Springview Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the facility failed to ensure food was served at a palliative and warm food temperature. This had the potential to affect all residents in the facility at the time of entrance. The census was 56. Findings include: Review of medical record for Resident #4 revealed an admission date of 06/22/22 with diagnoses including but not limited to panlobular emphysema, influenza, other specified symptoms and signs involving the digestive system, congestive heart failure, auditory and visual hallucinations, major depressive disorder, anxiety, and other symptoms and signs concerning food and fluid intake. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was cognitively intact. Interview on 04/07/25 at 10:40 A.M. revealed Resident #4 stated that sometimes the food is cold. Resident #4 stated sometimes the food just does not taste good. Observation of the tray line was made on 04/09/25 at 12:18 P.M. with Culinary Support #205. The lunch menu…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and policy review, the facility failed to maintain the kitchen steamer in a safe operating condition. This had the potential to affect all residents in the facility at the time of entrance. The facility census was 56. Findings include: Observation on 04/07/25 at 11:49 A.M. of the kitchen steamer unit revealed it was leaking onto the floor, and it formed a large puddle. Interview on 04/07/25 at 11:49 A.M. with Director of Food Service #5 confirmed the steamer was leaking and making a puddle. Observation on 04/08/25 at 12:04 P.M. of the kitchen steamer unit revealed it was leaking onto the floor. Interview on 04/08/25 at 12:04 P.M. with Director of Food Service #5 confirmed the steamer is still leaking. Observation on 04/09/25 at 12:12 P.M. of the kitchen steamer unit revealed the steamer leaked onto floor out of two places and it made another puddle. Interview on 04/09/25 at 12:12 P.M. with [NAME] #65 confirmed the steamer unit is leaking on the floor. Review of the Preventative Maintenance Procedures policy dated 02/06/18 stated Each piece of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview, the facility failed to ensure no pervasive odors were present in hallways or common areas. This had the potential to affect all residents. The census was 56. Findings included: Observation on 04/07/25, 04/08/24, and 04/09/24 at various times revealed on the 200 and 300 halls, there was a strong urine smell. Observation on 04/09/24 at 10:40 A.M. in the legacy hall revealed a strong urine smell. Interview on 04/09/24 at 10:50 A.M. with Director of Environmental Services #250 verified strong urine smell throughout the 200 hall, 300 hall, and legacy hall. Director of Environmental Services #250 stated in legacy, two gentlemen urinate on the carpet instead of using the restroom. Director of Environmental Services #250 verified all carpets in the facility are cleaned once a month with a commercial carpet cleaner, dinning chairs are wiped down daily, and cloth upholstery couches are cleaned when housekeeping is notified.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, interview, and facility policy, the facility failed to have call lights within reach. This affected three residents (#40, #41, and #17) out of twelve residents observed for call lights. The facility census was 56. Findings included: 1. Medical record review revealed Resident #40 was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease, acute kidney failure, weakness, difficulty walking, peripheral vascular disease, atherosclerotic heart disease, and mild cognitive impairment. Review of the care plan dated 01/24/25 revealed Resident #40 was at risk for falling due to unsteady gait and poor safety awareness. Call light was to be kept within reach. Observation on 04/07/25 at 11:03 A.M. revealed Resident #40 was laying on her back in bed. Touch call light was on the furthest back corner of nightstand with the dividing curtain covering the touch pad. Call light was not in reach or in sight of Resident #40. 2. Medical record review revealed Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and policy review, the facility failed to ensure assessments were documented and/or completed prior to and after dialysis. This affected one (#9) of one resident reviewed for dialysis. The facility further failed to ensure dialysis documentation was completed by the dialysis center. This affected one (#9) of one reviewed for dialysis. The facility census was 56. Findings include: Review of medical record for Resident #9 revealed admission date of 09/24/24 with diagnoses including but not limited to Parkinson's disease, adjustment disorder with depressed mood, end stage renal disease, dependence on renal dialysis, malignant neoplasm, and atrial fibrillation. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #9 revealed the resident was cognitively intact. The resident required setup or clean-up assistance for eating. Supervision or touching assistance for oral hygiene, upper body dressing, and personal hygiene. Partial/moderate assistance for lower body…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the facility failed to ensure medications were not left at the bedside. This affected one (#23) of four residents reviewed for medication pass. The facility further failed to ensure medications were dated when opened. This affected one of three med carts reviewed for med storage. The facility census was 56. Findings include: 1. Record review for Resident #23 revealed admission date of 10/16/23 with diagnoses including but not limited to rheumatoid arthritis, cervicalgia, age-related osteoporosis, nonrheumatic mitral valve annulus calcification, cardiomegaly, chronic obstructive pulmonary disease, pleural effusion, lymphedema, hypothyroidism, and nutritional anemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #23 revealed the resident was cognitively intact. Resident #23 required supervision or touching assistance for transfers and ambulation. Setup or clean-up assistance for eating, oral hygiene, upper body dressing, lower body…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and facility