Springtree Rehabilitation & Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary orderly, and comfortable interior for Unit 1, for 7 of 7 observed resident rooms and the community shower, and Unit 2, for 1 of 1 observed resident rooms. The findings included: During the resident screenings performed by the surveyors on 05/20-21/24 and the Environment observation tour conducted on 05/22/24 at 1:00 PM, accompanied with the Administrator and Corporate Director of Procurement, the following findings were noted: 1. Unit 1: room [ROOM NUMBER]: A - The overbed light cord was too short (cord extension missing), the bathroom door frame & walls were scuffed and in disrepair, and the privacy curtain stained. room [ROOM NUMBER]: The call bell cord was too short; and bathroom ceiling vent-dust laden. room [ROOM NUMBER]: The room walls were in disrepair with scuff marks, the privacy curtain was stained, and the bathroom toilet was running continuously. room [ROOM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to store, prepare, distribute, and served food in accordance with professional standards for food services safety. The findings included: 1. During the initial observation tour conducted of the Main Kitchen on 05/20/24 at 9:00 AM and accompanied with the facility cook supervisor (Staff G), the following were noted: (a) A soiled rag was located on the clean food preparation counter next to the commercial toaster. The surveyor informed Staff G that all cleaning cloths must be stored within a chemical sanitizing solution when not in use. (b) The floor area located in front of the commercial toaster and food preparation counter was noted to have numerous missing tiles and holes (3). (c) The ceiling vent located outside of the paper / disposable room was noted to be soiled and dust laden. (d) Observation of the paper / disposable room noted to have freezer jackets that were hanging on shelving and coming into contact with paper / disposable goods. The surveyor informed Staff G that the jackets are soiled and sweaty and are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) per Centers for Disease Control (CDC) guidelines and facility policies and procedures for 10 of 10 sampled residents reviewed for Transmission-based precautions, Residents #18, #20, #33, #60, #77, #85, #92, #327, #334, and #371. The census at the time of survey was 108 residents. The findings included: Review of the Center for Disease Control (CDC) guidance for Enhanced Barrier Precautions (EBP), documented, in part, the following: When implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this: o Make PPE [Personal Protective Equipment], including gowns and gloves, available immediately outside of the resident room. The guidance for the Enhanced Barrier Precautions is located at:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and observation, the facility failed to address a urine culture and sensitivity result in a timely manner for 1 of 2 sampled residents reviewed for hospitalizations (Resident #103); and failed to maintain a secure catheter tubing for 1 of 1 sampled resident reviewed for urinary catheters (Resident #92). The findings included: Review of the facility's policy, titled, Laboratory Services and Reporting, dated 2/2023 and revised 2/2024, documented, in part: The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the timeliness of the services. Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range. 1. Record review documented Resident #103 was admitted to the facility on [DATE]. Review of the comprehensive assessment dated [DATE] documented the resident was cognitively intact and required…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to administer pain medicine as ordered for 1 of 4 sampled residents reviewed for pain (Resident #85). The findings included: Record review revealed Resident #85 was admitted to the facility on [DATE]. Review of the comprehensive assessment dated [DATE] documented the resident was cognitively intact and required partial / moderate assistance with activities of daily living (ADLs). Record review documented Resident #85 was care planned for pain and had interventions in place to assess and document pain and monitor effectiveness of interventions. An interview was conducted with Resident #85 on 05/21/24 at 12:00 PM. The resident stated he was only getting Tylenol for pain, and it was not effective. Record review revealed an order of 05/03/24 for Oxycodone 5 milligrams (mg) every 4 hours as needed for acute pain on a scale of 5-10 out of 10. Further review of the resident's orders revealed an order for Extra Strength Tylenol 500 mg every 6 hours…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policy and procedure, observation, interview and record review, the facility failed to ensure it secured and locked two (2) over-the-counter (OTC) medications and one (1) prescription medication for 3 of 3 sampled residents observed, Resident #63, Resident #79 and Resident #73; and failed to promptly discard one (1) expired OTC medication and one (1) prescription medication for 2 of 3 sampled residents, Resident #63 and Resident #79. The findings included: Review of the facility policy and procedure on 05/23/24 at 11:23 AM, titled, Storage of Medications, provided by the Assistant Director of Nursing (ADON), reviewed May 2022, documented, in part, in the Policy Statement: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .Procedures: .B. Only licensed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to prepare food in a pureed form designed to meet the needs of 2 of 4 sampled residents of 7 residents with physician ordered pureed diets, Residents #40 and #58, and that included sampled residents, Residents #20, and #373, who were on pureed diets. The census at the time of survey was 108 residents. The findings included: During the review of the facility's Level 4 Pureed Diet, the following were noted: a. Grains - Recommend Pureed soft-cooked hot cereals smooth with no lumps. Served without excess liquid. Do not serve any cooked cereal that is not pureed and has no lumps. b. Pasta - Recommend Pureed moist pasta without lumps. Liquids / sauces do not separate from food. Do not serve and cooked pasta that is not pureed and has no lumps. 