Spring Hill Care and Rehab

Inspectors wroteThe facility identified a census of 29 residents, including three residents sampled for abuse. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 1 remained free from staff-to-resident abuse on 10/11/25, when Certified Nurse Aide (CNA) M verbally, mentally, and physically abused R1. This deficient practice placed R1 in immediate jeopardy.

Inspectors wroteThe facility identified a census of 35 residents. The sample included three residents, with three residents reviewed for notification of changes. Based on observation, record review, and interviews, the facility failed to notify Resident (R) 1's representative of changes in condition, plan of care changes, and results. This deficient practice placed R1 at risk for further decline and a delay in treatment.

Inspectors wroteThe facility identified a census of 35 residents. The sample included three residents, with three residents reviewed for dental services. Based on observation, record review, and interviews, the facility failed to obtain emergency dental services for Resident (R) 1 after he broke a tooth on 03/27/25. This deficient practice had the risk of dental pain, difficulty eating, and unnecessary physical complications for R1.

Inspectors wroteThe facility identified a census of 36 residents. The facility failed to provide the services of a full-time certified dietary manager for the 36 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition.

Inspectors wroteThe facility identified a census of 36 residents. The sample included 12 residents. Based on observations, interviews, and record reviews, the facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during both day-to-day operations and emergencies. This failure affected all 36 residents residing in the facility. Findings Included: - On 06/09/25 Administrative Staff A provided a Facility Assessment updated 12/2024. A review of the assessment revealed the following: The assessment failed to identify the specific staffing levels needed for each unit and identify the number of Registered Nurses (RN), Licensed Nurses (LPN/LVN), Certified Medication Aides (CMA), and Certified Nurse Aides (CNA) needed for each unit, patient acuity, and census. [...]

Inspectors wroteThe facility had a census of 36 residents. The sample included 12 residents, with three reviewed for accidents. Based on observation, record review, and interview, the facility failed to secure pressurized supplemental oxygen tanks in a safe, locked area, and out of reach of the 22 cognitively impaired independently mobile residents. The facility additionally failed to ensure fall interventions were in place for Resident (R) 12 and R4. This deficient practice placed the residents at risk for preventable accidents and injuries.

Inspectors wroteThe facility identified a census of 36 residents. The facility identified eight residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record reviews, observations, and interviews, the facility failed to store Resident (R) 33, R34, R6, and R1's respiratory equipment in a sanitary manner, and the facility further failed to transport linens in a sanitary manner. These deficient practices placed the residents at risk for infectious diseases.

Inspectors wroteThe facility identified a census of 36 residents. The sample included 12 residents, with five reviewed for dignity. Based on observation, record review, and interviews, the facility failed to provide a dignified care environment for Resident (R) 20. This deficient practice placed R20 at risk for impaired dignity and unmet care needs. Findings Included: - The Medical Diagnosis section within R20's Electronic Medical Records (EMR) included diagnoses of benign prostatic hyperplasia (BPH - non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dysphagia (difficulty swallowing), and dementia (a progressive mental disorder characterized by failing memory and confusion). [...]

Inspectors wroteThe facility identified a census of 36 residents. The sample included 12 residents, with one resident reviewed for abuse and neglect. Based on observation, record review, and interview, the facility failed to prevent an episode of resident-to-resident sexual abuse between cognitively impaired Resident (R) 21 and R17. This deficient practice placed R17 at ongoing risk for preventable abuse and mistreatment. Findings Included: - The Medical Diagnosis section within R21's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, repeated falls, and the need for assistance with personal care. R21's Annual Minimum Data Set (MDS) dated 04/27/25 noted a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. [...]

Inspectors wroteThe facility identified a census of 36 residents. The sample included 12 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 1's psychotropic (alters mood or thought) medication had an indication for administration. This deficient practice placed R1 at risk for ineffective treatment, unnecessary medication use, and unwarranted side effects.

Inspectors wroteThe facility identified a census of 36 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to indicate on the comprehensive Minimum Data Set (MDS) that Resident (R) 33 received and required the use of a continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep). This placed R33 at risk for inaccurate reflections of the resident's status and needs to develop an individualized comprehensive plan of care.

Inspectors wroteThe facility identified a census of 36 residents. The sample included 12 residents, with five reviewed for care plan revisions. Based on observation, record review, and interviews, the facility failed to revise Resident (R) 20's Care Plan to remove his therapeutic diet. This deficient practice placed R20 at risk for uncommunicated care needs. Findings Included: - The Medical Diagnosis section within R20's Electronic Medical Records (EMR) included diagnoses of benign prostatic hyperplasia (BPH - non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dysphagia (difficulty swallowing), and dementia (a progressive mental disorder characterized by failing memory and confusion). [...]

