Springfield Health & Rehab

F 0552

Ensure that residents are fully informed and understand their health status, care and treatments.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review the facility failed to inform in advance of the risks and benefits of the proposed care, the treatment alternatives or other options for 1 of 5 sampled residents (Resident #1). This is a repeat deficiency for this facility, with the violation cited during a recertification survey dated 3/27/25.

Findings include:Per record review Resident #1 was admitted with physician's orders for an antidepressant, Protriptyline (Vivactil) 10 mg twice daily, and an antipsychotic medication, Aripiprazole (Abilify) 15 mg daily.

A consent form for antipsychotic medications was completed on and signed by the Resident's Guardian on 8/15/2025 listing the Aripiprazole as a prescribed medication. Further record review revealed a Consent for Antidepressant Medication form which was blank, it did not list the Protriptyline, and it was not signed by

the Guardian. There was no documented evidence that the facility obtained informed consent for the Protriptyline. A physician's order dated 9/13/2025 for Quetiapine (Seroquel, an antipsychotic) 600 mg daily was initiated. A Psychotropic Medication Administration Disclosure form that includes the Abilify, Seroquel, and Protriptyline was completed by the Unit Manager on and states that the guardian gave verbal consent for the psychotropic medications on 9/16/2025 however, this was one month after the Protriptyline was initiated and three days after the Seroquel was initiated. Review of Resident #1's care plan revealed a focus initiated on 8/16/2025 of [Resident] is at risk for complications related to the use of psychotropic drugs with

an intervention of Provide informed consent to resident or healthcare decision maker Date Initiated: 08/16/2025.Per interview with the facility Administrator on 11/6/2025 at 3:30 PM the consent for antipsychotic form in the Resident's chart dated 8/15/2025 did not reflect the Protriptyline. The Administrator also confirmed that the Psychotropic Medication Administration Disclosure form had not been completed until 9/16/2025, after the initiation of the Protriptyline and Seroquel.

Residents Affected - Few

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

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Springfield Health & Rehab

105 Chester Road Springfield, VT 05156

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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review the facility failed to notify the resident representative of a change in condition related to laboratory results and treatment options for one of three residents in the sample (Resident #1).

This is a repeat deficiency for this facility, with the violation cited during a partial survey dated 3/3/25.

Findings include:Based on record review Resident #1 had a court appointed guardian with the guardian's spouse listed as emergency contact #2 on their information sheet. A progress note dated 10/8/2025 states

The nurse received a fax from the [NAME] lab of a urine culture. The nurse sent the culture results to the [Nurse Practitioner]. The Resident was evaluated by OT [occupational therapy] and determined the resident is not safe to take anything orally other than a [tablespoon] of water every so often for comfort. Based on OTs evaluation the nurse attempted to call the [guardian] to talk about the results of the culture and talk about options regarding [antibiotic] treatment. The nurse left a voicemail for the [guardian] to call the nurse back. Another progress note dated 10/8/1025 states The nurse tried calling the [guardian's] phone but was not home just [spouse]. [Spouse] had questions regarding the resident being sent out to a different [facility] or hospital. The nurse did not talk with the [spouse] about the urine as [they] are not the resident's legal guardian. Per phone interview with Resident #1's guardian and their spouse on 11/4/2025 at 2:00 PM communication with the facility was not good and they did not return her/his calls even after s/he was told that someone will call back. The facility did not consistently share information regarding the Resident's condition. S/he stated that one nurse had hung up on her/him when s/he had called to ask questions about

the Resident's condition. Review of the facility policy titled Notification of change in condition or status states 1. The nurse will notify the resident's attending Physician or physician on call when there has been a (an) . d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; Per interview on 11/4/2015 at 3:15 PM the facility Administrator confirmed that Resident #1's guardian's spouse was emergency contact #2 and should have been updated regarding the positive results and treatment. The Administrator also confirmed that the nursing progress note reflected that the Nurse had not notified the Guardian's spouse of the results of the Resident's urine as she should have.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Springfield Health & Rehab

105 Chester Road Springfield, VT 05156

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 0600 Level of Harm - Immediate jeopardy to resident health or safety

that the resident was knowingly taken back to the facility with an IV antibiotic the facility could not provide, but the nurse was given notification of the need for IV Zosyn after the resident was already transported back to the facility. However, once the Resident returned to the facility the Nurse obtained orders from the NP for the IV Zosyn. Ref. F-F635, F-F656, F-F689, F-F760

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Springfield Health & Rehab

105 Chester Road Springfield, VT 05156

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 0635 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

behaviors the Resident had been experiencing such as refusals of medications and hallucinations, they questioned whether or not s/he had been getting the right medications. It was at this time that the facility realized that the hospital discharge orders had not been appropriately reconciled and only every other page had been available at the time.Per interview with the Regional Assistant Director of Nursing ([NAME]) on 11/6/2025 at approximately 4:30 PM it is the expectation that nursing staff reconcile medications using the discharge medication list. Staff are not expected to review the entire discharge summary or other information that comes from the hospital. The [NAME] confirmed that the missed medications on Resident #1's hospital discharge summary should have been ordered on admission and were not. Per interview with

the facility Administrator on 11/12/2025 at 11:30 AM she confirmed that once the facility identified there were missing pages to the discharge paperwork from the hospital, they did not review the rest of the summary to ensure that there were not additional orders that had been missed. Therefore, the sliding scale with insulin, the antibiotics, and the lidocaine patches were not identified until the surveyor identified the errors. Per interview with Resident #1's Primary Physician on 11/14/25 at 2:30 PM she had been made aware that the facility staff and herself had only reviewed every other page of the hospital discharge summary on the Resident's admission and that an order for Seroquel had been omitted as a result.

