The Springs Healthcare and Rehabilitation

Inspectors wroteBased on record review and interview, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 2 residents reviewed for accidents (Resident #1). The facility failed to ensure the side rails were up and locked in place on shower bed and CNA D did not shower Resident #1 with the assistance of a second staff, per the care plan, on 5/21/26. Resident #1 fell from the shower bed and hit her head which caused an injury requiring 4 staples. This deficiency could expose residents to harm and injury, due to not being adequately assisted. Finds include: Record review of Resident #1's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnosis included impulse disorder, anxiety disorder, repeated falls, personal history of traumatic brain injury. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 3 of 8 residents (Resident #84, Resident #108, and Resident #99) reviewed for ADL care. The facility failed to ensure Resident #84's incontinent brief was changed timely on 04/21/2026. The facility failed to ensure Resident #108 received scheduled showers/bed baths and linens changed after each shower. The facility failed to ensure that Resident #99 had his hair and beard groomed, fingernails trimmed and cleaned. This failure could place residents at an increased risk of not receiving services or care, diminishing quality of life, and decreased self-esteem.

Inspectors wroteBased on observations, interviews and record review, the facility failed to establish a system of accurate reconciliation, determine that drug records were in order, and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 4 medication carts (LVN C's 400-Hall Medication Cart) in the facility affecting 1 resident (Resident #87) and failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for 1 of 4 medication carts (LVN C's 400-Hall Medication Cart) affecting 2 residents (Resident #76 and Resident #12) reviewed for pharmacy services. The facility failed to ensure LVN C accurately reconciled Resident 87's narcotic medication log when she administered but did not sign for Resident 87's Lacosamide Sol 10mg/ml 15ml on 04/21/2025 at 8:00am. [...]

Inspectors wroteFindings included:Observation on 04/19/2026 at 9:15 AM in the kitchen of the walk-in cooler revealed: - Boiled eggs with no open date and a use-by date of 4-12-2026. - Tortillas with an open date of 4-10-2026 and a use-by date of 4-17-2026. - Tortillas with no open date and a use-by date of 4-12-2026. - Turkey lunch meat with no open date and a use-by date of 4-17-2026. - Ham lunch meat with no open date and a use-by date of 4-18-2026. - Turkey lunch meat with an open date of 4-11-2026 and no use-by date. - Jelly with an open date of 4-11-2026 and no use-by date. Observation on 04/19/2026 at 9:23 AM of the walk-in freezer revealed: Garlic Bread with no open date and a use-by date of 4-18-2026. Garlic Bread with no open date and no use-by date. Observation on 04/19/2026 at 9:30 AM of the Kitchen. - Cheerios with no open date and a use-by date of 4-11-2026. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' right to privacy during personal care for 1 of 3 residents (Resident #107) and the facility failed to ensure that each resident has the right to secure and confidential personal and clinical records for 1 out of 32 residents on 500 Hall (Resident #2) reviewed for privacy. The facility failed to ensure CNA H provided privacy by drawing the privacy curtain during incontinent care for Resident #107. The personal health information of one resident (Resident #2) was left unlocked and displayed on the computer screen on the medication cart of LVN D who administered medications to residents at 500 Hall. This failure could place residents at risk of lack of privacy, not having residents' rights acknowledged, and residents' personal clinical information being exposed to unauthorized individuals.

