Deficiencies (last 7 years)
Deficiencies (over 7 years)
8.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
53% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
97% occupied
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 1
Date: Jun 2, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide safe and appropriate pain management for a resident who required such services after knee replacement surgery.
Complaint Details
The complaint investigation found that the facility did not document administration of pain medication to address the resident's pain. The resident experienced moderate to severe pain, and staff delays in obtaining physician orders and medication delivery contributed to inadequate pain management. The resident and family expressed dissatisfaction with pain control and medication availability.
Findings
The facility failed to ensure timely administration and documentation of appropriate pain medication for Resident #93, admitted after knee replacement surgery. Staff delays in obtaining physician orders and medication delivery resulted in the resident experiencing moderate to severe pain without adequate pain control. Non-pharmacological interventions and Tylenol were provided, but narcotic pain medications were delayed due to lack of signed physician orders and pharmacy delivery issues.
Deficiencies (1)
Failure to provide safe, appropriate pain management and timely administration of pain medication for a resident after knee replacement surgery.
Report Facts
Facility census: 37
Pain level: 5
Pain level: 6
Pain level: 7
Medication dosage: 2
Medication dosage: 500
Medication dosage: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN C | Registered Nurse | Conducted pain assessment, admitted resident, responsible for narcotic medication drawer |
| RN F | Registered Nurse | Documented resident upset about lack of pain medication, called pharmacy for STAT delivery |
| LPN N | Licensed Practical Nurse | Administered hydromorphone and documented pain levels |
| CMT A | Certified Medication Technician | Documented resident pain levels |
| CNA K | Certified Nurse Aide | Assisted resident, reported resident's pain complaints |
| LPN M | Licensed Practical Nurse | Charge nurse on 05/25/25, assessed resident pain, did not administer pain medication |
| LPN L | Licensed Practical Nurse | Discussed medication order delays and pain assessment |
| LPN G | Unit Manager | Explained admission medication procedures and pharmacy delivery times |
| ADON | Assistant Director of Nursing | Administered Tylenol to resident, communicated about pain management |
| Director of Nursing | Director of Nursing | Discussed documentation and medication administration procedures |
| Administrator | Administrator | Discussed expectations for timely pain medication administration and pharmacy delivery |
| Corporate Staff | Described process for receiving and activating physician orders for new admissions |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 1
Date: Mar 4, 2025
Visit Reason
The inspection was conducted due to concerns about the facility's failure to provide appropriate pressure ulcer care, including inadequate wound assessment, lack of physician orders for treatment, and failure to update care plans for wounds.
Complaint Details
The investigation was complaint-related, focusing on pressure ulcer care deficiencies. The complaint was substantiated with findings of inadequate wound assessment, treatment, and documentation.
Findings
The facility failed to document full wound assessments upon admission, obtain physician orders for wound treatment, and update care plans for skin breakdown interventions for one resident out of seven sampled. Staff did not consistently document wound treatments or progress notes, and the resident's wounds worsened during the stay. Interviews with staff confirmed lapses in wound care documentation and treatment initiation.
Deficiencies (1)
Failed to provide care per professional standards related to pressure ulcers, including failure to document full wound assessments upon admission, failure to obtain physician's orders for treatment and interventions, and failure to update care plans regarding skin breakdown intervention changes.
Report Facts
Residents Affected: 1
Facility Census: 37
Wound measurements: 1.8
Wound measurements: 1.5
Wound measurements: 2.6
Inspection Report
Plan of Correction
Census: 37
Deficiencies: 2
Date: Mar 4, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards related to pressure ulcer prevention and treatment at Sunterra Springs Springfield.
Findings
The facility failed to provide care consistent with professional standards to prevent and treat pressure ulcers. Deficiencies included failure to document wound assessments, obtain physician orders, update care plans, and complete ordered treatments for a resident with pressure ulcers.
Deficiencies (2)
F686: The facility failed to provide care per professional standards related to pressure ulcers, including incomplete wound assessments, lack of physician orders, and failure to update care plans and document treatments for a resident with pressure ulcers.
A4083: Facilities shall keep residents free from avoidable pressure sores and provide adequate treatment. This regulation was not met as evidenced by the findings in F686.
