A list of the most recent deficiencies for The Waters of Springfield LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-10-19 | 2023-11-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-19 | 2023-11-29 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-10-19 | 2023-11-29 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-10-19 | 2023-11-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-19 | 2023-11-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-19 | 2022-08-07 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2022-03-04 | 2022-04-12 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-07-07 | 2021-08-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-07-07 | 2021-08-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-07-07 | 2021-08-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-07-07 | 2021-08-20 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-07-08 | 2021-08-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-08 | 2021-08-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-08 | 2021-08-10 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-07-08 | 2021-08-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-12-02 | 2020-01-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-02 | 2020-01-19 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-12-02 | 2020-01-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-02 | 2020-01-19 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-12-02 | 2020-01-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-12-02 | 2020-01-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-12-02 | 2020-01-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-12-05 | 2020-01-10 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-12-05 | 2020-01-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-05 | 2020-01-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-12-05 | 2020-01-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-12-05 | 2019-12-30 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-12-05 | 2019-12-30 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-12-05 | 2019-12-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-12-05 | 2019-12-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-05 | 2019-12-30 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-12-05 | 2019-12-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-12-05 | 2019-12-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-12-02 | 2019-12-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-01-14 | 2019-03-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-14 | 2019-03-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-01-14 | 2019-03-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-01-14 | 2019-03-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-01-14 | 2019-03-01 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-01-15 | 2019-02-25 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-01-15 | 2019-02-15 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-01-15 | 2019-02-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-15 | 2019-02-04 | N |
