Three Springs Sr Living & Rhab

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was prepared in a manner which prevents potential food born illness for 7 of 7 (R1, R2, R3, R4, R5, R6, and R7) residents reviewed for food temperatures in the sample of 7.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents had a clean and sanitary shower/restroom and paper towels in residents' rooms and shower/restrooms for 51 (R1-R5, R8-R12, R15-R37, R39-R55) of 55 residents reviewed for clean showers/restrooms and supplies in a sample of 55. The Findings Include:On 6/7/26 at 8:32 AM, V3 (Licensed Practical Nurse/LPN) stated that when supplies run low typically a staff member just runs up to the local grocery store to get what is needed to get by until the next delivery date. On 6/7/26 at 9:41 AM, V4 (Housekeeper) stated that they have been out of paper towels in the shower room on C Hall for the past couple days. V4 stated that they do occasionally have an issue of running out of items and someone will run up the local store to grab what they need. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure incontinence care was provided timely for 2 of 3 (R6 and R8) reviewed for activities of daily living (ADL) in the sample of 24. Findings Include: 1. R6's admission Record with a print date of 6/7/26 documents R6 was admitted to the facility on [DATE] with diagnoses that include heart failure, chronic kidney disease, weakness, edema, history of urinary tract infections, pain, and unsteadiness on feet. R6's Minimum Data Set (MDS) dated [DATE] documents R6 has a Brief Interview for Mental Status score of 12, indicating a moderate cognitive deficit. This MDS documents R6 requires partial/moderate assistance with toilet hygiene and toilet transfer. R6's current Care Plan includes a Focus area, (R6) is at risk for Self care deficit. Date Initiated: 12/06/2024. [...]

Inspectors wroteBased on interview and record review the Facility failed to ensure medication errors did not occur for 1 of 3 residents (R6) reviewed for medication errors in the sample of 9.

Inspectors wroteBased on interview and record review the facility failed to use the services of a registered professional nurse for at least 8 consecutive hours a day, 7 days a week. This has the potential to affect all 66 residents residing in the facility. Findings Include: The facility schedule dated August 11, 2025 through September 11, 2025 was reviewed and on 8/9/25, 8/27/25, 8/29/25, 9/1/25, 9/3/25, 9/6/25, 9/7/25 and 9/8/25 the facility did not have an Registered Nurse providing resident care for 8 Consecutive hours. On 9/12/25 at 9:00 AM V3 (Infection Preventionist) stated she completed the working schedules for the facility, and she scheduled what staff was available. At the time the facility only had 1 Registered Nurse. [...]

Inspectors wroteBased on interview and record review, the Facility failed to store foods in a manner that prevents foodborne illness. This has the potential to affect all 66 residents living in the Facility.

Inspectors wroteBased on observation and interview, the Facility failed to ensure adequate food was prepared for 5 of 5 residents (R10, R24, R51, R57, R63) reviewed for food and nutrition services in the sample of 60.

Inspectors wroteBased on interview, observation and record review the facility failed to ensure that Fentanyl patches were removed from 1 of 3 residents (R75) from a sample of 25 as ordered by the physician.

Inspectors wroteBased on observation and interview, the facility failed to provide 80 square feet of floor space per resident bed for 53 out of 53 residents (R1, R2, R3, R4, R5, R7, R8, R10, R11, R12, R14, R17, R18, R19, R20, R21, R23, R24, R25, R27, R28, R29, R30, R31, R32, R33, R34, R37, R38, R40, R41, R42, R43, R47, R48, R49, R50, R51, R52, R53, R54, R55, R56, R57, R59, R61, R62, R63, R64, R66, R67, R72, and R75) reviewed for room size in the sample of 61.

Inspectors wroteBased on interview and record review the Facility failed ensure a safe discharge for 1 of 3 residents (R1) reviewed for proper discharge in the sample of 12. This failure resulted in R1 being discharged to her home on 7/19/25 without her physician's knowledge, order, or consent.

