Springs Village Care Center

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#1) of four residents were provided the care and services necessary to ensure a safe discharge from the facility to the community out of 11 sample residents. Specifically, the facility failed to allow Resident #1 to return to the facility after an unplanned discharge to the hospital.

Inspectors wroteBased on record review and interviews, the facility failed to ensure prompt action was taken upon the filing of a grievance of a group. Specifically, the facility failed to make prompt efforts to resolve resident grievances about missing clothing that were brought up by the resident council.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on one of two units. Specifically, the facility failed to: -Ensure staff wore the appropriate personal protective equipment (PPE) when providing care for Resident #62, Resident #27 and Resident #30, who were on enhanced barrier precautions (EBP); and, -Ensure Resident #46 followed appropriate infection control procedures when emptying her own indwelling catheter.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the resident's right to be informed of, and participate in his or her treatment for one (#77) of two residents out of 32 sample residents reviewed for the right to be informed and make treatment decisions. Specifically, the facility failed to inform Resident #77 and/or her legal representative of her laboratory (lab) bloodwork values before being sent to the hospital for a transfusion or her lab values after returning from the hospital.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure the self-administration of medications was clinically appropriate for one (#46) of one resident out of 32 sample residents. Specifically, the facility failed to ensure Resident #46 was assessed for self-administration of Visine eye drops.

Inspectors wroteBased on record review and interviews, the facility failed to ensure three (#44, #45 and #41) of four residents were free from chemical restraint out of 32 sample residents. Specifically, the facility failed to: -Document resident specific care approaches, to include medication specific target behaviors and person-centered interventions for Resident #44, Resident #45 and Resident #41's psychotropic medications; and, -Document consistent behaviors or a physician's rationale for Resident #44, Resident #45 and Resident #41 to justify the continued use of psychotropic medications.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide provide assistance with activities of daily living (ADLs) to ensure the highest practicable quality of life for one (#45) of two residents reviewed out of 32 sample residents. Specifically, the facility failed to provide the necessary assistance for Resident #45, who required physical assistance with meals due to tremors.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure an environment free from risk of accident and hazards for two (#84 and #6) of five residents reviewed for accident hazards out of 32 sample residents. Specifically, the facility failed to: -Ensure the grab bar/hand rail in Resident #84's bathroom was repaired and a second one installed, per the recommendations of the occupational therapist (OT) as a fall intervention; and, -Ensure Dakin's solution (a topical antiseptic used in wound treatment) was not left unsecured in Resident #6's room.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#74) of two residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain the highest practicable mental and psychosocial wellbeing out of 32 sample residents. Specifically, the facility failed to monitor Resident #74, who had a history of suicide attempts, for worsening signs and symptoms of identified depression.

Inspectors wroteBased on observations and interviews, the facility failed to ensure medications and biologicals were stored in accordance with accepted professional standards for one of two medication storage refrigerators. Specifically, the facility failed to ensure controlled medications were in a locked storage container that was permanently secured to the inside of the medication storage refrigerator.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for one (#5) of three residents reviewed out of 16 sample residents. Specifically, the facility failed to ensure Resident #5 received timely incontinence care.

Inspectors wroteBased on record review and interviews, the facility failed to manage pain in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (#4) of three residents out of 16 sample residents. Specifically, the facility failed to ensure Resident #4 was administered the correct pain medication per physician's orders and failed to provide non-pharmacological interventions prior to administering PRN pain medication.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents with a pressure ulcer received the necessary treatment and services according to professional standards of practice to prevent or heal pressure injuries for one (#2) of three residents reviewed for pressure ulcers out of 16 sample residents. Specifically, for Resident #2, the facility failed to: -Ensure there was a physician's order in place for treating the resident's left knee wound; -Ensure staff utilized knee protectors, per the resident's care plan, when repositioning the resident to offload pressure; -Ensure staff appropriately cleansed the resident's left knee wound during a dressing change; and, -Ensure staff followed appropriate techniques when removing the resident's old knee wound dressing to avoid causing potential damage to the wound bed.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to manage pain in a manner consistent with professional standards of practice for one (#13) of four residents reviewed for pain out of 16 sample residents. Specifically, the facility failed to: -Ensure a thorough pain assessment was completed for Resident #13 which included recognizing the onset, presence of and characteristics of pain; and, -Offer non-pharmaceutical interventions before administering as needed pain medication.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infections. Specifically, the facility failed to: -Ensure proper infection control practices were followed for wound care; and -Ensure hand hygiene was performed appropriately.

Inspectors wroteBased on record review and interviews, the facility failed to report alleged violations of potential abuse to the State Survey and Certification Agency in accordance with state law for one (#1) of three residents reviewed for abuse out of three sample residents. Specifically, the facility failed to report an allegation of sexual abuse to the State Agency made by Resident #1.

Inspectors wroteBased on record review and interviews, the facility failed to investigate an allegation of abuse involving one (#1) of three residents reviewed for abuse out of three sample residents. Specifically, the facility failed to conduct an investigation when Resident #1 reported an allegation of abuse against certified nurse aide (CNA) #1.

Inspectors wroteBased on record review and interviews, the facility failed to provide notice before discharge for one (#1) of three residents reviewed for discharge out of four sample residents. Specifically, the facility failed to provide Resident #1 and her responsible parties, an appropriate notice of discharge that included: -The reason for transfer or discharge; -The effective date of transfer or discharge; -A statement of the resident's appeal rights, including the name, address (mailing and email) and telephone number of the entity which receives such requests; -Information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; and, -The name, address (mailing and email) and telephone number of the Office of the State.

