Arbors at Springfield

In the surveyor’s words

From the most serious findings on record at Arbors at Springfield, in the surveyor’s own words.

• Actual harm, isolatedF686Nov 19, 2025

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, hospital documentation review, staff interviews, policy review, and review of facility initiated corrective action, the facility failed to ensure appropriate treatment and care was provided to prevent a pressure wound from worsening. This resulted in actual harm when Former Resident (FR #35) sustained an unstageable pressure wound from a fracture boot that required debridement and developed an infection. This affected one (FR #35) of four residents reviewed for wounds. The facility census was 34. […]

• Actual harm, isolatedF689Oct 24, 2024

  Based on record review, staff interviews, and policy review, the facility failed to ensure proper positioning technique for safe bed mobility was implemented which resulted in a major fall with injury. The facility also failed to ensure a fall investigation was completed that included root cause analysis. This resulted in Actual Harm when Resident #30, who was severely cognitively impaired, at risk for falls and dependent on staff for turning and repositioning sustained a fall when two staff members were providing incontinent care and the resident fell to the floor face first due to improper positioning technique. This affected one (Resident #30) of three residents reviewed for falls. The census was 33. Findings include: Record review revealed Resident #30 was admitted of [DATE]. […]

• No harm, potential for more than minimal, widespreadF725Dec 20, 2023

  Based on resident interview, staff interview, and review of staff schedules, the facility failed to ensure adequate staffing to meet residents needs. This had the potential to affect all 40 residents of the facility. The facility census was 40. Findings Include: Interview on 12/19/23 at 4:25 P.M. with Resident #41 revealed he did not feel the facility had enough staff. Resident #41 stated there were long call light response times and they were longer on the three days per week the facility provided dialysis services. Resident #41 stated there was usually one nurse and one State tested Nurse Aide (STNA) on each of the two halls. Interview on 12/19/23 at 4:50 P.M. with Resident #15 revealed he only received bed baths once a week and was scheduled to receive showers twice a week. […]

• No harm, potential for more than minimal, widespreadF730Nov 9, 2022

  Based on review of the performance evaluations, staff interview and policy review, the facility failed to provide annual evaluations for two State tested Nursing Assistants (STNAs) potentially affecting all residents. The finding potentially affected all 37 residents. Findings include: On 11/08/22 at 9:20 A.M. the surveyor requested the performance evaluations for four State tested Nursing Assistants (STNAs) from the Payroll and Benefits Coordinator (PBC) #2. At that time both the Administrator and PBC #2 verified there was no annual evaluation completed for either STNA #39 hired on 06/15/16 and STNA #40 hired on 03/20/20. Review of the policy titled Performance Appraisals dated 01/01/22 revealed all employees were evaluated at least annually. […]

• No harm, potential for more than minimal, widespreadF880Nov 4, 2021

  Based on observations, staff interviews, review of the facility policy, and manufacturer's recommendation, the facility failed to properly disinfect glucometers (blood glucose monitors) between uses to prevent contamination. This affected four ( #1, #3,#4,#5) of five residents identified as using the glucometer for blood glucose monitoring on the 200 hallway. In addition, the facility failed to ensure staff wore proper personal protective equipment (PPE) in rooms where residents were in quarantine isolation. This had the potential to affect 27 of 27 residents who reside in the facility. Findings include: Observation on 11/02/21 at 11:45 A.M., revealed Registered Nurse (RN) #50 completed a finger stick blood sugar (FSBS) for glucose monitoring using a glucometer on Resident #1. […]