Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0582
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure each resident was informed before, or at the time of
admission, and periodically during the residents stay, of services available in the facility and of changes for
those services, which included changes for services not covered under Medicare/Medicaid or by the
facility's per diem rate for 2 of 3 residents (Resident #60, and #98) reviewed for Medicare/Medicaid
coverage.
Residents Affected - Few
The facility failed to ensure Residents #60 and #98 were given a completed SNF ABN (a notice given to
Medicare beneficiaries to transfer financial liability to the beneficiary before the SNF provides an item or
service that would usually be paid for by Medicare, but Medicare was not likely to provide coverage
because care was not medically reasonable and necessary, or was custodial in nature) when discharged
from skilled services at the facility prior to covered days being exhausted.
This failure could place residents at risk for not being aware of changes to provided services.
Findings included:
1. Record review of Resident #60's electronic face sheet dated 09/26/24 revealed resident was a [AGE]
year-old female who was admitted on [DATE] with diagnoses that include: muscle wasting and atrophy,
muscle weakness, acute respiratory failure with hypoxia (lung disease resulting in lack of oxygen),
abnormalities of gait.
Record review of the SNF Beneficiary Protection Notification Review indicated Resident #60 received
Medicare Part A Skilled Services on 6/22/24 and her last covered day of Part A services was 8/16/24. The
SNF Beneficiary Protection Notification Review indicated the facility/provider did not document on CMS
10123-NOMNC form which covered Medicare Part A service was ending.
2. Record review of Resident #98's electronic face sheet dated 09/26/24 revealed the resident was a [AGE]
year-old female who was originally admitted on [DATE] with diagnoses that include: muscle weakness,
cerebral infarction (reduced blood flow to brain), chronic respiratory failure with hypoxia (decreased
oxygen), unspecified asthma.
Record review of the SNF Beneficiary Protection Notification Review indicated Resident #98 received
Medicare Part A Skilled Services on 06/20/24 and her last covered day of Part A services was 08/23/24.
The SNF Beneficiary Protection Notification Review indicated the facility/provider initiated did not document
on CMS 10123-NOMNC form which covered Medicare Part A service was ending.
(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 10
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
09/26/2024
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 0582
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 09/26/24 at 02:49 PM the MDS nurse stated the NOMNC form wasn't completely
filled out for Residents #60 and #98. The MDS nurse further stated, That's why you complete an ADN. The
MDS nurse explained the NOMNC form was used when Medicaid part A services are discontinued or end.
She further explained that the ADN form was used for a payor change. She continued to deny the form
wasn't completed correctly and stated that I will get with my corporate on that.
Residents Affected - Few
During an interview on 9/26/24 at 3:15 PM the MDS nurse stated that she spoke with her corporate nurse
and the NOMNC form should be completed in its entirety and stated that she did not have the two reviewed
filled out completely. She stated the error happened due to receiving a new form 8/3/24 and she was not
aware it needed to be completed. She further stated that incomplete forms could lead to a resident not
being aware of actual services that were ending. The MDS Nurse stated that she was responsible for
NOMNC forms.
Review of Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 revealed the
form must include [in part]:
THE EFFECTIVE DATE YOUR {INSERT TYPE} SERVICES WILL END: {Insert Effective Date}: Fill the type
of services ending, {home health, skilled nursing, comprehensive outpatient rehabilitation services, or
hospice} and the actual date the service will end.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676499
If continuation sheet
Page 2 of 10
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
09/26/2024
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 0694
Provide for the safe, appropriate administration of IV fluids 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
observations, interviews and record reviews, the facility failed to ensure they followed professional
standards of practice in accordance with physician orders and facility policy for care of midline for 3
(Residents #13, #349, #354) of 4 residents reviewed for parenteral and intravenous care.
Residents Affected - Some
The facility failed to assess the midline intravenous catheter (an intravenous catheter that is suitable for
long term infusion therapy) dressing on Resident #13. Dressing was observed as soiled and dislodged
before flush being performed.
The facility failed to change the midline intravenous catheter (an intravenous catheter that is suitable for
long term infusion therapy) dressing on Resident #349 for more than 7 days.
The facility failed to change the midline intravenous catheter (an intravenous catheter that is suitable for
long term infusion therapy) dressing on Resident #354 for more than 7 days.
These failures placed the residents at risk of complications with their midlines needed for infusion therapy.
Findings included:
Resident #13
Review of Resident #13's face sheet dated 09/24/2024 revealed she was a [AGE] year-old female
admitted to the facility on [DATE] with diagnoses of Sepsis , (infection of the blood) Pneumonia, and Urinary
Tract Infection.