Inspectors wroteBased on record review and interviews, the facility failed to permit residents transferred to another facility to return to the facility for one (#1) of three residents reviewed for transfers out of four sample residents. Specifically, the facility failed to readmit Resident #1 to the facility following a transfer to the hospital.

Inspectors wroteBased on record review and interviews, the facility failed to ensure two (#8 and #52) of two out of 47 sample residents had the right to a dignified existence. Specifically, the facility failed to ensure call lights were answered timely for Resident #8 and Resident #52, who were both dependent on staff for assistance. Resident #8 said she felt lonely and ignored when staff took over an hour to answer her call light and Resident #52 said she felt humiliated when her call light was not answered timely resulting in an episode of incontinence.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure one (#32) of four out of 47 sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to ensure Resident #32, who had a history of falls, was a high fall risk and was identified by the facility upon admission to be impulsive and not ask for assistance, received the care and services indicated in her comprehensive care plan. The facility failed to ensure Resident #32 received the supervision required to prevent the resident from getting up without assistance. The facility failed to implement the interventions effectively and identify the trend that the resident's falls focused around the resident using the bathroom. On 4/24/23 and 4/26/23, Resident #32 sustained a fall in the bathroom. The resident complained of severe pain to the left shoulder. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to manage pain in a manner consistent with professional standard of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (#3) of three residents reviewed for pain out of 47 sample residents. Resident #3 had a diagnosis of schizophrenia (brain disorder), developmental disorder, anxiety, post-traumatic stress disorder (PTSD), restless leg syndrome, and pain. In an interview on 9/11/23 the resident, holding her left knee and grimacing, said the knee pain had started a couple of months ago. Resident #3 said her pain level had increased on 9/10/23 and progressively gotten worse. It was more intense, frequent, and extreme which made it difficult for her to complete her daily activities of living and to attend facility activities. [...]

Inspectors wroteBased on observations, interviews and record review the facility failed to store, prepare, distribute and serve food in a sanitary manner in the kitchen. Specifically, the facility failed to: -Ensure food was labeled and dated and disposed of timely in the walk-in refrigerators, dry storage and reach-in refrigerator in the main kitchen and in four nourishment rooms; -Ensure the handwashing sink was only used for handwashing; -Ensure cooked food items were monitored and cooled properly; and, -Ensure proper hand hygiene.

Inspectors wroteBased on interviews and record review, the facility failed to ensure three (#10, #17 and #46) of three residents reviewed were provided prompt efforts by the facility to resolve grievances out of 47 sample residents. Specifically, the facility failed to: -Provide a resolution to Resident #10 and Resident #17's voiced grievances; and, -Provide a resolution to Resident #46's filed grievance form.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for three (#5, #35 and #16) of seven residents reviewed out of 47 sample residents. Specifically, the facility failed to: -Ensure Resident #5 and Resident #35 received timely incontinence care; and, -Ensure Resident #16 received bathing according to her preference and plan of care.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater. Specifically, the medication administration observation error rate was 51.52% or 17 errors out of 33 opportunities.

Inspectors wroteBased on observations and interviews the facility failed to ensure two out of four medication refrigerators stored narcotic medications in accordance with accepted professional standards and that only licensed staff had access to resident-prescribed medications. Specifically, the facility failed to: -Ensure controlled medications were in a locked storage area that was permanently secured to the refrigerator; and, -Ensure the medication cart was locked when the nurse was not at the cart.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure activities designed to support residents physical, mental and psychosocial well-being were provided for one (#5) or six residents reviewed for activities out of 47 sample residents. Specifically, the facility failed to ensure Resident #5 was provided activities and developed a comprehensive care plan which addressed the resident's socialization and activity needs.

Inspectors wroteBased on record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain hearing abilities for two (#32 and #10) of two residents reviewed for hearing out of 47 sample residents. Specifically, the facility failed to ensure Resident #32 and Resident #10 were offered audiology services.

Inspectors wroteBased on record review, observations and interviews, the facility failed to provide the necessary treatment and services to treat and prevent pressure injuries from occurring for two (#8 and #35) of three residents out of 47 sample residents. Specifically, the facility failed to: -Provide treatments as ordered by the physician, implement preventative measures and implement physician recommendations for treatment timely for Resident #8; and, -Ensure timely identification of a Stage 1 pressure injury for Resident #35.

Inspectors wroteBased on observation, record review and staff interviews, the facility failed to ensure residents with a feeding tube received appropriate treatment and services to prevent complications for one (#5) of one resident reviewed for tube feeding out of 47 sample residents. Specifically, the facility failed to ensure Resident #5 received his tube feeding as ordered by the physician.

Inspectors wroteBased on record review and interviews, the facility failed to prevent a significant medication error for two (#35 and #67) of 15 residents reviewed out of 47 sample residents. Specifically, the facility failed to: -Ensure an epilepsy medication was administered in a timely manner and according to physician orders for Resident #35; and, -Ensure insulin was administered in a timely manner and according to physician orders for Resident #67.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide each resident with nourishing, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the allergens and preferences of each resident for on (#227) of one resident out of 47 sample residents. Specifically, the facility failed to ensure Resident #227's allergen to gluten was not served to him.

Inspectors wroteBased on observations and interviews, the facility failed to ensure beverages were provided and within reach for one resident (#35) of one resident reviewed for hydration out of 47 sample residents. Specifically, the facility failed to offer and assist Resident #35 fluids throughout the day.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to ensure proper hand hygiene was conducted during peri-care and wound care.