Inspection Reports for The Waters Of Springfield
704 5th Ave E, Springfield, TN 37172, United States, TN, 37172
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% worse than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 4
Date: May 19, 2025
Visit Reason
The inspection was conducted based on complaints regarding failure to provide a private space for resident group meetings, lack of supervision during dining, improper food storage and handling, and failure to follow infection prevention measures during medication administration.
Complaint Details
The visit was complaint-related, triggered by issues including interruptions during resident council meetings, lack of supervision during dining, improper food safety practices, and inadequate infection control during medication administration. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in providing a private, uninterrupted space for resident council meetings, supervising residents during dining, maintaining sanitary food storage and preparation conditions including proper refrigerator temperatures, and ensuring proper hand hygiene during medication administration by nursing staff.
Deficiencies (4)
Failed to provide a private space that prevented interference for the resident group meeting.
Failed to be present for supervision and assistance in the dining room for 2 of 7 residents during dining.
Failed to ensure food was stored, handled, prepared, and served under sanitary conditions, including unlabeled and undated food, carbon buildup on baking pans, grease trap with food debris, and walk-in cooler temperatures consistently above 41 degrees.
Failed to ensure measures to prevent the spread of infection were followed during medication administration, with 3 nurses failing to perform appropriate hand hygiene.
Report Facts
Residents affected: 5
Residents affected: 2
Census: 37
Residents receiving meal tray: 34
Walk-in cooler temperature readings: 58
Walk-in cooler temperature readings: 42
Number of baking pans with carbon buildup: 8
Number of nurses observed with hand hygiene failures: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Certified Dietary Manager | Certified Dietary Manager (CDM) | Confirmed issues with walk-in cooler temperatures, unlabeled powder, grease trap, and baking pans. |
| Administrator | Administrator | Confirmed interruptions during Resident Council meetings and elevated walk-in cooler temperatures were reported. |
| Activity Supervisor | Activity Supervisor | Confirmed interruptions during Resident Council meetings. |
| Director of Nursing | Director of Nursing (DON) | Confirmed nurses should perform hand hygiene before medication preparation and between glove changes. |
| LPN C | Licensed Practical Nurse | Failed to perform hand hygiene between glove changes during medication administration. |
| RN B | Registered Nurse | Failed to perform hand hygiene before and after medication administration and glove removal. |
| LPN D | Licensed Practical Nurse | Failed to perform hand hygiene before preparing medication, between glove exchanges, and after administering medication. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 25, 2024
Visit Reason
The inspection was conducted due to allegations of resident-to-resident abuse and failure to timely report suspected abuse within the facility.
Complaint Details
The complaint investigation revealed multiple resident-to-resident abuse incidents involving Residents #29, #10, #15, and others. The facility failed to report an allegation of sexual abuse involving Resident #36 to the State Survey Agency because the resident recanted the allegation within two hours. Interviews with staff, residents, and administrators confirmed the abuse events and deficiencies in reporting.
Findings
The facility failed to protect residents from physical abuse by other residents in multiple incidents involving Residents #29, #10, #15, and others. The facility also failed to timely report an allegation of sexual abuse involving Resident #36 to the State Survey Agency. Investigations confirmed the abuse incidents occurred, and corrective actions including psychiatric evaluations and one-to-one supervision were implemented.
Deficiencies (2)
Failed to protect residents from physical abuse by other residents in multiple incidents.
Failed to timely report an allegation of sexual abuse to the State Survey Agency.
Report Facts
Residents reviewed for abuse: 9
Residents affected by abuse: 3
BIMS scores: 13
BIMS scores: 10
BIMS scores: 10
BIMS scores: 0
BIMS scores: 5
BIMS scores: 7
One-to-one supervision duration: 30
One-to-one supervision duration: 150
One-to-one supervision duration: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Notified and separated residents during resident-to-resident abuse incident involving Resident #29 and Resident #33 |
| RN #2 | Registered Nurse | Recalled incident involving Resident #29 and Resident #33 and actions taken |
| Resident #4 | Resident Witness | Witnessed and described the incident between Resident #29 and Resident #33 |
| Director of Nursing | Director of Nursing (DON) | Provided expectations for abuse incident response and confirmed actions taken |
| Administrator | Facility Administrator | Notified of abuse incidents, conducted investigations, and reported to authorities |
| CNA #27 | Certified Nurse Aide | Reported observations during abuse incident involving Resident #10 and Resident #198 |
| MDS Coordinator | MDS Coordinator | Observed and reported abuse incident involving Resident #10 and Resident #198 |
| Resident #41 | Resident Witness | Witnessed abuse incident involving Resident #10 and Resident #198 |
| HA #21 | Housekeeping Aide | Attempted to intervene during altercation between Resident #15 and Resident #48 |
| PT #28 | Physical Therapist | Assisted during altercation between Resident #15 and Resident #48 |
Inspection Report
Routine
Deficiencies: 5
Date: Jul 25, 2024
Visit Reason
The inspection was conducted to assess compliance with Medicare and Medicaid regulations, including resident rights, abuse prevention, vision services, food safety, and other regulatory requirements.
