Springfield Villa

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was protected from possible contamination at all times when staff failed to air dry dishes, failed to wear hair/beard nets appropriately, failed to ensure the hood above the cooking area was clean, and when staff did not ensure a proper air gap for drain hoses/pipes. These failures had the potential to affect all residents. The facility census was 118.1. Review of the Food and Drug Administration (FDA) 2022 Food Code showed the following:-Items must be allowed to drain and to air-dry before being stacked or stored;-Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Review of the facility's policy titled General Dish Room Sanitation, dated May 2015, showed the following:-All items are to be air dried. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a policy in place that addressed the quantity of emergency water to be kept on-site and failed have a supply of emergency water on-site. The facility census was 118. Review of the facility's policy entitled, Emergency Water, undated, showed the following:-To ensure safe water for residents, staff, and visitors during a crisis, our facility maintains:-An emergency water supply that is suitable and accessible;-An emergency water supply consistent with applicable regulatory requirements; and-Methods for water treatment when supplies are low;-A corporation provides emergency water supply in the event it is needed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a clean, comfortable, and homelike environment to all residents and family when staff failed to address broken blinds in one resident's (Resident #94) room, failed to address a broken drawer handle in one resident's (Resident #3) room, and failed to address missing handrail end caps bumped into by one resident's (Resident #11) family member. The facility census was 118. Review showed the facility did not provide a policy related to physical environment and repairs. 1. [...]

Inspectors wroteBased on record review and interview, the facility failed to implement policies to prevent possible abuse when staff failed to maintain documentation for a criminal background check (CBC) for one staff member (Certified Medication Technician (CMT) N). The facility census was 118. Review of the facility's policy entitled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, undated, showed the following:-It is the policy to screen employees and volunteers prior to working with residents. Screening components include verification of references, certification and verification of license, and criminal background check;-A criminal background check will be conducted on all prospective employees using either the Family Care Safety Registry (FCSR - a database that includes a CBC check) or the facility's contracted independent investigation and consulting company. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities when staff failed to provide activities to three residents (Resident #11, #94, and #115) on the memory care unit who voiced importance of attending activities. The facility census was 118. Review of the facility policy Resident Activities, dated March 2012, showed the following;-The activities services of each facility will, plan, organize, and carry out a program of activities to meet individual resident needs;-The program is designed to give residents entertainment, communication, exercise, relaxation and an opportunity to express their creative talent;-Through the activities, residents can fulfill basic psychological, social and spiritual needs; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free of accident hazards when staff failed to maintain sink hot water temperatures between 105 and 120 degrees Fahrenheit (F) in four resident rooms (rooms 100, 102, 103, and 106) increasing the risk of burns due to hot water and when staff failed to ensure smoking materials and lighters were secured for one resident (Residents #28). The facility census was 118. Based on observation, interview, and record review, the facility failed to provide an environment free of accident hazards when staff failed to maintain sink hot water temperatures between 105 and 120 degrees Fahrenheit (F) in four resident rooms (rooms 100, 102, 103, and 106) increasing the risk of burns due to hot water and when staff failed to ensure smoking materials and lighters were secured for one resident (Residents #28). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all resident medications were secure, when staff members failed to lock medication carts containing resident medications while out of their line of sight and failed to ensure the narcotic medications (controlled substances regulated due to high potential for abuse, addiction, or dependence) were double locked inside of the medication carts. The facility census was 118. Review showed the facility did not provide a policy related to medication storage. 1. Observation on 04/16/26, at 12:05 P.M., showed the following:-Certified Medication Tech (CMT) N stood at a medication cart preparing medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food served was palatable when staff served food that was tough and the food that was not an appetizing temperature. The facility census was 118. Review of the facility's policy titled Food Temperatures, dated May 2015, showed the following: -Keep the temperature of hot foods no less than 140 degrees Fahrenheit (F) during meal service; -Hot foods should be at least 120 degrees F when served to the residents; -Food is not held in warm ovens more than 30 minutes before meal service; -It is recommended that food not be held on the steam table for longer than two hours before meal service; -Food items such as soup and pureed foods are never portioned ahead of time due to losing temperature; -Food carts are delivered immediately to the special care unit. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a complete and effective infection program when staff failed to follow Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO - microorganisms, predominantly bacteria that are resistant to one or more classes of antimicrobial agents. Although the names of certain MDROs describe resistance to only one agent, these pathogens are frequently resistant to most available antimicrobial agents) that employs targeted gown and glove use during high contact resident care activities) practices when providing wound care to three residents (Residents #4, #72, and #2) and when providing foley catheter (tubing placed to drain the bladder to outside the body into a collection bag) care for one resident (Resident #89). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen was clean and sanitary in non-food contact areas when the ceilings, shelving, walls, and floors were not kept clean and in good repair. The facility census was 118.1. Review of the facility's policy, Guidelines for Ceiling Vents, Doors, Walls, and Ceiling, dated May 2015, showed the following:-Walls, doors, vents, and ceiling must be free from chipped and or peeling paint and must be kept in good repair;-Walls, doors, vents, and ceiling must be washed thoroughly at least twice a year. Heavily soiled surfaces must be cleaned more frequently;-The type of surface will determine the type of detergent and cleaning method, following manufacturer's directions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely and complete urinary incontinence care for residents dependent on staff when staff did not check one resident (Resident #96) for incontinence for more than eight and one-half hours and did not provide complete and thorough perineal care for one resident (Residents #96). A sample of 29 residents was reviewed for personal hygiene and toileting needs. The facility census was 118. Review of the facility's policy titled Toileting Plans for Urinary Incontinence, undated, showed the following: -Purpose to provide guidance for the initiation and monitoring of and/or a toileting plan for the resident with urinary incontinence; -An incontinent management program involves checking the resident's continence status at regular intervals and providing incontinent care and garments as indicated by individual need. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a system was in place that clearly and consistently represented each resident's choice of code status (if they wished to receive cardiopulmonary resuscitation (CPR - lifesaving technique that's useful in many emergencies in which someone's breathing or heartbeat has stopped)) when staff failed to ensure two residents' (Residents #18 and #100) code status was consistent throughout the medical record. The facility census was 118. Review of the facility policy Advance Directive, dated [DATE], showed the following:-The facility will respect advance directives in accordance with state law; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure access to survey results to family, visitors, and residents when the prior survey results were not kept in a readily accessible, public location at all times of the day. The facility census was 118. Review showed the facility did not provide a policy regarding survey results accessibility. 1. Observations on 04/13/26, at 8:15 A.M., 04/14/26, at 10:40 A.M., and 04/16/26, at 8:30 A.M., showed the following:-A sign at the front entry desk of the building, approximately five feet high, stating the survey binder was available at the front desk;-No survey binder located or visible at the front desk. During an interview on 04/17/26, at 12:10 P.M., Registered Nurse (RN) C said the survey book was located at the front desk and should be available for anyone to view at any time. [...]