Report Facts
Facility census: 37
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 2
Date: Aug 5, 2024
Visit Reason
The inspection was conducted due to a complaint regarding failure to timely report an allegation of abuse involving a resident (Resident #3) and concerns about pressure ulcer care for two residents (Residents #1 and #2).
Complaint Details
The complaint involved an allegation by Resident #3 that two nurses humiliated and inappropriately touched him/her during a skin assessment. The facility delayed reporting the allegation to the state survey agency by seven days. Interviews with staff revealed confusion and failure to report within the required two-hour timeframe.
Findings
The facility failed to timely report an allegation of abuse to the state survey agency within the required two-hour timeframe. Additionally, the facility failed to provide appropriate pressure ulcer care, including incomplete wound assessments, failure to obtain and follow physician orders, and failure to update care plans for two residents with pressure ulcers.
Deficiencies (2)
Failed to timely report an allegation of abuse involving one resident to the state survey agency within the required two-hour timeframe.
Failed to provide appropriate pressure ulcer care including incomplete wound assessments, failure to obtain physician orders, failure to follow ordered treatments, and failure to update care plans for two residents.
Report Facts
Facility census: 36
Resident #3 admission date: Jul 23, 2024
Resident #3 MDS date: Jul 29, 2024
Resident #1 admission date: Jul 19, 2024
Resident #1 wound measurements: 4
Resident #1 wound measurements: 3.5
Resident #2 admission date: Jul 5, 2024
Resident #2 wound measurements: 1.5
Resident #2 wound measurements: 4.5
Resident #2 wound measurements: 7.2
Resident #2 wound measurements: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Admitted Resident #3 and involved in skin assessment during alleged abuse incident |
| CNA C | Certified Nurse Aide | Assisted LPN A during skin assessment of Resident #3 during alleged abuse incident |
| SSD | Social Services Director | Met with Resident #3 regarding abuse complaint and reported to DHSS |
| ADON | Assistant Director of Nursing | Interviewed regarding abuse allegation and investigation |
| DON | Director of Nursing | Interviewed regarding abuse allegation and wound care practices |
| LPN B | Licensed Practical Nurse | Provided care and observations related to Resident #1's wounds |
| LPN E | Licensed Practical Nurse (Wound Nurse) | Responsible for wound measurements and wound care documentation |
| RN D | Registered Nurse | Interviewed regarding skin assessments and wound care procedures |
| Administrator | Responsible for reporting abuse and overseeing facility compliance | |
| Medical Director | Provided expert opinion on skin breakdown prevention |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 3
Date: Aug 5, 2024
Visit Reason
The inspection was conducted in response to allegations of abuse involving a resident at Sunterra Springs Springfield. The investigation focused on the facility's reporting and handling of alleged abuse and neglect.
Complaint Details
The complaint investigation was substantiated. The facility failed to timely report an allegation of abuse involving Resident #3 and failed to provide adequate care for pressure ulcers for multiple residents.
Findings
The facility failed to report allegations of abuse involving a resident within the required two-hour timeframe. Additionally, deficiencies were found related to the treatment and prevention of pressure ulcers for multiple residents, including inadequate assessments, documentation, and care planning.
Deficiencies (3)
F609: The facility failed to report allegations of abuse involving Resident #3 to the state survey agency within the required two-hour timeframe as mandated by federal regulations.
F686: The facility failed to provide care per professional standards related to pressure ulcers for Residents #1 and #2, including incomplete wound assessments, failure to obtain physician orders, and inadequate care plan updates.
A4083: The facility did not keep residents free from avoidable pressure sores by failing to provide adequate treatment and prevention measures as required by regulation.
Report Facts
Facility census: 36
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) A | Admitted resident was assisted during assessment and discussed abuse reporting | |
| Certified Nurse Aide (CNA) C | Assisted with resident assessment and discussed abuse reporting | |
| Assistant Director of Nursing (ADON) | Discussed abuse reporting and investigation | |
| Director of Nursing (DON) | Involved in abuse investigation and wound care oversight | |
| Licensed Practical Nurse (LPN) B | Observed resident pain and assisted with wound care | |
| Licensed Practical Nurse (LPN) E | Wound nurse | Provided wound care and discussed wound management |
| Registered Nurse (RN) D | Discussed skin assessments for new admissions | |
| Medical Director | Discussed prevention of skin breakdown and wound care |
Inspection Report
Routine
Census: 37
Deficiencies: 8
Date: Nov 9, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including medication self-administration, resident assessments, code status documentation, medication error rates, food safety, infection control, and staff tuberculosis testing.
