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 failed to promote resident self-determination by not meeting shower/bathing preferences for residents and did not fully document fall events or implement adequate fall prevention interventions. Multiple residents experienced falls, some with injury, and care plans were not consistently updated to prevent future falls.

The facility was found to be in noncompliance with several Life Safety Code requirements including sprinkler system maintenance, smoke barrier construction, and emergency power system testing. Deficiencies had the potential to affect all 96 residents present during the survey.

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 substantiated that the facility failed to provide proper incontinent care and infection control, leading to potential infection risks for residents.

The facility failed to provide incontinent care for two residents in a manner that prevented possible infection, with staff failing to follow proper hand hygiene protocols. Multiple observations and interviews confirmed lapses in hand hygiene and care procedures.

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 meet professional standards of quality in timely identifying and assessing a significant bruise on a resident, resulting in delayed determination of cause and needed care changes. The report details extensive review of resident records, interviews, and observations documenting the bruise and related care issues.

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 facility was found deficient in electronically transmitting resident assessments within required timeframes, providing adequate incontinent care, ensuring a safe smoking environment, and serving food that meets nutritional and palatability standards. Multiple residents' records and observations showed failures in timely data transmission, incontinent care, smoking supervision, and food preparation.

The investigation was complaint-related focusing on infection prevention and control practices during the COVID-19 pandemic. The complaint was substantiated based on observations and record reviews.

The facility failed to use appropriate infection control procedures to prevent the spread of infectious diseases, including improper hand hygiene, failure to disinfect equipment, and improper use of personal protective equipment (PPE) during resident care. Observations and interviews confirmed multiple lapses in infection control practices among staff.

The facility failed to provide care in accordance with professional standards when a Licensed Practical Nurse (LPN) administered IV medication without required certification. The facility census was 91 at the time of inspection. The facility does not allow nurses who are not IV certified to perform IV administration.

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.

The facility was found to have multiple deficiencies related to resident rights, self-determination, activities, medication management, infection control, and food safety. The facility failed to provide adequate resident care, maintain proper medication and narcotic controls, and ensure infection prevention protocols were followed.

The facility failed to maintain the one-hour fire rating of ceilings due to unsealed penetrations, failed to keep sprinkler heads free from obstruction by insulation, and did not maintain smoke barrier doors properly, allowing them to remain partially open after fire alarm activation.

Complaint #M000147225 was investigated and substantiated. The complaint concerned insufficient nursing staff and inadequate care on the locked unit.

The facility failed to document administration of ordered treatments in a timely fashion for two residents and failed to provide sufficient nursing staff to meet residents' needs. Observations and interviews revealed understaffing and inadequate care on the locked unit.

The facility failed to develop and implement adequate abuse/neglect policies, specifically failing to check the Nurse Aide registry for new hires. The facility also failed to provide appropriate care and services for a resident with multiple stage three pressure ulcers.

The facility failed to meet several Life Safety Code requirements including installation of a complete fire alarm system, maintenance of the automatic fire sprinkler system, smoke barrier walls, conducting fire drills at varying times, and annual fuel quality testing of the emergency generator. Deficiencies had the potential to affect all residents, staff, and visitors.

The investigation was triggered by a complaint about inadequate wound care for Resident #1. The complaint was substantiated based on observations, record reviews, and staff interviews.

The facility failed to monitor, update care plans, and obtain and document treatment orders for a resident's left gluteal fold wound. Staff were unaware of the open wound and discontinued treatment without physician orders, resulting in inadequate wound care.