Findings
The facility was found deficient in several areas including failure to provide required Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), failure to protect residents from physical abuse by other residents, failure to timely report an allegation of abuse to the State Survey Agency, failure to arrange follow-up ophthalmology appointments as recommended, and failure to label and date food items in the kitchen refrigerator.
Deficiencies (5)
Failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) for 1 of 2 sampled residents reviewed for beneficiary notification.
Failed to protect residents from physical abuse perpetrated by other residents for 3 of 9 residents reviewed for abuse, including incidents involving hitting with a meal tray, striking and hair pulling, and physical altercations causing falls.
Failed to timely report an allegation of abuse to the State Survey Agency for 1 of 7 sampled residents reviewed for abuse.
Failed to arrange a follow-up appointment with an ophthalmologist based on a recommendation made by the optometrist for 1 of 2 sampled residents reviewed for vision services.
Failed to label and date food items in a walk-in refrigerator, including undated bowls of salad, pears, pudding, meat, and sauces.
Report Facts
Residents reviewed for beneficiary notification: 2
Residents affected by SNFABN deficiency: 1
Residents reviewed for abuse: 9
Residents affected by abuse deficiency: 3
Residents reviewed for abuse reporting: 7
Residents affected by abuse reporting deficiency: 1
Residents reviewed for vision services: 2
Residents affected by vision services deficiency: 1
Undated food items observed: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #24 | Named in SNFABN beneficiary notification deficiency | |
| Resident #33 | Named in resident-to-resident abuse incident involving meal tray | |
| Resident #29 | Named in resident-to-resident abuse incident involving meal tray and psychiatric evaluation | |
| Resident #10 | Named in resident-to-resident abuse incident involving hair pulling | |
| Resident #198 | Named in resident-to-resident abuse incident involving hair pulling | |
| Resident #15 | Named in resident-to-resident abuse incident involving physical altercation | |
| Resident #48 | Named in resident-to-resident abuse incident involving physical altercation | |
| Resident #36 | Named in failure to report abuse allegation | |
| Resident #25 | Named in failure to arrange follow-up ophthalmology appointment | |
| Business Office Manager | BOM | Interviewed regarding SNFABN notification |
| Social Services Director | SSD | Interviewed regarding SNFABN notification and vision services |
| Administrator | Interviewed regarding multiple deficiencies including abuse reporting and vision services | |
| Director of Nursing | DON | Interviewed regarding abuse incidents, SNFABN, and vision services |
| Registered Nurse #1 | RN | Responded to resident-to-resident abuse incident |
| Registered Nurse #2 | RN | Interviewed about resident-to-resident abuse incident |
| Certified Nurse Aide #27 | CNA | Witnessed resident-to-resident abuse incident |
| MDS Coordinator | Interviewed regarding SNFABN and abuse incidents | |
| Housekeeping Aide #21 | HA | Witnessed resident-to-resident abuse incident |
| Physical Therapist #28 | PT | Witnessed resident-to-resident abuse incident |
| Registered Nurse #12 | RN | Notified of sexual abuse allegation |
| Certified Nurse Aide #30 | CNA | Notified of sexual abuse allegation |
| Dietary Director | DD | Interviewed regarding food labeling deficiency |
| Registered Dietician | Interviewed regarding food labeling deficiency |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Oct 19, 2023
Visit Reason
The inspection was conducted based on complaints and allegations involving narcotic medication diversion, misappropriation of resident funds, failure to report abuse allegations timely, resident elopement, medication errors, and infection control breaches.
