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Inspection visit

Health inspection

SPRINGTOWN PARK REHABILITATION AND CARE CENTERCMS #6764998 citations on this visit
8 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to ensure the results of the most recent survey of the facility conducted by the State surveyors and the facility's plan of correction were posted in a place readily accessible to residents, family members and legal representatives of residents, and the public in 1 of 1 facility, in that: Residents Affected - Many The most recent State survey results and intake investigation findings of non-compliance with the facility's plan of correction were not readily accessible to residents. This failure could place residents and their family members and representatives at risk for violation of the right to review the findings from State surveys and investigations conducted in the facility without asking to review the reports. The findings included: Review of the facility's history during the off-site survey preparation revealed the facility was cited with non-compliance during the annual recertification survey dated 6/30/2022, and during intake investigations dated 8/31/2022 and 9/28/2022. Observation on 8/15/23 at 9:30 AM revealed required resident advocacy and other resident information was posted along the wall in the hallway to the right of the front entrance leading toward Hall 100. The posted information was located across the hallway from the front entrance reception desk and the Administrator's office. In a confidential group interview on 8/17/23 at 10:39 AM, during a Resident Council Meeting with 7 residents in attendance, the residents stated they were not aware they could review the State inspection findings from the facility's annual survey and intake investigations that cited noncompliance. They did not know where the inspection results were located for review. During an interview, observation, and record review on 8/17/23 at 11:41 AM, the RN Corporate Nurse stated there was a framed notice on the wall across from the front reception desk that indicated the State inspection results were located at the reception desk. She pointed to the framed notice hanging on the wall between other required posted information. The RN Corporate Nurse located the survey results on the reception desk in large white binder notebook that contained other facility information. The survey information was located in the back portion of the binder notebook. It did not include the CMS 2567 findings for the last annual survey or the citations from investigations since the last annual survey. The RN Corporate Nurse took the large binder notebook and stated it would be fixed. 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 18 Event ID: 676499 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 676499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springtown Park Rehabilitation and Care Center 201 Williams Ward Rd. Springtown, TX 76082 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to complete an assessment that accurately reflected the resident's status for 2 of 23 residents (Residents #11 and #243) whose records were reviewed for MDS accuracy, in that: Residents Affected - Some 1. Resident #11 had an order for the anti-platelet medication of Clopidogrel (Plavix). The resident's Comprehensive MDS Assessment documented the use of an anticoagulant medication. 2. Resident #243 had an admission medication order, dated 8/06/2023, for a pain patch to be applied one time a week every Monday. She received an order on 8/09/2023 for pain medication as needed. The resident's admission MDS Assessment, dated 8/09/23, documented the resident did not receive scheduled pain medication. 3. Resident #243 stated she had pain in her right shoulder due to having a torn rotator cuff and had back and leg pain, which limited movement and use of her right arm and legs. The admission MDS Assessment, dated 8/09/2023, documented the resident did not have any limitations in range of motion in her upper or lower extremities and did not use any devices for mobility assistance. This failure could place residents at risk for not receiving care and services to meet their needs. The findings included: 1. Resident #11 Review of Resident #11's admission MDS dated [DATE] revealed she was an [AGE] year-old female admitted to the facility 06/18/2023. She had diagnoses which included cerebrovascular accident (stroke) heart failure, hypertension (high blood pressure) and coronary artery disease (hardening of the major blood vessels of the heart). Review of Resident #11's admission MDS dated [DATE], section N revealed Resident #11 had taken an anticoagulant for 2 days prior to the assessment reference date (06/21/2023). Review of Resident #11's order summary report dated 06/18/2023 revealed Resident #11 took clopidogrel 75 mg for the prevention of blood clots. Review of Resident #11's care plan dated 7/21/2023 revealed Resident #11 was at risk for complications related to anticoagulant/antiplatelet therapy and took Aspirin and Plavix (clopidogrel) for coronary artery disease (hardening of the coronary artery vessels). Her goal was to be free of anticoagulant side effects. In an interview on 08/18/2023 at 2:30 PM the MDS Coordinator stated she was the nurse responsible for doing MDS assessments. She stated she completed the admission MDS for Resident #11 which was dated 06/21/2023. She stated the nurse completing the assessment was responsible for the accuracy of the MDS. She stated an inaccuracy on the resident's MDS could lead to the resident not receiving necessary care and services. She stated the failure occurred because she was not aware that the clopidogrel was an anti-platelet. She stated she thought it was classified as an anticoagulant. She also stated she referred to MDS 3.0 RAI Manual provided by CMS for instructions on how to complete (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676499 If continuation sheet Page 2 of 18 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 676499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springtown Park Rehabilitation and Care Center 201 Williams Ward Rd. Springtown, TX 76082 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 