Springfield Villa

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Feb 2, 2026

  The Administrator was notified on 01/29/26, at 5:29 P.M., of an Immediate Jeopardy (IJ) which began on 01/23/26. The IJ was removed on 01/30/26 as confirmed by surveyor on-site verification. 1.Please refer to F684, event ID 1DA88A-H2, exit date 02/02/26.NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. […]

• Actual harm, isolatedF689Feb 28, 2025

  Based on observation, record review, and interview, the maintain residents free from accident hazards when the facility failed to fully document fall events/investigations and to follow, update, develop, and ensure the accuracy of care plans and failed to implement new interventions in attempt to prevent falls consistent with the residents' physical and cognitive abilities for four residents (Residents #1, #3, #4 and #5). The facility census was 114. Review of the facility's policy Fall Prevention Manual, dated 06/2006, showed the following: -Identify all current residents at risk for falls at the beginning of the program using the facility risk assessment form or a chosen form. […]

• Actual harm, isolatedF689Aug 16, 2023

  1. Please refer to event ID XGPT712, exit date 08/16/23, for citation details. MO00222956

• Actual harm, isolatedF689Jun 27, 2023

  Based on interview and record review, the facility staff failed to ensure the safety of all residents when lack of staff supervision on the locked special care (memory) unit resulted in extended resident to resident interaction that ended with one resident (Resident #2) pushing one resident (Resident #1) to the floor resulting in one resident (Resident #1) sustaining a hip fracture. A sample do 25 residents were reviewed in a facility with a census of 94. Review of the facility policy titled, Routing Monitoring of Events (Incidents and Accidents), dated 11/14/16, showed the following: -This is a general guideline for event monitoring, to include, but not limited to bruises, skin tears, and falls; -Event prevention and actions to minimize them are ongoing each shift/day. […]

• Actual harm, isolatedF689Jun 27, 2023

  Based on interview and record review, the facility staff failed to ensure the safety of all residents when lack of staff supervision on the locked special care (memory) unit resulted in extended resident to resident interaction that ended with one resident (Resident #2) pushing one resident (Resident #1) to the floor resulting in one resident (Resident #1) sustaining a hip fracture. A sample do 25 residents were reviewed in a facility with a census of 94. Review of the facility policy titled, Routing Monitoring of Events (Incidents and Accidents), dated 11/14/16, showed the following: -This is a general guideline for event monitoring, to include, but not limited to bruises, skin tears, and falls; -Event prevention and actions to minimize them are ongoing each shift/day. […]