Inspection Reports for
Springs Village Care Center Skilled Nursing & Rehab
110 W Van Buren St, Colorado Springs, CO 80907, CO
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
73% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Routine
Deficiencies: 9
Date: May 15, 2025
Visit Reason
Routine inspection of Springs Village Care Center to assess compliance with healthcare regulations including resident rights, medication administration, infection control, safety, and care planning.
Findings
The facility was found deficient in multiple areas including failure to inform residents of their health status, improper medication self-administration assessments, unresolved resident grievances, inadequate documentation and monitoring of psychotropic medication use, failure to provide necessary assistance with activities of daily living, unsafe environmental conditions, improper medication storage, and lapses in infection control practices.
Deficiencies (9)
F 0552: The facility failed to inform Resident #77 and/or her legal representative of her laboratory bloodwork values before and after hospital transfer, violating the resident's right to be informed and participate in treatment decisions.
F 0554: The facility failed to ensure Resident #46 was assessed for self-administration of Visine eye drops and lacked a physician's order for self-administration before allowing it.
F 0565: The facility failed to take prompt action to resolve resident grievances about missing clothing raised by the resident council over several months.
F 0605: The facility failed to document resident-specific care approaches and physician rationale for continued use of psychotropic medications for Residents #44, #45, and #41, and failed to monitor behaviors effectively.
F 0676: The facility failed to provide necessary assistance with meals for Resident #45 who had tremors, resulting in difficulty eating and risk of nutritional decline.
F 0689: The facility failed to repair a loose grab bar and install an additional grab bar in Resident #84's bathroom as recommended by occupational therapy, and failed to secure Dakin's solution in Resident #6's room.
F 0742: The facility failed to monitor Resident #74, with a history of suicide attempts, for worsening signs and symptoms of depression and suicidal ideation, and did not incorporate resident-specific triggers or interests into care plans.
F 0761: The facility failed to ensure controlled medications were stored in a locked container permanently affixed inside the medication storage refrigerator, and the refrigerator was found unlocked.
F 0880: The facility failed to ensure staff wore appropriate personal protective equipment (PPE) when providing care to residents on enhanced barrier precautions (Residents #62, #27, and #30), and failed to ensure Resident #46 followed infection control procedures when emptying her own indwelling catheter.
Report Facts
Sample residents reviewed: 32
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 2
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #4 | Registered Nurse | Responsible for medication storage and interviewed regarding unlocked medication refrigerator and narcotic box |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including medication storage, infection control, and psychotropic medication monitoring |
| OT | Occupational Therapist | Recommended grab bar repair and installation for Resident #84 |
| CNA #1 | Certified Nurse Aide | Interviewed regarding PPE use and resident behavior monitoring |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding Resident #44 and #45 behaviors and care |
| SSD | Social Services Director | Interviewed regarding psychotropic medication monitoring and resident #74 |
Inspection Report
Routine
Deficiencies: 5
Date: Feb 10, 2025
Visit Reason
Routine inspection to assess compliance with care standards including activities of daily living assistance, pain management, pressure ulcer care, and infection control.
Findings
The facility failed to provide timely incontinence care, manage pain according to physician orders and non-pharmacological interventions, provide appropriate pressure ulcer care including wound treatment and offloading, and maintain proper infection control practices during wound care.
Deficiencies (5)
F 0677: The facility failed to ensure Resident #5 received timely incontinence care, resulting in prolonged soiling and inadequate hygiene.
F 0684: The facility failed to manage pain for Resident #4 by administering pain medication outside physician ordered parameters and not providing non-pharmacological interventions.
F 0686: The facility failed to provide appropriate pressure ulcer care for Resident #2, including lack of physician orders, improper wound cleansing, failure to use knee protectors, and improper dressing techniques.
F 0697: The facility failed to manage pain for Resident #13 by not completing thorough pain assessments and not offering non-pharmaceutical interventions before administering pain medication.
F 0880: The facility failed to maintain infection control during wound care by not performing hand hygiene appropriately, not using barrier pads, reusing gauze on wounds, and contaminating supplies.