0641 assessments. She stated the facility did not have a written policy regarding resident assessment. Level of Harm - Minimal harm or potential for actual harm 2. Resident #243 Review of the Resident Profile Information, not dated, for Resident #243 revealed an Residents Affected - Some [AGE] year-old female who was admitted to the facility on [DATE]. Review of Resident #243's diagnoses list revealed it included diagnoses of pain in unspecified joint and restless leg syndrome (an uncontrollable urge to move the legs). Review of Resident #243's Interim Plan of Care (Admit), dated 8/06/23, documented the resident had constant pain. Review of Resident #243's Physician Order Summary revealed an order dated 8/06/2023 to assess pain every shift using 0-10 pain scale for pain monitoring. Review of Resident #243's Physician Order Summary revealed the following orders for pain medication: 8/06/23 - Butrans Transdermal Patch - weekly 5 mcg/hour (Buprenorphine) *Controlled Drug*; apply 1 patch transdermally (topically on the skin) one time a day every Monday for arthritis pain and remove per schedule. 8/09/23 - Tylenol with Codeine #4 oral tablet (Acetaminophen 300 mg with Codeine 60 mg) *Controlled Drug*; give 1 tablet by mouth every 8 hours as needed for pain control, and give 2 tablets by mouth every 8 hours as needed for pain. 8/16/23 - Ropinirole Hydrochloride 2 mg oral tablet; give 2 tablets by mouth two times a day for restless legs. [Order received following completion of the admission MDS Assessment.] Review of Resident #243's admission MDS Assessment, with an ARD of 8/09/23, revealed Section J documented scheduled pain medication was not received, PRN pain medication was received, and the resident had occasional pain at an intensity of 4. Section G Functional Status and ADLs documented the resident required extensive assistance with 2 persons assisting for bed mobility and required extensive assistance with one person assisting for transfers and mobility. The resident did not walk. Section G for Range of Motion documented there were no limitations in the upper or lower extremities and no mobility devices were used. Review of Resident #243's admission MDS Assessment CAA Summary, signed by the DON on 8/14/2023, revealed pain did not trigger as a care area. During and observation and interview on 8/16/23 at 3:34 PM, Resident #243 was lying on her back in bed, with the head of the bed slightly elevated, and with a bed pillow positioned under her right arm and against her right side. A wheelchair was in the room. She stated she had right shoulder surgery for a torn rotator cuff during the past, about 2 years ago, and her right shoulder had torn again. The resident stated she had pain in right shoulder, back and legs. She stated she took pain medication but needed to ask for it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676499 If continuation sheet Page 3 of 18 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 676499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springtown Park Rehabilitation and Care Center 201 Williams Ward Rd. Springtown, TX 76082 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 8/18/23 at 7:35 PM, the DON stated Resident #243 had a right bicep tear. She stated the resident kept her right arm tight against her side and a positioning pillow was placed under her right arm for support. Review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, dated October 2019 revealed [in part]: The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status (2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals (3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. Nursing homes are left to determine (1) who should participate in the assessment process (2) how the assessment process is completed (3) how the assessment information is documented while remaining in compliance with the requirements of the Federal regulations and the instructions contained within this manual. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676499 If continuation sheet Page 4 of 18 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 676499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springtown Park Rehabilitation and Care Center 201 Williams Ward Rd. Springtown, TX 76082 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received adequate care to maintain highest practical physical and psychosocial well-being for 1of 23 residents (Resident # 62) reviewed for ADL care, in that: Residents Affected - Some The facility failed to ensure Resident #62's fingernails were cut This failure placed residents at risk of experiencing a decreased quality of life and an increased risk of infection. Findings included: Resident #62 Record review of the Quarterly MDS dated [DATE] revealed Resident # 62 was a [AGE] year-old female originally admitted to the facility on [DATE]. Her diagnoses included: dementia, malnutrition, and neurogenic bladder (lack of bladder control due to brain, spinal cord, or nerve problem). Her BIMS score was 8 (moderate cognitive impairment). Section G of Resident # 62's MDS revealed the resident required extensive assistance for bed mobility, dressing, and personal hygiene. . In an observation and interview on 08/15/2023 at 10:30AM, Resident #62 was sitting up in her bed alone in her room. She was noted to have a contracture to her right hand. Her fingernails on her contraccted rt hand needed to be trimmed. She stated she would like to have them trimmed. Indentations were noted on her Rt palm from her nailsdigging in to them. In an interview and observation on 08/15/23 at 03:31 Resident # 62's fingernails remained untrimmed. The observation revealed the 4th finger had a fungus and was large and untrimmed. The skin at the base of the nail was slightly swollen. Resident # 62 stated again her fingernails were too long and she would like to have them trimmed. She stated she had asked to have them cut, but she did not remember who she asked. In an interview with CNA E on 8/16/23 at 10:10 AM she stated CNAs were responsible for checking incontinent residents and residents that could not reposition themselves every 2 hours. She stated The CNA'S were responsible for keeping the resident's nails clean and cut unless they were diabetic. She