Pennsylvania Department of Health
SPRINGFIELD REHABILITATION AND HEALTHCARE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

SPRINGFIELD REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:

There are 141 surveys for this facility. Please select a date to view the survey results.

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SPRINGFIELD REHABILITATION AND HEALTHCARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on an Abbreviated Survey in response to two complaints completed January 28,2026 , it was determined that Springfield Rehabilitation and Healthcare Center was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.

Plan of Correction:

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Based on the review of clinical record, facility investigation, review of policies and procedures, and interviews with staff, it was determined that the facility failed to ensure resident environment was free of accident hazard related to unlocked elevator providing access to a door that resident was able to leave the facility. (Resident R1). This deficiency was identified as past non-compliance.

Findings Include:
Review of facility policy "Safety and Supervision of Residents", dated July 2017, revealed "Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and facility- wide commitment to safety at all levels of the organization."
Review of facility policy "Wandering and Elopements", dated March 2019, revealed "The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.
Review of information dated January 21, 2026, submitted by the facility on January 22, 2026 revealed Resident R1 "left the Center and was seen by staff getting on a Septa bus near the entrance to the Center. He was approached by staff and assisted back to the Center without an issue."
Review of Resident R1's clinical record revealed admission date of January 18, 2026, with a diagnosis of dementia and difficulty walking.
Review of Resident R1's progress notes, dated January 18, 2026, revealed "Resident awake alert and oriented x 1-2 with forgetfulness, able to recall long-term events, doesn't remember what was said 30 mins to 1 hour ago."
Review of Resident R1's Elopement/ Wandering Risk Evaluation, dated January 18, 2026, revealed that resident was at moderate risk for elopement.
Interview with Employee E1, Nursing Home Administrator, and tour of the facility on January 28, 2026 at 10:05 a.m. revealed that Resident R1 was on a locked unit, however with new construction of dialysis suite, the elevator was accessible to residents. Resident R1 entered the elevator and took the elevator to the unoccupied dialysis suite hallways. Resident R1 pushed on emergency exit door until it opened and exited the building. Resident R1 was observed walking towards bus station and the staff member was able to redirect the resident and returned to the facility.
On January 20, 2026 following the incident, the facility immediately implemented the following corrective actions:
On 1/20/2026, Resident R1 was returned to the center by staff. An interim pain and skin assessment was completed with no abnormalities noted. A detailed statement was obtained from [Resident R1]. The physician and responsible party were notified.On 1/20/2026, The Assistant Director of Nursing on January 20th completed a headcount of all residents and compared it to the midnight census to ensure all residents were accounted for and resting comfortably.On 1/20/2026, a lookback of all residents that have three identifiers (independently ambulatory, dementia diagnosis and cognitive impairment) triggered were reviewed and assessed for further safety measures.On 1/20/2026, nursing administration reviewed all resident EHR for accurate elopement/wandering evaluations, orders for every shift placement checks, daily function tests and care plans. Elopement book found at reception desk was reviewed to ensure that all residents identified as elopement risks were current and resident identifiers were available.On 1/20/2026, review of Center elopement drills for completeness and staff participation. Plant Operations provided elopement drills held monthly for the last quarter.Initiated on 1/20/2026 and 100% on 1/21/2026, RN supervisors were educated on completion of headcount of all residents compared to midnight census and the immediate reporting of any discrepancy to the Director of Nursing/ designee.Initiated on 1/20/2026 and 100% on 1/21/2026, Staff educated on signs and symptoms that may indicate a risk for elopement.Initiated on 1/20/2026 and 100% on 1/21/2026, Staff educated on leave of absence process which includes the nurse signing the resident out at the nursing station and calling reception/ security to notify of approval to leave center and/or premises.Initiated on 1/20/2026 and 100% on 1/21/2026, Reception/security educated on leave of absence process which includes the nurse signing the resident out at the nursing station and calling reception/security to notify of approval to leave center and/ or premises.Initiated on 1/20/2026 and 100% on 1/21/2026, staff educated on abuse/ elopement/ missing person policy and procedure including code yellow announcement to notify staff in Center, search both on the premise and the surrounding areas, notification processes including Springfield Police Department.Initiated on 1/20/2026 and 100% on 1/21/2026, staff educated on elopement drills including how often and expected responses.On 1/20/2026, Door audit completed by Vice President of PA Operations. Any variances were addressed.Initiated on 1/20/2026 and 100% on 1/21/2026, professional staff were educated on the need to further assess patients/residents with three identifiers (independently ambulatory, dementia diagnosis and cognitive impairment.Completed on 1/20/2026, elevator usage will be restricted to an operator with a key.On 1/20/2026, Nursing Home Administrator and Director of Nursing, educated on job description and responsibility to ensure resident safety.Ongoing compliance will be monitored by:Auditing census compared to headcount every 4 hours for 7 days then every shift for 14 days then daily for 30 days.Interviewing one staff nurse and one reception/security staff to ensure that there is knowledge and understanding of the LOA process daily for 14 days.Daily assurance that the elevator is in the locked position until the facility is able to get the elevator locked in place with code.All ongoing compliance audits/ interviews will be reviewed at the QAPI Meetings monthly for further recommendations and further actions required.This deficiency was identified as past non-compliance.

28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(b)(1)(e)(1) Management.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Plan of Correction - To be completed: 02/10/2026

Past noncompliance: no plan of correction required.

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