Springdale Village Post Acute

Inspectors wroteBased on resident and staff interviews, facility documentation and policy review, the facility failed to ensure there was sufficient staff to meet the needs of the residents. The deficient practice could result in residents not receiving appropriate care and treatment that they need.

Inspectors wroteBased on review of facility documentation, staff interviews and facility policy, the facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The deficient practice has the potential to affect resident care.

Inspectors wroteBased on observation, staff interviews and policy review, the facility failed to ensure current nurse staffing information was posted on a daily basis. The deficient practice could result in staffing information not being readily available to residents and visitors.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy and procedure review, the facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Level 1 evaluation was completed after 30 days for 1 of 18 sampled residents (Resident #14) with adiagnosis of Serious Mental Illness (SMI). This deficient practice occurred within a resident census (universe) of 70. Failure to complete the required PASRR screening and referral process may result in residents with serious mental illness not being identified for, assessed for, or receiving necessary specialized mental health services and supports. -Regarding Resident #14Resident #14 was admitted to the facility on [DATE], with diagnoses that included bipolar disorder, diabetes mellitus, muscle weakness, rheumatoid arthritis, and hypertension. [...]

Inspectors wroteBased on interviews, review of the clinical record, review of facility documentation, and review of facility policy and procedures, the facility failed to ensure that physician orders for weekly weights were followed for two residents (#77 and #14) in accordance with professional standards. The deficient practice could result in a lack of monitoring of weight changes and malnutrition. -Regarding Resident #77 Resident #77 was admitted to the facility on [DATE], with diagnoses that included displaced trimalleolar fracture of the right lower leg, muscle weakness, lobar pneumonia, coccidioidomycosis, type 2 diabetes, schizophrenia, depression, chronic kidney disease, polyneuropathy, hyperlipidemia, and a history of transient ischemic attack and cerebral infarction. A physician's order dated February 5, 2026, revealed weekly weights for 4 weeks, every day shift, every 7 days for 4 weeks. [...]

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure two of three sampled residents (#15 and #43) reviewed for advance directives right to formulate an advance directive. The deficient practice could result in residents not receiving proper care according to their preferences or potential harm to the resident ' s life. Findings Include: -Regarding Resident #15 Resident #15 was admitted to the facility on [DATE] with diagnoses that included pneumonia, COVID-19, chronic obstructive pulmonary disease, hypoxemia, type 2 diabetes, protein-caloric malnutrition, anxiety, and dysphagia (difficulty swallowing). A physician ' s order dated February 6, 2023 was written for full code. [...]

Inspectors wroteBased on clinical record review, interviews with staff, and facility policies, the facility failed to ensure that 2 residents (#23 & #62) representatives were informed after a change in condition.

Inspectors wroteBased on clinical record review, interviews with staff, and facility policies, the facility failed to ensure that professional standards were followed in regards to care planning and an interdisciplinary review of the fall regarding one resident (#210).

Inspectors wroteBased on clinical record review, interviews and facility policy review, the facility failed to ensure one resident's (#110) medication was administered according to physician orders. The deficient practice could result in medication errors that could harm residents.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation and policy review, the facility failed to properly monitor one of three sampled residents (#62) who were at risk of elopement. The deficient practice could result in elopement, and physical injury.

Inspectors wroteBased on clinical record review, interviews, facility policy review, State Agency complaint tracking system, the facility failed to ensure medical records were complete and readily accessible for one resident (#110). The deficient practice could result pertinent medical information being missed by staff members which could be harmful.

Inspectors wroteBased on observation, clinical record review, interviews with residents and staff, and review of facility policy, the facility failed to ensure appropriate infection control guidelines were implemented and followed for one resident (#1). The deficient practice could result in the spread of infectious disease.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to protect the rights of one resident (#1) to be free from abuse by staff. The deficient practice could result in appropriate action not taken and further abuse of residents.

Inspectors wroteBased on clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) 3.0 User's manual, the facility failed to ensure the completion of comprehensive Minimum Data Set (MDS) assessments for three residents (#8, #10, #12) within the regulatory time frames. The deficient practice could result in inadequate assessment of resident needs.