stated the LVN's were responsible for keeping the diabetic residents' nails trimmed. She stated nail care should be done on resident bath day. She stated Nail care was not documented when it was performed in the CNA point of care. She stated should be documented on the resident shower sheet if the aide does nail care. She stated she always does nail care with her showers. A record review of the facility shower sheets provided by the DON on 8/1 /23 showed documentation of nail care for Resident #62 on 8/16/23 and for no other dates. A record review of Resident # 62's care plan revealed the following in part: Resident has an ADL self-care performance deficit related to immobility, weakness, contracture to right hand, muscle wasting and atrophy. Resident will maintain current level of function in ADLs through the review date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676499 If continuation sheet Page 5 of 18 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 676499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springtown Park Rehabilitation and Care Center 201 Williams Ward Rd. Springtown, TX 76082 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 0677 Level of Harm - Minimal harm or potential for actual harm Intervention: Bathing/Showering: Check nail length trim and clean on bath day and as necessary. Report any changes to the nurse. Record Review of the facility policy Activities of Daily Living (ADLs), Supporting, revised March 2018, revealed the following in part: Residents Affected - Some .Policy Statement Residents will provide with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation . 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care). b. Mobility (transfer and ambulation, including walking). c. Elimination (toileting). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676499 If continuation sheet Page 6 of 18 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 676499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springtown Park Rehabilitation and Care Center 201 Williams Ward Rd. Springtown, TX 76082 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide each resident with an ongoing program of individual activities designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident for 1 of 1 resident (Resident #82) who was reviewed for individual in-room activity programs, in that: Residents Affected - Few Resident #82 did not have an individualized activity program developed and implemented for in-room activity pursuits based on her past and current activity interests. This failure could place the residents at risk for social isolation, a decline in mental health status, and decreased feelings of well-being within their environment. The findings included: Review of Resident #82's admission Record, dated 8/18/2023, revealed an [AGE] year-old female who was initially admitted to the facility on [DATE]. The resident's admission diagnoses included acute respiratory failure with hypoxia (low blood oxygen saturation), cognitive communication deficit, dysphagia, oropharyngeal phase (difficulty swallowing), chronic obstructive pulmonary disease (breathing disorder), unspecified dementia, anxiety, essential (primary) hypertension (high blood pressure), congestive heart failure, cerebral infarction (stroke), gastro-esophageal reflux disease (regurgitation of stomach acid), anxiety, and depression. A diagnosis of gastrostomy status was added 6/11/23 after the resident returned from the hospital following placement of a feeding tube. Review of Resident #82's Initial admission Activity Review, dated 5/08/2023, revealed the resident's past activity interests were watching television, puzzles, sewing, and socializing. The review documented the resident wished to participate in activities, group activities, and individual activities. The review documented the resident required assistance to and from activities. Review of Resident #82's admission MDS Assessment with an ARD of 5/08/2023 revealed a BIMS score of 14 out of 15 (cognitively intact). Review of Section F0500 for Interview for Activity Preferences revealed it was somewhat important to do favorite activities. The remaining activity preference options were documented as not very important. Review of Resident #82's admission MDS Assessment CAA Summary, dated 8/15/2023, revealed the category of Activities did not trigger as a care area. Review of Resident #82's comprehensive care plan, dated 5/24/23, addressed the resident's desire to maintain long fingernails, but did not address activity programs. Review of Resident #82's re-admission Activity Review, dated 6/23/2023, revealed the resident wished to participate in individual activities and liked watching television and listening to stories. She wished to have visits from clergy. She did not wish to participate in group activities. During an observation and interview of 8/16/23 at 9:50 AM, Resident #82 was resting on her back in bed with the head of the bed elevated. She stated she had a stroke and had right-sided weakness. Resident #82 stated she had been in the facility for 3 months and had gone to the hospital and had a feeding tube placed. She stated she got out of bed for therapy and received speech therapy and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676499 If continuation sheet Page 7 of 18 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 676499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springtown Park Rehabilitation and Care Center 201 Williams Ward Rd. Springtown, TX 76082 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few physical therapy. Resident #82 stated she did not go to scheduled group activities. She stated she could hear the country music singer yesterday afternoon from her room. In an interview on 8/18/23 at 4:07 PM, the Activity Director stated she did in-room activity programs with Resident #82. She stated she went in and did chit-chats with the resident 3 times a week. She stated the resident liked her fingernails long and polished and only wanted them filed if they were chipped. The Activity Director stated Resident #82 did not want to come out of her room. She stated the resident's family visited. The Activity director stated she would not know what was on the resident's