Community Springs Healthcare Facility

In the surveyor’s words

From the most serious findings on record at Community Springs Healthcare Facility, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF922Jun 30, 2023

  Based on observation, record review, and interview, the facility failed to establish procedures to estimate the water needed and ensure that water was available to essential areas if there was a loss of normal water supply, such as in an emergency. The facility has a capacity of 120 and had a census of 60 at the time of survey. Review of a Centers for Disease Control and Prevention (CDC) document named Emergency Water Supply Planning Guide for Hospitals and Healthcare Facilities, dated 2019, showed that water needs can vary greatly from facility to facility, but general guidelines show a need of one to three gallons of water needed per person, per day for consumption and sanitary needs. 1. […]

• No harm, potential for more than minimal, patternF561Jan 3, 2025

  Based on interview and record review, the facility failed to support each resident's right to self-determination related to care when staff failed to care plan and provide showers per residents' preference for three residents (Resident #3, #28, and #6). Review of the facility's policy titled, Personal Hygiene, revised 03/2023, showed the following: -Purpose to establish guidelines for ensuring the hygiene needs of residents are addressed and met; -Purpose to identify the roles of the nursing staff and the patients in maintaining the patients' and residents' personal hygiene; -Staff are to assist with personal hygiene tasks as patients need; -If a patient is unable to care for self, nursing staff will provide full assist with bathing, changing clothing, oral care and other… […]

• No harm, potential for more than minimal, patternF657Jan 3, 2025

  Based on record review and interview, the facility failed to ensure each resident's care plan was updated and review for accuracy timely when the care plans of five residents (Resident #37, #31, #33, #10, and #26) were not updated to reflect the residents' current conditions. Review of a facility's policy titled, Assessments in Long Term Care. dated 12/2024, showed the following: -The nursing care plan will be initiated according to identified needs from the admission assessment by a licensed nurse; -Licensed nursing personnel will update care plans as needs are assessed; -The dietitian, social worker, and rehabilitation personnel can assess patients, within the scope of their service and will integrate information into the medical record and assist in identifying and assigning priorities… […]

• No harm, potential for more than minimal, patternF812Jun 30, 2023

  Based on observation, interview, and record review, the facility failed to ensure food was protected from contamination at all times when staff touched resident food with bare hands and failed to complete hand hygiene after touching soiled surfaces during meal service. The facility census was 60. Review of the Food and Drug Administration (FDA) 2013 Food Code showed foods that are ready to eat should not be touched by staff's bare hands. Review of the facility Competencies for Food and Nutrition Services Employees checklist, undated, showed the following: -Practice appropriate hand hygiene and glove use when necessary during food preparation activities, such as between handling raw meat and other foods, to prevent cross-contamination; -Properly wash hands before serving food to resident… […]

• No harm, potential for more than minimal, patternF602Aug 13, 2021

  Based on interview and record review, the facility failed to protect residents from misappropriation of property when staff discovered missing doses of controlled medications which were replaced with another medication while in the possession of the facility for seven residents (Resident #1, #2 #3, #4, #5, #6, and #7). The facility census was 58. The administrator and Director of Nursing (DON) were notified on 06/11/21, of the Past Non-Compliance which was discovered on 6/11/21. Facility staff notified the Department of Health and Senior Services (DHSS) of the noncompliance, started an investigation, and began in-servicing licensed staff who were involved in medication pass and medication storage. In-services were finished on 06/15/21. The noncompliance was corrected 6/15/21. […]