Sunterra Springs Springfield

In the surveyor’s words

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

• Immediate jeopardy, isolatedF760Jul 18, 2023

  Based on interview and record review, the facility failed to ensure residents were free of significant medication errors when staff failed to administer insulin as ordered for two days for one resident (Resident #1,) out of a sample of one resident, resulting in the resident being hospitalized with hyperglycemia (high blood sugar). The facility census was 33. On 07/15/23, at 12:30 P.M., the Administrator was notified of the past noncompliance immediate jeopardy (IJ) which occurred on 07/10/23. […]

• No harm, potential for more than minimal, widespreadF812Jun 2, 2025

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in a manner to prevent possible contamination when staff failed to wash hands and change gloves appropriately during food prep and service, and when staff failed to cover food on a rack. The facility was census was 37. 1. Review of the facility's policy titled, Maintaining a Sanitary Tray Line, revised April 2025, showed the following: -This facility prioritizes tray assembly to ensure foods are handled safely and held at proper temperatures in order to prevent the spread of bacteria that may cause food borne illness; -During tray assembly, staff shall use utensils such as tongs and serving spoons to handle food as much as possible; -Wear gloves when handling food items,… […]

• No harm, potential for more than minimal, widespreadF812Nov 9, 2023

  Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in a manner to protect the food from possible contamination when staff failed to store food in sealed containers, when staff stacked dishes while still wet, and when staff failed to ensure the dishwasher rinsed the dishes at the recommended temperature. This had the potential to affect all residents who consumed food from the facility kitchen. The facility had a census of 37 residents. 1. […]

• No harm, potential for more than minimal, patternF607Jun 2, 2025

  Based on record review and interview, the facility failed to ensure the facility implement their abuse and neglect policies when staff failed to complete a criminal background checks (CBCs) for one of ten sampled employees prior to their hire/start date in a facility with a census of 37. Review of the facility's policy, Abuse, Neglect and Exploitation, revised April 2025, showed the following: -It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property; -Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident… […]

• No harm, potential for more than minimal, patternF880Jun 2, 2025

  Based on observation, interview, and record review, the facility failed to implement and maintain an effective infection control program when staff failed to follow Enhanced Barrier Precautions (EBP-infection control measures used to reduce transmission of resistant organisms) while providing wound care for three residents (Resident #2, #197, and #14) and when staff failed to place a protective barrier beneath supplies in two resident rooms (Resident #197 and #14). The facility census was 37. […]