Inspectors wroteBased on observations, interviews, review of records, documents and policy, the facility failed to develop and implement a care plan for one resident (#4). The deficient practice could result in the resident's care needs not being met.

Inspectors wroteBased on interviews, record review, facility document review, and facility policy review, the facility failed to ensure that three staff members (#35, staff #15, and staff #17) had current cardiopulmonary resuscitation (CPR) certification training on file. The deficient practice could put the resident's safety at risk and could result in needs not being met.

Inspectors wroteBased on clinical record review, interviews, and review of facility policy and procedure, the facility failed to ensure a discharge summary was completed for a resident (#14) discharge. The deficient practice could result in an unsafe discharge for residents.

Inspectors wroteBased on interviews, facility documents and employee record review, the facility failed to ensure that the activities program was directed by a qualified professional. The deficient practice could result in the activities program not being directed by a qualified professional

Inspectors wroteBased on interviews, record review, facility document review, and facility policy review, the facility failed to ensure that one resident (#4) was administered pneumococcal vaccine. The deficient practice could result in residents not receiving vaccines.

Inspectors wroteBased on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure the comprehensive care plan was updated to reflect the changing needs of 1 out of 2 sampled residents (#3). The deficient practice could increase the risk for further falls and injuries.

Inspectors wroteBased on clinical record review, staff interviews and review of policy and procedure, the facility failed to ensure necessary care and services related to pressure ulcer was provided for one resident (#3). The sample size was 18. The deficient practice may result in development of pressure ulcer.

Inspectors wroteBased on clinical record review, staff interviews, and review of policy, the facility failed to ensure catheter care was provided according to physician orders for two residents (#42 and #222); and, failed to provide incontinence care to one resident (#274). The deficient practice could result in increased risk for complication such as infection, pain, and rehospitalization.

Inspectors wroteBased on observation, clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure the medication error rate was less than 5% by failing to ensure two out of three residents reviewed (#20 and #62 ) received medications according to the physician orders. The medication error rate was 6.67%. The deficient practice could result in further medication errors.

Inspectors wroteBased on observation, staff interviews, and review of policy and procedure, the facility failed to ensure that expired supplies and medication with missing and/or damaged labels were not available for resident use; and failed to ensure that a resident's home medications were not left unsecured on a counter in the medication room. The deficient practice could result in ineffective treatments/procedures, and/or in residents receiving expired medications, and/or schedule II - V controlled medications being unsecured.

Inspectors wroteBased on observation, staff interviews and review of policy and procedures, the facility failed to ensure that biohazardous material/sharps were disposed of properly. The deficient practice may increase the risk for needle sticks and/or the spread of bloodborne pathogens.

Inspectors wroteBased on observations, clinical record review, resident and staff interviews, and review of facility policy/procedure, the facility failed to ensure housekeeping services necessary to maintain a safe and clean environment were provided for one resident (#58). The sample size was 18. The deficient practice could result in residents not having a safe and clean environment.

Inspectors wroteBased on closed record review, staff interviews and facility policy and procedures, the facility failed to ensure medications were administered as ordered by the physician for one resident (#123). The deficient practice could result in resident not provided with medication needed.

Inspectors wroteBased on clinical record review, observations, staff interviews, and review of policy, the facility failed to ensure one resident (#8) was provided showers. The deficient practice could result in grooming and hygiene needs not being met.

Inspectors wroteBased on clinical record review, staff interviews, and review of policy, revealed the facility failed to ensure one resident (#223) received treatment and care in accordance with professional standards of practice. The sample size was one. The deficient practice could rsult in resident not receiving the treatment based on their assessed need.

Inspectors wroteBased on observation, staff interviews, and policy review, the facility failed to ensure the Daily Staff Postings for nursing staff was accurate for actual hours worked by licensed and unlicensed direct care nursing staff. The facility census was 74 residents and the sample was 18. The deficient practice could result in residents and visitors not being informed of accurate and current staffing information.