Springfield Skilled Care Center

In the surveyor’s words

From the most serious findings on record at Springfield Skilled Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Feb 13, 2025

  Based on observation, interview, and record review, the facility failed to provide wound prevention and treatment per standards of practice when staff failed to complete a full assessment and obtain treatment orders timely upon discovery of a wound, failed to follow physician orders for interventions, completion of wound treatments and labs, and failed to care plan interventions for one resident (Resident #95) who developed facility acquired pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device). The resident developed infection and was referred to a surgeon for possible amputation of the right lower leg. The facility census was 98. […]

• Immediate jeopardy, isolatedF600Oct 12, 2022

  Based on record review and interview, the facility failed to protect the residents' right to be free from sexual abuse by staff when one facility staff member (Certified Nurse Aide (CNA) A) had sexual contact with two residents (Resident #1 and Resident #2) and made sexually inappropriate comments at/around one resident (Resident #3). The facility census was 109. On 10/7/2022, at 5:17 P.M.,the Administrator and Director of Nursing were notified of the past noncompliance immediate jeopardy (IJ) which occurred previously. […]

• Immediate jeopardy, isolatedF684Mar 1, 2021

  Based on interview and record review, the facility failed to assess, monitor, notify the physician, and provide timely medical intervention for a change in condition for one resident (Resident #1), who received a physician prescribed blood thinning medication, and developed a [MEDICAL CONDITION], that required hospitalization and life sustaining blood products. The facility census was 96. The administrator was notified on 2/26/21, at 2:15 P.M., of an Immediate Jeopardy (IJ) which began on 2/21/21. The IJ was removed on 2/26/21, as confirmed by surveyor onsite verification. […]

• Actual harm, isolatedF684Jan 13, 2026

  Based on observation, interview, and record review, the facility failed to follow wound physician recommendations to obtain wound cultures and an X-Ray for one resident (Resident #7) with a vascular wound to his/her left shin. The facility census was 106.Review of the facility policy titled, Notification of a Change in Condition, revised on 02/06/25, showed:-The attending physician/nurse practitioner will be notified of a change in the resident's condition;-Responsibility: All licensed nursing personnel, nursing administration, and Director of Nursing (DON). 1. […]

• Actual harm, isolatedF760Jan 13, 2026

  Based on observation, interview, and record review, the facility failed to follow physician medication orders and/or medication recommendations resulting in significant medication errors for 4 residents (Resident #3, #4, #1, and #8) when staff transcribed Resident #3's medication order incorrectly for digoxin (a cardiac medication used to treat heart failure and irregular heartbeat, which has a narrow therapeutic range requiring careful monitoring for side effects), resulting in digoxin toxicity (dig tox, a condition resulting from taking too much digoxin causing symptoms like nausea, vomiting, confusion, vision changes, and serious cardiac issues) and hospitalization, when staff transcribed Resident #4's order incorrectly for Coumadin (warfarin, an anticoagulant medication/ blood thinner)… […]