Findings
The facility was found deficient in multiple areas including failure to ensure proper approval and care planning for resident self-administration of medications, incomplete and untimely resident assessments, inconsistent documentation of resident code status, medication errors related to insulin administration and pen priming, improper food storage and dish drying practices, incomplete documentation of fentanyl patch administration, and failure to complete required tuberculosis testing for residents and staff.
Deficiencies (8)
Failed to ensure interdisciplinary team approval, physician orders, and care planning for resident self-administration of medication for two residents with medication at bedside.
Failed to complete a discharge Minimum Data Set (MDS) assessment in a timely manner for one resident.
Failed to ensure resident code status was accurate and consistent throughout the medical record for three residents.
Failed to ensure medication error rate was less than 5% due to incorrect insulin type and dosage administration and failure to prime insulin pens for two residents.
Failed to ensure residents were free from significant medication errors related to insulin administration and pen priming for two residents.
Failed to store food in sealed containers, stack dishes only when dry, and maintain dishwasher rinse temperatures at recommended levels, risking contamination.
Failed to document administration and placement of fentanyl patch in the Medication Administration Record (MAR) for one resident.
Failed to maintain an effective infection prevention program by not ensuring two residents and three staff members received required tuberculosis testing per standards and guidance.
Report Facts
Facility census: 37
Medication error rate: 7.4
Fentanyl patch dosage: 50
Dishwasher rinse temperature: 167
Tuberculosis skin test induration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN L | Licensed Practical Nurse | Failed to complete second step of tuberculosis testing |
| CMA M | Certified Medication Assistant | Failed to complete tuberculosis testing |
| CNA N | Certified Nurse Aide | Tuberculosis test read after maximum allowed time, requiring retesting |
| CMT A | Certified Medication Technician | Described medication administration and documentation practices |
| RN B | Registered Nurse | Described medication administration and documentation practices |
| RN C | Registered Nurse | Described medication administration and insulin pen use practices |
| LPN I | Licensed Practical Nurse | Described insulin pen administration practices |
| Dietary Aide G | Described food storage and dish drying practices | |
| Dietary Manager | Described food storage and dish drying practices | |
| Administrator | Provided statements on medication administration, food safety, and infection control | |
| DON | Director of Nursing | Oversaw medication administration, infection control, and tuberculosis testing |
| ADON | Assistant Director of Nursing | Oversaw tuberculosis testing and infection control |
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 8
Date: Nov 9, 2023
Visit Reason
The inspection was the annual survey of Sunterra Springs Springfield nursing facility to assess compliance with federal and state regulations.
Findings
The facility was found deficient in multiple areas including resident self-administration of medications, accuracy of assessments, cardiopulmonary resuscitation procedures, medication error rates, food safety, infection prevention and control, resident records confidentiality, and tuberculosis testing. The facility census was 37 at the time of inspection.
Deficiencies (8)
F554 Resident self-administration of medications was not properly approved by the interdisciplinary team for two residents, and medication was found at bedside without proper orders.
F641 The facility failed to complete a discharge Minimum Data Set (MDS) assessment for one resident in a timely manner.
F678 The facility failed to ensure residents' code status was accurate and matched throughout medical records for three residents.
F759 The medication error rate exceeded 5%, with errors in insulin administration for multiple residents.
F760 The facility failed to ensure residents were free of significant medication errors related to insulin administration for two residents.
F812 The facility failed to procure, store, prepare, and serve food in a sanitary manner, with multiple food safety violations observed in the kitchen.
F842 The facility failed to maintain resident medical records in accordance with accepted professional standards, including confidentiality and documentation.
F880 The facility failed to establish and maintain an effective infection prevention and control program, including incomplete tuberculosis testing for staff and residents.
Report Facts
Facility census: 37
Medication error rate: 7.4
Medication opportunities observed: 27
Residents reviewed for code status: 3
Residents reviewed for infection control: 13
Residents reviewed for TB testing: 13
Staff tested for tuberculosis: 3
Inspection Report
Life Safety
Census: 37
Capacity: 38
Deficiencies: 4
Date: Nov 9, 2023
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with fire safety and emergency preparedness regulations at Sunterra Springs Springfield.
