Springdale Healthcare Center

Inspectors wroteBased on review of facility policy, record review and interview, the facility failed to ensure Resident (R)5 was free from significant medication errors. Specifically, R5 was discharged from the hospital and admitted to the facility on [DATE], with physicians orders for seizure medications, the facility failed to administer the medication as ordered resulting in the resident experiencing seizure activity and being sent to the hospital, for 1 of 1 resident reviewed for significant medication errors. On 05/21/25 at 10:35 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 05/06/25. The IJ was related to 42 CFR 483.45 - Pharmacy Services. On 05/21/25 at 11:32 AM, the facility presented an acceptable plan of removal. [...]

Inspectors wroteBased on observations, interviews, kitchen cleaning schedule review, and facility policy review, the facility failed to ensure the kitchen floor was free of debris and kept clean in a sanitary condition and failed to ensure the kitchen deep fryer was kept clean in 1 of 1 kitchen. The deficient practice had the potential to affect all 143 residents in the facility who receive meals prepared in and served from the facility's kitchen.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure residents received their medications in a timely manner according to physician's orders for 6 residents (Resident (R)34, R46, R72, R97, R102, and R107). This failure had the potential to lead to unwarranted medication side effects or improperly treated medical conditions.

Inspectors wroteBased on observations, interviews, record review, and review of facility policy, the facility failed to ensure: 1. staff used proper personal protective equipment (PPE) and/or performed hand hygiene with residents who required enhanced barrier precautions (EBP) for 2 residents (Resident (R)65 and R93), 2. proper sanitization of patient care equipment between uses for 2 (R35 and R1) residents, 3. Housekeeping staff used appropriated PPE and performed hand hygiene while cleaning rooms under EBP, and 4. immunization and education regarding the risks and benefits of the COVID-19 immunization was offered to 3 of 5 residents (Resident (R)62, R65, and R93) reviewed for COVID-19 immunizations out of a total sample of 33 residents. Failure to perform adequate infection control practices increased the risk of cross contamination and spread of infection.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to notify the physician for 1 resident's (Resident (R) 134) change in condition out of a sample of 33 residents. This failure delayed the physician in treating pressure ulcers.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to complete a thorough investigation of an altercation for 2 of 7 residents (Resident (R)59 and R0) reviewed for abuse out of a total sample of 33 residents.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to implement care plans for 2 residents (Resident (R)80 and R93) out of a sample of 33 residents. This failure placed the residents to be at risk for unmet care needs.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to ensure that care conferences were held for 2 of 4 residents (Resident (R)72, and R86) reviewed for care conferences of 33 sampled residents. The failure increased the risk of the resident's preferences and concerns not being included in the plan of care.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to assess and monitor the nutritional status of 1 of 4 residents (Resident (R)46) reviewed for weight loss in a total sample of 33 residents.

Inspectors wroteBased on the facility policy, record reviews and interviews, the facility failed to ensure 2 topical medications for wounds, were not left unattended in a dementia resident's room. Specifically, Dakin's Solution full strength and Remedy Barrier Creme were left in Resident (R)1's room unattended for an unknown amount of time for 1 of 2 residents reviewed for neglect.

Inspectors wroteBased on interviews, record reviews, document reviews, and facility policy review, the facility failed to protect the residents' right to be free from physical and verbal abuse perpetrated by staff for 2 (Resident (R)1 and R3) of 3 sampled residents reviewed for abuse.

Inspectors wroteBased on interviews, record review, document review, and facility policy review, the facility failed to timely report an allegation of physical abuse to the state survey agency for 1 (Resident (R)3) of 3 sampled residents reviewed for abuse.

Inspectors wroteBased on observation, interview, record review, facility document and policy review, the facility failed to protect seven (Resident (R)230, R44, R70, R91, R26, R37, and R39) of ten residents reviewed for abuse, from physical and/or psychosocial abuse perpetrated by another resident and/or staff member. Specifically, residents were not free from resident-to-resident physical abuse. Residents were slapped, hit, and/or pushed to the ground, with one resident (R91) being transported to the hospital for facial abrasions and chest wall tenderness, after being physically abused by another resident, who had previously physically abused two other residents. In addition, residents were not free from psychosocial abuse perpetrated by a Licensed Practical Nurse (LPN) who used a telephone to film and share images of cognitively impaired residents who could not give consent.

Inspectors wroteBased on observations, interview, and review of facility policy, the facility failed to ensure foods stored in the refrigerator, freezer, and dry storage were labeled, dated, and sealed shut after opening. This failure had the potential to affect all 138 residents in the facility who consumed food from the kitchen.