policy the facility failed to ensure staff practices hand hygiene when delivering meal trays. This affected two (#258 and #260) out of seven room trays observed. Census was 56. Findings include: Observation on 04/07/25 at 12:18 P.M. revealed Certified Nursing Assistant (CNA) #71 carried Resident #258's lunch tray into her room. Before placing lunch tray on bedside tray, CNA #71 removed kleenex box, TV remote and multiple personal items from bedside tray. CNA #71 placed lunch tray on bedside table and removed plastic wrap from top of food and silverware out of napkin and adjusted bedside tray. CNA #71 walked out of Resident #258's room, took a cup of lemonade off food tray and walked into Resident #260's with cup of lemonade, placed it on Resident #260's lunch tray, took the lid off, and walked out the door. No hand hygiene was performed at start of meal tray pass and no hand hygiene was performed in between one resident's room to another resident's room. Interview on 04/07/25 at 12:22 P.M. with CNA #71 and Culinary Support #205 verified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review and staff interview; the facility failed to timely finalize and transmit Minimum Data Set (MDS) assessments. This affected two (#30 and #2) of 15 residents reviewed for accuracy of the MDS assessment. The census was 54. Findings include: 1. Review of the medical record for Resident #30 revealed the resident was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, chronic kidney disease, a diabetes mellitus (DM) type two. Review of a significant change MDS assessment dated [DATE], for Resident #30 revealed the encoded data date finalized was 12/09/21. The assessment was transmitted on 12/10/21. Review of a quarterly MDS assessment dated [DATE] for Resident #30 revealed the assessment was finalized on 06/09/22 and transmitted on 07/05/22. Interview on 07/06/22 at 11:47 A.M. with Registered Nurse (RN) #330 verified the quarterly MDS assessment dated [DATE] for Resident #30 was not transmitted timely. The RN further verified the significant change MDS assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, medical record review, and staff interview, the facility failed to ensure a resident received treatment for edema to bilateral lower extremities. This affected one (#47) of two residents reviewed for skin conditions. The facility identified eight residents being treated for edema. The facility census was 50. Findings include: Review of Resident #47's medical record revealed an admission date of 07/02/19. Medical diagnoses included hypertensive heart disease with heart failure, atrial fibrillation, acute respiratory failure, pleural effusion, chronic obstructive pulmonary disease, moderate protein-calorie malnutrition, and urinary retention. Review of the Minimum Data Set (MDS) assessment, dated 07/09/19, revealed Resident #47 had moderate impairment in cognition. She required extensive assistance for dressing and hygiene. Review of the resident's nursing notes revealed documentation of two plus edema to bilateral lower extremities on 07/02/19, 07/03/19, 07/04/19, 07/06/19, 07/09/19, 07/19/19, and 07/20/19. Review of an interdisciplinary team (IDT) note dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and family and staff interview, the facility failed to ensure a splint was in place as ordered for one (Resident #1) of one residents reviewed for limited mobility. The facility identified three residents with splint devices ordered. The facility census was 50. Findings include: Review of Resident #1's medical record revealed an admission date of 02/26/14. Medical diagnoses included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, dysphagia, neuromuscular dysfunction of bladder, major depressive disorder, cognitive communication deficit, unspecified dementia with behaviors, cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, difficulty in walking, and generalized anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 07/01/19, revealed Resident #1's cognition was severely impaired. She required extensive assistance for bed mobility, transfers, dressing,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure a resident received medication as ordered. This affected one (Resident #47) of five residents reviewed for medication. The facility census was 50. Findings include: Review of Resident #47's medical record revealed an admission date of 07/02/19. Medical diagnoses included hypertensive heart disease with heart failure, atrial fibrillation, acute respiratory failure, pleural effusion, chronic obstructive pulmonary disease, moderate protein-calorie malnutrition, and urinary retention. Review of Resident #47's Minimum Data Set (MDS) assessment, dated 07/09/19, revealed moderate impairment in cognition. Review of the resident's laboratory results dated [DATE] revealed a potassium level of 2.9 millimoles per liter (mmol/L) (normal 3.5-5.3). The physician was notified and responded on 07/11/19 with an order for potassium supplement 40 milliequivalents (mEq) by mouth now, then potassium 40 mEq twice daily on 07/12/19. Review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to follow their isolation policy for a resident with a drug resistant infection. This affected one (Resident #47) of two residents reviewed for infections. The facility census was 50. Findings include: Review of Resident #47's medical record revealed an admission date of 07/02/19. Medical diagnoses included hypertensive heart disease with heart failure, atrial fibrillation, acute respiratory failure, pleural effusion, chronic obstructive pulmonary disease, moderate protein-calorie malnutrition, and urinary retention. Review of the Minimum Data Set (MDS) assessment, dated 07/09/19, revealed Resident #47 had moderate impairment in cognition. Review of the resident's laboratory results revealed a urine culture reported on 07/14/19 with results of vancomycin resistant enterococcus faecium (VRE). Continued review revealed no further urine cultures. Review of the resident's physicians orders revealed an order dated 07/15/19 for contact isolation. Review of an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.