Springbrook Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Springbrook Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Feb 13, 2024

  Based on observations, record review and staff, Physician, and resident interviews the facility failed to prevent a significant medication error when Nurse #1 administered Resident #63 medications prescribed to Resident #340 to include carvedilol (a medication classified as a beta blocker used to lower the heart rate and high blood pressure) 25 milligram (mg), losartan (a medication to treat high blood pressure) 25 mg, hydralazine (a medication to treat high blood pressure) 100 mg, and apixaban (a medication to thin the blood) 5 mg on 01/14/24. Resident #63 had previously received her own prescribed carvedilol 25 mg and losartan 100 mg that morning prior to receiving Resident #340's medication which resulted in duplicate medication. […]

• Actual harm, isolatedF600Jun 5, 2024

  Based on record review and resident and staff interviews, the facility failed to protect a cognitively intact resident from verbal and physical abuse by a family member when Family Member #1 threw cold tea and water onto Resident #1, put her hands around Resident #1's throat, threatened to kill her and pushed Resident #1 onto the bed. This resulted in redness to Resident #1's neck. Resident #1 was sent to the Emergency Department (ED) for evaluation and returned the same day with a diagnosis of the strain of the neck muscle. Staff reported the resident appeared out of breath, nervous, and shocked following the incident. A reasonable person would have experienced feelings such as fear, anxiety, and humiliation. […]

• No harm, potential for more than minimal, widespreadF814Feb 13, 2024

  Based on observations and staff interviews, the facility failed to maintain a dumpster that was in good condition and free of leaks and to maintain the dumpster area free of debris for 1 of 1 dumpster. This practice had the potential to attract pests and rodents. Findings included: Observation of the facility's dumpster area on 2/07/24 at 1:30 PM with the Regional Nutrition Consultant revealed an area of a black substance around the dumpster which extended about 10 feet toward the road. This area of black substance had a strong odor of refuse. The area observed under the dumpster had approximately 3 inches of black debris which had a strong odor of refuse. The area behind the dumpster and the recycle container but inside the dumpster area fence had several items. […]

• No harm, potential for more than minimal, widespreadF802Aug 20, 2021

  Based on interviews and record review the facility failed to have sufficient dietary staff with competencies to carry out meal preparation and service for 79 of 79 residents who received meal trays. The findings included: This tag is cross-referenced to F 804. Based on interviews with residents (Resident #28, #290, #54, #68) and staff, review of grievances (Resident #45), resident council minutes and a test tray the facility failed to provide food that was at an appetizing temperature for 4 of 4 residents reviewed for food palatability. This had the potential to affect all the residents in the facility. […]

• No harm, potential for more than minimal, widespreadF804Aug 20, 2021

  Based on interviews with residents (Resident #28, #290, #54, #68) and staff, review of grievances (Resident #45), resident council minutes and a test tray the facility failed to provide food that was at an appetizing temperature for 4 of 4 residents reviewed for food palatability. This had the potential to affect all the residents in the facility. The findings included: A grievance dated 3/20/21 by Resident #45's family member read; Breakfast tray was late, and meal was cold. […]