Inspectors wroteBased on observation, interview and record review the facility failed to supervise a moderately impaired resident with a history of stroke. R3 was left unattended outside and fell from the wheelchair for 1 of 3 residents (R3) reviewed for falls in the sample of 6. This failure resulted in R3 being sent to the hospital after sustaining a black eye and bruising to her forehead from the fall.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents who require assistance receive a shower or bath for 4 of 4 residents (R2, R8, R10, R11) reviewed for Activities of Daily Living assistance in the sample of 15. Findings Include: 1. R8's admission record, print date of 8/12/25, documented R8 has diagnoses including osteoarthritis, spinal stenosis, spondylosis of cervical region, depression, hypertension, bipolar disorder, schizophrenia, polyneuropathy, and intervertebral disc degeneration. R8's MDS (Minimum Data Set), dated 5/20/25, documented R8 is cognitively intact and requires partial to moderate assistance with bathing. R8's care plan, undated, documented R8 has an ADL (activities of daily living) self-care performance deficit impaired balance, requires assistance of 1 for transfers, and for bathing. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide enough nursing staff to adequately meet the needs for 4 of 4 (R2, R8, R10, and R11) residents reviewed for staffing in the sample of 15. These failures have the potential to affect all residents residing at the facility. Findings Include: 1. 1. R8's admission record, print date of 8/12/25, documented R8 has diagnoses including osteoarthritis, spinal stenosis, spondylosis of cervical region, depression, hypertension, bipolar disorder, schizophrenia, polyneuropathy, and intervertebral disc degeneration. R8's MDS (Minimum Data Set), dated 5/20/25, documented R8 is cognitively intact and requires partial to moderate assistance with bathing. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed implement fall interventions as care planned for 1 of 3 residents (R5) reviewed for falls in the sample of 15. Findings Include:R5's admission record, print date of 8/7/25, documented R5 has diagnoses including metabolic encephalopathy, orthostatic hypotension, chronic atrial fibrillation, atherosclerotic heart disease, hypothyroidism, hyperlipidemia, major depressive disorder, cognitive communication deficit, hypertension, urine retention, and a history of falling. R5's MDS (Minimum Data Set), dated 7/25/25, documented R5 is moderately cognitively impaired and requires supervision or touching assistance with transfers. [...]

Inspectors wroteBased on observation, interview, and record review the Facility failed to ensure staff were encouraging COVID-19 positive residents to wear masks and ensure staff don proper personal protective equipment (PPE) to prevent the spread of COVID-19. This has the potential to affect all 63 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) was working in the facility for at least 8 consecutive hours a day, 7 days a week. This failure has the potential to affect all 66 residents living in the facility.

Inspectors wroteBased on interview and record review the Facility failed to ensure infection control surveillance was being followed for residents experiencing vomiting and/or diarrhea. This has the potential to affect all 66 residents living in the facility.

Inspectors wroteBased on interview and record review the Facility failed to ensure resident showers were being given for 4 of 5 residents (R2, R3, R6 and R12) reviewed for activities of daily living in the sample of 13.

Inspectors wroteBased on interview and record review, the Facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, 7 days a week. This has the potential to affect all 70 residents living in the Facility.

Inspectors wroteBased on interview and record review, the Facility failed to respect end of life wishes for 1 of 3 residents (R2) reviewed for advanced directives in the sample of 4.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to store foods in a manner that prevents foodborne illness. This has the potential to affect all 66 residents living in the Facility.

Inspectors wroteBased on interview and record review, the facility failed to attempt Gradual Dose Reductions on psychotropic medications for 1 of 3 residents (R23) in a sample of 10.

Inspectors wroteBased on observation and interview, the facility failed to provide 80 square feet of floor space per resident bed for 50 residents (R2, R3, R4, R5, R6, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R21, R22, R23, R24, R26, R27, R28, R29, R32, R35, R37, R38, R41, R42, R45, R46, R47, R49, R51, R52, R53, R55, R58, R58, R59, R60, R61, R62, R63, R64, R167, R168, R169, R217, R267) reviewed for room size in the sample of 63.

Inspectors wroteBased on observation and interview, the facility failed to provide 80 square feet of floor space per resident bed for 54 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R13, R14, R15, R16, R17,R18, R19, R20, R22, R23, R25, R26, R27, R28, R30, R31,R33, R34, R35, R36, R37, R38, R39, R40, R41, R42,R45, R44, R46, R47, R48, R49, R51, R52, R54, R55, R56,R57, R110, R160, R210, R260, R261) reviewed for room size in the sample of 54. Findings Include: On 9/7/2023 at 8:39 AM, V1 (Administrator) stated there have been no changes to the historical measurements and accuracy of the facility's waivered resident room numbers and certifications. V1 stated: [...]