Springhill Village

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF657Jan 13, 2025

  Based on interview and record review, the facility failed to ensure care plan meetings were conducted quarterly for 4 of 24 residents reviewed for care plan meetings (Residents 24, 28, and 37), and the facility failed to ensure the resident and or the resident representative was present for an initial care plan meeting for 1 of 24 residents reviewed. (Resident 64). Findings include: 1. During an interview, on 1/8/25 at 10:12 a.m., Resident 24 indicated he did not remember being invited to or attending a care plan meeting recently. He thought maybe the last one was 6 months ago. Resident 24's record was reviewed on 1/9/25 at 10:42 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 11/12/24, indicated the resident had no cognitive impairment. […]

• No harm, potential for more than minimal, patternF585Aug 23, 2022

  Based on record review and interview, the facility failed to ensure concerns expressed by the Resident Council were addressed by the facility administration for 2 of 4 months of resident council minutes reviewed for grievance responses. Findings include: Resident Council minutes were provided by the Activity Director (AD) on 8/18/22 at 12:01 p.m. The AD indicated she took minutes for the Resident Council meetings. The meeting minutes included the months of May, June, July, and August 2022 and indicated the following concerns by the Resident Council: 1. On 5/5/22 - Staff were coming into the residents' rooms, turning off the call lights and saying they would be right back and then they did not return. 2. […]

• No harm, potential for more than minimal, patternF757Aug 23, 2022

  Based on record review and interview, the facility failed to ensure pain assessments were completed for residents who were administered pain medication for 4 of 5 residents reviewed for unnecessary medication (Residents 34, 58, 59, and 24). Findings include: 1. Resident 34's record was reviewed on 8/16/22 at 1:08 p.m. The record indicated the resident had been admitted to the facility on [DATE]. The profile indicated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission Minimum Data Set (MDS) assessment, dated 4/21/22, indicated the resident had no cognitive deficit, reported frequent moderate pain, received as needed (PRN) opioid (substances that act on opiod receptors to produce [MEDICATION(S)]-like effects) pain medications. […]

• No harm, potential for more than minimal, patternF804Aug 23, 2022

  Based on interview, observation, and record review, the facility failed to ensure the temperature and palatability of food served for 1 of 1 test tray reviewed for temperature and palatability (Residents 59, 47, and 27). Findings include: During an interview, on 8/15/22 at 10:24 a.m., Resident 59 indicated she ate meals in the dining room and the food, at times, was not good and was cold. During an interview, on 8/15/22 at 10:36 a.m., Resident 47 indicated she ate meals in her room and the food was often cold, when her meal came to her room. During an interview, on 8/15/22 at 11:21 a.m., Resident 27 indicated she ate meals in her room. The food was lousy, their combinations were not good, and often the food temperatures were not good. […]

• No harm, potential for more than minimal, isolatedF628Feb 23, 2026

  Based on record review and interview, the facility failed to ensure the resident received notice of transfer and bed hold policy, and failed to notify the hospital of transfer or condition report for 2 of 24 residents reviewed for hospitalization (Residents 96 and 7). Findings include:1. On 2/23/26 at 9:52 a.m., the medical record of Resident 96 was reviewed. The resident was admitted to the facility on [DATE]. admission diagnoses included, but was not limited to, Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and congestive heart failure (CHF) (a condition that develops when your heart doesn't pump enough blood for your body's needs). […]