Springfield Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Sep 11, 2024

  Based on review of clinical records, facility documentation and policy, and interviews with staff, it was determined the facility failed to provide adequate supervision to Resident R1 with a history of wandering, and at risk for elopement. This failure resulted in an Immediate Jeopardy situation to Resident R1 who eloped from the facility, crossed a high traffic street and was found by a member of the community in a lot across from the facility entrance, for one of four residents reviewed at risk for elopement (Resident R1). The deficiency was identified as Immediate Jeopardy past non-compliance. […]

• Immediate jeopardy, isolatedF689Jul 2, 2024

  Based on observation, review of facility policies, review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that water temperatures in resident bathroom hand sinks were maintained at a safe temperature for one of two nursing units. This failure placed residents on the North Side nursing unit exposed to unsafe hot water temperature and at risk of serious injury from a burn. This failure resulted in an Immediate Jeopardy situation. (North side nursing unit) Findings: Review of facility policy on Safety of Water Temperatures, under section Policy Statement revealed that tap water in the facility shall be kept within a temperature range to prevent scalding of residents. […]

• Actual harm, isolatedF600Oct 26, 2021

  Based on review of clinical records, review of facility documentation, review of facility policies, and interviews with residents and staff, it was determined that the facility failed to ensure that two of 32 residents reviewed were free of neglect during transfers from one surface to another (Resident R13 and Resident R80). This failure resulted in actual harm to Resident R13 who did not received the appropriate level of assistance during a transfer from bed to wheelchair and sustained a laceration to right calf requiring eight sutures. Findings include: Review of facility policy and procedure Abuse Prevention Program undated revealed residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. […]

• No harm, potential for more than minimal, patternF677Mar 27, 2025

  Based on observations, interview with staff and residents and review of facility provided documentation, it was determined that facility did not ensure residents received the necessary services to maintain personal hygiene and mobility for five out of 18 residents reviewed (Resident R35, R40, R65, R233, R13) Findings include: Review of facility's policy 'Activities of Daily Living (ADL), Supporting,' revised March 2018, indicates that appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. […]

• No harm, potential for more than minimal, patternF697Mar 27, 2025

  Based on review of facility policy, review of clinical record, and staff interview, it was determined that the facility failed to ensure that appropriate pain management was provided to a resident consistent with standards of professional practice for four of 18 residents reviewed (Residents R79, R290, R292 and R293). Findings include: Review of the facility Policy on Pain management revealed that the purpose of this procedure are to help the staff identify pain in the resident and to develop interventions that are consistent with the resident's goals and needs and that address. […]