Inspection Reports for
Springville

The substantiated complaint involved a resident sustaining a fracture due to staff neglect and failure to seek timely medical attention. Additional issues included retention of a resident with a prohibited health condition and receipt of a resident with a pressure injury.

The report discusses substantiated findings of resident injury due to staff neglect, retention of a resident with a prohibited health condition, and receipt of a resident with a pressure injury. Multiple prior annual visits noted deficiencies under Title 22 regulations related to medical care and dementia care. The licensee has implemented corrective actions to address these issues.

The inspection found medication storage violations including unsecured medications accessible to residents and a prescribed medication without a proper prescription label. Other areas such as fire safety equipment, emergency drills, food storage, and resident records were found compliant.

The facility was found generally compliant with regulations, but deficiencies were noted including medication not stored securely, insufficient non-perishable food supply, and missing 'No smoking oxygen in use' signs in hospice residents' rooms. All deficiencies were corrected during the visit.

The complaint alleged illegal eviction of residents R1 and R2. The allegation was substantiated based on interviews and records. The facility lacked staffing and isolation rooms during a COVID outbreak, which led to refusal to admit residents returning from hospital.

The investigation substantiated the allegation that residents R1 and R2 were denied re-admission to the facility after hospital discharge due to lack of staffing and absence of isolation rooms during a COVID outbreak. The administrator admitted the facility could not accommodate the residents at that time and there was miscommunication with the hospital and residents' families.

The complaint investigation was substantiated. Allegations included improper COVID-19 protocols, noncompliance with local health guidelines, violations of residents' personal rights, and visitor restrictions. Interviews with staff and residents corroborated these allegations.

The investigation substantiated that the facility imposed stricter COVID-19 protocols than required, including mandatory 5-day isolation after leaving the community, restricting visitors to outdoor visits by appointment only, and requiring COVID tests for visitors. These policies violated residents' personal rights, including restricting private visits and physically restraining residents by tying stanchion cords across their room doors.

The complaint alleging a resident received a pressure injury while in care was substantiated.

The investigation found systemic failures at the facility in preventing pressure injuries. An immediate $500 civil penalty was issued, with an Enhanced Civil Penalty determination pending.

The complaint was substantiated based on evidence including interviews, medical records, and observations. The resident sustained an acute fracture due to staff neglect and delayed medical care. A civil penalty of $500.00 was issued immediately.

The investigation substantiated that Resident #1 sustained acute fractures to the left tibia and fibula after staff neglected to provide a two-person assist during transfer, resulting in a fall. Staff delayed seeking medical attention, with the fracture identified days later and the resident sent to the hospital.

The complaint investigation was substantiated for allegations that a resident sustained a fracture due to staff neglect and delayed medical attention. The allegation that staff left a resident in a soiled diaper was unsubstantiated. An immediate civil penalty of $500 was issued related to the fracture incident.

The investigation substantiated that a resident sustained fractures to the left tibia and fibula after staff failed to provide a two-person assist during transfer and delayed seeking medical care. Another allegation that staff left a resident in a soiled diaper was unsubstantiated based on interviews and documentation.

The complaint investigation was substantiated for allegations that the facility retained a resident with a prohibited health condition, the resident received pressure injuries while in care, and staff failed to notify the authorized representative of the resident's change in condition. One allegation regarding timely medical care was unsubstantiated.

The investigation substantiated that the facility retained a resident with stage 3 and 4 pressure injuries without submitting an exception request. The resident developed multiple pressure ulcers while in care, and the facility failed to update or implement a plan of care. Additionally, staff did not notify the resident's family of the change in condition. One allegation regarding timely medical care was unsubstantiated.

The inspection found deficiencies related to staff training, admission agreement formatting, emergency preparedness drills, and hot water temperature. The facility has hospice residents and maintains required documentation, but staff lack CPR, first aid, and emergency training. Hot water temperatures in two resident rooms were below regulatory standards.

The visit was triggered by a complaint investigation under control # 28-AS-20230503164443.

The inspection found multiple deficiencies including unsecured medications accessible to all residents, water temperatures below regulatory standards in two bathrooms, an unlocked storage area containing potentially dangerous tools, and confidential resident care logs taped outside resident doors.

The facility was found generally compliant with clean and safe conditions, but deficiencies were noted including a staff member without a criminal record clearance, unlocked cleaning supplies accessible to residents, and hot water temperature exceeding regulatory limits.

The facility was toured and found generally well-maintained with proper safety equipment and supplies. However, the Administrator did not have accurate, up-to-date centrally stored prescription medication records or Medication Administration Record Sheets (MARS) for residents.