Review of Resident #13's MDS dated [DATE] revealed the resident had BIMS (Brief Interview Mental
Status) of 2 which suggest severe cognitive impairment .
Review of Resident #13's physician's orders dated 09/24/2024 revealed an order 09/04/2024 intravenously
for antibiotics of Ertapenem Sodium Solution 1 Gram intravenously one time a day for urinary tract infection
for 10 days from 09/18/2024 thru 09/28/2024.
Record review of Resident # 13's progress note dated 09/24/2024 revealed the midline was removed and
replaced 09/24/24 due to occlusion.
Observation and interview on 09/24/2024 at 4:24 pm, Resident # 13's midline dressing site was wet and not
sealed. The DON said it needed to be changed due to being saturated and not secured.
Observation and interview 09/24/2024 at 4:30 pm with LVN A revealed Resident #13's midline site to right
arm was flushed by LVN A before checking infusion site. Site was dripping around soiled dressing covering
midline insertion site. Post flush of midline dressing caused Resident #13's face to grimace. LVN A stated
post flush, midline was occluded and would need to be changed. She said she did not look at site until flush
was injected.
Resident #349
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676499
If continuation sheet
Page 3 of 10
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
09/26/2024
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 0694
Level of Harm - Minimal harm
or potential for actual harm
Record review of Resident # 349's face sheet dated 09/24/2024 revealed she was a [AGE] year-old-female
admitted to services on 09/17/2024 with diagnosis of Metabolic Encephalopathy (which happens due to
organ dysfunction) and Extended Spectrum Beta Lactamase (ESBL) Resistance which is a type of enzyme
that is produced by certain bacteria, making resistance to certain antibiotics which cause urinary tract
infection difficult to treat (give medical care or attention to).
Residents Affected - Some
Record review of Resident # 349's Care Plan dated 9/17/2024 revealed the resident's cognition was alert,
cognitively intact. Resident was admitted to service for IV medications.
Record review of #349's Order summary report dated 09/24/2024 revealed order for midline dressing
change once a week and as needed if dressing becomes soiled.
Record review Resident # 349's Medication Administration Record under Schedule for Sep 2024 revealed,
Changed Midline Dressing once a week and PRN if becomes soiled.
Observation and interview on 09/23/2024 at 12:10 PM revealed Resident # 349 had a single lumen midline
to left arm with a dressing dated 9/13/2024. Dressing edges were not intact, and tape was discolored.
Resident #349 stated the same dressing had been on since insertion.
Resident #354
Review of Resident # 354's face sheet dated 9/24/2024 revealed she was an [AGE] year-old female
admitted to facility on 09/16/2024 for metabolic encephalopathy (a change in how a brain works due to an
underlying condition) and sepsis with bone infection to right ankle, foot which is resistance to multiple
antimicrobial drugs.
Review of Resident # 354's physician's orders dated 9/24/2024 revealed an order in part: May change
Midline dressing every seven days or as indicated for soiled or damaged dressing. Change stabilization
device and injection caps with each dressing change. As needed for soiled or damaged dressing.
Observation on 09/23/2024 at 11:59 AM revealed Resident #354's midline to left arm with dressing
covering site dated 09/11/2024.
Interview 09/24/24 @ 3:30 PM with LVN A. She said, usually the nurse on 6am-2pm shift changed the
midline dressing, but the 6am-2pm shift nurse has been off a few days. LVN A said she did change dressing
for Resident #354 that morning (9/24/24) and the previous dressing was dated 9/13/24. She stated that
upon admission they add 7 days from date of admission not date of dressing for dressing to be changed.
She further stated she had IV training at hospital.
Interview on 09/24/24 at 3:33PM with the DON, she said a midline dressing should be changed every 7
days or PRN as needed. The DON said Charge nurses were responsible for changing the dressings and
the residents should have had orders that would show up on the MAR when the dressings needed to be
changed. Possible failures to change the dressings on the midlines could cause infections at the infusion
sites.
Review of the facility's current Midline Dressing Changes policy and procedure Level III, dated April 2016:
In-part: General Guidelines
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676499
If continuation sheet
Page 4 of 10
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
09/26/2024
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 0694
1.
Level of Harm - Minimal harm
or potential for actual harm
Change midline dressing 24 hours after insertion, every 5-7 days, or if it is wet, dirty, not intact, or
compromised in any way.
Residents Affected - Some
Documentation
1.
The following information should be recorded in the resident's medical record: (in-part)
a.
Date and time dressing was changed.
b.
Location and objective description of insertion site.
c.
Any complications, interventions that were done.
Reporting
2.
Intervene as necessary.
