Failure to ensure neurological checks were completed per standards of practice after multiple falls involving head strikes for Resident #2.
Report Facts
Resident census: 110
Medication refusals: 22
Medication refusals: 27
Medication refusals: 56
Medication refusals: 22
Medication refusals: 6
Falls: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | LPN | Interviewed regarding medication refusal notification and fall notification policies |
| Registered Nurse B | RN | Interviewed regarding medication refusals and fall notification policies |
| Certified Medication Technician C | CMT | Interviewed regarding medication refusal reporting procedures |
| Certified Medication Technician D | CMT | Interviewed regarding medication refusal reporting procedures |
| Director of Nursing | DON | Interviewed regarding medication refusal documentation and fall notification policies |
| Administrator | Administrator | Interviewed regarding medication refusal documentation and fall notification policies |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 21, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Springfield Skilled Care Center following a survey completed on April 21, 2023.
Findings
No health deficiencies were found during the survey.
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 1
Date: Mar 1, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a staff member (Certified Medication Tech A) yelling at a resident (Resident #1), potentially violating the resident's right to dignity and respect.
Complaint Details
The complaint involved CMT A yelling at Resident #1 during medication administration on 2/28/2023. The resident reported feeling disrespected and hurt. Witnesses including LPNs, RN, CNA, and other residents confirmed the incident. CMT A was terminated following the investigation.
Findings
The facility failed to ensure all residents were treated with dignity and respect when CMT A yelled at Resident #1. Multiple interviews and record reviews confirmed the incident, and CMT A was terminated for poor customer service. Staff and administration acknowledged that yelling at residents is inappropriate and disrespectful.
Deficiencies (1)
Failure to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights due to staff yelling at a resident.
Report Facts
Facility census: 111
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Tech | Named in deficiency for yelling at resident and terminated for poor customer service |
| LPN C | Licensed Practical Nurse | Witnessed the incident and reported it |
| RN D | Registered Nurse | Interviewed and confirmed incident, stated it was disrespectful |
| CNA E | Certified Nursing Aide | Interviewed and stated yelling at residents is inappropriate |
| Social Services Director | Social Services Director | Provided statement regarding resident's account of the incident |
| Administrator | Administrator | Interviewed and stated yelling at residents is never appropriate |
| Director of Nursing | Director of Nursing | Interviewed and stated yelling at residents is not respectful |
Inspection Report
Routine
Census: 109
Deficiencies: 11
Date: Feb 3, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to promote resident self-determination regarding bathing, inadequate maintenance and cleanliness of resident bathrooms, verbal abuse by staff, failure to timely report and investigate abuse allegations, failure to notify residents and representatives of hospital transfers and bed hold policies, failure to transmit discharge assessments timely, incomplete care plans, medication administration errors including insulin administration and meal timing, failure to perform proper infection control practices including hand hygiene and glucometer disinfection, and failure to offer pneumococcal vaccines to residents.
Deficiencies (11)
Failed to promote resident self-determination when staff failed to provide routine baths or showers to four residents.
Failed to ensure a clean and homelike environment for residents due to inadequate cleaning and maintenance of resident bathrooms.
Failed to protect a resident from verbal abuse by staff member who cursed at the resident.
Failed to timely report suspected abuse to management and State Survey Agency.
Failed to complete a timely written investigation of an allegation of possible employee-to-resident abuse.
Failed to notify residents and representatives in writing of hospital transfers and bed hold policies.
Failed to electronically transmit accurate and complete Minimum Data Set (MDS) discharge assessment within required timeframe.
Failed to revise and update comprehensive care plans for five residents to reflect current needs and treatments.
Failed to ensure medication error rate less than 5%, including errors in insulin administration and timing of meals.
Failed to implement infection prevention and control program including proper hand hygiene and glucometer disinfection.
Failed to offer pneumococcal vaccine to residents following admission and provide education on risks and benefits.
