Sunterra Springs Springfield

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in a manner to prevent possible contamination when staff failed to wash hands and change gloves appropriately during food prep and service, and when staff failed to cover food on a rack. The facility was census was 37. 1. Review of the facility's policy titled, Maintaining a Sanitary Tray Line, revised April 2025, showed the following: -This facility prioritizes tray assembly to ensure foods are handled safely and held at proper temperatures in order to prevent the spread of bacteria that may cause food borne illness; -During tray assembly, staff shall use utensils such as tongs and serving spoons to handle food as much as possible; [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the facility implement their abuse and neglect policies when staff failed to complete a criminal background checks (CBCs) for one of ten sampled employees prior to their hire/start date in a facility with a census of 37. Review of the facility's policy, Abuse, Neglect and Exploitation, revised April 2025, showed the following: -It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property; -Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain an effective infection control program when staff failed to follow Enhanced Barrier Precautions (EBP-infection control measures used to reduce transmission of resistant organisms) while providing wound care for three residents (Resident #2, #197, and #14) and when staff failed to place a protective barrier beneath supplies in two resident rooms (Resident #197 and #14). The facility census was 37. Review of a facility policy titled Enhanced Barrier Precautions, dated April 2025, showed the following: -It is the facility policy to implement EBP for the transmission of multi-drug resistant organisms (MDRO); -All staff receive training on EBP upon hire and at least annually, and are expected to comply with all designated precautions; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a sanitary environment when staff failed to keep non-food contact surfaces of the floor, stove, warmer, and can opener clean and well maintained in the kitchen. The facility census was 37. Review of the 2013 Missouri Food Code showed the following information: -Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris; -The physical facilities shall be cleaned as often as necessary to keep them clean. Review of the facility's policy titled, Sanitation Inspection, revised April 2025, showed the following: -It is the policy of the facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary, and in compliance with applicable state and federal regulations; [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure each resident's choice of code status (the level of medical interventions a resident wishes to have if their heart or breathing stops) was clearly and consistently documented throughout the resident's medical record when staff did not update the care plan for one resident (Resident #36) and when the physician did not date the code status form for one resident (Resident #140) out of a sample of two residents. The facility census was 37. Review of the facility's policy titled, Communication of Code Status, revised [DATE], showed the following: -It was the policy of the facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, the facility will implement procedures to communicate a resident's code status to those individuals who need to know this information; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure care was provided in accordance with standards of practice when staff failed to consistently document full assessments of a wound, failed to document physician notification of wound deterioration and resident refusals of treatment, failed to maintain a current and accurate wound care plan, and failed to fully document regarding new wounds and failed to document physician notification of new wounds for one resident (Resident #37). The facility also failed to failed to monitor blood glucose level four times daily per physician's order for one resident (Resident # 197). The facility census was 37. 1. Review of the facility's policy titled, Documentation of Wound Treatments, revised April 2025, showed the following: [...]

Inspectors wroteBased on record review and interview, the facility failed to obtain ensure catheter (a tube inserted into the bladder, allowing your urine to drain freely) use per standards of practice when staff failed to obtain a complete order indicating the size of the catheter used and a corresponding diagnosis and when staff failed to document monitoring and care of the catheter as ordered for one resident (Resident #14) out of a sample size of 13 residents. The facility census was 37. Review of a facility policy titled, Appropriate Use of Indwelling Catheters, dated May 2025, showed the following: -An indwelling catheter will be utilized only when a resident's clinical condition demonstrates that catheterization was necessary; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care for all residents on oxygen per professional standards of practice when staff failed to administer oxygen per physician orders for one resident (Resident #142) out of a sample of four residents. The facility census was 37. Review of the facility's policy titled Oxygen Administration, revised April 2025, showed the following: -Oxygen is administered to residents who need it consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences; -Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control; [...]

Inspectors wroteBased on interview and record review, the facility failed ensure pain services provided per standards of practice when staff failed to document providing appropriate pain medication to address pain in a timely manner for one resident (Resident #93) admitted from the hospital after knee replacement surgery. The facility census was 37. Review of the facility policy admission Orders. revised 04/2025, showed the following: -A physician must personally approve, in writing, a recommendation that an individual be admitted to a facility. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide written and/or verbal orders for the resident's immediate care and needs; -The written and/or verbal orders should include at a minimum dietary, medication orders if indicated, and routine care orders; [...]