1. During the observation of the lunch meal in the main dining room on 05/20/24 at 12:30 PM, it was noted that Resident #40 was served a Pureed Diet. Further observation noted that the pureed Spaghetti was not smooth in texture and there were visible lumps. At the request of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior that included 2 of 2 residential areas (Unit 1 and Unit 2) and the facility's laundry department. The findings included: 1. During the initial resident screening conducted on 06/05/23 and the Environment Tour conducted on 06/07/23 at 12:30 PM, accompanied with the facility's Assistant Administrator, and corporate Housekeeping Director, the following were noted the following: (a.) 100 Unit: room [ROOM NUMBER]: The room walls were noted to be damaged and in disrepair and required repainting, an approximate 2 feet of floor damage next to the A-bed, and the exterior of the bathroom entry door was damaged and in a state of disrepair. room [ROOM NUMBER]: The room walls were noted to be damaged and in disrepair, and the exterior of the bathroom entry door was damaged and was in a state of disrepair. room [ROOM NUMBER]: The room walls…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide foot care to 4 of 4 sampled residents reviewed for foot care, Residents #7, #28, #54, and #65. The findings included: Review of the facility's policy, titled, Skin Integrity- Foot Care, implemented on 01/2023, documented, in part, .comprehensive assessment will include an assessment of the feet for disorders which may require treatment .nail disorders. Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse immediately after the task .the attending physician will assume responsibility for the overall care and treatment of the resident's medical conditions . 1. Review of Resident #7's, clinical record documented an admission to the facility on [DATE] with no readmissions documented. The resident's diagnoses included Ataxic (awkward, uncoordinated walking) Gait, Unspecified Mood, Anxiety Disorder and Hereditary and Idiopathic Neuropathy (an illness where sensory and motor nerves of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure medications were not stored at residents' bedsides for 4 sampled residents, Residents #240, 44, 45, 255; failed to ensure proper medication disposal; failed to maintain medication carts in proper order for 1 of 3 medication carts reviewed for medication storage; and failed to ensure expired medications were properly disposed of in 1 of 1 treatment carts reviewed for medication storage. The findings included: Review of the facility policy, titled, Medication Storage in the Facility, last revised January 2018 revealed the following, in part: Medications and biologicals are stored safely, securely, and properly following manufacturers recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Outdated medications are immediately removed from inventory, disposed of according to procedures for medication disposal, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety that included; failure to hold hot foods at regulatory temperatures at 135 degrees or greater. This potentially effected 28 facility residents that included sampled Residents #5, #7, #38, #59. and #184. The findings included; During the second Kitchen/Food service observation tour conducted on 02/08/22 at 9:30 AM, it noted that numerous containers of foods were noted to be located on a utility cart near the oven area. Further observation noted that the pans contained : Ground Cooked Beef - 10 portions prepared on 02/07/22. Pureed Chicken - 10 Portions prepared on 02/07/22. Baked Fish - 6 portions prepared on 02/07/22. Baked Potatoes - 8 portions prepared on 02/07/22. At the request of the surveyor the temperatures of these foods were taken by the Corporate Food Service Manager with the use of the facility's calibrated digital thermometer and were recorded as follows; Ground Cooked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, it was determined that the facility failed to dispose of garbage and refuse in a safe and sanitary manor. The findings included: During the observation of the dumpster/refuse area accompanied with the Corporate Food Service Manager on 02/08/22 at 9:30 AM, the following were noted: 1) Upon exit of the rear door of the facility in route to the dumpster area, it was noted that there was an open trash barrel next to the exit door. Further observation noted that the open barrel was full of staff discarded Personal Protection Equipment (PPE) that included masks, gloves, and gowns. The Corporate Director stated that it was not the facility's procedure for disposing of infectious PPE's. The surveyor requested that the barrel contents be safely discarded as soon as possible and educate staff on proper disposal of PPE's. 2) Observation of the dumpster noted that 1 of 2 garbage dumpsters was noted to have a large hole in the bottom right corner. It was also noted that a rag had been placed in the hole. It was discussed with the Corporate Director that the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and review of policy and procedure, it was determined that the facility failed to ensure that it secured medications for Resident #37, during a Medication Pass Observation and properly disposed of over-the-counter (OTC) medication for Resident #13, during an observational room tour. The findings included: 1) On 02/07/22 at 9:50 AM during a Medication Administration Observation, it was noted that there were three (3) unidentified, loose pills---one (1) orange and two (2) pink on Resident #37's floor, one (1) near the doorway and two (2), near her bedside table, unsecured and accessible to other residents, staff and visitors. Resident #37 was originally admitted to the facility on [DATE] with diagnoses which included Dementia, Osteoarthritis, Major Depressive Disorders and History of Falling. She had a Brief Interview Mental Status (BIM) score of 6 (severely impaired). Photographic evidence obtained of the three (3) loose, unidentified pills located on the floor in Resident #37's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.