Inspection Reports for
Springfield Skilled Care Center

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.

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.

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.

The facility failed to provide a written discharge notice including the reason for discharge and right to appeal to one resident who refused to return after hospitalization. The resident census at the time was 99. The facility did not document or complete a discharge notice for the resident.

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.

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.

The facility was found noncompliant with resident rights due to staff disrespect and failure to protect resident dignity. The facility also failed to maintain sufficient nursing staff to meet resident needs and did not ensure a fully functional resident call system.

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.

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.

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.

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.

The complaint involved allegations of verbal and mental abuse by a CNA, including smoking while working and disrespectful behavior toward residents. The allegation was anonymous and was not reported by the facility to DHSS within the required timeframe. The facility's investigation found no abuse but failed to report the allegation to DHSS.

The facility failed to report an anonymous allegation of possible verbal and mental abuse to the State Survey Agency within the required two-hour timeframe. The facility's investigation showed no abuse, but the allegation was not reported to DHSS as required.

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.

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.

The facility was found deficient in maintaining a safe, clean, and homelike environment, including housekeeping failures and inadequate care plan updates. Additional deficiencies included failure to provide necessary care for dependent residents, inadequate infection prevention and control, and failure to ensure protective oversight and supervision.

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.

The facility failed to maintain an ongoing monitoring process for accurate documentation and accountability of expired or unusable medications. Multiple observations revealed discontinued medications and controlled substances were not properly destroyed or documented, with several expired medications found in the Director of Nursing's office.

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.

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.

The facility failed to maintain a safe, clean, and homelike environment due to black substance on walls and ceilings in a resident's room. The infection prevention and control program was ineffective as staff failed to properly don and doff PPE and follow hand hygiene protocols when caring for residents with influenza A.

The visit was complaint-related focusing on dialysis care deficiencies for Resident #1. The complaint was substantiated as the facility failed to meet dialysis care standards.

The facility failed to ensure that residents requiring dialysis received care consistent with professional standards. Staff did not obtain necessary physician orders, failed to document monitoring due to missed dialysis services, and did not notify the dialysis clinic or physician of missed treatments for one resident.

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.

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.

The complaint investigation found substantiated issues with the resident call system not functioning properly, causing residents to wait long periods for assistance and staff difficulty in identifying which room was calling.

The facility failed to maintain a fully functional resident call light system across multiple halls, causing residents difficulty in summoning staff assistance. Multiple residents reported call lights not working for extended periods, and staff confirmed intermittent or non-functioning call lights.

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.

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.

The complaint investigation was substantiated with findings of misappropriation of narcotic medications. The facility took corrective actions including suspending involved staff, notifying authorities, conducting audits, and revising medication policies.

The facility failed to protect residents from misappropriation of narcotic medications, with multiple residents' narcotics missing while in possession of the facility. The investigation revealed discrepancies in medication counts and improper documentation by staff, leading to suspension of involved employees and corrective actions implemented.

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.

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.

The facility failed to document physician notification for resident medication refusals and next of kin notification following falls or changes in condition. Neurological checks were not completed per standards after multiple falls for one resident.

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.

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.

The complaint investigation was substantiated. It involved a Certified Medication Tech yelling at a resident, calling the resident offensive names, and failing to provide medications timely. The staff member was terminated following the investigation.

The facility failed to ensure all residents were treated with dignity and respect when a Certified Medication Tech (CMT A) yelled at a resident. Multiple interviews and record reviews confirmed inappropriate staff behavior and poor customer service.

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.

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.

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.

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.

The complaint investigation substantiated sexual abuse by a CNA involving Residents #1, #2, and #3. The facility notified authorities, suspended the CNA, and initiated an investigation and corrective actions.

The facility failed to protect residents from sexual abuse by a staff member, as evidenced by sexual contact and inappropriate comments involving multiple residents. The facility initiated an investigation, suspended the CNA, and began staff education and monitoring.

The facility failed to ensure pain management was provided according to professional standards and resident preferences, with issues in medication availability and documentation. Deficiencies were also found in maintaining accurate and accessible clinical records for residents.

The facility was found deficient in ensuring residents' drug regimens were free from unnecessary drugs, maintaining the building in good repair, having a safe and effective medication system, developing and implementing abuse/neglect policies, verifying nurse aide registry and retraining, infection prevention and control, nursing staff qualifications, and communicable disease control. Several deficiencies were noted with evidence from record reviews, interviews, and observations.

The facility failed to perform the required yearly review of the Emergency Operations Plan, failed to maintain the integrity of the furnace room fire barrier, failed to notify the Department of Health and Senior Services of a fire, and failed to monitor the fire area for 24 hours after a fire event.

The facility failed to provide restorative nursing services as care planned or recommended to ensure residents' functional status was maintained for four residents. Documentation and treatment plans for restorative services were missing, and the facility lacked a restorative aide since November 2021.

The visit was complaint-related, investigating allegations of inadequate wound care and medication management. The deficiencies were substantiated as evidenced by multiple failures in care and documentation.

The facility failed to provide timely wound treatment and proper medication transcription and administration for residents. Staff did not complete required skin assessments, notify physicians of changes, or complete admission orders timely.

The facility failed to prohibit the use of portable space heaters in resident rooms, specifically Resident #1's room, which posed a fire hazard. Multiple interviews confirmed the resident was using a prohibited heater despite policy.

