Violet Springs Health Campus

Inspectors wroteBased on observation, record review, interviews and facility policy review, the facility failed to ensure three residents (#65, #79 and #93) who were dependent on staff received appropriate grooming. Additionally, the facility failed to ensure one resident (#91) who required assistance from staff received routine bathing. This affected four residents (#65, #79, #91 and #93) of four residents received for activities of daily living (ADL). The facility census was 54. Findings Include: 1. Review of the medical record for Resident #91 revealed an initial admission date of 01/06/26 with the diagnoses including but not limited to hypertension, hyperlipidemia, prediabetes, severe tricuspid regurgitation, cardiomegaly with aortic arch calcifications, purulent cellulitis of left lower extremity, atrial fibrillation and congestive heart failure. [...]

Inspectors wroteBased on observation, medical record review and interviews, the facility failed to ensure one resident (#52) who was utilizing a c-pap machine had a physician's order for the use of the c-pap machine. Additionally, the facility failed to ensure one resident (#93) received oxygen therapy as physician ordered and failed to store nebulizer medication delivery systems appropriately for two residents (#41 and #43). This affected four residents (#41, #43, #52 and #93) of four residents reviewed for respiratory care and treatment. The facility census was 54. Findings Include:1. Review of the medical record for Resident #93 revealed an initial admission date of 01/10/26 with the diagnoses including but not limited to acute respiratory failure, chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease, severe morbid obesity. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure Resident #86, #88, #91, and #93's medical record reflected their diagnoses and failed to document Resident #91's treatment time accurately. This affected four residents (#86, #88, #91, and #93) of 24 records reviewed. The facility census was 54.

Inspectors wroteBased on medical record review, interviews and facility policy review, the facility failed to ensure one resident (#91) was bathed according to their preference. This affected one resident (#91) of four residents reviewed for activities of daily living (ADL). The facility census was 54. Findings Include:Review of the medical record for Resident #91 revealed an initial admission date of 01/06/26 with the diagnoses including but not limited to hypertension, hyperlipidemia, prediabetes, severe tricuspid regurgitation, cardiomegaly with aortic arch calcifications, purulent cellulitis of left lower extremity, atrial fibrillation and congestive heart failure. Review of the resident's admission life enrichment assessment dated [DATE] revealed it was very important to the resident to choose between a tub bath, shower, bed bath or sponge bath. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policy the facility failed to regularly assess and obtain a physician order for a restraint for Resident #8. This affected one resident (#8) of one resident reviewed for restraints. The facility census was 54.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure psychotropic medications used on an as needed basis (prn) were limited to 14 days, unless the prescribing physician and/ or advanced level provider documented a rationale in the medical record and indicated the duration for the prn order. This affected one resident (#45) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, medical record review, review of activity calendar, and review of policies revealed the facility failed to provide preferred independent activities to Resident #86, and failed to provide evidence Resident #49 and Resident #86 were invited to or attended group activities. This affected two residents (#49 and #86) of two residents reviewed for activities. The facility census was 54.

Inspectors wroteBased on record review, observation, interview, and policy review, the facility failed to ensure a resident with non-pressure wounds had wound treatments provided timely as per physician's orders and another resident received treatment to dry, flaky skin from eczema as per physician's orders. This affected two residents (#65 and #93) of four residents reviewed for non-pressure skin conditions.

Inspectors wroteBased on medical record review, observations, and interviews, the facility failed to identify, assess, and implement interventions to prevent pressure ulcers for Resident #40, and failed to ensure pressure relieving interventions were in place for Resident #91. This affected two residents (#40 and #91) of the three residents reviewed for pressure ulcers. The facility census was 54.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to provide double portions as ordered for Resident #3 and failed to provide adequate meal assistance and hydration for Resident #79. This affected two residents (#3 and #79) of the seven residents reviewed for nutrition. The facility census was 54.

Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to ensure their medication error rate did not exceed 5%. The facility had two errors out of 30 opportunities for a medication error rate of 6.6%. This affected one resident (#61) of three residents reviewed for medication administration observations.

Inspectors wroteBased on record review, observations, and interviews, the failed to ensure medications were not kept at bedside without orders for Resident #21 and #43. This affected two residents (#21 and #43) of the three residents reviewed for medications. This facility census was 54.

Inspectors wroteBased on observation, interview, and medical record review the facility failed to prepare a vegetarian menu in advance and follow the menu for Resident #85. This affected one resident (#85) of five residents reviewed for dining. The facility census was 54.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the appropriate diet texture as ordered for Resident #65 and #67. This affected two residents (#65 and #67) of twelve reviewed for dining. The facility census was 54.