Inspectors wroteThe Administrator was notified on 01/29/26, at 5:29 P.M., of an Immediate Jeopardy (IJ) which began on 01/23/26. The IJ was removed on 01/30/26 as confirmed by surveyor on-site verification. 1. Please refer to F684, event ID 1DA88A-H2, exit date 02/02/26. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level.

Inspectors wroteBased on observations, interview, and record review , the facility failed to provide care per standards of practice when staff failed to promptly assess one resident (Resident #2) after a change in condition. The census was 123. [...]

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure an environment as free from accident hazards as possible when staff failed to identify, assess, investigate, and document bruising of an unknown source for one resident (Resident #1). The census was 123. Based on observations, interview, and record review the facility failed to ensure an environment as free from accident hazards as possible when staff failed to identify, assess, investigate, and document bruising of an unknown source for one resident (Resident #1). The census was 123. [...]

Inspectors wrote1. Please refer to event ID HP9H-H2, exit date 09/04/25, for citation details.

Inspectors wrote1. Please refer to event ID HP9H-H2, exit date 09/04/25, for citation details.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document regarding identification of potential pressure ulcers, failed to document timely assessment and tracking for potential pressure ulcers, and failed to care plan regarding newly identified possible pressure ulcers. The facility census was 116. Review of the facility policy titled Wound Care and Treatment, undated, showed prevention strategies include on-going skin assessment with weekly documentation of status, minimize dry skin by applying lotion, avoid massage, minimize friction and sheer through proper positioning, transferring, and turning, and develop and implement a method of communication position changing. Review of the facility policy titled Care Area Assessments, dated March 2015, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents' right to free from misappropriation was protected when medication of three residents (Resident #1, Resident #2, and Resident #3) went missing and were unaccounted for while in the possession of the facility. The facility had a census of 110. Review of the facility provided document titled, The National Consumer Voice Fact Sheet: Abuse, Neglect, Exploitation, and Misappropriation of Property, showed federal law gave each nursing home resident the right to quality care and quality of life. This included freedom from neglect, abuse, exploitation, and misappropriation of property. Review of the facility's Abuse Prohibition Protocol Manual: Identification, undated, showed the following: [...]