Findings
The facility was found deficient in several areas related to egress door locking arrangements, hazardous area enclosures, fire alarm system testing and maintenance, and electrical system generator testing and maintenance. The facility failed to ensure timely release of delayed-egress doors, proper storage of hazardous materials, documentation of fire alarm sensitivity testing, and generator testing policies.
Deficiencies (4)
K222 Egress Doors: The facility failed to ensure two egress doors with 15-second delayed-egress locking released immediately upon fire alarm activation. This posed a risk to timely evacuation.
K321 Hazardous Areas - Enclosure: The facility failed to protect hazardous storage areas with required fire-rated barriers and self-closing doors, allowing combustible materials to be stored improperly.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to document required two-year smoke alarm sensitivity testing, risking delayed fire alarm identification.
K918 Electrical Systems - Essential Electric System: The facility failed to document monthly generator testing and load calculations, risking power failure during emergencies.
Report Facts
Facility capacity: 38
Census: 37
Deficiencies cited: 4
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 3
Date: Sep 12, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding misappropriation of resident property involving a staff member taking medications belonging to a resident.
Complaint Details
The complaint investigation substantiated that a Registered Nurse took medications belonging to a resident and attempted to conceal the act by disposing of pills and returning some medication. The facility conducted an investigation including video footage review and police involvement. The resident missed some medication doses due to the staff's actions.
Findings
The facility failed to keep all residents free from misappropriation of property when a Registered Nurse took medications belonging to a resident. The facility also failed to provide care in accordance with professional standards when staff did not follow physician orders and did not administer medication as ordered for four days.
Deficiencies (3)
F602 Free from Misappropriation/Exploitation: The facility failed to keep all residents free from misappropriation of property when a staff member took medications belonging to a resident.
F658 Services Provided Meet Professional Standards: The facility failed to provide care in accordance with professional standards when staff did not follow physician orders and did not administer medication as ordered for four days for one resident.
A4055 Safe/Effective Medication System: The facility failed to maintain a safe and effective system of medication distribution, administration, control, and use as evidenced by deficiencies F602 and F658.
Report Facts
Resident census: 35
Number of pills taken: 164
Plan of Correction completion date: All corrective actions completion date 2023-10-11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in medication misappropriation finding |
| DON | Director of Nursing | Involved in investigation and notification of lost medication |
| HR Manager | Human Resources Manager | Assisted in investigation and video review |
| LPN D | Licensed Practical Nurse | Reported missing medication to DON |
| CMT B | Certified Medication Technician | Notified about missing medication and reported to DON |
| RN E | Registered Nurse | Documented medication administration error |
| RN C | Registered Nurse | Interviewed regarding medication handling |
| RN G | Registered Nurse | Interviewed regarding suspected misappropriation |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 2
Date: Sep 12, 2023
Visit Reason
The inspection was conducted due to an allegation of misappropriation of property by a staff member who took medications belonging to a resident. The investigation focused on the missing medication and failure to administer medication as ordered.
Complaint Details
The complaint was substantiated. The allegation of misappropriation was made to DHSS on 2023-08-23. Video footage showed the nurse taking pills from a resident's medication bottle and disposing of the bottle. The nurse returned the medication after being confronted and was arrested. The resident missed several doses of medication due to this incident.
Findings
The facility failed to keep residents free from misappropriation of property when a registered nurse took a resident's medication and failed to administer medication as ordered for four days. The medication was recovered but could not be administered. The nurse was arrested for stealing medication. The facility also failed to ensure medication was administered as ordered, resulting in missed doses for the resident.
Deficiencies (2)
Failed to protect residents from wrongful use of belongings or money when a staff member took resident medication.
Failed to provide care in accordance with professional standards by not administering medication as ordered for four days.
Report Facts
Pills returned: 164
Resident census: 35
Missed medication doses: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Staff member who took resident medication and was arrested for stealing medication. |
| CMT B | Certified Medication Technician | Reported missing medication to the Director of Nursing. |
| DON | Director of Nursing | Notified of missing medication and involved in investigation. |
| HR Manager | Reviewed video footage, confronted RN A, and called police. | |
| RN E | Registered Nurse | Documented medication administration error and noted missing medication. |
| LPN D | Licensed Practical Nurse | Notified about missing medication from the cart. |
Inspection Report
Plan of Correction
Census: 33
Deficiencies: 3
Date: Jul 18, 2023
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of care and medication administration, including a review of a resident's PICC line dressing and medication errors. The document also includes a plan of correction for cited deficiencies.
