The Waters of Springfield LLC

Inspectors wroteBased on policy review, American Heart Association (AHA) Adult Basic Life Support Algorithm for Healthcare Professionals dated 2025, Rules of the Tennessee Board of Nursing review, Tennessee Code Annotated (TCA) rules review, medical record review, 911 audio recording review, facility video footage review, facility investigation, Employee file review, Emergency Medical Services (EMS) record report review, County Emergency Communication and interviews, the facility failed to provide continuous Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR) for 1 of 3 (Resident #1) sampled residents reviewed for CPR. Resident #1 was a vulnerable resident who was found on [DATE] at 6:07 AM, in the bathroom, on his knees slumped over the commode unresponsive. [...]

Inspectors wroteBased on policy review, refrigerator temperature logs, observation, and interview, the facility failed to ensure food was stored, handled, prepared, and served under sanitary conditions, when food was found unlabeled and undated, baking pans contained carbon buildup, a grease trap under the stove was found with aluminum foil torn and with a large amount of food debris, and when the walk-in cooler temperatures were consistently above 41 degrees. The census was 37 with 34 of those residents receiving a meal tray from the kitchen.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to provide a private space that prevented interference for the resident group meeting (Resident #1, #9, #11, #25 and #33) for 1 of 1 (Resident Council) sampled group reviewed.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to be present for supervision and assistance in the dining room for 2 of 7 (Resident #6 and #8) residents in the dining room during dining.

Inspectors wroteBased on facility policy review, observation, and interview, the facility failed to ensure measures to prevent the spread of infection were followed for 3 of 6 (Resident #2, #25, and #26) residents observed for medication administration when 3 of 3 (Registered Nurse (RN) B, Licensed Practical Nurse (LPN) C and LPN D failed to perform appropriate hand hygiene during medication administration.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to label and date food items in a walk-in refrigerator. This had the potential to affect all residents who received food from the kitchen.

Inspectors wroteBased on record review, facility document review, facility policy review, and interview, the facility failed to protect the residents' right to be free from physical abuse perpetrated by other residents for 3 (Residents #33, #198, and #48) of 9 residents reviewed for abuse. Specifically, on 03/17/2024, Resident #29 hit Resident #33 with a meal tray. On 11/29/2023, Resident #10 struck Resident #198 on the right forearm and grabbed and pulled the resident's hair. On 12/19/2023, Resident #15 struck Resident #48, which caused the resident to fall backwards out of their wheelchair.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) for 1 (Resident #24) of 2 sampled residents reviewed for beneficiary notification.

Inspectors wroteBased on record review, interview, document review, and facility policy review, the facility failed to report an allegation of abuse to the State Survey Agency (SSA) for 1 (Resident #36) of 7 sampled residents reviewed for abuse.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to arrange a follow-up appointment with an ophthalmologist based on a recommendation made by the optometrist for 1 (Resident #25) of 2 sampled residents reviewed for vision services.

Inspectors wroteBased on policy review, medical record review, document review, timeanddate.com, and interview, the facility failed to ensure all residents received supervision to ensure a safe environment that was free of accident hazards for 1 (Resident #20) of 3 sampled residents reviewed for accident hazards/supervision. On 08/06/2022 at approximately 9:00 PM, an agency nurse entered the code on the door keypad and let Resident #20 out of the facility. Approximately 30 minutes later, the facility was notified Resident #20 was found in the parking lot of another facility, less than half a mile from the facility. The failure placed Resident #20 in at risk for harm, serious injuries, or death, resulting in Immediate Jeopardy. [...]

Inspectors wroteBased on interviews, record reviews, document reviews, and facility policy review, the facility failed to ensure narcotic medication was not diverted for 1 (Resident #6) of 7 sampled residents reviewed for abuse. The facility further failed to ensure money that belonged to 1 (Resident #17) of 7 sampled residents reviewed for abuse was not misappropriated by the staff.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to report allegations of abuse and misappropriation of resident report that involved 3 (Residents #1, #2, and #17) of 7 sampled residents reviewed for abuse and misappropriation of resident property.

Inspectors wroteBased on facility policy, medical record review, observations and interview, the facility failed to maintain a medication error rate of less than 5%. There were two (2) medication errors in 27 opportunities for a medication error rate of 7.4%. This deficient practice affected 2 of 2 (Resident #23 and Resident #24) sampled residents reviewed for medication administration.

Inspectors wroteBased on medical record review, document review and interview, the facility failed to implement a quality assurance plan when concerns were identified related to misappropriation of resident funds and controlled medications for 2 of 7 (Resident #6 and Resident #17) sampled residents reviewed for misappropriation.

Inspectors wroteBased on policy review, medical record review, observation and interview, the facility failed to follow guidelines and wear the proper personal protective equipment (PPE) when care was provided for 1 of 3 (Resident #11) residents observed who required enhanced barrier precautions.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to ensure residents' personal property was maintained for 2 of 2 sampled residents (Resident #10 and #22) reviewed for personal property.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to provide a comprehensive Care Plan related to anticoagulants and diuretics for 2 of 5 sampled residents (Resident #10 and #25) reviewed for unnecessary mediations.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to implement neurological (neuro) checks after an unwitnessed fall for 1 of 2 sampled residents (Resident #5) reviewed for falls.

Inspectors wroteBased on policy review, Certified Nursing Assistant (CNA) training record review, and interview, the facility failed to ensure 8 of 16 CNAs (CNA #1, #2, #3, #4, #5, #6, #7, and #8) employed for a full year received at least 12 hours of in-service training.