Review on 09/26/2024 of the Guidelines for the Prevention of Intravascular Catheter-Related Infections at:
https://www.cdc.gov/infectioncontrol/guidelines/bsi/recommendations revealed evidenced based
recommendations for the preparation, insertion, administration, maintenance, and discontinuance of the IV
as well as prevention of infection at the site to the extent possible.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676499
If continuation sheet
Page 5 of 10
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
09/26/2024
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 needed respiratory
care, was provided such care, consistent with professional standards of practice, the comprehensive
person-centered care plan, the residents' goals and preferences for 1 of 1 resident (Residents #12's)
reviewed for respiratory care.
Residents Affected - Few
1. The facility failed to ensure Residents #12's nasal cannula was 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. Record review of Resident #12's face sheet, dated 09/26/2024, reflected an [AGE] year-old female, who
was admitted to the facility on [DATE]. Resident #12 had diagnoses which included Congestive Heart
Failure (heart cannot pump blood efficiently enough to supply the body), Shortness of breath, Depression,
Anxiety, chronic obstructive pulmonary disease (a lung disease that blocks airflow and makes it difficult to
breathe).
Record review of Resident #12's annual MDS assessment, dated 01/02/2024, reflected a BIMS score of 00,
which indicated severe cognitive impairment. Section I: Active diagnosis reflected chronic pulmonary
disease, or chronic lung disease. Section O: Respiratory Treatments was marked for Oxygen Therapy.
Record review of Resident #12's quarterly Care Plan, 06/17/2024, reflected a care plan for has COPD
(obstructive pulmonary disease) - Oxygen at 3 liters per minute continuously to keep oxygen saturation
above 90%. The Care Plan did not have an intervention regarding when the oxygen tubing needed to be
changed.
Record review of Resident #12's Physician's Orders, dated 09/26/2024, reflected an order for Oxygen at 3
liters per minute via nasal cannula to maintain 02 saturation above 90%. Change oxygen and nebulizer
tubing weekly.
In an observation on 09/23/2024 at 10:30 AM revealed Resident #12 was sitting in the dayroom in her
wheelchair. Her nasal cannula was uncovered and hanging over the bed rail in her room with the nose
prongs on the floor.
In an observation and interview on 09/24/2024 at 10:45 AM, during morning rounds, revealed Resident #12
was sitting in her wheelchair in her room and her nasal cannula was uncovered and hanging over the
concentrator in her room with the nose prongs on the floor. Attempted to interview Resident #12 regarding
the oxygen tubing, however she very confused and unable to answer.
In an Interview on 09/26/2024 at 3:10 PM the DON stated oxygen tubing was changed weekly based on the
resident's orders, or as needed if the tubing become contaminated or occluded. The DON said oxygen
tubing and the humidifier bottle should be changed per doctor's orders and the nasal cannula should have
been stored in a plastic bag when not in use to prevent cross contamination and infection. He. The DON
said the charge nurses were responsible for seeing that it was done.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676499
If continuation sheet
Page 6 of 10
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
09/26/2024
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
In an Interview on 09/26/2024 at 4:00 PM the Administrator stated the resident care was handled by the
nursing department and nasal cannulas should be put in a plastic bag when not in use.
Policy requested from the DON on 09/26/2024 at 3:10 PM. Policy requested from the ADM on 09/26/2024
at 4:00 PM. No policies given.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676499
If continuation sheet
Page 7 of 10
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
09/26/2024
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals
used in the facility were secured and stored in accordance with current accepted professional principles for
1 Treatment Cart observed for medication storage.
The facility did not ensure the Treatment Cart was locked and secured.
This failure could place the residents at risk of gaining access to unlocked medications not prescribed to
them.
Findings included:
Observation on 9/24/24 at 1:19 PM revealed the treatment cart was parked in the 200 hallway with a
resident within 6 feet of the opened, unsecured cart. The cart lock was popped out, and all drawers were
able to be opened. No nurse was in sight of the cart. Present in cart were medicated dressings, prescription
ointments and creams, over the counter creams, antifungal creams, Iodine swab sticks, adhesive remover,
and wound cleanser.
In an interview on 09/24/2024 at 1:24 ADON B stated that her expectation was for carts to be locked if
nurse walks away from the cart. ADON B further stated that lack of ensuring cart security could lead to
adverse outcomes due to residents being able to get into the cart. ADON B also stated the person
responsible for cart security is the nurse assigned to cart with keys. ADON B stated that she is also
responsible and should be observing to ensure cart is secure.
In an interview on 9/24/2024 at 1:28 PM the Wound Care Nurse stated the treatment cart is to be always
locked when not in use or directly in her sight to prevent residents accessing cart items that could harm
them. The Wound Care Nurse further stated that it was her responsibility to ensure the treatment cart was
locked.
