Deficiency Records for Springbrook Nursing and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Springbrook Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-02-13 | 2024-03-11 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-02-13 | 2024-03-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-13 | 2024-03-11 | N |
| Dispose of garbage and refuse properly. | Health | 2024-02-13 | 2024-03-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-13 | 2024-03-11 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-02-13 | 2024-03-11 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-13 | 2024-03-11 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2024-02-13 | 2024-03-11 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2024-02-13 | 2024-03-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-13 | 2024-03-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-13 | 2024-03-11 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-02-13 | 2024-03-11 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-02-13 | 2024-03-11 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-02-13 | 2024-02-13 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-11-03 | 2022-11-28 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-11-03 | 2022-11-28 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-09-22 | 2022-10-18 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-09-22 | 2022-10-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-22 | 2022-10-18 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-09-22 | 2022-10-18 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-09-22 | 2022-10-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-22 | 2022-10-18 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-09-22 | 2022-10-18 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-09-22 | 2022-10-18 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-09-22 | 2022-10-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-22 | 2022-10-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-22 | 2022-10-18 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2022-05-12 | 2022-06-06 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-12-22 | 2022-01-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-22 | 2022-01-18 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-08-20 | 2021-09-28 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-08-20 | 2021-09-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-08-20 | 2021-09-28 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-08-20 | 2021-09-28 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-08-20 | 2021-09-28 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-08-20 | 2021-09-28 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-08-20 | 2021-09-28 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-08-20 | 2021-09-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-20 | 2021-09-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-20 | 2021-09-28 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-20 | 2021-09-28 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-08-20 | 2021-09-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-20 | 2021-09-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-20 | 2021-09-28 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-08-20 | 2021-09-28 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-08-20 | 2021-09-28 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-08-20 | 2021-09-28 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-08-20 | 2021-09-28 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-01-23 | 2020-02-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-23 | 2020-02-18 | N |