Inspectors wroteBased on record review and interviews, the facility failed ensure resident representatives were notified of changes in condition in a timely fashion when staff failed to document contact of one resident's (Resident #1) responsible party regarding changes in the resident's health condition. The facility census was 122. Review of the facility provided policy titled, Change in Condition of a Resident, dated 05/15/28, showed the following: -The facility is committed to timely recognition and response to significant changes in a resident's condition. [...]

Inspectors wroteBased on record review and interviews, the failed to provide care per standard of practice when staff failed to document continued monitoring and assessment on one resident (Resident #1) with an ongoing change of condition resulting in new medication orders and a follow-up x-ray. The facility census was 122. Review of the facility policy titled, Change in Condition of a Resident, dated 05/15/28,showed the following:-The facility is committed to timely recognition and response to significant changes in a resident's condition. [...]

Inspectors wroteBased on observation, record review, and interview, the maintain residents free from accident hazards when the facility failed to fully document fall events/investigations and to follow, update, develop, and ensure the accuracy of care plans and failed to implement new interventions in attempt to prevent falls consistent with the residents' physical and cognitive abilities for four residents (Residents #1, #3, #4 and #5). The facility census was 114. Review of the facility's policy Fall Prevention Manual, dated 06/2006, showed the following: -Identify all current residents at risk for falls at the beginning of the program using the facility risk assessment form or a chosen form. This should be done by the charge nurse, supervising registered nurse, or interdisciplinary care team (IDT); -Assess all new residents for fall risk on admission using an additional fall assessment screen. [...]

Inspectors wroteBased on interview and record review, the facility failed to promote each resident's right to self-determination when the facility failed to complete showers/bathing to meet resident preferences for two residents (Resident #1 and #2). The facility census was 114. Review showed the facility did not provide a policy regarding showers/bathing. 1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was sufficient staffing of the dietary department to ensure timely meal service for all residents when meals were served late to all units due to staffing shortages in the dietary department. The facility census was 94. Review of the document titled Mealtimes, provided by the facility, showed the following: -Breakfast 7:00 A.M. to 8:15 A.M.; -Lunch 11:30 A.M. to 1:00 P.M.; -Dinner 5:00 P.M. to 6:15 P.M. 1. During an interview on 11/21/23, at 8:27 AM, the Dietary Manager (DM) said the serving order of the meal carts was the Secure Unit, the Dining Room, Love 1 (100 hall), Hope (200 - 300 halls), and Love 2 (100 hall). 2. Review of Resident Council Minutes, dated 11/03/23, showed residents voice a concern with ,mealtimes getting later. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper food service practices were implemented in the kitchen to prevent the potential spread of food borne illness to all residents receiving meals in the facility when four residents (Residents #92, #200, #7, and #33) were served over easy non-pasteurized eggs creating risk for salmonella (bacteria) food borne illness; when bulk foods and refrigerated shakes were not labeled; when the dishwasher's wash temperature was below the minimum required temperature; when food from significantly dented cans was served, and when a dietary staff member failed to wear a hair covering in the kitchen. The facility census was 94. Review of the facility's policy titled Safe Food Handling, dated May 2015, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide selected food and beverage choices for six residents (Resident #51, #92, #71, #84, #83, and #89) out of a total of 20 sampled residents and 10 supplemental residents when residents' food preferences and selections for meals documented on their tray cards were not followed. The facility census was 94. 1. During an interview on 11/19/23, at 9:42 A.M., the Dietary Manager (DM) said residents were provided meal choices daily and utilized an Anytime menu. When breakfast trays were distributed, residents were sent paper menus with the meal selections for lunch and dinner that day and for breakfast the following day. Residents marked on the paper menus which foods and beverages they wanted, and the menus were returned to the kitchen via the residents' returned breakfast trays. [...]