MDS assessment and activity assessments for activity preferences, because she was not working there when they were completed. In an interview on 8/18/23 at 4:19 PM, the Activity Director stated she had been employed in the facility since 6/26/23. She stated she did in-room activity programming with 3 residents, which included Resident #82. The Activity Director stated she did not have or use individual activity programming sheets or participation record forms. She stated she used a daily resident census sheet to document P for participate or R for refused. She did not document the activities the residents participated in or refused. She stated she was doing what the prior Activity Director had done. The Activity Director stated she did not have a printed job description or a policy and procedure for activity programs. In an interview on 8/18/23 at 4:51 PM, the Director of Human Resources provided a copy of the Job Description of Activity Director for review. She stated the current Activity Director signed the job description the day she was hired on 6/26/23. The Director of Human Resources stated she did not know if she gave the Activity Director a copy of the signed job description. She stated the prior Activity Director had already left and was not able to help the current Activity Director transition into the position. Review of the Job Description for Activity Director, not dated, revealed [in part]: Duties: - Ability to develop, organize and implement a program of activities for the social, emotional, physical, and other therapeutic needs of the residents within a specified budget. - Maintain detailed records of activity programs and participation records of individual residents, identifying progress toward established care plan goals . Review of the facility policy and procedure for Activity Programs, dated as revised June 2018, revealed [in part]: Policy Statement Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident. Policy Interpretation and Implementation 1. The Activities Program is provided to support the well-being of residents and to encourage both independence and community interaction. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676499 If continuation sheet Page 8 of 18 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 676499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springtown Park Rehabilitation and Care Center 201 Williams Ward Rd. Springtown, TX 76082 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 0679 Level of Harm - Minimal harm or potential for actual harm 2. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. 3. The Activities Program is ongoing and includes facility-organized group activities, independent individual activities, and assisted individual activities. Residents Affected - Few 4. Activities are considered any endeavor, other than routine ADLs, in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance physical, cognitive or emotional health. 5. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676499 If continuation sheet Page 9 of 18 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 676499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springtown Park Rehabilitation and Care Center 201 Williams Ward Rd. Springtown, TX 76082 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 23 residents (Resident #46) reviewed for resident care, in that: Residents Affected - Some The facility failed to ensure Resident #46 was provided treatment for her edema. This failure could place residents at risk for a decline in health status. Findings included: Record review of Resident #46's MDS admission assessment, dated 04/05/2023, revealed Resident #46 was admitted to the facility on [DATE]. Section C: Cognitive Patterns revealed a BIMS score of 6 (severe impairment). Section I: Active diagnosis revealed heart failure, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and pneumonia. Review of Resident #46's Care Plan (review date 7/27/23) reflected, the resident had congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should). The goal was for the resident to be free of peripheral edema (swelling caused by the retention of fluid in the legs, arms, feet, ankles, or hands) and have clear lung sounds. Review of Resident #46's physician order summary report dated 8/17/23, reflected an order to check for edema every shift, and see order for prn furosemide 20 mg if 1+ edema is noted. Review of Resident #46's treatment administration record for the month of August, dated 8/17/23 reflected the resident had no edema documented. on 08/01/23 thru 8/15/23 on the day, evening or night, shift. On 08/16/ 23 there was no edema documented on the day and evening shift and 2+ edema was documented to bilateral lower extremities on the night shift. Review of Resident #46's medication administration record for August 2023 dated 08/17/23 revealed furosemide 20 mg (a diuretic) was administered on 8/17/23 by the night shift charge nurse for 2+ edema. Review of nurse's progress notes for 8/7/23 at 7:04 AM revealed the following documentation: 2+ bilateral lower extremity edema, skin warm and dry, pedal pulses palpable bilaterally. An observation by the RN surveyor, on 08/15/23 at 12:28 PM revealed the resident sitting up in her wheelchair 2+ bilateral lower extremity edema was noted. An observation on 08/16/23 09:25 AM revealed Resident #46 sitting in her wheelchair with 2+ edema to bilateral lower extremities. An observation on 08/16/23 at 11:30 AM revealed Resident #46 remained up in in her wheelchair with 2+ edema to bilateral extremities. In an interview on 08/18/23 at 8:15 AM, LVN C stated it is the Charge Nurse's responsibility to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676499 If continuation sheet Page 10 of 18 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 676499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springtown Park Rehabilitation and Care Center 201 Williams Ward Rd. Springtown, TX 76082 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some monitor residents for edema. She stated the charge nurse is responsible for administering prn Lasix. She stated she was charge nurse for Resident #46 and did not notice her having edema on 8/15/23 or 8/16/23. She stated failure to