Springfield Nursing and Rehabilitation Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF578Jan 8, 2026

  Based on interview, record review, and review of the facility's documents and policy, the facility failed to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive for 12 of 14 sampled residents, Resident (R) 2, R7, R8, R9, R11, R12, R18, R20, R26, R42, R51, and R70.Review of those residents' admission packet document titled, Advance Directives Policy and Record, revealed the space indicating the resident had a Living Will, Declaration or Directive to Physicians was blank. […]

• No harm, potential for more than minimal, patternF880Jul 22, 2026

  Based on observation, interview, record review, review of the Lippincott Manual of Nursing Practice Ninth Edition, 2010, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases. The facility failed to implement the appropriate infection prevention and control practices during wound care. […]

• No harm, potential for more than minimal, patternF761Jan 8, 2026

  Based on observation, interview, review of an article from the Cleveland Clinic, and review of the facility's policy, the facility failed to ensure that all drugs and biologicals used in the facility were stored and labeled in accordance with professional standards, which affected 1 of 4 medication carts. The findings include:Review of the facility's policy titled, Label/Store Drugs & Biologicals Standard of Practice, most recently revised 4/2025, revealed drugs and biologicals must be labeled in accordance with currently accepted professional principles and include the expiration date when applicable. Further review revealed expired and/or discontinued medication shall be removed from the medication storage area. […]

• No harm, potential for more than minimal, isolatedF880Jan 8, 2026

  Based on observation, interview, record review, review of a Centers for Disease Control and Prevention (CDC) article, and review of the facility's policy, the facility failed to ensure staff complied with gowning while administering medications via gastrostomy tube, while the resident was under Enhanced Barrier Precautions (EBP) for 1 of 30 sampled residents, Resident (R) 60. The findings include: Review of the facility's policy titled, Infection Control, last revised 10/2018, revealed no specific guidance for Enhanced Barrier Precautions (EBP).Review of the CDC's article, Enhanced Barrier in Skilled Nursing Facilities, https://www.cdc.gov/infection-control/media/pdfs/Webinar-EBPinNH-Nov2022-Slides-508.pdf, dated 11/15/2022, revealed the use of gown and gloves was indicated for residents… […]