Complaint Details
The complaint investigation included allegations of narcotic diversion for Resident #6, misappropriation of money from Resident #17, failure to timely report abuse involving Residents #1, #2, and #17, and failure to prevent elopement of Resident #20 which resulted in immediate jeopardy. The investigation found substantiated issues with medication diversion, misappropriation, late reporting, and resident safety lapses.
Findings
The facility was found to have failed in preventing narcotic diversion and misappropriation of resident funds, timely reporting of abuse allegations, ensuring resident safety from elopement resulting in immediate jeopardy, maintaining medication error rates below 5%, implementing a quality assurance plan for abuse and misappropriation issues, and following infection control protocols for enhanced barrier precautions.
Deficiencies (6)
Failed to ensure narcotic medication was not diverted for Resident #6 and money was not misappropriated from Resident #17.
Failed to timely report allegations of abuse and misappropriation involving Residents #1, #2, and #17.
Failed to ensure adequate supervision to prevent elopement of Resident #20, resulting in immediate jeopardy.
Failed to maintain medication error rate below 5%, with 2 errors in 27 opportunities affecting Residents #23 and #24.
Failed to implement a quality assurance plan addressing misappropriation of resident funds and controlled medications for Residents #6 and #17.
Failed to follow infection control guidelines by not wearing proper personal protective equipment during wound care for Resident #11.
Report Facts
Medication error rate: 7.4
Loan amount: 320
Medication quantity: 30
BIMS score: 15
BIMS score: 14
BIMS score: 9
BIMS score: 9
BIMS score: 13
BIMS score: 14
BIMS score: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #9 | Licensed Practical Nurse | Signed medication packing slip and distributed medication related to narcotic diversion investigation |
| Licensed Practical Nurse #10 | Licensed Practical Nurse | Assigned nurse who did not cooperate with narcotic diversion investigation |
| Housekeeper #29 | Housekeeper | Employee who borrowed money from Resident #17 and was terminated |
| Registered Nurse #12 | Registered Nurse | Agency nurse who let Resident #20 out of the facility leading to elopement |
| Licensed Practical Nurse #13 | Licensed Practical Nurse | Cared for Resident #20 during elopement incident |
| Licensed Practical Nurse #8 | Licensed Practical Nurse | Provided wound care to Resident #11 without wearing gown as required |
| Registered Nurse #4 | Registered Nurse | Administered medication to Resident #23 including multivitamin error |
| Registered Nurse #2 | Registered Nurse | Prepared medication for Resident #24 and made medication error with aspirin |
| Administrator | Administrator | Interviewed regarding multiple findings including reporting delays and QAPI failures |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple findings including elopement and infection control |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jul 8, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to residents' personal property, care planning for medications, fall management, and staff training at The Waters of Springfield LLC nursing home.
Findings
The facility was found deficient in maintaining residents' personal property inventories, developing comprehensive care plans for anticoagulants and diuretics, performing neurological checks after an unwitnessed fall, and ensuring certified nursing assistants received the required annual in-service training hours.
Deficiencies (4)
Failed to ensure residents' personal property was maintained for 2 of 2 sampled residents, including missing items and unsigned inventory sheets.
Failed to provide a comprehensive care plan related to anticoagulants and diuretics for 2 of 5 sampled residents.
Failed to implement neurological checks after an unwitnessed fall for 1 of 2 sampled residents.
Failed to ensure 8 of 16 CNAs employed for a full year received at least 12 hours of in-service training.
Report Facts
In-service training hours: 6.25
In-service training hours: 6.25
In-service training hours: 6.25
In-service training hours: 5
In-service training hours: 4.75
In-service training hours: 6.75
In-service training hours: 7.25
In-service training hours: 6.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activity Director | Confirmed purchase of missing black velvet robe for Resident #10 and failure to update inventory list. | |
| Assistant Director of Nursing | ADON | Confirmed inventory sheets should be completed and signed; confirmed care planning deficiencies and neurological check requirements; confirmed CNA in-service training requirements. |
| Director of Nursing | DON | Confirmed inventory list completion and signing requirements. |
| MDS Coordinator | Confirmed care plans should be created on admission, quarterly, and with physician orders; confirmed care planning deficiencies. | |
| Licensed Practical Nurse | LPN #1 | Confirmed Resident #25 was on a diuretic. |
| Business Office Manager | Confirmed CNA in-service hours should be tracked from date of hire each year. |
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