administer prn furosemide could lead to fluid overload. She stated the failure occurred due to her not noticing the edema. In an interview at 8:40 AM on 08/18/23 the ADON stated it was the charge nurse's responsibility to monitor residents for edema. She looked at the medication administration record and treatment administration record and confirmed that Resident # 46 was first documented as having edema on the night shift nurse. and did not receive her furosemide until 8/17 /23 when the night shift nurse administered, she stated the resident had Lasix 20 mg po for 1+ edema or greater. In an interview on 08/18/23 at 1:13 PM the DON stated the charge nurse is responsibility to monitor residents for edema. She looked at the medication administration record and treatment administration record and confirmed that Resident # 46 was first documented as having edema on the night shift on 8/16/23 nurse and did not receive her furosemide until 8/17 /23 when the night shift nurse administered it. The DON stated Resident #46 had a diagnoses of congestive heart failure and failure to administer the prn furosemide could result in fluid overload. Review of the facility policy titled Resident Examination and Assessment, dated as revised February 2014, reflected [in part]: Purpose: the purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan. Steps in the procedure 8. (Areas to note) Skin: a. intactness, b. moisture. C. color, d. texture and presence of bruises pressure sores, redness, edema, or rashes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676499 If continuation sheet Page 11 of 18 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 676499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springtown Park Rehabilitation and Care Center 201 Williams Ward Rd. Springtown, TX 76082 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 2 of 3 residents (Resident #'s 46 and #191) reviewed for respiratory care. Residents Affected - Some 1. The facility failed to ensure oxygen tubing for Residents #46 was dated and kept in a bag when not in use. 2. The facility failed to ensure Resident #191's nebulizer tubing was dated and kept in a bag while not in use. These failures could place residents at risk for infections and transmission of communicable diseases. The findings included: 1. Resident #46 Record review of Resident #46's MDS admission assessment, dated 04/05/2023, revealed Resident was admitted to the facility on [DATE]. Section C: Cognitive Patterns revealed a BIMS score of 6 (severe impairment). Section I: Active diagnosis revealed heart failure, peripheral vascular, and pneumonia. In an observation on 8/15/2023, at 11:30 AM Resident #46 was not in her room. Her O2 tubing was hanging over the concentrator with the nasal cannula touching the floor. It was dated 8/15/2023. There was no plastic bag for storage of the tubing when not in use. In an observation on 08/15/23 at 12:10 PM, Resident #46 was sitting in the dining room with her oxygen cannister was on the back of the back of the wheelchair and her oxygen was on via nasal cannula at 2 liters per minute. The tubing was not dated. The resident was not interviewable. In an observation on 08/16/2023 at 8:30 AM, the resident's oxygen tubing was hanging over the top of the portable cannister while not in use. The tubing was dated 08/15/2023. Record review of Resident #46's Order Summary Report, accessed on 08/18/2023 revealed an order for O2: Oxygen @ 2 liters via nasal cannula as needed for O2 saturation of less than 92 % room air (start date 11/20/2021). Record review of Resident #46's care plan revealed it did not include the use of oxygen. The care plan had a start date of 07/26/2023. 2. Resident #191 Record review of Resident #45's Order Summary Report, dated 08/22/2023 revealed an order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 vial inhale orally via nebulizer four times a day for SHORTNESS OF BREATH (R06.02). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676499 If continuation sheet Page 12 of 18 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 676499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springtown Park Rehabilitation and Care Center 201 Williams Ward Rd. Springtown, TX 76082 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #191's MDS admission assessment, dated 08/09/2023, revealed Resident was admitted to the facility on [DATE]. Section C: Cognitive Patterns revealed a BIMS score of 3 (severe impairment). Section I: Active diagnosis revealed heart failure and shortness of breath. In an observation on 08/15/23 at 2:57 PM during initial rounds, Resident #191 was lying in bed with a nebulizer machine on his bedside table. His mask was lying uncovered on the bedside table and the tubing was not dated. The resident was not interviewable. In an Interview with the DON on 08/18/23 at 2:55 PM the DON stated she expected 02 tubing to be changed weekly and dated and stored in a zip lock baggie when not in use. She stated nebulizer mask and tubing should be stored in a baggie when not in use. She said failure to store oxygen tubing and nebulizer equipment properly could result in infection. A policy on respiratory care was requested from the DON, but was not provided by the time of exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676499 If continuation sheet Page 13 of 18 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 676499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springtown Park Rehabilitation and Care Center 201 Williams Ward Rd. Springtown, TX 76082 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs) to meet the needs for 2 of 6 residents (Residents #62 and #63) reviewed for pharmaceutical services, in that: 1. Medication Aide A left Resident #62's medication with her in a cup to take later. 