Springbrook Center
SPRINGBROOK CENTER in WESTBROOK, ME — inspection on July 19, 2024.
Found 12 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
possessions.
dignity and respect for 1 of 19 residents reviewed. (Resident #419)
Finding
On 9/23/2024 at 10:15 a.m., upon entrance to Saccarappa house, a surveyor observed the shower room door wide open, exposing a naked resident, sitting on a shower chair actively showering him/herself. A Certified Nurses Aid and a Registered Nurse were observed on the other side of the unit.
Approx 1 min later, the Occupational Therapist (OT) came from the far end of the unit with a face cloth and a bottle.
The Surveyor asked why the door was left open, the OT stated, I didn't mean to and entered the shower room and closed the door. At 10:29 a.m., both the resident and the OT exited the shower room. At this time, the above was confirmed with the OT.
On 9/23/24 at approx. 10:45 a.m., the above was discussed with the Administrator
205068 07/19/2024
Springbrook Center 300 Spring St Westbrook, ME 04092
-Resident room [ROOM NUMBER] - the entrance door was missing a piece of laminate from the door
-The unit kitchenette counter was missing multiple areas of laminate on the counter.
205068 07/19/2024
Springbrook Center 300 Spring St Westbrook, ME 04092
sleeping in the Broda chair sitting at the dining room table with his/her right side against the wall. In
the CNA again approached the resident from the left side and removed the uneaten breakfast, served
CNA again, approached the resident from the left side and discarded the uneaten blueberry muffin, leaving the chocolate milk. At 11:52 a.m., lunch was delivered to Resident #53 from the left side, usign a regular plate.During this time of 3 hours and 42 mins, the CNA continued to approach the resident from the left side, did not attempt to wake up the residen up to assist with his/her meal or offer toileting.
On 7/17/24 at 8:11 a.m., during an interview with the Administrator, the above concerns were discussed.
205068 07/19/2024
Springbrook Center 300 Spring St Westbrook, ME 04092
During this time, the CNA did not attempt to wake up Resident #53 or assist with his/her meal.
On 7/17/24 at 8:11 a.m., during an interview with the Administrator, the above concerns were discussed.
205068 07/19/2024
Springbrook Center 300 Spring St Westbrook, ME 04092
The surveyor asked what type of treatment would be used.
The charge nurse stated I would use Z-guard and combine it with miconazole.
The surveyor asked if there was an order for this treatment.
The charge nurse stated he/she had left a message regarding the wound for the nurse on the facility's skin care team.
The charge nurse confirmed the provider had not been notified and no order had been obtained since the wound assessment was completed on 7/15/24.
On 7/17/24 at 9:45 a.m., the surveyor discussed the finding with the Market Clinical Advisor and the Administrator.
The Administrator confirmed the facility's process would be if a nurse found a new wound, the provider would be called, and an order obtained.
- Review of Resident #407's clinical record revealed Progress Note dated 7/29/23 stating At
approximately 0025 (12:25 a.m.) nursing staff including this nurse heard someone call out and a clash of noises coming from patient room.
This nurse and other staff quickly responded and found resident on the floor laying supine, Resident said [he/she] lost balance on [his/her] way out from the bathroom and fell onto [his/her] bottom .
Vital signs were WNL (within normal limits), neuros were baseline .
Will continue to monitor.
Review of Resident #407's entire clinical record lacked evidence of continued neurological monitoring or ''Neurological Evaluation Flow Sheet'' for fall occurring 7/29/23.
On 7/15/24 at 1:26 p.m. during an interview, the Administrator was unable to provide evidence of continued neurological monitoring following the resident's fall on 7/29/23.
Review of policy titled Falls Management last reviewed 3/15/24 states, .
Any patient who sustains an injury to the head from a fall and/or has a fall unwitnessed by staff will be observed for neurological abnormalities by performing neurological check per policy .
Review of policy titled Neurological Evaluation Flow Sheet states .
Evaluate every 15 minutes for first 2 hours after final evaluation .After first 2 hours completed above, evaluate every 30minutes for 2 hours, after first 4 hours completed above, evaluate every hour for 4 hours .
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Springbrook Center 300 Spring St Westbrook, ME 04092
or respirator.
This includes policies and procedures to provide specialized respiratory care for
licensed nurses are required to complete a combination of online trainings and attend an annual skills fair where annual competencies are tested.
On 7/17/24 at 3:00 p.m., in an interview with the surveyor, the Marketing Clinical Advisor, confirmed the last skills fair and competency testing for tracheostomy care and suctioning, that the charge nurse on the Wayside Unit completed was 9/29/22.
