Springdale Healthcare Center

In the surveyor’s words

From the most serious findings on record at Springdale Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jan 23, 2026

  F600 Free from Abuse and Neglect - related to sexual abuseBased on observation, interview, and record review, the facility failed to ensure Resident (R)6 remained free from sexual abuse. The facility failed to protect R6, a cognitively impaired female who lacked the capacity to consent, from sexual contact initiated by R119. On 1/17/26, the Administrator was notified that R119 was engaged in inappropriate sexual interactions with R6, when R119 had his hand around R6's wrist, using R6's hand to masturbate R119's p****.Due to the cognitive impairment of R6, the Reasonable Person Approach was utilized to determine the negative effects of this non-compliance. […]

• Immediate jeopardy, isolatedF609Jan 23, 2026

  Based on review of facility policy, interview, observation, and record review, the facility failed to report the elopement of Resident (R)13 to the required community agencies. Specifically, on 01/15/26 at approximately 2:30 PM, R13 had a successful, unwitnessed elopement from the facility. The facility failed to report the elopement to the State Survey Agency as required. On 01/22/26 at 11:57 AM, it was determined that the facility's non-compliance with one or more federal health, safety, and or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death.On 01/22/26 at 11:57 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 01/15/26 when the… […]

• Immediate jeopardy, isolatedF689Jan 23, 2026

  Based on review of facility policy, interview, observation, and record review, the facility failed to ensure Resident (R)13 was adequately supervised to prevent him from eloping from the facility on 01/15/26, for 1 of 1 resident reviewed for elopement. Specifically, on 01/15/26 at approximately 2:30 PM, R13 had a successful, unwitnessed elopement from the facility. R13 was found by staff members on a gravel road leading to the main street approximately 200 feet from the door he exited from. Review of R13's medical record showed no clinical notes were written and no clinical assessments were conducted related to the elopement. […]

• Immediate jeopardy, isolatedF760May 21, 2025

  Based on review of facility policy, record review and interview, the facility failed to ensure Resident (R)5 was free from significant medication errors. Specifically, R5 was discharged from the hospital and admitted to the facility on [DATE], with physicians orders for seizure medications, the facility failed to administer the medication as ordered resulting in the resident experiencing seizure activity and being sent to the hospital, for 1 of 1 resident reviewed for significant medication errors. On 05/21/25 at 10:35 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 05/06/25. […]

• Immediate jeopardy, isolatedF600Nov 17, 2022

  Based on review of the facility policy, interview and record review, the facility failed to protect 1 of 5 residents reviewed for sexual abuse. Resident (R)2 was discovered by staff in R1's bed in room [ROOM NUMBER] on 11/09/22 at approximately 8:25 PM. R2's hand was on R1's breast, and his leg was over her. R2 was clothed, but R1's gown was lifted. Her brief was intact. The incident caused R1 significant emotional distress, as she did not consent to sexual contact and was unable to call for help. On 11/17/22 at approximately 2:30 PM, the facility was notified of an Immediate Jeopardy (IJ) at past noncompliance was identified related to F600-Sexual Abuse. At this time, the facility presented a credible plan of action after identifying their own deficiency. […]