F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of clinical records, facility policy, and interviews with resident and staff , it was determined that the
facility failed to provide a reasonable accommodation of needs for one of nine sampled residents. (Resident
R7)
Residents Affected - Few
Findings include:
Review of the facility policy titled Answering the call light not dated states, Be sue that the call light is
plugged in and functioning at all times.:
Review of Resident R7 order summary report revealed the resident was admitted on [DATE] diagnosed with
a fractured pelvis due to a fall at home and ordered that the resident be toe touch weight-bearing, (meaning
the ability to touch the foot or toes to the floor without the affected limb providing support and weight
bearing as tolerated in the lower left extremity).
Interview with Resident R7 and his family member on August 28, 2024, at approximately 10:30 a.m.
revealed on admission the resident was given a small bell to use in place of his call bell. The resident's
room was down the hall, one of the last rooms, furthest away from the nursing station. The resident stated It
had to do with my roommate needing special equipment that used my call bell outlet. Resident R7's spouse
said, Considering my husband was non-weight bearing, and could not do anything for himself, made me
uneasy. If something happened, he was too far away to use that little bell. No one would hear it.
This was confirmed with the Director of Nursing on August 28, 2024, at 2:00 p.m. that the resident did not
have a call bell and was given a small bell to use.
28 Pa. Code 211.12(d)(5) Nursing services.
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:
395690
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
395690
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/29/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Springfield Rehabilitation and Healthcare Center
463 West Sproul Road
Springfield, PA 19064
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)
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of facility policies, facility documentation, clinical record reviews and interviews with staff, it
was determined that the facility failed to ensure that residents remained free from significant medication
errors for one of nine residents reviewed (Resident R9).
Residents Affected - Few
Findings include:
Review of the facility policy titled, Administering Medications not dated states, The individual administering
the medication checks the label three times to verify the right resident, right medication, right dosage, right
time, and right method of administration before giving the medication.
Review of Resident R9's physician admission note dated August 1, 2024 indicated the resident presented
to the emergency room on July 30, 2024 with left-sided weakness and balance issues. The resident
reported lower extremity weakness to be progressive over the last month and associated with intermittent
slurred speech and trouble swallowing. The resident reported earlier hospitalization at another hospital for
the same symptoms. Continuing with the same note states to see therapy for left sided weakness, continue
the medication Propranolol for high blood pressure -monitor vitals, continue Keppra for seizures and to
maintain seizure precautions, continue Gabapentin for neuropathy, continue Zofran for nausea and
vomiting, and to continue Trazadone, Sertraline for depression and follow up with psych.
Review of the incident report dated August 20, 2024, indicated Resident R9 was noted with increased
lethargy. Upon investigation it was noted that the resident's medication list in the discharge paperwork from
the hospital was incorrect. The medication list belonging to another patient from the hospital. All of Resident
R9's medications were discontinued or were tapered down until discontinued.
Interview with the Director of Nursing on August 28, 2024 at 11:30 a.m., confirmed the medication error and
stated the hospital sent the wrong medication list for Resident R9. The facility did not notice the name was
different on the medication list.
28 Pa Code 211.12(d)(1) Nursing services
28 Pa Code 211.12(d)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395690
If continuation sheet
Page 2 of 2