Findings
The facility failed to obtain orders for changing a resident's PICC line dressing and did not document dressing changes as required. Additionally, the facility failed to ensure residents were free of significant medication errors, resulting in hospitalization of one resident due to insulin administration errors.
Deficiencies (3)
F658 Comprehensive Care Plans: The facility failed to obtain orders for changing a resident's PICC line dressing and did not document dressing changes as required. The resident's care plan did not address the PICC line dressing.
F760 Residents are Free of Significant Med Errors: The facility failed to ensure residents were free of significant medication errors, resulting in hospitalization of one resident due to insulin administration errors.
A4075 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with their condition. This regulation was not met as evidenced by deficiencies noted in F658.
Report Facts
Facility census: 33
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denise Beall | Executive Director | Signed the report and plan of correction |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 2
Date: Jul 18, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to obtain orders and properly change PICC line dressings for one resident, and failure to administer insulin as ordered for another resident, resulting in hospitalization.
Complaint Details
The complaint investigation revealed failure to obtain and document orders for PICC line dressing changes and failure to administer insulin as ordered, resulting in resident harm including hospitalization.
Findings
The facility failed to obtain physician orders for PICC line dressing changes and failed to change the dressing per professional standards for Resident #2. Additionally, the facility failed to administer insulin as ordered for Resident #1 for two days, leading to hospitalization with hyperglycemia. The facility census was 33.
Deficiencies (2)
Failed to obtain orders regarding when to change a PICC line dressing and failed to change the dressing per professional standards for one resident.
Failed to ensure residents were free from significant medication errors when staff failed to administer insulin as ordered for two days for one resident, resulting in hospitalization.
Report Facts
Facility census: 33
Days without PICC line dressing change order: 16
Days without PICC line dressing change order: 17
Days insulin not administered: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Interviewed regarding PICC line dressing change procedures and expectations |
| RN B | Registered Nurse | Interviewed regarding order entry responsibilities and medication administration |
| RN C | Registered Nurse | Interviewed regarding admission order entries and medication administration |
| Licensed Practical Nurse D | Licensed Practical Nurse | Interviewed regarding admission order entry and missed insulin orders |
| RN E | Registered Nurse | Hospital nurse interviewed regarding resident admission to ICU with hyperglycemia |
| Director of Nursing | Interviewed regarding expectations for order entry and medication administration | |
| Administrator | Interviewed regarding expectations for order entry and medication administration |
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 2
Date: Aug 23, 2021
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to pressure ulcer prevention and treatment at Sunterra Springs Springfield.
Findings
The facility failed to provide adequate pressure ulcer care consistent with professional standards, including failure to document wound treatment, complete wound assessments, and obtain proper physician orders. Staff did not follow wound care protocols, resulting in unstageable pressure ulcers and incomplete treatment documentation.
Deficiencies (2)
F686 Pressure Ulcer Treatment/Services: The facility failed to provide pressure ulcer care consistent with professional standards, including failure to document wound treatment, complete wound assessments, and obtain physician orders for treatment.
A4082 Pressure Sore Prevention/Treatment: The facility did not ensure residents were free from avoidable pressure sores by failing to provide adequate treatment and prevention measures.
Report Facts
Resident census: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in wound care treatment and documentation deficiencies |
| RN L | Registered Nurse (Wound Nurse) | Named in wound care treatment and documentation deficiencies |
| CNA F | Certified Nurse Aide | Interviewed regarding wound care procedures |
| CNA D | Certified Nurse Aide | Interviewed regarding wound care procedures |
| DON | Director of Nursing | Provided information on wound care protocols and orders |
| NP | Nurse Practitioner | Assessed resident's pressure ulcer and recommended antibiotics |
Inspection Report
Plan of Correction
Census: 38
Deficiencies: 6
Date: Jul 29, 2021
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding food quality, resident preferences, infection control, and COVID-19 protocols at Sunterra Springs Springfield.
Findings
The facility failed to ensure food served was palatable and at an appropriate temperature, and did not accommodate a resident's food preferences and intolerances. Infection control practices were inadequate, including improper use of face masks and glucometer disinfection, and failure to maintain proper COVID-19 infection control procedures.
