NHC Healthcare, Springfield

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Sep 15, 2025

  Based on facility policy review, medical record review, observation and interview, the facility failed to protect the residents' right to be free from sexual abuse by another resident for 3 of 6 (Resident #1, Resident #6, and Resident #9) sampled residents reviewed for abuse. At an unknown date and time between [DATE] - [DATE], Resident #1 who was severely cognitively impaired was sexually assaulted by Resident #6. Resident #6 who was moderately cognitively impaired was found naked from the waist down and had climbed into his roommate's bed (Resident #1) and attempted sexual intercourse. Certified Nursing Assistant (CNA) C observed that the lights were off, the curtain was pulled between A and B bed, and Resident #6 was on top of Resident #1 (B bed). CNA C screamed for assistance. […]

• Actual harm, isolatedF726Sep 15, 2025

  Based on Facility Assessment review, employee file review, medical record review, observation, and interview, the facility failed to ensure all nursing staff possessed the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely for 1 of 10 (Resident #11) sampled residents. On 1/21/2025, Resident #11 was found in the floor of her room laying face down with her right lower extremity (RLE) next to her face and her left upper extremity (LUE) under her abdomen. Resident #11 was crying and moaning in pain. Licensed Practical Nurse (LPN) L documented that she gently repositioned Resident #11's RLE to baseline, which resulted in actual Harm to Resident #11. […]

• No harm, potential for more than minimal, widespreadF812Sep 5, 2024

  Based on observation, interview, and review of the facility's policy, the facility failed to ensure food was stored, prepared, and distributed in accordance with professional standards. The deficient practice has the potential to 80 of 82 residents who receive food by mouth and placed residents at risk for food borne illnesses. Findings include: Observation on 09/02/24 at 9:10 AM revealed bacon bits wrapped in cellophane the size of a football in the first reach in cooler in the main kitchen. The bacon bits were not labeled and dated. The observation also revealed a Styrofoam divided container with spareribs, macaroni and cheese, and potato salad in the first reach in cooler in the main kitchen. The items were not labeled or dated. […]

• No harm, potential for more than minimal, patternF755Sep 5, 2024

  Based on observation, interview, record review, review of manufacturer's instructions, and review of the facility's policy, the facility failed to ensure residents were provided and received pharmaceutical services to meet the needs of each resident for one of 30 sampled residents (Resident (R) 76) and for three of 15 supplemental residents (R123, R20, and R21). R123's medications were not delivered timely by the pharmacy and the resident was not administered her medications as ordered by her physician. Also, R20's medications were administered via the resident's gastronomy tube (G-Tube); however, the nurse did not check the resident's G-Tube placement prior to the administration of the medications. […]

• No harm, potential for more than minimal, isolatedF689Dec 3, 2025

  Based on policy review, medical record review, observation, and interview, the facility failed to provide an environment free of hazardous materials for 2 of 93 (Resident #3 and #96) sampled for accident hazards. The findings include: 1. Review of the facility's policy titled Environmental Services Toolkit, dated 8/2025, revealed .Keep chemicals locked up away from patients when not in use . The facility was unable to provide a policy regarding razors and hazardous sharps unsecured and unattended in a resident's room. 2. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses including Obstructive Pulmonary Disease, Atrial Fibrillation, Heart Failure, Diabetes, and Major Depressive Disorder. […]