Inspectors wroteThe facility identified a census of 36 residents. The sample included 12 residents, with five reviewed for care plan revisions. Based on observation, record review, and interviews, the facility failed to revise Resident (R) 20's Care Plan to remove his therapeutic diet. This deficient practice placed R20 at risk for uncommunicated care needs. Findings Included: - The Medical Diagnosis section within R20's Electronic Medical Records (EMR) included diagnoses of benign prostatic hyperplasia (BPH - non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dysphagia (difficulty swallowing), and dementia (a progressive mental disorder characterized by failing memory and confusion). [...]

Inspectors wroteThe facility identified a census of 36 residents. The sample included 12 residents, with one resident reviewed for activities of daily living (ADL) care. Based on observation, record review, and interviews, the facility failed to provide Resident (R) 9 with assistance with eating and further failed to ensure R9's call light was within his reach. This defiant practice placed R9 at risk of aspiration and unmet needs.

Inspectors wroteThe facility identified a census of 36 residents. The sample included 12 residents, with three reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on interviews, observations, and record reviews, the facility failed to ensure Resident (R) 27's pressure-reducing low air-loss mattress (specialized air mattress used to reduce the pressure applied to the body) was utilized per her weight and manufacturer's safe use recommendations. The facility additionally failed to apply R9's pressure-reducing boots, which were used to off-load the heels of his feet per his care plan. These deficient practices placed both residents at risk for preventable wounds and impaired wound healing.

Inspectors wroteThe facility identified a census of 36 residents. The sample included 12 residents, with two residents reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 33's continuous positive airway pressure (CPAP - ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) mask was stored in a sanitary manner. This placed R33 at an increased risk for respiratory infection and complications.

Inspectors wroteThe facility identified a census of 36 residents. The sample included 12 residents, with two residents reviewed for dementia (a progressive mental disorder characterized by failing memory and confusion) care. Based on observation, record review, and interviews, the facility failed to provide Resident (R) 17 with dementia services related to supervision and accidents. The defiant practice placed R17 at risk for preventable accidents. Findings Included: [...]

Inspectors wroteThe facility identified a census of 36 residents. The sample included 12 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities in Resident (R) 1's medication which lacked an indication for administration. The facility also failed to ensure the CP identified and reported the physician's order for monitoring the pulse for an antihypertensive (a class of medication used to treat high blood pressure) medication. This deficient practice placed R1 at risk for unnecessary medication use, side effects, and physical complications.

Inspectors wroteThe facility identified a census of 36 residents. The sample included 12 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure physician parameters were followed for a hypertensive medication (class of medication used to treat hypertension (high blood pressure) for Resident (R) 1. The facility also failed to ensure R1's medication had an indication for administration. These deficient practices placed R1 at risk for the potential of unnecessary medication administration thus leading to possible harmful side effects.

Inspectors wroteThe facility identified a census of 36 residents. The sample included 12 residents, with two residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to provide a description of the medication and equipment provided to Resident (R) 12 by hospice. This deficient practice created a risk for missed or delayed services, impaired physical, and psychosocial care for R12.

Inspectors wroteThe facility identified a census of 36 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to post its updated daily posted staffing sheet.

Inspectors wroteThe facility reported a census of 36 residents. The sample included 12 residents. Based on record review and interviews, the facility failed to submit accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ - Staffing Data Report), when the facility failed to submit accurate weekend staffing coverage hours. This placed the residents at risk for unidentified and ongoing inadequate staffing.

Inspectors wroteThe facility identified a census of 43 residents. Based on record review and interviews, the facility failed to provide a Registered Nurse (RN) for at least eight consecutive hours, seven days a week. This placed all residents in the facility at risk for decreased quality of care.

Inspectors wroteThe facility had a census of 43 residents. The sample included 12 residents and five Certified Nurse Aide's (CNA) reviewed for performance evaluations and required in-service training. Based on record review and interview, the facility failed to ensure four of the five CNA staff reviewed had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care.

Inspectors wroteThe facility identified a census of 43 residents. Based on record review, and interviews, the facility failed to provide a certified infection preventionist to oversee the facility's Infection Prevention and Control Program (IPCP). This deficient practice placed all residents at increased risk for infections related to lack of identification, tracking/trending, and treatment of infections.

Inspectors wroteThe facility identified a census of 43 residents. Based on interview and record review, the facility failed to conduct a criminal background check as required for two employees. The two employees were allowed access to residents without knowing if they had been found guilty of abuse, neglect, exploitation, misappropriation of property or mistreatment by a court of law. The deficient practice placed affected residents at risk for abuse, neglect, misappropriation, or mistreatment.