Inspectors wroteBased on observations, interview and review of the facility's policy and procedures, the facility failed to ensure that the laundry room provided space for separation of processing clean and dirty laundry; was free of trash on the floor, and that clean linen was properly covered from environmental contaminations from the open window and dusty fan.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain a clean homelike environment for 11(R118, R53, R36, R26, R115, R119, R39, R27, R59, R49, and R110) of 24 resident rooms toured during the survey conducted from 04/17/23 through 04/19/23.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure for one Resident(R)46 of two residents reviewed for advanced directives had the decision-making capacity when explaining and signing the full code status.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure one Resident (R)112) of one resident reviewed for hospitalization, received a written bed hold policy upon emergent transfer to the hospital.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who were independent on staff for oral care, received services for one resident (R)53) of five residents reviewed for Activities of Daily Living (ADL) assistance.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure that one of five residents (R69), reviewed for unnecessary medications, was free from unnecessary psychotropic medication use. R69's current medication orders included an as needed (PRN) anti-anxiety medication (Ativan) for more than 14 days without a stop date for reassessment of the resident's mental stability and continued need for the psychoactive medication.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure that expired medications and lab supplies were removed from stock, medications were stored at the proper temperature, refrigerator temperatures were being monitored and that Hall 200 medication room was unattended by authorized personnel when unauthorized personnel were making repairs on 2 of 3 medication rooms, 5 of 6 medication carts and 3 of 3 treatment carts.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to conduct kitchen operations in a safe and sanitary manner for one of one kitchen. This failure placed 113 residents receiving food from the kitchen at risk for potential food-borne illness (cross reference Tag F908).

Inspectors wroteBased on Medical Record Review and Interviews, the facility failed to ensure accurately documented, readily accessible and systematically organized Medical Records on resident weights identifying significant weight losses on 7 of 7 residents (# 91, #4, #63, #62, #25, #32, and #69) reviewed for weights. In addition, Resident #98 medical record did not accurately reflect his/her code status for 1 of 1 residents reviewed for code status. Findings Include: Resident #91 was admitted to facility on 6/3/21. Medical record review on 7/22/21 at 10:00 a.m. revealed that Resident #91 had a significant weight loss of -6.03 % within 2 months. Resident #4 was admitted to the facility on [DATE]. Medical Record Review on 7/22/21 at 10:15 a.m. revealed that Resident #4 had a significant weight loss of -11% within the last 6 months. Resident #63 was admitted to facility on 6/2/19. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure all kitchen equipment was in a safe operating condition, affecting one of one kitchen. This failure caused the kitchen to consistently remain in an unsanitary condition. This placed 113 residents that receive food from the kitchen at risk for food borne illnesses (cross reference Tag F812).

Inspectors wroteBased on observations and interview, the facility failed to ensure a safe, clean, comfortable and homelike environment, on 2 of 3 halls observed.

Inspectors wroteBased on record review, interviews and review of the facility policy titled, Nutritional Policies and Procedures, Preventing or Mitigating Undesirable Weight Loss, the facility failed to ensure Resident #63, #69, and Resident #91 have interventions in place to prevent further weight loss, and interventions in place to aid in gaining lost weight for 3 of 5 residents reviewed for Nutrition.

Inspectors wroteBased on observations, records reviews, interviews, manufacturer package insert and Facts and Comparisons (updated daily), the facility failed to ensure a medication error rate of less than 5% (percent) during medication pass observation. The medication error rate was 16.7% based on 5 of 30 observations for 2 of 3 residents.

Inspectors wroteBased on observations, record reviews, and interviews it was determined the facility failed to assure proper infection control techniques were maintained during wound care for one resident (R) (R73) out of 3 residents and during catheter care for 1 R (R73) of 2 residents. The failure to maintain proper techniques potentially placed the resident at risk for potential cross-contamination and infection. The facility also failed to ensure proper sanitization techniques were followed in 1 of 1 laundry room. Findings Include: Record review of R73's undated Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses to include urinary tract infection. Review of R73's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 05/31/21, revealed that R73 had no bowel or bladder devices. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure care plans were implemented for catheter care for 1 resident (R) (R73) of 2 residents reviewed with urinary catheters. The failure to develop approaches to address catheter care potentially placed the resident at risk for potential infections and invasion of the resident's privacy. Additionally, the facility failed to develop and implement a care plan for side effects related to Benadryl (diphenhydramine) for one of five residents (R) (R97) reviewed for unnecessary medications. This failure had the potential to impact R97's physical and emotional well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise the care plan related to Oxygen use for Resident #21. Findings Include: Record review of resident (R) (R21) undated Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses to include acute and chronic respiratory failure. Record review of R21's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 04/29/21, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The assessment further revealed the resident had received oxygen both while not a resident of the facility and while as a resident of the facility. Review of R21's care plan, dated 04/21/21, revealed R21 had a diagnosis of respiratory failure. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to follow physician orders to remove oxygen that had been discontinued for 1 resident (R) (R21) of 1 resident reviewed for oxygen. This failure placed the resident at potential risk for oxygen toxicity from breathing too much supplemental oxygen. Findings Include: Record review of R21's undated Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses to include acute and chronic respiratory failure. Record review of R21's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 04/29/21, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. [...]

Inspectors wroteBased on observations, records reviews, interviews and Facts and Comparisons, the facility failed to ensure a medication error rate of less than 5% (percent) during medication pass observation. The medication error rate was 16.7% based on 5 of 30 observations for 2 of 3 residents.

Inspectors wroteBased on interviews, record reviews, and observations, the facility failed to ensure psychotropic pro re nata (PRN) orders were limited to 14 days, then re-evaluated by the physician for its extended use, for one resident (R) (R48), out of a sample of five residents reviewed for unnecessary medications. This failure had the potential to result in adverse effects for the resident.

Inspectors wroteBased on record review, interviews, and review of the facility policy titled, Medication Procurement, the facility failed to ensure Resident #98 was free from a significant medication error related to Antibiotic therapy for 1 of 5 residents reviewed for Unnecessary Medication.