Accela Rehab and Care Center at Springfield

In the surveyor’s words

From the most serious findings on record at Accela Rehab and Care Center at Springfield, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600May 13, 2024

  Based on review of facility policies, review of facility documentation, clinical record review and interviews with staff and residents, it was determined that the facility failed to ensure that residents were free from sexual abuse for two of 23 residents reviewed (Residents R5 and R36). This failure resulted in an Immediate Jeopardy situation for Residents R5 and R36 who were sexually abused by Resident R119. Findings include: Review of facility policy, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, undated, revealed that, each resident will be free from 'Abuse'. […]

• Immediate jeopardy, isolatedF610May 13, 2024

  Based on review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to thoroughly investigate sexual abuse for three residents of three residents reviewed for sexual abuse (Residents R5, R36 and R71). This failure resulted in an Immediate Jeopardy situation for Residents R5 and R36. Findings include: Review of facility policy, Abuse Investigation and Reporting, last reviewed October 2022, revealed that, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility… […]

• Actual harm, isolatedF684Nov 13, 2023

  Based on review of facility policy, review of clinical record, review of facility documents, interview with staff and resident, it was determined that the facility failed to ensure that a resident received treatment and care according to professional standards of practice, related to insertion of catheter without a physician's order for one of three residents reviewed (Resident R1). This failure resulted in actual harm to Resident R1, who experienced gross hematuria from the penis, required transfer to the hospital and admission into the intensive care unit. […]

• Actual harm, isolatedF690Nov 13, 2023

  Based on review of facility policy, review of clinical record, review of facility documentation, interview with staff and resident, it was determined that the facility failed to ensure that an indwelling catheter was not used without a valid medical justification for catheterization. This failure resulted in actual harm to Resident R1 who experienced gross hematuria from the penis, required transfer to the hospital into the intensive care unit and intravenous antibiotics for one of three residents reviewed. (Resident R1). Findings include: Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on [DATE]. […]

• Actual harm, isolatedF692Sep 12, 2022

  Based on review of facility policy, review of clinical records, and staff and resident interviews, it was determined that the facility failed to timely assess a resident's weight change, assess potential contributing factors to decreased oral intake, implement applicable interventions and address resident's nutritional status for four of seven residents reviewed for nutrition maintenance (Resident R9, R4, R62, and R84). This failure resulted in actual harm to Resident R9 who sustained a 35 pounds weight loss in one month, was transferred to the hospital and admitted with elevated sodium levels related to poor oral intake and dehydration. […]