Avenues at Springfield

In the surveyor’s words

From the most serious findings on record at Avenues at Springfield, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 15, 2025

  Based on interview and record review, the facility failed to prevent an elopement in 1 of 4 residents (R2) reviewed for elopement/supervision in the sample of 4. This failure resulted in an Immediate Jeopardy when R2 eloped from the facility on 12/30/24 and while missing, R2 sustained a fall resulting in a laceration and nasal fracture. This past non-compliance occurred on 12/30/24. Past noncompliance-no plan of correction required. The Immediate Jeopardy began on 12/30/24, when R2 eloped from the facility and sustained a fall resulting in a laceration and nasal fracture. On 1/15/25, at 9:30 AM, V1, Administrator, and V2, Director of Nurse, DON, were notified of the Immediate Jeopardy. […]

• Actual harm, isolatedF677Jul 12, 2023

  Based on interview, and record review, the facility failed to assist residents with transfers out of bed for 1 of 3 residents (R8) reviewed for activities of daily living (ADLs) assistance in the sample of 13. This failure resulted in R8 being left in bed for 7 days feeling alone, fearful, anxious, and scared. Findings include: R8's Minimum Data Set, MDS, dated [DATE], documents R8 has no cognitive impairments and R8 is totally dependent on two staff person physical assistance for transfers. On 07/05/2023 at 11:05AM, R8 stated she was in bed for seven days because the sit to stand mechanical lift was not working. R8 stated, It was broke. R8 stated she remained in bed from Friday, 6/23 through Thursday 6/29/23. […]

• Actual harm, isolatedF692Jun 15, 2023

  Based on observation, interview and record review, the facility failed to report a resident's significant weight loss to the physician and initiate appropriate interventions to maintain and/or improve nutritional status for 1 of 4 residents (R29) reviewed for weight loss in the sample of 65. The failure resulted in R29 having an insidious weight loss of 14.5 pounds (lbs.), a 10% weight loss in the last six months. Findings include: On 6/11/23 at 12:15 PM R29 was standing at the entrance to the dining room. He had not eaten any lunch or drank any of his fluids. He walked to the dining room and then turned around and went right back down to his room. He stated he was not going to eat lunch. His pants were so loose that he had to hold them up at the waist while he was walking. […]

• Actual harm, isolatedF740Jun 15, 2023

  Based on observation, interview, and record review the facility failed to assess, develop, and implement interventions to address the worsening symptoms of mental illness disorders for 1 of 5 residents (R29) reviewed for behavioral health services in the sample of 65. This resulted in R29 having a significant weight loss due to worsening and ongoing hallucinations telling him not to eat or drink. Findings include: R29's Face Sheet documents his diagnoses to include Schizophrenia, Major Depressive Disorder, Vitamin B Deficiency, Bipolar Disorder, Avoidant Personality Disorder, Panic Disorder and Anxiety Disorder. R29's Minimum Data Set (MDS) dated [DATE] documents he is alert and oriented and able to feed self independently with supervision and set up assist by staff. […]

• Actual harm, isolatedF684Aug 31, 2022

  Based on interview, observation and record review, the facility failed to provide monitoring of water intake for 1 of 16 residents (R4) reviewed for quality of care in the sample of 66. This failure has resulted in R4 being hospitalized multiple times for a low sodium level related to excessive water consumption. Findings Include: R4's Admission Record, print date of 8/24/22, documents that R4 was admitted originally on 9/17/2015 and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's Minimum Data Set (MDS), dated [DATE], documents that R4 is cognitively intact, has hallucinations and delusions, Verbal behavioral symptoms directed toward others and behavioral symptoms not directed towards others that occurred 1 to 3 days. […]