Inspectors wroteThe facility identified a census of 43 residents. The sample included 12 residents with two reviewed for accommodation of needs. Based on record review, interviews, and observations, the facility failed to provide Resident (R)33's care planned adaptive equipment to support his dietary needs during meal service. The facility additionally failed to provide R27 wheelchair foot pedals during transport. This deficient practice placed both residents at risk for decreased quality of care. Findings Included: [...]

Inspectors wroteThe facility identified a census of 43 residents. The sample included 12 residents with two residents reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide written notification of the reason and location for the facility-initiated transfer for Resident (R)35. This deficient practice placed the resident at risk of delayed care or uncommunicated care needs. Findings Included: - R35's Electronic Medical Record (EMR) noted diagnoses of morbid obesity (severely overweight), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), heart failure, and chronic kidney disease. [...]

Inspectors wroteThe facility identified a census of 43 residents. The sample included 12 residents with one resident reviewed for hospitalization. Based on observation, interview and record review, the facility failed to provide a copy of the facility bed hold policy to Resident (R)35 and/or their representative, with a written notice specifying the duration and cost of the bed hold, at the time of the resident's two transfers to the hospital. This placed the resident at risk for impaired rights. Findings Included: - R35's Electronic Medical Record (EMR) noted diagnoses of morbid obesity (severely overweight), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), heart failure, and chronic kidney disease. [...]

Inspectors wroteThe facility identified a census of 43 residents. The sample included 12 residents. Based on observation, record review, and interviews, The facility failed to update/revise Residents (R)9 care plans to reflect post-fall interventions and changes in assistive care requirements. This deficient practice placed the resident at risk for preventable injuries and ineffective treatment due to uncommunicated care needs. Findings Included: - R9's Electronic Medical Record (EMR) noted a diagnose of overactive bladder, major depressive disorder (major mood disorder), abnormalities of gait and mobility, fracture of left femur (broken large bone), obesity (overweight), and history of falls. R9's Annual Minimum Data Set (MDS) completed 06/01/23 noted a Brief Interview for Mental Status (BIMS) score of nine indicating moderate cognitive impairment. [...]

Inspectors wroteThe facility identified a census of 43. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure Resident (R)33 had an appropriate indication for use, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of Zyprexa (antipsychotic-class of medications used to treat major mental conditions which cause a break from reality). This deficient practice placed R33 at risk of unnecessary medication administration and possible adverse side effects. Findings Included: [...]

Inspectors wroteThe facility identified a census of 41 residents. The sample included 13 residents with one resident reviewed for reasonable accommodations. Based on observations, record reviews, and interviews, the facility failed provide Resident (R)37 with access to his room's assigned telephone. This deficient practice placed the resident at risk for physical and psychosocial well-being. Findings Included: - The electronic medical records (EMR) documented the following diagnosis for R37: [...]

Inspectors wroteThe facility had a census of 41 residents. The sample included 13 residents with three reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on record review and interview, the facility failed to provide form CMS 10055, Advanced Beneficiary Notice (ABN), which included the estimated cost for continued services for skilled services to the resident or their representative for the two residents, Resident (R) 28, and R32. This deficient practice placed both residents at risk for uninformed decisions and unanticipated costs related to skilled services.

Inspectors wroteThe facility identified a census of 41 residents. The sample included 13 residents. Based on observations, record reviews, and interviews, the facility failed provide R37 with a comfortable home-like environment as evidenced by loud television noises in his room and uncomfortable water temperatures during showers. This deficient practice placed the resident at risk for impaired psychosocial well-being. -Findings Included: -The electronic medical records (EMR) documented the following diagnosis for R37: [...]

Inspectors wroteThe facility identified a census of 41 residents. The sample included 13 residents, five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed ensure the Consultant Pharmacist (CP) identified and reported irregularities for hypertensive medication (class of medication used to treat hypertension (high blood pressure) given outside the physician ordered parameters. which had the potential of unnecessary medication administration thus leading to possible harmful side effects. The CP had not reported irregularities related to physician notification and insulin (medication to regulate blood sugar) administered when blood sugar was outside the physician ordered parameters for Resident (R) 24. These failures placed the resident at risk for possible harmful side effects.

Inspectors wroteThe facility identified a census of 41 residents. The sample included 13 residents, five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed ensure that hypertensive medication (class of medication used to treat hypertension (high blood pressure) given outside the physician ordered parameters. which had the potential of unnecessary medication administration thus leading to possible harmful side effects. The facility failed to ensure the physician was notified and insulin (medication to regulate blood sugar) administered when blood sugar was outside the physician ordered parameters for Resident (R) 24. These failures placed the resident at risk for possible harmful side effects.