Inspectors wroteBased on observations, medical record review, interviews and facility policy review, the facility failed to maintain appropriate infection control practices to prevent the potential spread of infection. This affected two residents (#91 and #93) of 22 sampled residents. The facility census was 54. Findings Include:1. Review of the medical record for Resident #93 revealed an initial admission date of 01/10/26 with the diagnoses including but not limited to acute respiratory failure, chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease, severe morbid obesity. right bundle branch block, bifascicular block, ventricular tachycardia, gout, Parkinson's disease, benign prostatic hyperplasia, hyperlipidemia, hypothyroidism, constipation and prediabetes. [...]

Inspectors wroteBased on observation, interview, and medical record review the facility failed to ensure Resident #49's call light was kept within reach. This affected one resident (#49) of five reviewed for environment. The facility census was 54.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy review, the facility failed to document and address a resident representative grievance timely. This affected one (Resident #54) of three resident grievances reviewed. The census was 52. Findings Include:Record review for Resident #54 revealed he was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on closed medical record review, hospital record review, review of an Emergency Medical Services (EMS) run report, staff interview, and facility policy review, the facility failed to timely and adequately identify an acute change in medical condition resulting in a delay in medical intervention/hospital care for Resident #54 resulting in the resident being found unresponsive and requiring cardiopulmonary resuscitation (CPR). Actual harm occurred beginning during the night shift on [DATE] when staff failed to identify an acute change in Resident #54's condition to ensure timely and adequate medical intervention was provided. At 6:00 A.M. Resident #54 sustained an unwitnessed fall. Resident #54 had an emesis (vomiting) and voiced complaints of not feeling well. The resident did not consume any breakfast and continued vomiting. [...]

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to ensure fall interventions were in place for a resident at risk for falls. This affected one resident (Resident #54) out three residents reviewed for falls. The facility census was 52. Findings Include: Review of Resident #54's medical record revealed admission date [DATE] with the following diagnoses including but not limited to acute respiratory failure, congestive heart failure (CHF), cardiomegaly, atrial fibrillation, and history of hemorrhagic stroke. Resident #54 expired on [DATE]. Review of Resident #54's admission fall risk evaluation dated [DATE] revealed Resident #54 was at risk for falling related to poor mobility, history of stroke, and weakness. [...]

Inspectors wroteBased on employee file review and staff interview, the facility failed to ensure State Tested Nursing Assistants (STNAs) received annual performance reviews. This had the potential to affect all residents residing in the facility. The facility census was 46 residents. Findings Include: Review of STNA #139's employee file revealed a date of hire of 05/30/23. STNA #139's file contained a 90-day evaluation dated 11/10/23. STNA #139's file did not include an annual performance appraisal as of 10/17/24. Interview on 10/17/24 at 10:25 A.M. with Business Office Staff (BOS) #136 confirmed there was no annual evaluation present in the employee file for STNA #139. BOS #136 stated they were not required to do evaluations after the 90-day evaluation. Interview on 10/17/24 at 12:00 P.M. with the administrator confirmed there was no annual evaluation in the employee file for STNA #139.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure State Tested Nurse Aides (STNAs) completed the minimum required 12 hours of in-servicing a year. This affected one (STNA #139) of two STNAs reviewed for required in-services. This had the potential to affect all residents in the facility. The facility census was 46. Findings Include: Review of STNA #139's personnel record revealed a hire date of 05/30/23. The record revealed STNA #139 completed six hours of training as a new hire in orientation. STNA #139 was assigned 12 hours of inservice/ on-line training that had not been completed. Interview on 10/17/23 at 10:35 A.M., with Business office staff member #136 verified STNA #139 did not complete the required 12 hours of in-service training for the last year. [...]

