Spring Mill Meadows

Inspectors wroteBased on interview and record review, the facility failed to ensure care plan meetings were held quarterly, the residents and the residents' representatives were invited to participate, and to develop a comprehensive care plan related to a PICC line (peripherally inserted central catheter) and enhanced barrier precautions for 4 of 20 residents reviewed for care plans. (Resident 40, 57, 5 and 2)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Personal Protection Equipment (PPE) was used during care for residents on Enhanced Barrier Precautions (EBP), staff removed soiled gloves after cleaning a catheter line and prior to touching items in a resident's environment, to ensure EBP signage was posted, and to properly store a bed pan for 5 of 5 residents reviewed for infection control. (Resident 67, 81, 6, 2 and 5)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the interdisciplinary team (IDT) determined that a resident was safe to self-administer medications and to obtain a physician's order for self-administration for 1 of 1 resident reviewed for self-administration of medication. (Resident 57)

Inspectors wroteBased on interview and record review, the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC) was signed by the resident or resident's representative for 1 of 3 residents reviewed for beneficiary notices. (Resident 68)

Inspectors wroteBased on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was updated when new diagnoses or psychotropic medications were added for 2 of 2 residents reviewed for PASARR. (Residents 3 and 79)

Inspectors wroteBased on interview and record review, the facility failed to ensure baseline care plans were developed within 48 hours of admission and included enhanced barrier precautions for 2 of 4 residents reviewed for baseline care plans. (Resident 5 and 79)

Inspectors wroteBased on interview and record review, the facility failed to ensure physician's orders were followed related to obtaining and documenting weekly weights following an admission and to notify the physician when a bladder scan showed greater than 400 milliliters for 2 of 2 residents reviewed for quality of care. (Resident 5 and 11)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a physician's order for the use of oxygen was prescribed for 1 of 3 residents reviewed for respiratory care. (Resident 16)

Inspectors wroteBased on interview and record review, the facility failed to ensure the attending physician documented in the resident's medical record the rationale for not acting upon a pharmacist's recommendations for 1 of 5 residents reviewed for drug regimen review. (Resident 57)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two tuberculin bottles, containing solution, had been labeled with an open date and a medication had a legible label for 1 of 3 medication storage refrigerators reviewed for medication storage. (PACU medication refrigerator)

Inspectors wroteBased on observation and interview, the facility failed to ensure refrigerator temperatures were monitored and documented to maintain proper temperatures and to discard food before the expiration date for 1 of 2 refrigerators reviewed for food storage. (the reach-in cooler)

Inspectors wroteBased on interview and record review, the facility failed to ensure a staff member followed the facility policy and procedure related to the use of a gait belt during a transfer which resulted in a resident fall for 1 of 3 residents reviewed for accidents. (Resident B) This deficient practice resulted in an abrasion on the resident's forehead and a fracture of the right femur. The deficient practice was corrected on 5/5/25, prior to the start of the survey, and therefore was past noncompliance.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received a medication for cancer as ordered, follow-up appointments with an oncologist were scheduled, and the facility's medical director did not discontinue a medication without consulting with the resident's oncologist for 1 of 2 residents reviewed for quality of care. (Resident B) This deficient practice resulted in Resident B having no follow-up oncology care to prevent further spread of the metastasis to the bone related to his prostate cancer.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physical therapy recommended method to transfer a resident was used for 1 of 5 residents reviewed for accidents. (Resident E) The deficient practice was corrected on 3/17/24, prior to the start of the survey, and therefore was past noncompliance.

Inspectors wroteBased on interview and record review, the facility failed to complete an abnormal involuntary movement scale (AIMS) assessment on a resident who started on an antipsychotic for over a month and did not educate about the black box warnings associated with taking an antipsychotic medication while having dementia for 1 of 5 residents reviewed for unnecessary medications. (Resident 37)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication carts were free of loose medications, label an inhaler, keep narcotic cards free of compromise, and ensure the narcotic count log was correct for 3 of 3 medication carts reviewed for medication storage (medication cart 1, 4 and 3)

Inspectors wroteBased on observation, interview and record review, the facility failed to assist a resident to obtain dentures as recommended during a dental exam for 1 of 3 residents reviewed for dental services. (Resident 20)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure frozen foods were sealed and to ensure food was free of moisture in 1 of 1 freezer reviewed for food safety. (the walk-in freezer)

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified as ordered according to the physician's ordered parameters, to hold medications according to the physician's ordered hold parameters, and to ensure medications were given as ordered for 5 of 5 residents reviewed for quality of care. (Resident J, H, K, B and 37)

Inspectors wroteBased on record review and interview, the facility failed to ensure a facility arranged transfer for a resident included the correct address of the receiving facility for 1 of 1 resident reviewed for discharge. (Resident F). The deficient practice was corrected on 5/23/24, prior to the start of the survey, and therefore was past noncompliance.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' credit cards were kept safe and secure during their admission for 2 of 3 residents reviewed for misappropriation of property. (Residents B and C) The deficient practice was corrected on 1/18/24, prior to the start of the survey, and was therefore past noncompliance.

Inspectors wroteBased on interview and record review, the facility failed to administer medications to ensure a resident was free from significant medication errors for 1 of 3 residents reviewed regarding medication errors. (Resident G) Resident G required a hospital admission of five days.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure interventions were being used to prevent a potential decline to a resident's bilateral heel pressure ulcers for 1 of 3 residents reviewed for pressure ulcers. (Resident M)

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor daily weights as ordered for a resident with the diagnosis of congestive heart failure (CHF) for 1 of 1 resident reviewed for edema. (Resident 7)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dependent residents were transferred as care planned using proper technique and transfer assist times two for 2 of 10 residents reviewed for accidents. (Residents 46 and 49)

Inspectors wroteBased on interview and record review, the facility failed to reweigh a resident after a significant weight loss to ensure a correct weight was obtained and to notify the physician of the weight loss for 1 of 3 residents reviewed for nutrition. (Resident 10)

Inspectors wroteBased on observation and record review, the facility failed to label liquid narcotics stored in the narcotic box in the medication cart for 1 of 3 medication carts reviewed. (Cart 2)