Springtree Healthcare & Rehab Center

In the surveyor’s words

From the most serious findings on record at Springtree Healthcare & Rehab Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF761May 23, 2024

  Based on observation and staff interview, the facility staff failed to ensure safe and secure storage of medications and/or blood collection tubes for 3 of 6 medication carts (200 Hall, 400 Hall, and 500 Hall) and 1 of 2 medication storage rooms (Unit 2). The findings included: 1. The 500 Hall medication cart contained three used insulin pens which were not labeled with a resident's name or date of opening. The 400 Hall medication cart contained an insulin pen without a clearly identifiable resident name, an expired box of Levothyroxine 75 mg tablets, and a half full vial of Insulin Glargine with a dispense date of 2/14/24 and a beyond use date of 5/13/24. On 5/23/24 at 9:43 AM, surveyor observed Registered Nurse (RN) #3 drawing insulin out of an insulin pen into an insulin syringe. […]

• No harm, potential for more than minimal, patternF684Jun 9, 2023

  Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to provide treatment and care in accordance with the comprehensive person-centered care plan and physician's orders for 8 of 34 residents in the survey sample, Resident #109, #113, #316, #317, #318, #167, #216, and #41. 1. For Resident #109, the facility staff failed to administer medications as ordered by the medical provider and failed to treat a wound to the chest for five days following admission. Resident #109's diagnosis list indicated diagnoses, which included, but not limited to Neuropathy, Muscle Weakness, Cardiogenic Shock, Laceration to Left Front Wall of Thorax, Pericardial Effusion, Cardiac Tamponade, Hypovolemic Shock, and Low Back Pain. […]

• No harm, potential for more than minimal, patternF727Jun 9, 2023

  Based on staff interview, facility document review and CMS report the facility staff failed to ensure the services of a registered nurse for at least 8 consecutive hours per day on 6 dates in one fiscal quarter. The PBJ (payroll based journal) staffing data report for January 1-March 31 2022 listed 8 dates with no RN hours reported. The surveyor reviewed the daily staffing sheets for those dates with the director of nursing. On 2 of those dates, 2/6/22 and 2/26/22, a registered nurse supplied by an agency worked 7AM-7PM. On the remaining dates (1/29/22, 2/5/22, 2/19/22, 2/20/22, 3/5/22, and 3/19/22) no registered nurse worked in the facility. The administrator and director of nursing were made aware of the concern during a summary meeting on 6/8/23.

• No harm, potential for more than minimal, patternF812Jun 9, 2023

  Based on observation and staff interview, the facility staff failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The findings included: During a tour of the facility kitchen on [DATE] at 2:06 PM, the surveyor noted 4 containers of expired food in the walk- in cooler. The first container was a 5 pound container of sour cream with an expiration date of [DATE]. The clear plastic film covering the opening was intact indicating it had not been used. The second container was a 5 pound container of cottage cheese with an expiration date of [DATE]. The clear plastic film covering the opening was intact. The third container was a 5 pound container of cottage cheese with an expiration of [DATE]. The clear plastic film was intact. […]

• No harm, potential for more than minimal, isolatedF656Mar 11, 2026

  Based on staff interview and clinical record review, the facility staff failed to follow the comprehensive person-centered care plan for one of four residents in the survey sample, resident #1.The findings include: For resident #1 the facility staff failed to follow the comprehensive care plan that stated the resident was to be fed by staff.Resident #1's diagnoses included but were not limited to dementia, dysphagia (difficulty swallowing), chronic obstructive pulmonary disease, diabetes, protein-calorie malnutrition, congestive heart disease, chronic kidney disease and gastroesophageal reflux disease.The annual minimum data set (MDS) assessment with an assessment reference date of 11/19/25 was reviewed. […]