Deficiencies (6)
F804 Food and drink: The facility failed to ensure food served to residents was palatable, attractive, and at an appetizing temperature. Residents reported meals were often cold.
F806 Resident Allergies, Preferences, Substitutes: The facility failed to accommodate one resident's food intolerances and preferences. Documentation and communication of food preferences were inconsistent.
F880 Infection Prevention & Control: The facility failed to maintain infection control practices, including improper face mask use by staff and inadequate disinfection of glucometers. COVID-19 infection control policies were not properly followed.
A4085 Infection Control/Communicable Disease: The facility did not follow acceptable infection control procedures to prevent the spread of infection. A report to the state was not made within seven days of a communicable disease diagnosis.
A5001 Nutritional Needs Met, Assess Res, Inform Dr: The facility failed to serve nutritious food properly prepared and seasoned according to resident preferences and physician orders.
A5005 Hot Food Hot, Cold Food Cold: The facility failed to assure hot food was served hot and cold food was served cold.
Report Facts
Facility census: 38
Deficiencies cited: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Performed blood glucose testing and glucometer disinfection |
| RN E | Registered Nurse | Observed exiting resident room with improper mask use |
| Certified Nursing Assistant (CNA) F | Reported resident complaints about cold food | |
| Certified Medication Technician (CMT) H | Reported resident complaints about food temperature | |
| Director of Nursing (DON) | Provided statements about food complaints and infection control training | |
| Dietary Manager | Provided information on food preference documentation and complaints |
Inspection Report
Life Safety
Census: 38
Capacity: 38
Deficiencies: 2
Date: Jul 29, 2021
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association, focusing on smoke barrier construction and fire safety.
Findings
The facility failed to maintain the smoke resistive properties of the Smoke Barrier Walls, with incomplete and unsealed areas allowing potential passage of smoke between compartments. Deficiencies were observed in the attic area, above hallways, and near the laundry/dryer room.
Deficiencies (2)
K372: The facility failed to maintain the smoke resistive properties of the Smoke Barrier Walls. Observations showed incomplete and unsealed areas in the attic, above hallways, and near the laundry/dryer room allowing potential smoke passage.
A2054: Each smoke section must be separated by one-hour fire-rated walls continuous from outside wall to roof deck, with doors rated at least 20 minutes and self-closing. This regulation was not met as evidenced by K372.
Report Facts
Facility capacity: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding smoke barrier walls and maintenance | |
| Environmental Specialist | Interviewed regarding repairs and inspections of smoke barrier walls | |
| Administrator | Interviewed regarding contract worker repairs and facility policies |
Inspection Report
Routine
Census: 38
Deficiencies: 3
Date: Jul 29, 2021
Visit Reason
The inspection was conducted to assess compliance with regulations related to food service quality, resident food preferences, and infection prevention and control practices at the facility.
Findings
The facility failed to ensure food was served at a palatable temperature, accommodate a resident's food preferences, and maintain proper infection control practices including proper use of face masks and cleaning of glucometers between residents.
Deficiencies (3)
Failed to ensure food served to residents was palatable, attractive, and at an appetizing temperature.
Failed to accommodate one resident's intolerances and food preferences.
Failed to provide and implement an infection prevention and control program, including improper cleaning of glucometers and improper wearing of face masks by staff.
Report Facts
Facility census: 38
Meal trays on hall cart: 17
Contact time for disinfectant: 3
Date of inspection: Jul 29, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) F | Mentioned in relation to resident complaints about cold food and food preference communication | |
| Certified Nursing Assistant (CNA) G | Mentioned in relation to resident complaints about cold food and food preference communication | |
| Certified Medication Technician (CMT) H | Mentioned in relation to resident complaints about cold food and food preference communication | |
| Dietary Manager | Provided information on food temperature policies and food preference documentation | |
| Director of Nursing (DON) | Provided information on food complaints and infection control practices | |
| Administrator | Provided information on food service procedures and mask policies | |
| Licensed Practical Nurse (LPN) A | Observed performing glucometer testing and cleaning | |
| Licensed Practical Nurse (LPN) B | Observed performing glucometer testing and cleaning | |
| Registered Nurse (RN) E | Observed wearing mask improperly | |
| Housekeeper D | Observed wearing mask improperly | |
| Physical Therapy Assistant (PTA) C | Observed wearing mask improperly | |
| Certified Nurse Aide (CNA) K | Provided information on mask policies | |
| RN L | Provided information on mask policies |
Inspection Report
Plan of Correction
Census: 82
Deficiencies: 1
Date: Apr 23, 2021
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction related to a medication misappropriation incident at Sunterra Springs Springfield nursing facility. It addresses a past noncompliance regarding failure to protect residents from misappropriation of medication.