Inspectors wroteBased on interviews and record review the facility failed to ensure resident assessments accurately reflected the resident's status for 1 of 8 residents (Resident #23) reviewed for accuracy of assessments. The facility failed to accurately code Resident #23's use of an antiplatelet medication on her most recent comprehensive MDS assessment dated [DATE]. This failure could have placed the resident at risk of incorrect care and services necessary for their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 4 medication carts (nursing treatment cart) reviewed for medication storage. The facility failed to ensure that the nursing treatment cart was locked and medications/treatment supplies were secured and not accessible to other staff, residents or visitors. This failure could place residents at risk of having unauthorized access to prescriptions, biologicals, and over-the-counter medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 6 residents (Resident #107) reviewed for infection control, as indicated by:The facility failed to ensure CNA H changed dirty gloves when handling clean items while providing peri care to Resident #107. Thise failure could place the residents at risk of transmission of diseases and infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (Resident #1) reviewed for accident, hazards, and supervision. The facility failed to ensure there was adequate supervision to prevent Resident #1 from leaving the facility 01/10/26 without staff knowledge. This failure could place residents at risk of avoidable accidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' right to privacy during personal care for one resident ( Resident #1) of three residents reviewed for privacy and confidentiality. The facility failed to ensure the staff provided privacy to Resident #1 by closing the door during bed bath. This failure could place residents at risk of having their bodies exposed to the public, resulting in low self-esteem and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 of 10 residents (Resident #9, Resident #367, and Resident #371) residents reviewed for resident rights. The facility failed to ensure CNA A and CNA B knocked on Resident #9, Resident #367, and Resident #371's door when going into the residents' rooms. The deficient practice could place residents at risk of feeling like their privacy was being invaded or the facility was not their home.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. Also, provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 6 of 11 residents (Resident #52, Resident #63, Resident #10, Resident #8, Resident #97, and Resident #46) reviewed for infection control. The facility failed to ensure [NAME] E was practicing proper hand hygiene while preparing foods and CNA C while lunch passing trays. This failure could place residents who were served from the kitchen at risk for consuming contaminated food, developing foodborne illnesses, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of three residents reviewed for pharmaceutical services. The facility failed to administer Resident #1's Amlodipine and Metoprolol (blood pressure medications) for eight days after being admitted to the facility on [DATE]. This failure could affect residents by putting them at risk of exacerbation and/or deterioration of their health conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 2 of 6 residents (Residents #1, and #2) reviewed for infection control, as indicated by: The facility failed to ensure MA A cleaned and disinfected the wrist blood pressure monitor while using it on Residents in Hall 6 of the facility; on Resident #1 and Resident # 2. This failure could place the residents at risk of transmission of disease and infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure all drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 1 of 2 medication storage rooms (Transition Care Unit Storage room) and 4 of 5 medication carts (600 Hall MA cart, 600 Hall Nurse cart, 300 Hall Nurse cart, 400/500 Hall MA cart) reviewed. The facility failed to ensure expired medications were removed, food products were not in the carts and failed to ensure the carts were clean of potential contaminants. These failures could place residents who receive medications at risk for receiving outdated or contaminated medications which could result in residents not receiving the intended therapeutic effects of their medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens reviewed for food storage and sanitation. The facility failed to ensure all foods were properly covered, labeled, dated and discarded. The facility failed to ensure chemicals were not stored near food items. The facility failed to ensure the trash can was covered when not in use. The facility failed to ensure CK N washed her hands in between tasks. The facility failed to ensure sanitized the food processor after washing it. These failures placed residents at risk for foodborne illness.

Inspectors wroteBased on observation interview, and record review, the facility failed to make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS for 3 of 9 residents (Resident #32, Resident #41, and Resident #103) reviewed for comprehensive assessments. Interviews for activity preferences for Residents #32, #41, and #103 were not completed in the most recent comprehensive MDS assessments. This failure placed residents at risk of not having their recreational needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for each resident for 3 of 8 (Resident #2, Resident #32, and Resident #103) residents reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #32's and Resident #103's care plans addressed their activity preferences. 2. The facility failed to ensure Resident #2's care plan reflected her current wounds. These failures placed residents at risk of not having interventions in place to address wounds and activities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 4 residents of 24 residents (Resident #32, Resident #41, Resident #103, and Resident #104) reviewed for activities. 1. Residents #32 and #103 were not engaged in a person-centered activity program and were not receiving activities. 2. The group activity program did not occur as scheduled from 01/04/24 to 01/05/24, and there were no activities scheduled on 01/03/24. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 4 of 6 residents (Resident #51, Resident #65, Resident #97 and Resident #314) reviewed for infection control, in that: 1. The facility failed to ensure Resident #97's enteral formula was timed and initialed after it was opened. 2. LVN E did not wash or sanitize her hands during glove change following removal of Resident #314's old wound care dressing. 3. Resident #65's oxygen nasal canula was not dated and was laying on the floor and Resident #51's oxygen nasal cannula was laying on the floor. These deficient practices place residents in the facility at risk for infections due to improper care practices.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's right to formulate an advance directive for 1 of 21 residents (Resident #29) reviewed for advance directive. Resident #29's Out of Hospital Do Not Resuscitate order did not have a physician's signature. This failure placed residents at risk of traumatic, undesired resuscitation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an environment as free of accident hazards as is possible for 1 of 6 halls (hall 600) and 1 of 24 residents (Resident #11) reviewed for accident hazards. The shower room located next to room [ROOM NUMBER] was unlocked due to a broken lock. Residents had full access to the room. Toxic solutions with poison control warnings and hazardous sharps items were stored in the room unsecured. The locking cabinet inside the room was missing a lock. Resident #11 had an unmonitored bottle of hand sanitizer on the resident bedside table. The bottle had a poison control warning. These deficient practices place residents in the facility at risk for avoidable accidents and hazards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident for 1 of 24 residents (Resident #42) reviewed for pharmaceutical services. The facility failed to ensure that Resident #42 received his medications on the morning of 01/03/24. This failure placed residents at risk of not receiving medication therapy.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents had physician orders for the resident's immediate care for one (Resident #1) out of 15 residents reviewed for physician orders. A nurse failed to transcribe NP telephone orders for Resident #1, a new admission with a diagnosis of diabetes, for accu-checks to the residents EMR to receive the necessary care and services upon admission. Resident #1 was sent to the hospital for a change of condition, his BS level was 498. An IJ was identified on 10/11/2023. The IJ Template was provided to the facility on [DATE] at 04:05 p.m. While the IJ was removed on 10/12/2023, the facility remained out of compliance at a scope of isolated and a severity level of potential harm because the facility's need to evaluate the effectiveness of the corrective systems. [...]