Inspectors wroteBased on observation, staff interview and review of facility policy the facility failed to ensure multi use vials of tuberculin purified protein derivative (PPD) were dated when they were opened. This had the potential to affect the 30 new admissions since 09/26/27 which included Residents #18, #38, #39, #40, #41, #42, #43, #132, #133, #134, #135, #136, #137, #138, #232, #234, #235, #236, #237, #239, #240, #241, #242, #243, #244, #245, #246, #247, #244 and #245. The facility census was 46. Findings Include: Observation on 10/17/24 at 10:08 A.M. of the 200 hallway medication room with the Director of Nursing (DON) revealed three open, used and unlabeled tuberculin purified protein derivative (PPD) solutions. Interview on 10/17/24 at 10:10 A.M. with the DON confirmed the tuberculin PPD solution was opened but neither the box nor the vials were dated as to when opened. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to take vital signs in connection to an as needed blood pressure medication. This affected one (Resident #5) of five residents reviewed for unnecessary medications. Also, the facility failed to hold blood pressure medications and notify the physician when vital signs were outside safe/accepted parameters. This affected one (Resident #27) of five residents reviewed for unnecessary medications. The census was 46. Findings Include: 1. Resident #5 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on record review, observation and interview the facility failed to ensure care planned interventions for falls were implemented for Resident #20. This affected one (Resident #20) out of four residents reviewed for falls. The facility census was 46. Findings Include: Review of the medical record for Resident #20 revealed an admission date of 06/14/23, with diagnoses including hydrocephalus, disorientation, altered mental status, hemiplegia, type two diabetes, depression, and anxiety. Review of the most recent Minimum Data Set (MDS) 3.0 assessment, completed on 08/23/24, indicated that the resident was severely cognitively impaired and required assistance with ambulation. Review of the care plan, dated 06/16/23, revealed Resident #20 was at risk for falls related to impaired balance, left hemiparesis, right thalamic mass, medication side effects, incontinence and cognition deficits. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide evidence to support pharmacy recommendations were reviewed in a timely manner. This affected three (Residents #5, #27, and #7) of five residents reviewed for unnecessary medications. Also, the facility failed to follow a pharmacy recommendation after the physician agreed to the recommendation. This affected one (Resident #7) of five residents reviewed for unnecessary medications. The census was 46. Findings Include: 1. Resident #5 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide proper parameters for as needed and scheduled medications. This affected four (Residents #5, #27, #137, and #7) of five residents reviewed for unnecessary medications. The census was 46. Findings Include: 1. Resident #5 was admitted to the facility on [DATE]. Resident #5's diagnoses included multiple fractures of pelvic with stable disruption of pelvic ring, pneumonia, type II diabetes, hypertensive heart and chronic kidney disease with heart failure, heart failure, chronic kidney disease (stage III), acute posthemorrhagic anemia, hypothyroidism, vitamin B deficiency, hypo-osmolality and hyponatremia, pure hypercholesterolemia, depression, unspecified hearing loss, gastroesophageal reflux disease (GERD), parasthesia of skin, dysphagia, and need for assistance with personal care. [...]

Inspectors wroteBased on medical record review, medication administration observation, staff interviews, and medication administration policy review, the facility failed to ensure a medication error rate of five percent or less. Two errors occurred in 35 opportunities for error. The medication error rate was 5.77 percent. This affected one resident (Resident #20) of four residents observed for medication administration. The facility census was 46. Findings Include: Review of the medical record for Resident #20 revealed an admission date of 06/14/23, with diagnoses that include hydrocephalus, disorientation, altered mental status, hemiplegia, type two diabetes, depression, and anxiety. The most recent Minimum Data Set (MDS) 3.0 assessment, completed on 08/23/24, indicated Resident #20 was severely cognitively impaired. [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, review of emergency medical services (EMS) records, review of hospital records, review of video footage, interviews with facility staff, the coroner, law enforcement and restaurant owner, and review of facility policy, the facility failed to ensure Resident #51 was provided a safe environment, adequate supervision and assistance during an outing to prevent a fall down a flight of stairs. [...]

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to provide Resident #27 dignity related to the use of an indwelling urinary catheter when the urinary collection bag was observed uncovered. This affected one resident (#27) of two residents reviewed for dignity.

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure a potential incident of physical abuse was immediately reported to the Administrator and to the State agency as required. This affected two residents (#7 and #8) of two residents reviewed for abuse.

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to provide a bed hold notice to Resident #42 and/or the residents representative at the time of discharge to the hospital. This affected one resident (#42) of two residents reviewed for hospitalization.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #243's peripherally inserted central catheter (PICC) line dressing was changed as ordered by the physician. This affected one resident (#243) of two residents reviewed for intravenous catheter lines.

Inspectors wroteBased on record review and interview the facility failed to ensure pre and post hemodialysis assessments were completed for Resident #14. This affected one resident (#14) of one resident reviewed for hemodialysis.

Inspectors wroteBased on observation, record review and interview the facility failed to maintain a medication error rate of less than five percent (%). The medication error rate was calculated to be 12.90% and included four medication errors of 31 medication administration opportunities. This affected one resident (#293) of three residents observed for medication administration.

Inspectors wroteBased on observation, record review and interview the facility failed to prepare and serve pureed foods in a manner to ensure they were served at the proper temperature and to ensure palatability. This had the potential to affect two residents (#241 and #244) of two residents identified to be on a pureed diet. The facility census was 48.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #5 was provided assistive devices at meals as ordered. This affected one resident (#5) of three reviewed for nutrition.