The complaint investigation was substantiated. The facility failed to report and investigate allegations of sexual abuse involving a resident and a Certified Nurse Aide (CNA C). Interviews and record reviews showed the facility did not report the allegation timely and did not conduct a thorough investigation.

The facility failed to report alleged sexual abuse by a staff member to the State Survey Agency within the required timeframe and did not complete a thorough investigation of the allegations. The facility also failed to complete an immediate investigation for the allegation of sexual abuse made against staff.

The facility failed to maintain an infection control program that ensured staff consistently wore masks and followed COVID-19 policies. Multiple observations and interviews revealed staff and residents not wearing masks properly or at all, increasing risk of infection spread.

The complaint investigation was substantiated. The facility failed to prevent and report abuse between residents and did not conduct a proper investigation as required by regulations.

The facility failed to ensure residents were treated with dignity and respect, as evidenced by staff not intervening in resident altercations. The facility also failed to report allegations of abuse involving two residents to the State Survey Agency within required timeframes and did not thoroughly investigate the allegations.

The facility failed to maintain air temperatures between 71 and 81 degrees Fahrenheit and did not implement their extreme heat precautions policy timely when temperatures rose above 81 degrees. Multiple resident rooms and common areas were observed with temperatures exceeding the required range, causing discomfort among residents.

The complaint investigation was substantiated. Multiple residents and staff reported verbal abuse by a Certified Medication Technician. The facility failed to report abuse allegations timely and failed to protect residents from abuse. An immediate jeopardy was identified and removed after corrective actions.

The facility was found out of compliance with resident rights, reporting of alleged violations, quality of care, and medication storage and destruction. Multiple residents reported verbal abuse by staff, and the facility failed to report abuse allegations timely. An immediate jeopardy was identified and later removed after corrective actions.

The facility was found to be in compliance with COVID-19 emergency preparedness requirements but failed to administer medications as ordered, including missed doses and duplicate doses of antipsychotic medication. The facility also failed to maintain an infection prevention and control program to provide a safe environment during the COVID-19 pandemic.

The complaint investigation substantiated short staffing issues on the night shift, confirmed by interviews with residents, nursing staff, and the administrator.

The facility was found to be in compliance with COVID-19 related regulations but failed to maintain minimum staffing requirements on the third shift with only three staff present for 99 residents. Multiple interviews and record reviews confirmed short staffing and lack of a staffing policy.

The facility failed to provide adequate supervision and monitoring for three residents, resulting in elopement incidents. The deficiency was initially cited at immediate jeopardy level but was lowered to a lower severity level after corrective actions were implemented.

The facility failed to send a resident to the hospital immediately after a change in condition involving smoking while on oxygen, causing combustion and injury. The resident suffered burns and blisters, and the facility's policies on notification and smoking safety were inadequate.

The facility failed to notify the Department of Health and Senior Services (DHSS) of the fire incident as required. The facility also failed to implement documented monitoring for 24 hours following the fire incident. Policies regarding fire safety and evacuation were found to be undated or insufficiently followed.

The complaint involved allegations that a Licensed Practical Nurse (LPN A) physically abused Resident #1 by slapping and punching, and that the facility delayed reporting these allegations to the State Survey Agency. The investigation included interviews with residents, staff, and review of records. The allegations were substantiated based on evidence of delayed reporting and failure to notify appropriate authorities.

The facility failed to report allegations of abuse involving three residents to the State Survey Agency within the required timeframe. Multiple interviews and record reviews confirmed delays and failures in reporting and investigating the abuse allegations.

The facility was found to have multiple deficiencies related to resident rights, abuse prevention, quality of care, infection control, medication management, and safety. The facility failed to meet several regulatory requirements, including proper documentation, resident care planning, and staff training.

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.

The facility failed to meet several Life Safety Code requirements including maintaining fire-rated walls, proper delayed egress door function, exit signage, fire alarm system maintenance, corridor wall fire resistance, smoking regulations, electrical equipment maintenance, and safe oxygen storage. These deficiencies had the potential to affect all residents and staff.

The complaint investigation substantiated issues related to resident dignity, personal care, medication errors, pressure ulcer care, and environmental conditions.

The facility failed to ensure residents were treated with respect and dignity, maintain safe and comfortable environmental conditions, provide consistent and timely personal care, and prevent pressure ulcers. Medication administration errors and improper storage of drugs were also identified.

The facility failed to test the fire alarm after completing a silent fire drill on night shift, did not provide corridor doors that fit tightly within the door frame to resist smoke passage, and allowed the use of extension cords and power strips beyond temporary installation. Additionally, the facility failed to have electrical equipment inspected and certified within the required two-year period and did not complete the annual fire department consultation as required.

The complaint investigation was substantiated. The facility failed to notify families of significant changes, failed to report abuse allegations timely, and failed to ensure proper care and medication administration for residents.

The facility failed to notify families of significant resident changes, failed to report allegations of abuse timely, and failed to ensure proper medication administration and pain management. Several residents experienced injuries, seizures, and medication errors, and the facility did not follow proper protocols for notification and investigation.

The facility failed to document completion of treatments for three sampled residents and did not follow infection control measures to prevent wound infection transmission. Staff did not consistently document treatment administration or follow hand hygiene protocols.