The Waters of Springfield LLC

In the surveyor’s words

From the most serious findings on record at The Waters of Springfield LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 19, 2026

  Based on facility policy review, Administrator job description review, Director of Nursing (DON) job description review, Time and Date.com review, medical record review, facility investigation review, Emergency Medical Services (EMS) record review, hospital record review, observation, and interview, the facility failed to ensure a safe environment and provide adequate supervision to prevent an incident of elopement for 1 of 3 (Resident #2) sampled residents reviewed for wandering and behaviors. […]

• Immediate jeopardy, isolatedF678Feb 23, 2026

  Based on policy review, American Heart Association (AHA) Adult Basic Life Support Algorithm for Healthcare Professionals dated 2025, Rules of the Tennessee Board of Nursing review, Tennessee Code Annotated (TCA) rules review, medical record review, 911 audio recording review, facility video footage review, facility investigation, Employee file review, Emergency Medical Services (EMS) record report review, County Emergency Communication and interviews, the facility failed to provide continuous Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR) for 1 of 3 (Resident #1) sampled residents reviewed for CPR. Resident #1 was a vulnerable resident who was found on [DATE] at 6:07 AM, in the bathroom, on his knees slumped over the commode unresponsive. […]

• Immediate jeopardy, isolatedF689Oct 19, 2023

  Based on policy review, medical record review, document review, timeanddate.com, and interview, the facility failed to ensure all residents received supervision to ensure a safe environment that was free of accident hazards for 1 (Resident #20) of 3 sampled residents reviewed for accident hazards/supervision. On 08/06/2022 at approximately 9:00 PM, an agency nurse entered the code on the door keypad and let Resident #20 out of the facility. Approximately 30 minutes later, the facility was notified Resident #20 was found in the parking lot of another facility, less than half a mile from the facility. […]

• No harm, potential for more than minimal, widespreadF812Jul 25, 2024

  Based on observation, interview, and facility policy review, the facility failed to label and date food items in a walk-in refrigerator. This had the potential to affect all residents who received food from the kitchen. Findings included: 1. An undated facility policy titled, Food Safety, indicated, Food items that do not have a manufacturer's expiration date will be labeled and dated with a received and use by date. 2. During a tour of the kitchen on 07/22/2024 at 8:50 AM, with the Dietary Director (DD), the following was observed in the walk-in refrigerator: Six, undated bowls of salad; Four, small, undated bowls of pears; Four, small, undated and unlabeled bowls of yellow pudding; Two, undated and unlabeled pieces of meat, of which the DD identified as country fried steak; and… […]

• No harm, potential for more than minimal, patternF812May 20, 2025

  Based on policy review, refrigerator temperature logs, observation, and interview, the facility failed to ensure food was stored, handled, prepared, and served under sanitary conditions, when food was found unlabeled and undated, baking pans contained carbon buildup, a grease trap under the stove was found with aluminum foil torn and with a large amount of food debris, and when the walk-in cooler temperatures were consistently above 41 degrees. The census was 37 with 34 of those residents receiving a meal tray from the kitchen. The findings include: 1. […]