Inspectors wroteBased on observations and interviews, the facility failed to provide a homelike environment to all residents when one resident (Resident #56) had a dresser with a broken drawer; when two residents (Residents #51 and #88) had broken blind slats; and when staff failed to maintain the Memory Care Unit in good repair. The sample size was 20 residents with a facility cenus of 94. 1. Observation and interview on 11/19/23, at 4:25 P.M., showed Resident #56's dresser drawer had a broken front panel on the right side of the dresser that prevented the resident from opening the drawer. The resident said he/she had requested several times that the drawer be repaired, but it was still broken. The drawer contained personal items and the resident was not able to open the drawer to access them. During an interview on 11/21/23, at 2:55 P.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and serve palatable food to seven residents (Residents #92, #71, #34, #51, #12, #28, and #200) out of a total of 20 sampled residents and 10 supplemental residents, when the food was not hot, not flavorful, overcooked, and served without seasoning and/or without condiments when residents received their meal trays. The facility census was 94. Review of the facility's policy titled Food Temperatures, dated May 2015, showed hot foods should be at least 120 degrees F (Fahrenheit) when served to the resident. Review of the facility's policy titled Food Preparation and Distribution, dated May 2015, showed the Dining Services Department will prepare foods by methods that are safe and sanitary while conserving nutritive value as well as enhancing flavor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a sanitary environment for all residents, staff and public when staff failed to ensure one of two exterior doors, on the secured dementia care unit, had proper weather stripping to prevent cold air, rodents, or bugs from entering the facility. The facility census was 94. 1. Observations on 11/19/23, at 9:53 A.M., of the secured dementia care unit, showed two exterior doors leading from the lounge out to a courtyard were noted to be missing weather stripping allowing a gap approximately 3/4th inches between the doors and approximately 7/16th inches underneath the doors. Four live crickets were observed on the floor in the lounge and two live crickets were observed in the dining room attached to the lounge. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #92), out of five sampled residents, resuscitation status as in accordance with the resident's and resident's wishes. The facility census was 94. Review of theCardiopulmonary Resuscitation (CPR - lifesaving technique that's useful in many emergencies in which someone's breathing or heartbeat has stopped), undated, document provided by the facility showed the following: -Purpose to establish circulation on a resident with absence of respirations and pulse; -Do not initiate CPR if a valid DNR (resident did not wish to receive CPR) order is in place. Review of the Advance Directive document, undated, provided by the facility showed the following: -The facility will respect advance directives in accordance with state law; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an environment free of accident hazards for all residents when the staff failed to lock two tub/shower rooms in the dementia care unit where one resident (Resident #75), of 13 sampled residents, wandered continuously and routinely pushed on doors throughout the dementia care unit. The facility census was 94. 1. Review of Resident #75's Census Record, located under the Resident Census tab of the electronic medical record (EMR), showed the following: -admission date of 08/25/22; -Diagnoses included Alzheimer's disease early onset. [...]

Inspectors wroteBased on interview and record review, the facility failed to electronically transmit encoded Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) from the facility to the Centers for Medicare & Medicaid Services (CMS) system within 14 days after completion for four residents (Resident #1, Resident #3, Resident #4, and Resident #22 ) out of a sample of 19 residents selected for review. The facility had a census of 58 residents. Record review showed the facility did not provide a policy regarding transmitting MDS data. 1. Record review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following information: -readmitted to the facility on [DATE]; -Diagnoses included anxiety disorder, chronic pain, and Alzheimer's disease. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide incontinent care for one resident (Resident #20) and failed to assist two residents (Resident #3 and Resident #19) with toileting or incontinent care in a timely manner. The facility census was 58. Record review of the facility's policy titled Perineal Care, dated March 2015, stated the purpose of perineal care is to cleanse the perinium (the area between the anus and the genitalia) and to prevent infection and odor. 1. Record review of Resident #20's face sheet (brief resident profile sheet) showed the following information: -readmitted to the facility on [DATE]; -admitted to hospice services on 7/20/2021; [...]

Inspectors wroteBased on observation, record review, and interview, the facility staff failed to ensure serving sizes met the approved menu when preparing pureed food for residents. The facility census was 58. Record review of the facility's Food Preparation and Distribution, dated May 2015, showed the following: -Recipes should be followed on each item prepared; -Adequate amount of food is prepared to serve residents, allowing for seconds; -Measured utensils are used to serve proportions as described on the menu. 1. Record review of the facility's puree menu showed residents should receive one slice of bread per resident for lunch on 9/16/21. Observations on 9/16/21, at 11:09 A.M., showed the following: -Dietary Aide (DA) D had the recipe book out and completed purees; -DA D put six pieces of bread into the blender and added milk; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two residents (Resident #47 and Resident #56) were routinely assessed for the ability to safely smoke independently and to store their smoking supplies in their rooms. The facility census was 58. Record review of the Non-Smoking Facility-Resident Agreement, undated, showed the following information: -The purpose of the agreement is to verify understanding that the facility was a non-smoking facility upon admission. Residents of the facility who choose to smoke/use tobacco (including smokeless tobacco, cigarettes, vape (a device used for inhaling vapor containing nicotine and flavoring) cigarettes, etc) must agree and acknowledge the following: -Resident must sign out in the leave of absence (LOA) binder; [...]