Inspection Reports for
Springfield Villa

The complaint investigation focused on Resident #2's change in condition that was not promptly assessed by nursing staff, leading to hospitalization, and Resident #1's bruising of unknown origin that was not properly assessed or documented by staff.

The facility failed to provide appropriate treatment and care according to orders and standards of practice for Resident #2 by not promptly assessing a change in condition, resulting in immediate jeopardy to resident health or safety. Additionally, the facility failed to ensure an environment free from accident hazards by not identifying, assessing, investigating, and documenting bruising of unknown origin for Resident #1.

Complaint investigation related to complaints #2572449 and #2586807. The deficiencies cited involved minimal harm or potential for actual harm affecting a few residents.

The report identified deficiencies related to failure to promptly notify relevant parties of resident situations, with a level of harm assessed as minimal harm or potential for actual harm affecting a few residents. Another deficiency involved failure to provide appropriate treatment and care according to orders and resident preferences, though detailed deficiency text was not available.

Complaint #2572449 and #2586807 were investigated. The complaint involved failure to notify residents, doctors, and family members about situations affecting residents, and inadequate pressure ulcer care and documentation.

The facility failed to properly document and assess potential pressure ulcers, failed to update care plans and physician orders timely, and did not complete weekly skin assessments as required. There were identified open pressure ulcers with inadequate documentation and delayed treatment adjustments.

Complaint numbers #2572449 and #2586807 triggered the investigation. The complaints involved failure to notify family of changes in condition, medication misappropriation, and failure to document monitoring of a resident's health changes.

The facility failed to ensure timely notification of resident representatives about changes in condition for Resident #1, failed to protect residents from medication misappropriation involving gabapentin for three residents, and failed to document ongoing monitoring and assessment for Resident #1 during a change in condition. The facility census was 122. Several interviews and record reviews confirmed these deficiencies.

The complaint investigation found substantiated issues related to failure to meet resident shower preferences and inadequate fall prevention and documentation practices.

The facility failed to consistently provide showers according to resident preferences and failed to document refusals or offerings properly. Additionally, the facility did not update care plans with fall incidents or new interventions to prevent future falls, despite multiple falls with injuries among residents. Staff were unaware of the 'falling leaf' program used to identify high fall risk residents.

The facility was found deficient in multiple areas including failure to honor resident food choices, inadequate maintenance of the environment, improper life support documentation, unsafe wandering risk management, insufficient dietary staffing causing late meals, poor food quality and preparation, unsafe food handling practices including use of non-pasteurized eggs, and failure to maintain a sanitary environment with proper door weather stripping.

The report identifies a deficiency related to accident hazards and supervision in the nursing home, with a level of harm classified as actual harm affecting a few residents. Detailed deficiency text is not available.

The complaint investigation was triggered by an incident where Resident #2 pushed Resident #1 on the memory care unit, causing Resident #1 to fall and sustain a hip fracture. Video footage confirmed the incident occurred without staff supervision. Interviews revealed inadequate staffing overnight and lack of timely assistance. Resident #1 was admitted to the hospital for hip fracture surgery. The facility investigation confirmed the event and staffing issues.

The facility failed to ensure adequate supervision on the memory care unit, leading to Resident #2 pushing Resident #1, causing a fall and hip fracture. Staffing was inadequate overnight with only one nurse and one aide on the memory unit. Resident #1 had multiple falls and behavioral issues, and Resident #2 exhibited aggressive behaviors. The facility also failed to follow proper hand hygiene protocols during incontinent care for two residents, increasing infection risk.

The complaint involved an allegation of sexual abuse by Resident #1 against Resident #2 on 4/30/2023. A prior investigation by DHSS from 1/27/2023 to 2/3/2023 found no deficiency. The current investigation found the care plan was not updated to reflect these behaviors.

The facility failed to revise Resident #1's comprehensive care plan to include prior sexual behaviors and allegations, despite multiple staff interviews confirming that such behaviors should be documented in the care plan. The care plan did not reflect the sexual abuse allegation from 1/27/2023 or prior incidents.

The facility failed to timely transmit MDS data for four residents, did not provide adequate incontinent care for three residents, lacked proper supervision and assessment for residents who smoke, and failed to ensure proper serving sizes for pureed food. The facility census was 58 residents.

The investigation was complaint-driven, focusing on allegations of poor resident care, medication errors, infection control breaches, and food safety violations.

The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, failure to provide resident choices regarding bathing and menu planning, inadequate activities programming for a cognitively impaired resident, medication management errors including narcotic security and missing medications, improper storage and handling of medications, food safety violations including storage of dented cans and poor sanitation, and failure to follow infection control procedures during resident care.