F 0687
Provide appropriate foot care.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record reviews, interviews with residents and staff and reviews of policies and procedures, it was
determined that the facility failed to provide foot care and treatment for one of eight residents reviewed.
(Resident R1)Findings include: A review of the policy and procedures titled medication and treatment
orders dated July 2016 revealed that orders for medications and treatments will be consistent with the
principles of safe and effective writing. The policy indicated that only authorized licensed practitioners, or
individuals authorized to take verbal orders from practitioners shall be allowed to write orders in the clinical
record. The policy also said that verbal orders must be recorded immediately in the resident's clinical
record. The order must include prescriber's last name, credentials and date and time of the order. A review
of the policy and procedure titled consultant physician services dated February 2023 revealed that the
consultant physician services must be inwriting and signed by the attending physician. After completion of
the consult, the consultant physician was to provide the facility with a consultation report which was to
include any orders, recommendations or follow-up actions. The policy indicated that consultation reports
were filed in the resident's clinical record. The policy said that the orders from the consultant physician were
to be entered into the resident's clinical record by the nursing staff Clinical record review revealed that
Resident R1 was admitted to the facility on [DATE]. The resident was admitted to the facility for
rehabilitation and nursing care post-surgical TMA traumatic amputation of left foot and left tendon Achilles
lengthening. Clinical record review revealed that the consulting podiatrist (a physician that specializes in the
diagnosis, treatment and surgical care of the foot, ankle and related structures of the leg) evaluated
Resident R1 on July 10, 2025. The podiatrist removed the staples from the surgical site, advised the facility
staff to work with Resident R1 and the physical therapy department to work at encouraging weight bearing,
as tolerated to the left foot. The podiatrist report also indicated that Resident R1 required a diabetic shoe
with filler, as adaptive equipment to meet her foot care needs for eventual ambulation. The podiatrist
requested that the nursing staff assist Resident R1 in obtaining a diabetic shoe that would be custom fitted
to meet her foot care needs for returning to ambulation status. Clinical record review revealed no
documented evidence that an appointment and transportation was made for Resident R1 to be fitted for the
adaptive equipment (diabetic shoe with filler) as assessed by the podiatrist on July 10, 2025. The podiatrist
again evaluated Resident R1 on July 24, 2025, and requested that the resident be fitted for a diabetic shoe
with filler. Observations of Resident R1 at 1:00 p.m., on July 28, 2025, revealed that the resident was not
wearing any adaptive equipment for the left foot. Resident R1 was observed seated in a wheelchair and
using it to ambulate on July 28, 2025. Clinical record review revealed a physical therapy progress note
dated July 15, 2025, indicating Resident R1 was demonstrating hopping on her right foot with a roller
walker and staff supervision. During an interview with Resident R1 at 1:30 p.m., on July 28, 2025, the
resident reported that the physical therapy department trialed her with a boot
Residents Affected - Few
(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:
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
07/28/2025
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 0687
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
that was painful to wear. Clinical record documentation by the occupational therapist on July 18, 2025,
indicated that the resident was complaining of aching, throbbing, discomfort of her left foot, while wearing
the trialed boot. Interview with Resident R1 at 1:45 p.m., on July 28, 2025, confirmed that she was not
afforded the opportunity to use the custom-made diabetic shoe with filler that the podiatrist recommended
on July 10, 2025. Interview with the physical therapist assistant, Employee E3, registered nurse, Employee
E4 and social worker, Employee E5 at 11:00 a.m., on July 28, 2025 confirmed that Resident R1 was not
afforded the opportunity to obtain the adaptive equipment (custom fitted diabetic shoe with filler) as
recommended by the consulting podiatrist on July 10, 2025 to meet the foot care needs of this resident, for
walking and ambulation. Interview with the social worker, Employee E5 at 10:30 a. m., on July 28, 2025,
revealed that Resident R1 was formerly living in an assisted living and that the resident wished to return to
living in the community at that home. The assisted living building had stairs/steps that Resident R1 would
have to use for safe evacuation in an emergency. Interview with the physical therapist assistant on July 28,
2025 revealed that Resident R1 required the custom fitted diabetic shoe with filler, as requested by the
podiatrist to be trialed with ambulation, steps and stairs before discharge into the community assisted home
where she had resided. 28 PA. Code 211.10(c)(d) Resident care policies 28 PA. Code 211.12 (d)(1)(3)(5)
Nursing services
Event ID:
Facility ID:
395690
If continuation sheet
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