2. Medication Aide B failed to reorder medication for Resident #63 before her supply was depleted. These failures could place residents who receive medications at risk for a decline in health and of not receiving the intended therapeutic benefit of the medications. The findings included: 1. Resident #62 Record review of the MDS dated [DATE] revealed Resident #62 was a [AGE] year-old female originally admitted to the facility on [DATE]. Her diagnoses included: dementia, malnutrition, and neurogenic bladder (lack of bladder control due to brain, spinal cord, or nerve problem). Her BIMS score was 8 (moderate cognitive impairment). In an observation and interview on 08/15/2023 at 10:30AM, Resident #62 was sitting up in her bed alone in her room. A plastic cup with a pink liquid was sitting in front of her and a cup of nutritional supplement was also on the bedside table. There was a white powdery like residue along the sides of the cup just above the pink liquid. Resident #62 stated the medicine nurse leaves my medicine for me to take later, because I do not like to take it before lunch. She stated the medicine nurse left it for her to take every morning because she does not like to take it before lunch. She stated she did not know what the medicine was. Record review of the medication administration record on 08/15/2023 at 10:35 AM revealed Resident #62's azo-cranberry 250-60 mg was initialed by medication Aide A as taken, her D3 k2 complex was initialed as taken, and her Ensure was also initialed as taken while they remained sitting on her bedside table. Record review of Resident #62's physician's orders dated 10/05/2023 documented an order for Neo40 Give 1 tablet in the morning for supplement one time a day for supplement dissolve in 8oz water with d3k2 complex, ensure 1 can by mouth three times a day for inadequate nutrition, and azo cranberry urinary tract capsule 250-60 mg give 2 capsules by mouth one time a day. In an interview on 08/15/2023 at 10:45 AM with Medication Aide A, (who was assigned the med pass for Resident #62) stated she did not know why she had left the medication with the resident to take. She stated residents should be observed to ensure the medication was taken by the correct resident at the correct time. She stated the medication should not be documented as taken unless the nurse actually watched them take the medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676499 If continuation sheet Page 14 of 18 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 676499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springtown Park Rehabilitation and Care Center 201 Williams Ward Rd. Springtown, TX 76082 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 0755 Level of Harm - Minimal harm or potential for actual harm In an interview on 08/15/2022 at 1:05 PM, the DON stated the person administering the medication should always verify medication with resident, date, time, and route with medication being given. When giving medication to a resident the nurse providing medications should always witness medication has been taken by the resident for whom it was ordered. She stated failure to do so could result in the resident not receiving the intended dose and effect and result in a decline in health. Residents Affected - Some 2. Resident # 63 Record review of the MDS dated [DATE] revealed Resident # 63 was a [AGE] year-old female originally admitted to the facility on [DATE]. Her diagnoses included: glaucoma, dementia, Alzheimer's Disease, and hypertension. Her BIMS score was 11 (moderate cognitive impairment). In an observation and interview on 08/15/23 at 11:11 AM, Resident #63 stated she had been out of her glaucoma medicine for 3 days. She stated she takes the medication at night (1 drop in each eye). She stated it was not the first time she has run out of medicine. She stated she was not sure what the medicine was called but she needs it for her glaucoma. Record review of Resident #63's Medication orders dated 8/15/23 revealed the resident had Lantoprost Solution 0.005% 1 drop in each eye at bedtime ordered for glaucoma. Record review of the medication administration record dated 8/2023 revealed the resident had not received her eye drops on 8/11/23 and 8/14/23. In an interview with the DON on 08/15/23 at 11:30 AM, she reported she expects medication to be ordered and residents should not run out of their medications . She stated failure to receive medication as ordered could be detrimental to a resident's health. She confirmed the medication could not be found and it had been ordered today. She stated the family and the physician had been notified of the missed doses. In an interview with Medication Aide B on 8/15/23 at 3:00 PM she stated on 8/14/23 Resident #63 was out of her medication. She stated she ordered the medication, disposed of the empty bottle, and reported the missed dose to the charge nurse. She stated she came back on Monday and still could not find the medication and she ordered it again. Review of the facility policy statement on medication administration, dated 2007 PharMerica, Inc. (Revised October 2010) stated [in part]: Follow documentation guidelines. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication. The physician and the family should be notified if a medication is not administered. The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the MAR, and action is taken as appropriate. Review of the facility policy titled Ordering and Receiving Non-Controlled Medications dated 1/20 stated in part: Timely delivery of new orders is required so that medication is not delayed. If available, the emergency kit is used when the resident needs a non-controlled medication prior to pharmacy delivery. Licensed nurse or appropriate personnel receives medication delivered from the pharmacy and should check the medications and document delivery on the pharmacy manifest. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676499 If continuation sheet Page 15 of 18 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 676499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springtown Park Rehabilitation and Care Center 201 Williams Ward Rd. Springtown, TX 76082 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 1 resident (Resident #146) whose record was reviewed for accurate and complete documentation, in that: 1. Resident #146 was admitted to the facility on [DATE]. A copy of an existing Out of Hospital - Do Not Resuscitate Order form was provided to the to the facility and had been scanned into her electronic health record. A DNR order was entered into the Physician Order Summary on [DATE]. 