Avenues at Springfield

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to rid the facility of roaches. This failure has the potential to affect all 60 residents currently residing in the facility.

Inspectors wroteBased on observation and interview, the facility failed to provide a homelike environment by failing to maintain residents' rooms free of roaches for two (R2, R10) of four residents reviewed for pest control in a total sample list of 10 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to perform hand hygiene and glove changes appropriately and failed to label, date and cover food in the kitchen refrigerator. The failure could affect all 64 residents who live in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to implement and maintain effective measures to prevent the growth and transmission of Legionella bacteria within the water system. This has the potential to affect all 64 residents residing at the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a trained infection preventionist at the facility. This has the potential to affect all 64 residents at the facility.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to provide 80 square feet of floor space per resident bed for 32 two-bed resident rooms residents. This has the potential to affect all 64 residents in the facility.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to ensure there was an air gap in the ice machine between the ice storage bin and floor sewage drain in ice machine and staff had warm water to wash their hands. This has the potential to affect the 61 residents living in this facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the plumbing system provided comfortable hot water temperatures for resident use for 10 of 15 residents (R1, R2, R3, R8, R9, R10, R11, R12, R14 and R15) reviewed for safe in the sample of 15.

Inspectors wroteBased on interview and record review, the facility failed to prevent an elopement in 1 of 4 residents (R2) reviewed for elopement/supervision in the sample of 4. This failure resulted in an Immediate Jeopardy when R2 eloped from the facility on 12/30/24 and while missing, R2 sustained a fall resulting in a laceration and nasal fracture. This past non-compliance occurred on 12/30/24. Past noncompliance-no plan of correction required. The Immediate Jeopardy began on 12/30/24, when R2 eloped from the facility and sustained a fall resulting in a laceration and nasal fracture. On 1/15/25, at 9:30 AM, V1, Administrator, and V2, Director of Nurse, DON, were notified of the Immediate Jeopardy. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide 8 consecutive hours of Registered Nurse Coverage. This has the potential to affect all 61 residents residing in the facility.

Inspectors wroteBased on interview, observation, and record review, the facility failed to wear hair nets covering the hair, store food at a safe temperature, document food temperature after taking them, and have clean and sanitary equipment to prevent potential food contamination and food-borne illness. This failure has the potential to affect all 61 residents residing in the facility.

Inspectors wroteBased on interviews and record review the facility failed to provide services to residents with gastrostomy tube to restore/maintain eating skills for one of one resident (R40) reviewed for tube feedings in the sample of 65.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to provide 80 square feet of floor space per resident bed for 32 two-bed resident rooms residents. This has the potential to affect all 61 residents in the facility.

Inspectors wroteBased on interviews and record review the facility failed to always maintain a nurse on duty to meet the needs and safety of all residents. This failure has the potential to affect all 62 residents that reside in the facility. On 4/23/2024 at 12:27pm, V5, (Ambulance staff), stated that on 4/19/2024 around 8pm, V5 was returned R2 to the facility via ambulance transfer. V5 stated, there was no Nurse on duty in the building when they arrived to receive R2 back into the facility for care. V5 stated, V4, (Certified Nursing Assistant, CNA), told her that V3 had left and would be back shortly. V5, (Ambulance staff), stated 15-minutes passed with no signs or return to the facility of V3, (LPN). On 4/23/2024 at 2:30pm, V4, (CNA), stated, that on 4/19/2024 around 8pm, R2 returned from the hospital via Ambulance and V3, (LPN), was not in the facility. [...]

Inspectors wroteBased on record review and interviews the facility failed to provide the services of a Registered Nurse for 8 consecutive hours on the dates of 04/01/2024, 04/06/2024, 04/15/2024, 04/18/2024, 04/19/2024 and 04/20/2024. This failure has the potential to affect all 62 residents that reside in the facility. On 04/23/2024 at 1:00pm, V1 (Administrator) stated there are some days that the facility does not have a Registered Nurse for 8 consecutive hours a day. V1 stated current census is 62 and noted by the Matrix obtained from V1. On 04/23/2024 at 1:30pm, Facility provided the Nursing schedules with no RN scheduled to work on the following dates 04/01/2024, 04/06/2024, 04/15/2024, 04/18/2024, 04/19/2024 and 04/20/2024. On 04/23/2024 at 2:30pm, V4 (Certified Nursing Assistant) stated there are some days that there is no RN working in 24-hours. [...]

Inspectors wroteBased on interview and record review the facility failed to document narcotic pain medication administration for 4 of 4 (R1, R2, R3 and R4) residents reviewed for medication administration, in a sample of 4.

Inspectors wroteBased on record review and interview the facility failed to thoroughly investigate an allegation of misappropriation of narcotic pain meds, for 1 of 3 (R2) residents, reviewed for abuse, in a sample of 4.

Inspectors wroteBased on observations and interviews the facility failed to provide a safe environment by having toilets that were not securely bolted to the floor for 8 of 20 residents (R4, R5, R7, R8, R9, R10, R11 and R12) and failed to have toilet in hallway A shower room securely bolted to floor with the potential to affect 23 of 24 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to report a resident's significant weight loss to the physician and initiate appropriate interventions to maintain and/or improve nutritional status for 1 of 4 residents (R29) reviewed for weight loss in the sample of 65. The failure resulted in R29 having an insidious weight loss of 14.5 pounds (lbs.), a 10% weight loss in the last six months.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess, develop, and implement interventions to address the worsening symptoms of mental illness disorders for 1 of 5 residents (R29) reviewed for behavioral health services in the sample of 65. This resulted in R29 having a significant weight loss due to worsening and ongoing hallucinations telling him not to eat or drink.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, serve, and sanitize food and dining surfaces in a manner to prevent potential contamination and food borne illness. This failure has the potential to affect all 63 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide Pneumococcal vaccine for 4 of 4 residents (R4, R5, R35, R64) reviewed for immunizations in the sample of 65.

Inspectors wroteBased on interview, observation and record review, the facility failed to promote residents dignity by protecting their right to a sense of well-being and safety for 1 of 1 resident (R37) reviewed for dignity in the sample of 65.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide supervision to prevent residents with substance abuse disorders from acquiring and smoking marijuana for one of 14 residents (R7) reviewed for supervision in the sample of 65.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide 80 square feet of floor space per resident bed for 32 two bed resident rooms for 63 of 63 residents. This failure affects all 63 residents residing in the facility.