Springfield Health & Rehab

In the surveyor’s words

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

• Immediate jeopardy, widespreadF835Mar 3, 2025

  Based on observation, interview, and record review, the facility was not administered in a manner that enables it to maintain the physical well-being of each resident, whereby actions and decisions by the facility's leadership team directly contributed to multiple deficiencies that resulted in harm and immediate jeopardy by failing to ensure that the physician was notified of changes, residents were free from abuse, care plans were implemented, pressure ulcer care and prevention was provided, adequate supervision of residents, residents' care is supervised by a physician, the responsibilities of the Medical Director were met, implement an effective infection prevention program, and have a qualified infection preventionist. […]

• Immediate jeopardy, widespreadF880Mar 3, 2025

  3. Per record review Resident #9 has a urinary catheter and open pressure ulcers that require dressing changes. A care plan focus initiated on [DATE] reflects that the Resident requires the use of enhanced barrier precautions (EBP) related to indwelling device: Foley Catheter. Interventions initiated on [DATE] state use of face mask or eye protection if there is a risk of splash or spray and use of gloves and gown for high-contact care activities. A facility policy titled Enhanced Barrier Precautions states the Enhanced barrier Precautions require staff to wear a gown and gloves while performing high-contact care activities with all residents who are at higher risk of acquiring or spreading an MDRO [Multi-drug resistance organism]. 1. Enhanced barrier precautions will be applied to: . b. […]

• Immediate jeopardy, patternF635Nov 19, 2025

  Based on interview and record review, the facility failed to accurately reconcile physician orders needed to provide necessary care and services on admission, once the facility identified an issue with the admission orders, they failed to review the rest of the discharge summary for other potential missed orders for 1 of 3 residents in the sample (Resident #1). All residents admitting or readmitting to the facility are at risk for serious injury or death as a result of noncompliance. […]

• Immediate jeopardy, patternF580Mar 3, 2025

  Based on observation, interview, and record review the facility failed to ensure consultation with the attending physician during a COVID-19 outbreak, and failed to notify the physician of positive COVID-19 results for 3 of 11 residents who tested positive for COVID-19 (Residents #6, #7, and #12). The facility also failed to notify the physician after a resident physically assaulted another resident causing injury (Resident #1 and #4), and at the time of significant changes in condition regarding development of pressure ulcers (Resident #9). […]

• Immediate jeopardy, patternF689Mar 3, 2025

  Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent 1 of 3 sampled residents (Resident #6) from gaining access to an alarmed stairwell and falling down a flight of 8 stairs, sustaining a head injury. The facility failed to ensure resident safety by not responding timely to a door alarm that is used to alert staff of potential resident elopement. The facility also failed to provide adequate supervision of 2 residents in the applicable sample (Resident #1 and Resident #4) to prevent a resident-to-resident assault that resulted in fear and injury to Resident #4. […]