2. The OOH-DNR Order form was signed by the resident's family member on [DATE], with her signature witnessed and notarized. The OOH-DNR Order form was not accurately completed and had not been signed by a physician. This failure could place residents at risk for discrepancies in the provision of necessary medical care and services and desired end-of-life decisions not being honored. The findings included: Review of Resident #146's admission Record, dated [DATE], revealed an [AGE] year-old female who was admitted to the facility from an acute care hospital on [DATE]. The resident had a principal admitting diagnosis of unspecified dementia, moderate, with psychotic disturbance. Additional diagnoses included nontraumatic intracerebral hemorrhage, unspecified (bleeding in the brain); acute respiratory failure with hypoxia (low blood oxygen level); unspecified acute lower respiratory infection (pneumonia); depression; anxiety disorder; insomnia; essential (primary) hypertension (high blood pressure); hyperlipidemia (high cholesterol); and cerebral infarction due to unspecified occlusion or stenosis of left cerebellar artery (stroke). Review of Resident #146's electronic health record revealed copies of advance directives had been scanned into the record, including: - Medical Power of Attorney, signed by Resident #146 on [DATE] with her family member designated as her agent; - Durable Power of Attorney, signed by Resident #146 on [DATE] with her family member designated as her agent; - Directive to Physicians, signed by Resident #146 on [DATE]; - Out of Hospital - Do Not Resuscitate Order form, signed by Resident #146's family member on [DATE]. Review of the OOH-DNR Order form for Resident #146 revealed her family member, the designated agent for medical power of attorney, had signed the form on [DATE]. The family member's signature had been witnessed and notarized. The family member selected the incorrect option as the qualified relative for Resident #146. The form had not been completed or signed by a physician and did not document any physician information. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676499 If continuation sheet Page 16 of 18 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 676499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springtown Park Rehabilitation and Care Center 201 Williams Ward Rd. Springtown, TX 76082 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 0842 Review of Resident #146's Physician Order Summary revealed an order for DNR dated [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of the Social Service Note dated [DATE] revealed a care plan meeting was held on that date for Resident #146 with her family in attendance. The Social Worker documented the resident was new to the facility and had been living at an assisted living facility. The family reported they would like Resident #146 to return there someday, if possible. The Social Worker documented the resident enjoyed doing activities and was currently on a pureed diet. The Social Worker documented the family had no further concerns at this time. Residents Affected - Few [There was no documented evidence that Resident #146's code status had been included in the discussion with the family.] During an interview and record review on [DATE] at 5:30 PM, the facility Social Worker stated she was not aware of a facility policy for advance directives or DNRs. She stated she talked with the residents and responsible parties about code status at the time of admission. The Social Worker stated when there were existing advance directives, copies were obtained and given to the Medical Records Coordinator to scan into the resident's EHR. The Social Worker reviewed Resident #146's OOH-DNR Order form in the EHR. She stated it was the first time she had looked at it, and the copy may have been given to the admissions Coordinator. She reviewed the form and stated that it had not been signed by the doctor. The Social Worker stated she would call Resident #146's family and explain the need to sign a new OOH-DNR Order form. In an interview on [DATE] at 5:39 PM, the Medical Records Coordinator stated she had scanned Resident #146's OOH-DNR Order form into the EHR. She stated she had not noticed that it had not been signed by the physician. In an interview on [DATE] at 7:23 PM, the DON stated the OOH-DNR form had been removed from Resident #146's EHR and the DNR order had been removed from her physician orders. She stated the resident's family was notified that the OOH-DNR was not signed by the physician, and it was not an order yet. The DON stated she was not sure where the OOH-DNR form had originated. She stated it was completed prior to Resident #146's admission to the facility and a copy had been provided to the facility following the resident's admission. Review of the facility's resident admission packet revealed General Policies and Procedures, not dated, which included Advance Directives. The policy documented: Advance Directives: To the extent allowed by law, it is our policy to follow the directions of our residents who have the capacity to make decisions. If the resident is unable to make decisions, but has signed a valid advance directive, we will follow the directive to the extent allowed under [state name] law. If you need information about Advance Directives, No CPR, or Living Wills, please contact our Social Service Director. Review of the facility's policy and procedure for Charting and Documentation, dated as revised [DATE], revealed the following [in part]: Policy Statement (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676499 If continuation sheet Page 17 of 18 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 676499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springtown Park Rehabilitation and Care Center 201 Williams Ward Rd. Springtown, TX 76082 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 0842 Level of Harm - Minimal harm or potential for actual harm All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition shall be documented in the resident's medical record . Policy Interpretation and Implementation Residents Affected - Few 1. Documentation in the medical record may be electronic, manual or a combination . 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676499 If continuation sheet Page 18 of 18