Report Facts
Census: 109
Medication errors: 5
Insulin administration timing: 120
MDS discharge transmission timeframe: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA I | Certified Nurse Aide | Named in verbal abuse and failure to report abuse allegations |
| CNA K | Certified Nurse Aide | Witness to verbal abuse incident and reported to nurse |
| RN F | Registered Nurse | Provided statements on shower frequency and hand hygiene expectations |
| CMT E | Certified Medication Technician | Provided statements on shower refusals, hand hygiene, and medication administration |
| LPN D | Licensed Practical Nurse | Observed administering insulin and performing wound care with hand hygiene lapses |
| Administrator | Provided statements on facility policies and oversight | |
| DON | Director of Nursing | Provided statements on facility policies, hand hygiene, and abuse reporting |
Inspection Report
Routine
Census: 109
Deficiencies: 17
Date: Feb 3, 2023
Visit Reason
The inspection was a routine survey of Springfield Skilled Care Center to assess compliance with healthcare regulations, including medication administration, resident care, infection control, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including medication administration errors, failure to provide adequate showers, incomplete care plans, failure to report and investigate abuse allegations, inadequate infection control practices, failure to notify residents and representatives of transfers and bed hold policies, failure to offer pneumococcal vaccines, and failure to maintain a clean and safe environment.
Deficiencies (17)
Failed to ensure interdisciplinary team approved self-administration of medication and obtained orders for self-administration for one resident.
Failed to provide routine showers to four residents, resulting in poor hygiene and resident complaints.
Failed to post abuse and neglect hotline number in a manner accessible to residents and families.
Failed to maintain clean and safe bathroom environment for two residents, including broken toilet and unsafe threshold.
Failed to protect a resident from verbal abuse by staff and failed to timely report and investigate the allegation.
Failed to notify residents and representatives in writing of hospital transfers and bed hold policies for seven residents.
Failed to electronically transmit accurate and complete Minimum Data Set (MDS) discharge assessment for one resident.
Failed to ensure accurate MDS assessments by not identifying dialysis received by one resident.
Failed to develop and implement complete care plans for two residents including catheter care and psychiatric needs.
Failed to revise and update comprehensive care plans for five residents to reflect current needs and treatments.
Failed to provide adequate activities of daily living (ADLs) including routine showers to two dependent residents.
Failed to post nurse staffing information in a prominent and accessible location for residents and visitors.
Failed to ensure medication error rate less than 5%, including errors in insulin administration and timing of meals.
Failed to provide and implement an infection prevention and control program including hand hygiene and proper cleaning of glucometers.
Failed to develop and implement policies and procedures for flu and pneumococcal vaccinations, including offering and educating residents.
Failed to provide safe and appropriate respiratory care including lack of physician order for oxygen and failure to care plan oxygen use.
Failed to provide safe, appropriate dialysis care/services including lack of physician orders and contract with dialysis provider.
Report Facts
Medication errors: 5
Facility census: 109
Shower refusals: 1
Shower refusals: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) I | Cursed at Resident #14 and was involved in verbal abuse allegation | |
| Certified Nurse Aide (CNA) K | Witnessed verbal abuse incident involving CNA I and Resident #14 | |
| Registered Nurse (RN) C | Observed medication administration and provided interview on insulin administration and transfers | |
| Licensed Practical Nurse (LPN) D | Observed medication administration, wound care, and provided interview on care plans and transfers | |
| Certified Medication Technician (CMT) E | Provided interview on medication administration and shower refusals | |
| Director of Nursing (DON) | Provided multiple interviews regarding facility policies and deficiencies | |
| Administrator | Provided multiple interviews regarding facility policies and deficiencies | |
| Certified Nurse Aide (CNA) B | Observed providing incontinent care without hand hygiene | |
| Licensed Practical Nurse (LPN) G | Provided interview on hand hygiene expectations | |
| Certified Nurse Aide (CNA) A | Observed providing incontinent care without hand hygiene | |
| Registered Nurse (RN) F | Provided interview on shower frequency and hand hygiene | |
| Certified Nurse Aide (CNA) O | Provided interview on shower schedule and frequency | |
| Licensed Practical Nurse (LPN) L | Reported abuse allegation and provided interview on care expectations | |
| Assistant Social Services Director (SSD) | Provided interview on transfer and bed hold notification practices | |
| Minimum Data Set (MDS) Coordinator | Provided interview on MDS accuracy and posting accessibility | |
| Certified Medication Technician (CMT) P | Observed medication administration during internet outage | |
| Housekeeping Staff R | Provided interview on accessibility of posted information |
Inspection Report
Routine
Census: 106
Deficiencies: 16
Date: Nov 26, 2019
Visit Reason
The inspection was a routine survey of Springfield Skilled Care Center to assess compliance with regulatory requirements including resident rights, abuse prevention, transfer notifications, resident care, medication administration, infection control, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, failure to timely report abuse allegations, failure to notify residents and representatives of transfers, inadequate supervision and assistance with meals, failure to assess and monitor changes in condition, improper wound care, unsafe storage of smoking supplies, lack of physician orders and care planning for indwelling catheters and dialysis, medication administration errors, failure to maintain food at proper temperatures, incomplete medical record documentation, and unsafe kitchen environment with standing water.