205068 07/19/2024
Springbrook Center 300 Spring St Westbrook, ME 04092
Based on observations, and interviews the facility failed to ensure that medications were stored
addition, the facility failed by leaving a resident's medications unattended at a bedside, allowing residents and unauthorized persons access to medications. (#33) (Saccarappa House Unit, Wayside Unit).
Findings
- On 7/15/24 at 9:42 a.m., two surveyors observed the unlocked and unattended medication cart in
the hallway on Saccarappa House Unit. At 9:46 a.m., the Certified Medication Technician returned to the unlocked medication cart and began to prepare a resident's medication.
On 7/17/24 at 11:27 a.m., the above finding was discussed with the Administrator and the Market Clinical Advisor.
- On 7/15/24 at 11:05 a.m., a surveyor observed Resident #33 asleep in bed. A cup of pills was
observed on the overbed table next to Resident #33. At 11:14 a.m., the Wayside Unit charge nurse confirmed he/she had left the pills next to Resident #33, who must have forgotten to take them.
On 7/15/24 at 1:15 p.m., the surveyor discussed the finding with the Market Clinical Advisor.
205068 07/19/2024
Springbrook Center 300 Spring St Westbrook, ME 04092
Resident #29's clinical record contained a physician's order dated 3/18/23 instructing staff to refer the resident to a dentist for gingivitis and a cleaning. Resident #29's clinical record lacked evidence of any follow up with the dental referral.
In an interview with the surveyor on 7/17/24 at 11:06 a.m. the Marketing Clinical Advisor confirmed that Resident #29's dental referral had not been scheduled.
205068 07/19/2024
Springbrook Center 300 Spring St Westbrook, ME 04092
Review of the certified nursing aid documentation for 7/15/24 lunch and 7/16/24 breakfast states the amount eaten my mouth was 50%.
The documentation for eating: self-performance for 7/15/24 lunch states resident was supervision with encouragement or cueing, and the lunch on 7/16/24 the documentation states resident was independent with no help or staff oversight at any time.
On 7/17/24 at 8:11 a.m., during an interview with the Administrator, the above concerns were discussed.
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Springbrook Center 300 Spring St Westbrook, ME 04092
During the follow up survey on 9/23/24, it was determined the F-F656 would be recited for the same issue: failure to implement a comprehensive person-centered care plan for each resident.
On 9/23/24 at 4:15 p.m., during and interview, the above was confirmed with the Administrator and Director of Nursing.
gloves and removed the soiled dressing, then cleansed the wound with the wet gauze.
She then
With the same gloved had she then applied the primary dressing of xeroform and then the secondary foam dressing. At this time, the surveyor discussed the lack of PPE and the lack of hand hygiene preformed between removing old dressing and cleansing/applying new dressing.
The LPN stated, she should have washed wash her hands and applied new gloves before cleansing and applying the new dressing.
On 9/23/24 at 9:42 a.m., during an interview with the Director of Nursing, the above was discussed.
On 9/23/24 at 11:27 a.m., during an interview, the Infection Preventionist confirmed the nurses are expected and educated on the use Enhanced Barrier Precautions and should wear a gown, glove and whole face covering and/or mask/goggles when preforming tracheostomy or wound care due to risk of splashes or sprays.
205068 07/19/2024
Springbrook Center 300 Spring St Westbrook, ME 04092
Review of Resident #48's medical record had Special Instructions: MDRO: MRSA [Methicillin-resistant Staphylococcus aureus], PSEUDOMONAS AERUGINOSA (Enhanced Barrier Precaution).
Outside the entrance to Resident #48's bedroom was a stop sign stating, Enhanced Barrier Precaution instructing nursing to wear gown and gloves prior to . wound care: any opening requiring a dressing and face protection may also be needed if preforming activity with risk of splash or spray. A cart with PPE was available outside of the room which contained gowns, masks and eye protection.
On 9/23/24 at 9:10 a.m., the surveyor observed Resident #48's tracheostomy care with the Licensed Practical Nurse (LPN).
The LPN entered the room, preformed hand hygiene and applied sterile gloves.
She completed the tracheostomy care which included suctioning the tracheostomy cannula, removing the soiled split sponge, cleaning around the stoma, removing the inner cannula and replacing with a new cannula and applying a new splint sponge around the stoma all without the use of the appropriate Personal Protective Equipment (PPE) of a gown and face/eye protection. At this time, surveyor asked the LPN if she is to wear a gown, face/eye protection while preforming tracheostomy care. LPN stated, she does not wear a gown and or face/eye protection, only gloves when she performs the trach care.
205068
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 205068 B.
Wing 07/19/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Springbrook Center 300 Spring St Westbrook, ME 04092
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.