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Citations

8 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0641GeneralS&S Epotential for harm

    F641 - Accuracy of Assessments

    Ensure each resident receives an accurate assessment.

  • 0677GeneralS&S Epotential for harm

    F677 - A resident who is unable to carry out activities of daily living receives

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • 0679GeneralS&S Dpotential for harm

    F679 - Activities

    Provide activities to meet all resident's needs.

  • 0684GeneralS&S Epotential for harm

    F684 - Quality of care

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0695GeneralS&S Epotential for harm

    F695 - Respiratory care, including tracheostomy care and tracheal suctioning

    Provide safe and appropriate respiratory care for a resident when needed.

  • 0755GeneralS&S Epotential for harm

    F755 - Pharmacy Services

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  • 0842GeneralS&S Dpotential for harm

    F842 - Resident-identifiable information

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  • 0577GeneralS&S Cno actual harm

    F577 - The resident has the right to-

    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

FAQ · About this visit

Common questions about this visit

What happened during the August 18, 2023 survey of SPRINGTOWN PARK REHABILITATION AND CARE CENTER?

This was a inspection survey of SPRINGTOWN PARK REHABILITATION AND CARE CENTER on August 18, 2023. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at SPRINGTOWN PARK REHABILITATION AND CARE CENTER on August 18, 2023?

Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure each resident receives an accurate assessment."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

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Next steps

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.