Report Facts
Residents reviewed: 16
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Staff educated: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in wound care infection control deficiencies and observations of improper wound care technique |
| LPN #1 | Licensed Practical Nurse | Named in pain management deficiency for Resident #13 |
| LPN #2 | Licensed Practical Nurse | Named in incontinence care deficiency for Resident #5 |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for care and deficiencies |
| Wound Care Physician | Wound Care Physician | Interviewed regarding wound care and infection prevention |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 8, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to report and investigate an allegation of sexual abuse made by Resident #1 against a staff member.
Complaint Details
The complaint investigation found that the facility did not report or investigate an allegation of sexual abuse made by Resident #1 against a certified nurse aide. The allegation was made on 12/16/23, but the facility lacked documentation of reporting to the State Agency or conducting an investigation. The former nursing home administrator was responsible but left the facility without completing the investigation.
Findings
The facility failed to report the alleged sexual abuse to the State Survey and Certification Agency and did not conduct an investigation into the allegation. Staff interviews confirmed the lack of reporting and investigation, and documentation was missing.
Deficiencies (2)
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities for one resident.
F 0610: The facility failed to investigate an allegation of abuse involving one resident, specifically failing to conduct an investigation when the resident reported sexual abuse by a staff member.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding the abuse allegation and investigation; stated she notified the nursing home administrator and suspended the accused staff member but did not participate in the investigation. |
| Nursing Home Administrator | Nursing Home Administrator | Former NHA responsible for conducting abuse investigations and reporting; left the facility and took facility information without completing the investigation. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 6, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide timely discharge notice and failure to readmit a resident after hospitalization.
Complaint Details
The complaint investigation found that Resident #1 was discharged without written notice to her or her representative and was not readmitted after hospitalization despite improvement. The facility staff and hospital case manager interviews confirmed these failures.
Findings
The facility failed to provide Resident #1 and her responsible parties with appropriate written notice of discharge including appeal rights. The facility also failed to readmit Resident #1 after hospitalization despite improvement in her condition and court-ordered medication.
Deficiencies (2)
F 0623: The facility failed to provide timely written notification to Resident #1 and her responsible parties before discharge, including appeal rights and contact information for the state office.
F 0626: The facility failed to readmit Resident #1 following hospitalization despite her improved condition and court-ordered medications.
Report Facts
Residents reviewed for discharge: 4
Residents reviewed for transfers: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding discharge and readmission of Resident #1. |
| Social Services Director | Social Services Director | Interviewed regarding Resident #1's discharge and behaviors. |
| Regional Resource Nurse | Regional Resource Nurse | Interviewed regarding discharge notice and decision-making for Resident #1. |
| Hospital Case Manager | Hospital Case Manager | Interviewed regarding Resident #1's hospitalization and readmission refusal. |
Inspection Report
Routine
Deficiencies: 15
Date: Sep 14, 2023
Visit Reason
Routine inspection of Springs Village Care Center to assess compliance with regulatory requirements including resident rights, grievance resolution, care and services, medication administration, infection control, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to ensure timely response to call lights, inadequate grievance resolution, failure to provide timely incontinence care and bathing, insufficient activities programming, failure to provide hearing aids and audiology services, inadequate pressure ulcer care, insufficient supervision to prevent falls, medication administration errors, improper medication storage, failure to accommodate food allergies, inadequate hydration assistance, improper food storage and handling, poor hand hygiene practices, and ineffective pain management.
Deficiencies (15)
F0550: The facility failed to ensure timely response to call lights for two residents dependent on staff, resulting in feelings of loneliness and humiliation.
F0585: The facility failed to provide prompt efforts to resolve grievances for three residents, including failure to address roommate concerns and filed grievance forms.
F0677: The facility failed to ensure timely incontinence care for two residents and bathing according to preference for one resident, resulting in residents sitting in soiled briefs and missing showers.
F0679: The facility failed to provide activities to meet all needs for one resident, who was often left in bed with closed blinds and not invited to activities.
F0685: The facility failed to assist a resident in gaining access to hearing aids and audiology services, resulting in a resident with moderate hearing difficulty not receiving replacement hearing aids.
F0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers for two residents, including failure to apply ordered treatments and reposition residents timely.
F0689: The facility failed to provide adequate supervision to prevent accidents for a resident with a history of falls, including leaving the resident unattended in the bathroom resulting in multiple falls and a fracture.
F0693: The facility failed to ensure a resident with a feeding tube received tube feeding as ordered, including incorrect formula volume and failure to notify dietitian of abnormal labs.