Inspectors wroteBased on record review and interview, the facility failed to provide pharmacy services per standards of practice when staff failed to administer medications after receipt for one newly admitted resident (Resident #93) and when staff failed to properly document the removal of Fentanyl patches (a narcotic pain medication) for one resident (Resident # 197). The facility census was 37 residents. 1. Review of the facility policy admission Orders. revised 04/2025, showed the following: -A physician must personally approve, in writing, a recommendation that an individual be admitted to a facility. A physician, physician assistant, nurse practitioner or clinical nurse specialist must provide written and/or verbal orders for the resident's immediate care and needs; -The written and/or verbal orders should include at a minimum dietary, medication orders if indicated, and routine care orders. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure a medication error rate of less than 5% when staff made 4 errors out of 45 opportunities resulting in an 8.8% error rate affecting one resident (Resident #142). The facility had a census of 37. Review of a facility policy titled Medication Administration, dated April 2025, showed the following: -Medications are administered as ordered by the physician and in accordance with professional standards of practice; -Obtain and record vital signs per physician orders; -Hold medication for those vital signs outside the physician's prescribed parameters; -Ensure the six rights of medication administration are followed which are right resident, right drug, right dosage, right route, right time, and right documentation; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care per professional standards related to pressure ulcers (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) when the facility staff failed to document a full assessment of wounds upon admission, failed to obtain physician's orders for treatment and interventions of wounds, and failed to update the care plan regarding skin breakdown intervention changes for one resident (Resident #1) out of 7 sampled residents. The facility census was 37. Review of the facility's policy titled, Skin Assessment, dated 07/21, showed the following information: -A full body, or head to toe skin assessment will be conducted by a licensed or registered nurse (RN) upon admission/re-admission and weekly thereafter. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegations of possible abuse were reported timely when staff failed to report an allegation of abuse involving one resident (Resident #3) to the state survey agency (Department of Health and Senior Services (DHSS)) within the required two hour time frame. The facility census was 36. Review of the facility's policy Abuse, Neglect and Exploitation, revised 06/2023, which showed the following: -Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care per professional standards related to pressure ulcers when staff failed to document a full assessment of wounds upon admission; failed to document on-going full assessments of wound to assist with monitoring and possible decline of wound; failed to obtain physician's orders for treatment and failed to follow ordered treatments of pressure ulcers; and failed to care plan and update care plans regarding actual skin breakdown and intervention changes for two residents (Residents #1 and #2) of six sampled residents. The facility census was 36. Review of the facility policy Skin Assessment, revised 7/2024, showed the following: -A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in a manner to protect the food from possible contamination when staff failed to store food in sealed containers, when staff stacked dishes while still wet, and when staff failed to ensure the dishwasher rinsed the dishes at the recommended temperature. This had the potential to affect all residents who consumed food from the facility kitchen. The facility had a census of 37 residents. 1. Review of the 2013 Missouri Food Code showed food shall be protected from contamination by storing the food in a clean, dry location and where it is not exposed to splash, dust, or other contamination. Observations of the kitchen on 11/06/23, at 8:45 A.M., showed the following: -An opened bag of parmesan cheese in the walk in refrigerator with a binder clip on it. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's choice of code status (the type of emergency treatment a person would or would not receive if their heart or breathing were to stop) was accurate and matched throughout the record when three residents' (Resident #135, #133, & #132) code statuses (do not resuscitate (DNR - the resident did not wish to received cardiopulmonary resuscitation (CPR - an emergency procedure consisting of chest compressions often combined with artificial ventilation) or CPR (full code status)) failed matched through the medical record. A sample of 13 residents was selected for review out of a facility census of 37. Review of the facility policy titled Communication of Code Status. dated June 2023, showed the following: -It is the policy of this facility to adhere to residents' rights to formulate advance directives; [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure the interdisciplinary team approved all self-administration of medication, obtained orders for the self-administration of medication, and care planned the self-administration for two residents (Resident #182 and #87) with a medication at bedside. The facility census was 37. Review of the facility policy titled Resident Self-Administration of Medication, dated June 2023, showed the following information: -It is the policy of this facility to support each resident's right to self-administer medication; -A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely; - Each resident is offered the opportunity to self-administer medications during the routine assessment by the facility's interdisciplinary team; [...]

Inspectors wrote\\ Based on record review and interview, the facility failed to complete a discharge Minimum Data Sets (MDS - a federally mandated comprehensive assessment instrument completed by facility staff) for one resident (Resident #6) in a timely manner. The facility census was 37. Review showed the facility did not provide a policy related to MDS assessments. 1. Review of Resident #6's face sheet showed an admission date of 06/30/23. Review of the resident's electronic medical record (EMR), census tab, showed the following: -admission date of 06/08/23; -discharge date of 06/30/23 with return not anticipated. Review of the resident's EMR progress notes showed the following: -On 06/29/23, at 5:00 P.M., Social Services documented the resident planned to discharge home with family and any needed services and/or equipment were in place. Family planned to pick up the resident at 4:00 P.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5% when the facility staff made two errors out of 27 opportunities resulting in an error rate of 7.4% when staff failed to administer the correct insulin type for one resident (Resident #132); failed to administer the correct insulin dosage for one resident (Resident #134); and failed to follow manufacturer guidelines and did not prime the insulin pen prior to insulin administration for two residents (Resident #132 and #134). The facility census was 37. Review of the facility policy titled Medication Administration, dated June 2023, showed the following information: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident were free of significan medication erros when failed to administer the correct insulin type for one resident (Resident #132); failed to administer the correct insulin dosage for one resident (Resident #134); and failed to follow manufacturer guidelines and did not prime the insulin pen prior to insulin administration for two residents (Resident #132 and #134). The facility census was 37. Review of the facility policy titled Medication Administration, dated June 2023, showed the following information: -Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection; [...]