Findings
The facility failed to protect residents from misappropriation when a resident's bottle of oxycodone went missing. An investigation was conducted involving staff interviews, medication counts, and drug testing, with corrective actions implemented including new medication storage procedures.
Deficiencies (1)
F 602: The facility failed to protect residents from misappropriation of property when a resident's oxycodone medication bottle went missing. Staff investigations and interviews revealed no resolution until new medication storage procedures were implemented.
Report Facts
Facility census: 82
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 8, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Oct 16, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Sep 23, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with federal regulations and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 20, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Annual Inspection
Census: 25
Deficiencies: 4
Date: Jul 18, 2019
Visit Reason
Annual survey conducted to assess compliance with federal and state regulations for Sunterra Springs Springfield nursing facility.
Findings
The facility was found deficient in care plan timing and revision, psychotropic medication management, and communicable disease employee screening. Deficiencies included failure to revise a resident's comprehensive care plan, failure to provide medication regimens free from unnecessary psychotropic drugs, and failure to ensure employee tuberculosis screening tests were completed and documented.
Deficiencies (4)
F657 Care Plan Timing and Revision: The facility failed to ensure staff revised one resident's comprehensive care plan to include the resident's choice for code status.
F758 Free from Unnecessary Psychotropic Medications: The facility failed to provide a medication regimen free from unnecessary psychotropic medication for one resident by not providing rationale to continue PRN psychotropic medication past 14 days.
A4029 Communicable Disease-Employees: The facility failed to ensure three employees completed tuberculosis screening tests in accordance with requirements for long-term care employees.
A4054 Safe/Effective Medication System: The facility failed to maintain a safe and effective system of medication distribution, administration, control, and use as evidenced by issues noted in F758.
Report Facts
Facility census: 25
Sample size: 12
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deanna Bechard | Administrator | Signed deficiency statements and plan of correction |
Inspection Report
Life Safety
Deficiencies: 0
Date: Jul 18, 2019
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and licensure requirements for Sunterra Springs Springfield.
Findings
The facility met applicable provisions of the 2012 Life Safety Code with no deficiencies cited. No state licensure deficiencies were found during this inspection.
Inspection Report
Routine
Census: 25
Deficiencies: 2
Date: Jul 18, 2019
Visit Reason
The inspection was conducted to assess compliance with care planning requirements and medication management, including review of residents' code status documentation and use of psychotropic medications.
Findings
The facility failed to ensure that one resident's comprehensive care plan was revised to reflect the resident's choice for code status, and failed to provide a rationale for continuing an as needed psychotropic medication beyond 14 days for another resident. The facility census was 25.
Deficiencies (2)
Failed to revise one resident's comprehensive care plan to include the resident's choice for code status.
Failed to provide a rationale to continue an as needed psychotropic medication past 14 days for one resident.
Report Facts
Facility census: 25
Residents in sample: 12
PRN alprazolam administration dates: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) A | Interviewed regarding code status placard system | |
| Social Service Director | Interviewed regarding admission procedures and code status documentation | |
| MDS Coordinator | Interviewed regarding documentation of code status on care plans | |
| Director of Nursing (DON) | Interviewed regarding expectations for code status documentation and medication review | |
| Licensed Practical Nurse (LPN) B | Interviewed regarding administration of PRN anti-anxiety medications |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 23, 2018
Visit Reason
Annual licensure inspection of Sunterra Springs Springfield facility to assess compliance with health and state licensure requirements.
Findings
No health facility survey deficiencies or state licensure deficiencies were cited as a result of this inspection.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Aug 23, 2018
Visit Reason
The inspection was conducted as an initial certification survey for licensure and compliance with emergency preparedness and life safety codes.
Findings
No Emergency Preparedness deficiencies were cited. The facility meets the applicable provisions of the 2012 edition of the Life Safety Code. No state licensure deficiencies were cited as a result of this inspection.
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