The Springs Nursing & Rehab Center

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to store food properly in the main kitchen; dried food and meat were not labeled. The Findings Include: On 9/18/23 at 11:45 AM, the initial kitchen tour was conducted with the dietary manager (other staff, OS #2). The dry storage room yielded opened bulk bags of sugar, powdered gravy, and flour without dates indicating when the item was opened or when the item was to be used by. When asked about the opened containers, OS #2 said that the items should have been dated with an open date and an use by date. The reach-in refrigerator was then observed, a storage bag of approximately 15 leftover cooked pork links was also found without a label indicating when it was placed in the refrigerator (opened) or the use by date. [...]

Inspectors wroteBased on clinical record review, staff interview, and facility document review, the facility staff failed to accurately assess and document pnemococcal vaccine status for one of five resident records reviewed: Resident # 17.

Inspectors wroteBased on employee file review and staff interview, the facility staff failed to follow the abuse policy for two of 25 employee files reviewed. Two employee files did not have a background investigation check obtained.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to develop a comprehensive care plan for one of twenty residents (Resident #7).

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to assess and/or initiate treatment for skin impairments for two of twenty residents (Resident #7 and #9) and failed to follow standards of care for medication administration during a medication pass observation on one of two units (100 hall).

Inspectors wroteBased on observation, staff interview, and review of facility documents, the facility failed to ensure food was stored in a manner to ensure food safety, and kitchen staff failed follow proper handwashing procedures.

Inspectors wroteBased on complaint investigation, clinical record review, staff interview, and family interview, the facility staff failed for one of 18 residents in the survey sample, Resident # 58, to offer compassionate care visits. The family of Resident # 58 was not offered compassionate care visits while visitation in the facility was restricted.

Inspectors wroteBased on staff interview and clinical record review, the facility failed to ensure an accurate MDS (minimum data set) assessment for one of 18 resident's in the survey sample. Resident #59's discharge MDS assessment was coded as being discharged to the hospital instead of home. The Findings Include: Diagnoses for Resident #59 included: Compression fracture, dementia, adult failure to thrive, and dehydration. The most current MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of 3/17/22. Resident #59's cognitive score was a 11 indicating moderately cognitively intact. During a closed record review, Resident #59 was added to the sample as a hospital discharge review. On 8/10/22 Resident #59's clinical record was reviewed. Section A2100 of Resident #59's discharge MDS (dated 5/26/22) documented Resident #59 had been discharged to Acute Hospital. [...]

Inspectors wroteBased on staff interview, clinical record review and facility document review, the facility staff failed to ensure one of 18 residents (Resident #32) had a targeted resident review coordinated with the appropriate state designated authority according to the Level II PASARR (pre-admission screening and resident review).

Inspectors wroteBased on staff interview and clinical record review, the facility failed to develop care plans for two of 18 resident's in the survey sample. Resident #7 did not have a care plan for antidepressant medication and mood. Resident #27 did not have a complete care plan for tube feeding care and management. The Findings Include: 1. Diagnoses for Resident #7 included: Respiratory failure, chronic obstructive pulmonary disease, anxiety, and depression. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 6/5/22. Resident #7's cognitive score was a 15 indicating cognitively intact. Section D0200 (B) documented Resident #7 had felt down, depressed, or hopeless 7 to 11 days of the 14 day look back period. [...]

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, the facility staff failed to ensure specific physician's orders and interventions were in place for the the care, treatment and management of a gastrostomy tube for one of 18 residents in the survey sample, Resident #27.

Inspectors wroteBased on staff interview, family interview, clinical record review, facility document review and in the course of a complaint investigation, the facility staff failed to ensure one of 14 residents (Resident #2) was free from neglect. Facility staff failed to get an order for a urinalysis for Resident #2 after a request by the family. Resident #2, who had a history of urinary tract infections, subsequently was admitted to the hospital and treated for a urinary tract infection a week later.

Inspectors wroteBased on resident interview, clinical record review, facility document review and staff interview, the facility staff failed for one of 14 residents to conduct a complete and thorough investigation for an injury sustained during an altercation between a resident and a staff member. Resident #7 sustained a large bruise covering the left eye. The Findings Include: Resident #7 was admitted to the facility on [DATE]. Diagnoses for Resident #7 included: Dementia with behaviors, mild cognitive impairment, impulse disorder, and chronic obstructive pulmonary disease. The most current MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 3/12/21. Resident #7 was assessed with a cognitive score of 14 indicating cognitively intact. On 03/21/21 at 11:24 AM, Resident #7 was interviewed. [...]

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure documentation regarding transfer was in the clinical record for one of 14 residents, Resident #45. Resident #45 was transferred to another skilled nursing facility; there was no documentation in the clinical record regarding coordination of care and service needs of the resident prior to her discharge.

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards during a medication pass and pour observation, for one of 14 residents, Resident #22 License practical nurse (LPN #1) was going to give Resident #22 the wrong dose of Tylenol.

Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to ensure drugs and biologicals were stored properly in the facility's medication room. The facility failed to ensure an expired multi dose vial of influenza and a multi dose via of tuberculin were not available for administration; and failed to ensure a 30 ml bottle of Lorazepam concentrate belonging to a deceased resident, was not available for administration.