Springs Village Care Center

Resident Rights Deficiencies

Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

Emergency Preparedness Deficiencies

Establish policies and procedures including evacuation.

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Pharmacy Service Deficiencies

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.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Services Deficiencies

Install properly constructed and protected linen or trash chutes.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Resident Rights Deficiencies

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Services Deficiencies

Install properly constructed and protected linen or trash chutes.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

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.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Smoke Deficiencies

Provide properly protected cooking facilities.

A recertification survey with Incident #39320 was conducted on 5/12/15 to 5/15/25. Nine deficiencies were cited. An Emergency Preparedness survey was conducted from 5/12/25 to 5/15/25. Two deficiencies were cited. Based on observations and interviews, the facility failed to ensure medications and biologicals were stored in accordance with accepted professional standards for one of two medication storage refrigerators. Specifically, the facility failed to ensure controlled medications were in a locked storage container that was permanently secured to t.. Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on one of two units. Specifically, the facility failed to:-Ensure staff wore the appropriate pers.. Based on observations, record review and interviews, the facility failed to develop and implement policies and procedures to provide for the safe evacuation from the facility in the event of an emergency.Specifically, the facility failed to develop a safe evacuation plan in the event the elevators were not usable for the second and third floors, w.. Based on observations, record review and interviews, the facility failed to provide provide assistance with activities of daily living (ADLs) to ensure the highest practicable quality of life for one (#45) of two residents reviewed out of 32 sample residents. Specifically, the facility failed to provide the necessary assistance for Resident #45, who req.. Based on observations, record review, and interviews, the facility failed to ensure an environment free from risk of accident and hazards for two (#84 and #6) of five residents reviewed for accident hazards out of 32 sample residents.Specifically, the facility failed to:-Ensure the grab bar/hand rail in Resident #84' s bathroom was repaired a.. Based on record review and interviews, the facility failed to conduct two exercises annually to test the facility' s emergency plan and maintain documentation of the facility' s response to all drills, tabletop exercises, and emergency events, and then revise the facility' s emergency plan, as needed.Specifically, the facility failed to:-Participate in a c.. Based on record review and interviews, the facility failed to ensure one (#74) of two residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain the highest practicable mental and psychosocial wellbeing out of 32 sample residents. Specifically, the facility failed to .. Based on record review and interviews, the facility failed to ensure prompt action was taken upon the filing of a grievance of a group.Specifically, the facility failed to make prompt efforts to resolve resident grievances about missing clothing that were brought up by the resident council. Findings include:I. Facility policy and procedureThe Gr.. Based on record review and interviews, the facility failed to ensure the resident' s right to be informed of, and participate in his or her treatment for one (#77) of two residents out of 32 sample residents reviewed for the right to be informed and make treatment decisions.Specifically, the facility failed to inform Resident #77 and/or her legal re.. This Citation text meets this visualizations limit for 32,000 characters, please reach out to CDPHE HFEMSD Records Team for the full citation text at cdphe_hfemsd_records@state.co.us. Within your email, please include Facility Name, Inspection ID and Citation Code.

A survey prompted by #CO38256, #CO38838, #CO38839, #CO39040 and #CO39115 was conducted on 2/5/25 to 2/10/25. Five deficiencies were cited. Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infections.Specifically, the facility failed to:-Ensure proper infection control practices were followed for wound care; and-Ensure hand hygiene was performed appropriately. Findings include:I. Facility policy and procedureThe Wound Care policy and procedure, revised October 2010, was received from the director of nursing (DON) on 2/10/25 at 6:50 p.m. It revealed in pertinent part, "The purpose of this procedure is to provide guidelines for the care of wounds to p.. Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for one (#5) of three residents reviewed out of 16 sample residents. Specifically, the facility failed to ensure Resident #5 received timely incontinence care. Findings include:I. Facility policy and procedureThe Urinary Incontinence-Clinical Protocol, revised March 2018, was received from the nursing home administrator (NHA) on 2/6/25 at 3:11 p.m. It read in pertinent part, "As appropriate based on assessment of the category and causes of incontinence the staff will provi.. Based on observations, record review, and interviews, the facility failed to ensure residents with a pressure ulcer received the necessary treatment and services according to professional standards of practice to prevent or heal pressure injuries for one (#2) of three residents reviewed for pressure ulcers out of 16 sample residents.Specifically, for Resident #2, the facility failed to:-Ensure there was a physician' s order in place for treating the resident' s left knee wound;-Ensure staff utilized knee protectors, per the resident' s care plan, when repositioning the resident to offload pressure;-Ensure staff appropriately cleansed the resident' s left knee wound during a dressing change; and, -Ensure s.. Based on observations, record review, and interviews, the facility failed to manage pain in a manner consistent with professional standards of practice for one (#13) of four residents reviewed for pain out of 16 sample residents.Specifically, the facility failed to:-Ensure a thorough pain assessment was completed for Resident #13 which included recognizing the onset, presence of and characteristics of pain; and,-Offer non-pharmaceutical interventions before administering as needed pain medication.Findings include:I. Facility policy and procedureThe Pain-Clinical Protocol, revised October 2022, was received from the nursing home administrator (NHA) on 2/6/25 at 4:05 p.m. It r.. Based on record review and interviews, the facility failed to manage pain in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident' s goals and preferences for one (#4) of three residents out of 16 sample residents. Specifically, the facility failed to ensure Resident #4 was administered the correct pain medication per physician' s orders and failed to provide non-pharmacological interventions prior to administering PRN pain medication. Findings include:I. Professional referenceAccording to Treas, L. &, Barnett K., & Smith M., (2022) Basic Nursing (3rd ed.) p. 1257, "Medications administered PRN are giv..