Inspectors wroteBased on interview and record review, the facility failed maintain all residents records per standard of practice when the facility failed to document administration and placement of a Fentanyl patch in the Medication Administration Record (MAR) for one resident (Resident #183). The facility census was 37. 1. Review of showed the facility did not provide a policy regarding documentation of medication administration. Review of Resident #183's face sheet (a brief profile) showed the following: -admission date of 10/27/23; -Diagnoses included of spinal stenosis of sacral and sacrococcygeal region (narrowing of the spine causing compression of the bottom of the spine near the tailbone) and spondylosis without myelopathy or radiculopathy of lumber region (osteoarthritic changes affecting the triad of joints forming the spinal columns). [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain an effective infection prevention program when staff failed to ensure two residents (Residents #5 and #82) and three staff members were tested for tuberculosis (a type of bacterial infection mainly affecting the lungs and is a communicable disease) per standards of practice and current guidance. A sample of 13 residents was selected for review out of a facility census of 37. 1. Review showed the facility did not provide a policy regarding TB testing or monitoring of residents. Review of the Centers for Disease Control (CDC) guidance for resident TB testing showed the following: -Skin tests should be administered to all new residents as soon as their residency begins unless they have documentation of a previous positive reaction; [...]

Inspectors wroteF602 Based on observation, interview, and record review, the facility the facility failed to keep all residents free from misappropriation of property when one staff (Registered Nurse (RN) A) took medications belonging to one resident (Resident #1). The census was 35. Please refer to event OSDG11 for full survey text. The surveyor interviewed seven residents, 12 staff, and one family members,and reviewed five medical records, including the record of [NAME] Revie. The facility conducted proper pre-employment screening of the alleged perpetrator (AP), [NAME], prior to hiring him. This screening included, application for employment, Missouri Certified Nurse Assistant Registry check, the Family Care Safety Registry Check, and an exclusions screening. In addition, the facility provided Resident Rights, and Abuse and Neglect training. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide all resident with care in accordance with professional standards when staff failed to follow physician orders and did not administer a medication as ordered for four days for one resident (Resident #1). The facility census was 35. Review of the facility policy, Medication Administration, revised 06/2023, showed the following information: -Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician, in accordance with the professional standards of practice, and in a manner to prevent contamination or infection; -Keep medication cart clean, organized, and stocked with adequate supplies; -Review Medication Record Administration (MAR) to identify medication to be administered; -Administer medication as ordered; -Sign MAR after administered; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have practices in place to ensure food served to residents was palatable, attractive, and at an appetizing temperature. The facility had a census of 38. 1. During an interview on 7/27/2021, at 9:50 A.M., Resident #266 said he/she received cold green beans on the first evening meal when he/she came to the facility. During the resident council meeting on 7/27/2021, at 2:00 P.M., Resident #220 said the following: -Breakfast is always cold on 100 hall; -The biscuits and gravy are so cold, the grease sticks to the roof of his/her mouth. Observation on 7/28/2021, at 12:25 P.M., of a sampled food tray pulled from the 200 hall cart showed the following: -The chicken sandwich and roasted potatoes were both cold and unappetizing. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper infection control practices based on facility policy and acceptable standards of practice when all staff did not properly wear face coverings in the rooms of residents and common areas of the facility during a Coronavirus disease 2019 (COVID-19 - an infectious disease caused by severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2)) pandemic. Additionally, staff failed to properly clean and disinfect glucometers (machine used to test blood glucose levels) between uses for four residents (Residents #1, #121, #123 and #223). The facility census was 38. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate one resident's (Resident #267) intolerances and food preferences. The facility census was 38. Record review of the facility's policy titled, Resident Food Preferences, dated 11/17/2017, showed the following information: -Upon the resident's admission, or within twenty-four hours after his/her admission, the dietician or nursing staff will identify a resident's food preferences. When possible, this will be done by direct interview with the resident; -The resident's clinical record (orders, care plan, or other appropriate locations) will document the resident's likes and dislikes and special dietary instructions or limitations such as altered food consistency and caloric restrictions; -The dietician will visit residents periodically to determine if revisions are needed regarding food preferences; [...]