Deficiencies (16)
Failure to provide dignity bags for residents with indwelling catheters and failure to assist residents to dress in a dignified manner for dinner.
Failure to timely report an allegation of abuse to the Department of Health and Senior Services within the required two hours timeframe.
Failure to notify residents, representatives, and ombudsman in writing of transfers or discharges to hospital.
Failure to provide supervision and/or meal assistance for residents identified as needing assistance with meals.
Failure to adequately assess, monitor, treat, and document a change of condition for a resident with diabetic ketoacidosis and other complications.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, including failure to document wound measurements and follow wound care procedures.
Failure to ensure staff and residents stored smoking supplies in a safe manner, including lack of lockboxes for unsupervised smokers.
Failure to obtain physician orders and care plan the use and care of an indwelling catheter for a resident.
Failure to ensure physician's order indicating where and when a resident was to go to dialysis treatment.
Failure to document complete information in the resident's medical record regarding significant change in condition, catheter use, and dialysis treatment.
Failure to complete side rail gap assessment, obtain risk/benefit review, document alternatives attempted prior to use, document ongoing assessments, and obtain informed consent for use of side rails.
Failure to conduct glucose meter control testing per nursing standards of practice, with multiple out of range control readings and no documented corrective action.
Failure to ensure food was palatable, attractive, and served at an appropriate temperature, and failure to follow puree food recipes.
Failure to ensure foods were held at appropriate temperatures to inhibit growth of pathogens that can cause foodborne illness.
Failure to document complete information in the resident's medical record regarding significant change in condition and transfer to hospital, catheter use, and dialysis treatment.
Failure to ensure a sanitary environment when standing water was observed in the kitchen on multiple days.
Report Facts
Facility census: 106
Residents reviewed: 23
Medication error rate: 7.4
Weight loss: 27
Weight loss: 33.6
Glucose meter control high readings: 326
Glucose meter control high readings: 351
Glucose meter control high readings: 337
Glucose meter control high readings: 325
Glucose meter control high readings: 362
Glucose meter control high readings: 317
Glucose meter control high readings: 333
Glucose meter control high readings: 374
Food temperature: 118
Food temperature: 120
Food temperature: 116
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Administered insulin and performed AccuCheck for Residents #65 and #76 |
| CNA Q | Certified Nurse Aide | Interviewed regarding catheter bag dignity and call light response |
| CMT R | Certified Medication Technician | Interviewed regarding catheter bag dignity and call light response |
| Administrator | Interviewed regarding catheter bag dignity, transfer notifications, dialysis orders, side rails, and kitchen standing water | |
| Director of Nursing | Interviewed regarding catheter bag dignity, transfer notifications, dialysis orders, side rails, wound care, and kitchen standing water | |
| CNA C | Certified Nurse Aide | Observed leaving Foley catheter bag on floor |
| CNA D | Certified Nurse Aide | Observed Foley catheter bag placement and resident hospital transfer |
| Corporate Quality Assurance Nurse | QA Nurse | Interviewed regarding abuse reporting, side rails, medication administration, and glucometer control testing |
| Dietary Supervisor | Interviewed regarding food temperature and pureed food preparation | |
| LPN A | Licensed Practical Nurse | Interviewed regarding catheter orders, call light response, wound care, dialysis orders, and smoking supplies |
| CNA E | Certified Nursing Assistant | Interviewed regarding call light response and smoking supplies |
| Social Services Assistant | Interviewed regarding smoking supplies and resident code status | |
| Social Services Director | Interviewed regarding transfer notifications and smoking supplies | |
| RN L | Registered Nurse | Observed wound care procedure |
| RN T | Registered Nurse | Observed wound care procedure and glucometer control testing |
| CMT P | Certified Medication Technician | Interviewed regarding call light response |
| LPN B | Licensed Practical Nurse | Interviewed regarding side rails and resident condition |
| Housekeeper S | Interviewed regarding call light response |
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