In an interview with the DON on 9/24/24 at PM revealed her expectation is for treatment cart to be locked if
not in use by the nurse. The DON also stated if the cart is not locked residents could get into the cart and
have access to contents of the cart. The DON further stated that nurse who receives the cart is responsible
for making sure it is secure. The DON continued stating that it is the DON's responsibility to observe cart
security.
In an interview on 9/24/24 ADM at 4:08 PM the ADM stated that medication carts security should follow
policy. The ADM that he could not speculate outcome regarding effect of unsecured cart.
Record review of policy Storage of Medication dated 2001 revealed the following [in-part]:
8. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes)
containing drugs and biologicals are locked when not in use.
9. Unlocked medication carts are not left unattended.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676499
If continuation sheet
Page 8 of 10
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
09/26/2024
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observations, interviews, and record reviews the facility failed to properly store, prepare,
distribute, and serve food in accordance with professional standards for food service safety for 1 of 1
kitchen reviewed.
The facility failed to ensure foods were labeled properly in the refrigerator and the freezer.
The facility failed to ensure food that had spoiled was discarded timely.
The facility failed to ensure that staff performed hand hygiene while preparing food.
These failures could place residents that eat out of the kitchen at risk for food borne illnesses.
The findings included:
During an observation on 09/23/24 between 9:40 AM and 10:15 AM, in the kitchen, revealed:
Refrigerator #1
1.
An open box, that contained 15 individually wrapped uncrustable peanut butter and jelly sandwiches, that
were unthawed. The box had a manufacturer label that reflected keep frozen and did not have a date when
opened and/or removed from the freezer.
2.
One green bell pepper with a black soft spot on the top on the green pepper.
Freezer #1
1.
A plastic bag that contained garlic bread, out of the original container, that was not labeled with contents of
package or with an open or use by date.
2.
A plastic bag that contained cookie dough, out of the original container, that was not labeled with contents
in package or with an open or use by date.
During an interview on 09/23/2024 at 10:15 AM the DM stated items that had been removed from the
original container should have been labeled with an item description and an open date. The DM stated if
the manufacturer directions said to keep frozen then the item should have been kept frozen. The DM stated
she was not sure how long the uncrustables had been out of the freezer.
During an observation on 09/23/2024 between 11:30 AM and 12:15 PM revealed the DA exited the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676499
If continuation sheet
Page 9 of 10
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
09/26/2024
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
kitchen and returned to the kitchen pushing a cart. The DA failed to wash her hands when entering the
kitchen. The DA emptied the container and refilled the container with ice. The DA failed to wash her hands
before and after switching between preparing food The DM failed to wash her hands numerous times after
touching her face, glasses and changing between tasks and assisting the cook.
During an interview on 09/26/24 at 4:03 PM the DM stated her expectation was that food items be
discarded per policy, and food times should have be labeled with an open date and/or use by date, item and
description. The DM stated the affect could have been residents received food that was spoiled or the
wrong food. The failure was staff got in a hurry and new staff. The DM stated her expectation was that staff
perform hand hygiene every time they changed tasks, touched their face or glasses. The DM stated she
was responsible for monitoring staff. The DM stated residents could have been affected by bacteria which
could have led to residents getting sick. The DM stated what led to failure was staff was nervous and new
staff.
During an interview on 09/26/2024 at 4:45 Pm the ADM stated he expected staff to follow the polices for
hand hygiene and labeling food. The ADM stated the DM was responsible to monitor the kitchen. The ADM
stated he would not speculate to what led to the failures in the kitchen.
Record review of the facility policy titled, Hand Washing dated 2021 revealed: Hands and exposed portions
of arms (or surrogate prosthetic devices) should be washed immediately before engaging in food
preparation. When to wash hands: a. When entering the kitchen at the start of a shift. b. After touching bare
human body parts other than clean hands and wrists. c. After using the restroom .f. After handling soiled
equipment or utensils. g. During food preparation, as often as necessary to remove soil or contamination
and to prevent cross contamination when changing tasks .j. After engaging in other activities that
contaminate the hands.
Record review of the facility policy titled, Food Receiving and Storage dated July 2014 revealed: All foods
stored in the refrigerator or freezer will be covered, labeled and dated (useby).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676499
If continuation sheet
Page 10 of 10
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Back to topCitations
5 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.
F582 - The facility must—
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
F694 - Parenteral Fluids
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the September 26, 2024 survey of SPRINGTOWN PARK REHABILITATION AND CARE CENTER?
This was a inspection survey of SPRINGTOWN PARK REHABILITATION AND CARE CENTER on September 26, 2024. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SPRINGTOWN PARK REHABILITATION AND CARE CENTER on September 26, 2024?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered."
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
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.