Inspection·January 28, 2026

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of clinical record, facility investigation, review of policies and procedures, and interviews with staff, it was determined that the facility failed to ensure resident environment was free of accident hazard related to unlocked elevator providing access to a door that resident was able to leave the facility. (Resident R1). This deficiency was identified as past non-compliance.Findings Include:Review of facility policy Safety and Supervision of Residents, dated July 2017, revealed Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and facility- wide commitment to safety at all levels of the organization.Review of facility policy Wandering and Elopements, dated March 2019, revealed The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.Review of information dated January 21, 2026, submitted by the facility on January 22, 2026 revealed Resident R1 left the Center and was seen by staff getting on a Septa bus near the entrance to the Center. He was approached by staff and assisted back to the Center without an issue.Review of Resident R1's clinical record revealed admission date of January 18, 2026, with a diagnosis of dementia and difficulty walking.Review of Resident R1's clinical record revealed that resident has a BIMS (Brief Interview for Mental Status) of 15, indicating resident is cognitively intact. Review of Resident R1's progress notes, dated January 18, 2026, revealed Resident awake alert and oriented x 1-2 with forgetfulness, able to recall long-term events, doesn't remember what was said 30 mins to 1 hour ago.Review of Resident R1's Elopement/ Wandering Risk Evaluation, dated January 18, 2026, revealed that resident was at moderate risk for elopement.Interview with Employee E1, Nursing Home Administrator, and tour of the facility on January 28, 2026 at 10:05 a.m. revealed that Resident R1 was on a locked unit, however with new construction of dialysis suite, the elevator was accessible to residents. Resident R1 entered the elevator and took the elevator to the unoccupied dialysis suite hallways. Resident R1 pushed on emergency exit door until it opened and exited the building with jacket on. Resident R1 was observed walking towards bus station and the staff member was able to redirect the resident and returned to the facility.On January 20, 2026 following the incident, the facility immediately implemented the following corrective actions:On 1/20/2026, Resident R1 was returned to the center by staff. An interim pain and skin assessment was completed with no abnormalities noted. A detailed statement was obtained from [Resident R1]. The physician and responsible party were notified.On 1/20/2026, The Assistant Director of Nursing on January 20th completed a headcount of all residents and compared it to the midnight census to ensure all residents were accounted for and resting comfortably.On 1/20/2026, a lookback of all residents that have three identifiers (independently ambulatory, dementia diagnosis and cognitive impairment) triggered were reviewed and assessed for further safety measures.On 1/20/2026, nursing administration reviewed all (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 01/28/2026 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)