F0697: The facility failed to provide safe, appropriate pain management for a resident with severe pain, including failure to provide medication for pain levels above 6 and lack of nonpharmacological interventions.
F0759: The facility failed to ensure medication error rates were below 5%, with a 51.52% error rate observed during medication administration.
F0761: The facility failed to ensure controlled medications were stored in a locked, permanently affixed compartment and medication carts were locked when unattended.
F0806: The facility failed to provide food that accommodated resident allergies and preferences, serving gluten-containing gravy to a resident with gluten intolerance.
F0807: The facility failed to provide drinks consistent with resident needs and preferences and sufficient to maintain hydration, failing to offer and assist a resident with fluids throughout the day.
F0812: The facility failed to store, prepare, distribute and serve food in a sanitary manner, including failure to label and date foods, improper use of handwashing sinks, failure to monitor cooling of cooked foods, and poor hand hygiene.
F0880: The facility failed to maintain an infection prevention and control program, specifically failing to ensure proper hand hygiene during peri-care and wound care.
Report Facts
Medication administration error rate: 51.52
Weight gain: 3
Feeding tube formula volume missing: 118.5
Feeding tube water flush volume missing: 110
Medication late administration: 90
Medication late administration: 286
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Late medication administration and incorrect tube feeding volume |
| CNA #5 | Certified Nurse Aide | Left resident unattended in bathroom leading to fall risk |
| CDM | Certified Dietary Manager | Food labeling and allergy education |
| DON | Director of Nursing | Oversight of medication administration and infection control |
| RRN | Regional Resource Nurse | Oversight of clinical care and medication administration |
| LPN #4 | Licensed Practical Nurse | Medication cart locking and controlled medication storage |
| CNA #3 | Certified Nurse Aide | Failure to change gloves during peri-care |
| LPN #3 | Licensed Practical Nurse | Failure to change gloves during wound care |
| UM | Unit Manager | Pain management follow-up and medication oversight |
| RD | Registered Dietitian | Nutrition and allergy management |
| DA #2 | Dietary Aide | Improper hand hygiene in kitchen |
| DA #1 | Dietary Aide | Food preparation and allergy awareness |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 8, 2023
Visit Reason
The inspection was conducted based on complaints regarding offensive urine odor on the second floor and delayed response to call lights, as well as concerns about treatment and care for specific residents.
Complaint Details
The investigation was complaint-driven, focusing on resident grievances about offensive odors, delayed call light responses, and failure to provide ordered treatments and assessments. The complaints were substantiated based on resident interviews, observations, record reviews, and staff interviews.
Findings
The facility failed to provide a homelike environment due to a persistent offensive urine odor on the second floor and failed to respond timely to call lights, causing resident dissatisfaction. Additionally, the facility failed to provide timely physician-ordered treatment and notify the physician when ordered assessments could not be completed due to equipment malfunction.
Deficiencies (3)
F 0584: The facility failed to ensure the second floor did not have an offensive urine odor, which was reported by residents and observed during the survey.
F 0585: The facility failed to ensure call lights were answered timely, with documented delays up to several hours, causing resident distress and dissatisfaction.
F 0684: The facility failed to provide timely physician-ordered medication for a vaginal yeast infection and failed to notify the physician when a bladder scan assessment was not completed due to equipment malfunction.
Report Facts
Call light response delays: 158
Medication delay days: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #2 | Certified Nurse Aide | Interviewed regarding increased incontinence episodes and call light response delays |
| Certified Nurse Aide #3 | Certified Nurse Aide | Interviewed regarding insufficient night staffing and call light response delays |
| Director of Nursing | Director of Nursing | Interviewed regarding awareness of urine odor, call light response expectations, and medication/assessment issues |
| Housekeeper #1 | Housekeeper | Interviewed regarding urine odor observations and mattress replacement needs |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding awareness of urine odor and facility policies |
Inspection Report
Deficiencies: 0
Date: Feb 13, 2020
Visit Reason
The document is a statement of deficiencies and plan of correction for Springs Village Care Center following a survey completed on February 13, 2020.
Findings
No health deficiencies were found during the survey.
Report
May 15, 2025
Report
February 10, 2025
Report
April 8, 2024
Report
February 6, 2024
Report
September 14, 2023
Report
March 8, 2023
Report
February 13, 2020
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