Health inspection·January 16, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident and staff interviews and review of facility policy, the facility failed to ensure resident room temperatures were maintained to ensure a comfortable environment for the residents. This affected two (#1 and #3) out of four residents reviewed for comfortable room temperatures. Facility census was 63. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 02/22/21. Diagnoses included cerebral infarction, anxiety, hypertension, and acute kidney injury. Review of the annual Minimum Data Set (MDS) 3.0 assessment for Resident #3, dated 11/01/23, revealed the resident had mildly impaired cognition. Review of the plan of care for Resident #3 revealed the resident had potential for altered cardiac status related to hypertension with goal to remain free from complications related to altered cardiac status. Interventions include, but not limited to, monitor for chest pain, blood pressure, nausea and vomiting, shortness of breath, diaphoresis, and edema. Note changes in sensorium: lethargy, confusion, disorientation, anxiety, and depression. Observation on 01/11/24 at 2:50 P.M. of Resident #3's room temperature, using an ambient thermometer, revealed it was 65.1 degree Fahrenheit (F). Resident #3 had on a T-shirt, a sweatshirt, with a blanket draped over her shoulders. This finding was verified with Licensed Practical Nurse (LPN) #141. Interview with Resident #3 during this observation, revealed she stated she was chilled and they had taken her heater away. 2. Review ot the medical record for Resident #1 revealed admission date of 09/18/20. Diagnoses included schizophrenia, hypertension, and chronic obstructive pulmonary disease (COPD). Review of the quarterly MDS dated [DATE] revealed the resident had impaired cognition. Review of the plan of care dated 12/26/23 revealed the resident had potential for altered cardiac status related to hypertension with goal to remain free from complications related to altered cardiac status. Interventions include, but not limited to, monitor for chest pain, blood pressure, nausea and vomiting, shortness of breath, diaphoresis, and edema. Note changes in sensorium: lethargy, confusion, disorientation, anxiety, and depression. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 366099 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366099 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springfield Nursing & Independent Living 404 E McCreight Ave Springfield, OH 45503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)