However, she had not been aware that the other medications had been missed in the admission process.

The Physician stated that it is not best practice to be checking blood sugars four times daily on an elderly person, but that had not been addressed because it had been missed. The Physician confirmed that the expectation is that the Unit Manager and/or admissions person review the discharge summary in its entirety. Per interview with the facility Medical Director on 11/18/2025 at 10:10 AM confirmed that when a Resident is admitted from the hospital, it is important and their expectation that nursing staff review the discharge packet that comes with the resident. The Medical Director stated you need to know as much as possible about your patient. We should have a good idea of the patient, and the medication lists don't tell you the whole picture. You can build off the medication list but you should not rely solely on it.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Springfield Health & Rehab

105 Chester Road Springfield, VT 05156

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 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

returned. On 10/3/2025 Resident #1 returned to the hospital and was diagnosed with a worsening hematoma including an Uncal hernia according to the National Library of Medicine Uncal herniation occurs when rising intracranial pressure causes portions of the brain to flow from one intracranial compartment to another; this is a life-threatening neurological emergency . Upon return to the facility the care plan was not updated to reflect the Resident's care needs related to the diagnosis of the worsening subdural hemorrhage and uncal herniation. The Resident was transferred back to the facility on [DATE REDACTED] on comfort measures and on 10/16/2025 was transferred to a skilled nursing facility closer to the family and died.

Resident #1 was transferred to another facility on 10/9/2025 where s/he would be closer to family and died

on [DATE REDACTED]. Per review of Resident #1's death certificate s/he died on [DATE REDACTED]. The manner of death was listed as Accident. The date and time of the accident states September 11, 2025 / ~8:00 PM. How injury occurred is listed as Fall(s) from Standing Height and the cause of death was documented as Complications of Acute on Chronic Subdural Hemorrhage (Days to Weeks) due to B. Blunt Force Trauma of Head (Weeks) September 11, 2025 / ~8:00 PM.Per interview with Resident #1's Primary Physician on 11/14/25 at 2:30 PM she had been made aware that the Resident's Seroquel had not been ordered on admission when it was identified, but she was not aware that the other medications had been missed in the admission process. The Physician stated that it is not best practice to be checking blood sugars four times daily on an elderly person, however she did not address that because she had missed it. The Physician confirmed that the discharge summary that was used to admit Resident #1 only included every other page of information, and that the expectation is that the Unit Manager and/or admissions person review all of the discharge summary. Ref. F-F635

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Springfield Health & Rehab

105 Chester Road Springfield, VT 05156

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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

date and time of the accident states September 11, 2025 / ~8:00 PM. How injury occurred is listed as Fall(s) from Standing Height and the cause of death was documented as Complications of Acute on Chronic Subdural Hemorrhage (Days to Weeks) due to B. Blunt Force Trauma of Head (Weeks) September 11, 2025 / ~8:00 PM.During an interview on 11/4/2025 at 3:19 PM when the facility Administrator confirmed that family was notified on 9/12/2025 of the increased behaviors the Resident had been experiencing such as refusals of medications and hallucinations, they questioned whether or not s/he had been getting the right medications. It was at this time that the facility realized that the hospital discharge orders had not been appropriately reconciled and only every other page had been available at the time. The Administrator confirmed that the missed Seroquel was a medication error however, the facility did not implement an incident report per policy. Per interview with the facility Administrator on 11/12/2025 at 11:30 AM she confirmed that once the facility identified there were missing pages to the discharge paperwork from the hospital, they did not review it to ensure there were not additional orders that had been missed. Therefore,

the sliding scale with insulin, the antibiotics, and the lidocaine patches were not identified until the surveyor identified the errors. Ref. F-F635

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Springfield Health & Rehab

105 Chester Road Springfield, VT 05156

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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Based on interview and record review the facility failed to ensure that one of five nurses, an agency nurse in

the applicable sample had received training and competencies needed to provide care for the residents who reside in the facility. This is a repeat deficiency for this facility, with the violation cited during a recertification survey dated 3/27/25. Findings include: Per review of 5 nurse's education and training files to determine if they had the training and skill set to perform an admission the facility was unable to locate the employee training and competency files of an agency staff nurse. Per interview with the facility Administrator on 11/4/2025 at approximately 4:00 PM the agency nurse no longer works there, and they had a recent change in the education department. The Administrator confirmed that they were not able to find the agency nurses file that consists of training and competencies required to provide care to the residents who live there.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Springfield Health & Rehab

105 Chester Road Springfield, VT 05156

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 0760 Level of Harm - Actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

at the time. The Administrator confirmed that the missed Seroquel was a medication error however, the facility did not implement an incident report per policy. Per interview with the facility Administrator on 11/12/2025 at 11:30 AM, she confirmed that once the facility identified there were missing pages to the discharge paperwork from the hospital, they did not review it to ensure there were not additional orders that had been missed. Therefore, the sliding scale with insulin, the antibiotics, and the lidocaine patches were not identified until the surveyor identified the errors. Per interview with Resident #1's Primary Physician on 11/14/25 at 2:30 PM, she had been made aware that the Resident's Seroquel had not been ordered on admission when it was identified, but she was not aware that the other medications had been missed in the admission process. The Physician stated that it is not best practice to be checking blood sugars four times daily on an elderly person, however she did not address that because she had missed it. The Physician confirmed that the expectation is that the Unit Manager and/or admissions person review all of the discharge summary to ensure that all orders are noted.

Event ID:

Facility ID:

If continuation sheet