Wellspring Health Center

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #10) of three residents reviewed for pain medication. The facility census was 43 residents.

Inspectors wroteBased on record review, staff interview, review of the facility's investigation and policy review, the facility failed to provide adequate physical assistance for a resident who was dependent on staff for toileting, personal hygiene, and bed mobility. Actual Harm occurred on 01/19/26 at approximately 6:00 P.M. when one staff member was providing incontinent care to Resident #39 while in bed. Certified Nursing Assistant (CNA) #250 rolled Resident #39 to his left side and the resident fell from the bed onto the floor. Resident #39 had fractures to his right humerus (upper arm bone), right coronoid (elbow), left femur (upper leg bone), and left patella (kneecap). This affected one (Resident #39) of three residents reviewed for falls. The census was 48. Findings Include:Resident #39 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, facility policy and document review, and the Food and Drug Administration 2022 Food Code, the facility failed to ensure meals were prepared and food was stored in accordance with professional standards for food safety. This had the potential to affect 38 residents who received meals from the kitchen. The facility census was 40. 1. A facility policy titled, Sanitation - Dish and Utensil Procedure Guideline, dated 03/19/2019, specified, The following guidelines provides an overview of routine cleaning services and the general frequency of various cleaning tasks. The policy specified, 6. Dishes and utensils shall be air dried before storage. Do not towel dry, and 10. Cutting boards need to be washed and sanitized between each use. Replace cutting boards once they have deep knife marks and are unsanitizeable. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure care was provided in a dignified manner for one (Resident #43) of one resident reviewed for urinary catheter management. Specifically, the facility failed to ensure Resident #43's urinary catheter drainage bag was covered and urine in the bag was not visually exposed. The facility census was 40. A facility policy titled, Skilled Promoting/Maintaining Resident Dignity, dated 09/10/2025, indicated, It is the practice of this facility to protect and promote resident rights and treat each resident in a manner and in an environment that maintains or enhances the resident's quality of life by recognizing each resident's individuality. A facility policy titled, Urinary Catheter Care, dated 09/08/2013, indicated, Catheter bag should not be visible when in public areas. [...]

Inspectors wroteBased on observation, interview, record review, and facility document and policy review, the facility failed to ensure fingernails were clean and trimmed for one (Resident #26) of one resident reviewed for activities of daily living. The facility census was 40. A facility policy titled, Skilled - Nail Care, dated 09/10/2025, revealed, 3. Routine cleaning and inspection of nails will be provided during Activities of Daily Living (ADL) care on an ongoing basis. The policy continued, 5. The resident's plan of care will identify: a. The frequency of nail care to be provided. b. The type of nail care to be provided. An admission Record revealed the facility admitted Resident #26 on 03/08/2025. According to the admission Record, the resident had a medical history that included diagnoses of contracture of the right hand, adjustment disorder, and mild cognitive impairment. [...]

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to provide proper treatment and care to one (Resident #19) of one resident reviewed for bowel management. Specifically, the facility failed to address Resident #19's lack of a bowel movement for over three days. The facility census was 40. A facility policy titled, Constipation - Skilled, reviewed 07/14/2022, revealed, 1. The staff will be aware that if a resident has not had a bowel movement after three (3) days, further intervention may be necessary. 2. The certified nursing assistance [sic] will be responsible for documenting if the resident had a bowel movement in Point of Care [the electronic medical record, EMR]. This will be addressed at least every shift and PRN [as needed]. 3. [...]

Inspectors wroteBased on observation, interview, record review, and facility document and policy review, the facility failed to ensure effective coordination between facility staff, the provider, and the pharmacy regarding a refill for a narcotic medication for one (Resident #19) of five residents reviewed for pharmacy services. As a result, the pharmacy was unable to fill Resident #19's prescription for as-needed oxycodone (a narcotic pain reliever), and the resident did not have access to the medication for seven days. The facility census was 40. A facility policy titled, Unavailable Medications - Skilled, revised 04/02/2024, revealed, Policy: When medications or treatments are unavailable, the community should make every effort to obtain the medication or treatment for the resident prior to the scheduled dose. [...]

Inspectors wroteBased on review of the medical record, review of the Emergency Medical Services (EMS) report, staff interviews, review of witness statements, review of door repair invoices, review of maintenance work orders, review of facility Self-Reported Incident (SRI), review of hospital records and review of the facility policy, the facility failed to provide adequate supervision to prevent an elopement from the Memory Care Unit (MCU) of one resident (#45) who ambulated through a door on the MCU with a malfunctioning alarm and into the East side stairwell where Resident #45 fell down 11 cement stairs. [...]

Inspectors wroteBased on record review, observations, staff interviews, and policy review, the facility failed to ensure infection control measures were followed when providing catheter care. This affected one (#20) of three residents reviewed for urinary tract infections. The facility census was 44.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure medications for administration was not pre-poured prior to administration. This affected eight residents (#2, #3, #4, #5, #6, #18, #19, and #20) of thirteen residents who resided on the 200 hall reviewed for medication administration. The census was 43.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to follow physician orders for weekly weights and medication administration. This affected three residents (#36, #16, and #2) of eight residents reviewed for following physician orders. The census was 43.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to administer medications as ordered. This affected one (Resident #32) of three residents observed for medication administration. The facility census was 43.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure residents representatives were notified of a change in condition. This affected two (#25 and #42) of three residents reviewed for a change in condition. The facility census was 41.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure staff utilized appropriate practices to ensure residents were free from falls. This affected one (#42) of three residents reviewed for falls. Additionally, the facility also failed to ensure all falls were investigated. This affected one (#25) of three residents reviewed for falls. The facility census was 41.

Inspectors wroteBased on staff interview, review of the Centers for Medicare and Medicaid Services (CMS) memo, review of the infection control log, and policy review, the facility failed to implement a program to prevent Legionella (a type of pneumonia caused by bacteria). This had the potential to affect all residents at the facility. The facility census was 46.

Inspectors wroteBased on record review, facility policy review, and interview the facility failed to obtain witnessed authorization forms for residents and/or resident representatives allowing the facility to manage their funds in an interest bearing account. This affected four out of four Residents (#12, #13, #15, #19) reviewed for resident funds. The facility census was 46.

Inspectors wroteBased on medical record review, observation and staff interview, the facility failed to ensure a cognitively impaired resident was clothed while out in a common area. This affected one resident (#16 ) out of three residents reviewed for dignity. The facility census was 46. Findings Include: Review of Resident #16's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, and anxiety. Review of Resident #16's Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of the behavior plan of care dated on 06/05/22 revealed the resident would bite and chew on her clothes. Observations on 08/22/22 at 11:10 A.M. revealed Resident #16 was sitting in the hall by the nurses station. Resident #16 had other residents sitting near by her. [...]

Inspectors wroteBased on observation, record review, facility policy review, and interview, the facility failed to provide follow up regarding concerns during Resident Council Meetings. This affected two (Resident #07 and #29) out of three residents reviewed for Resident Council concerns. The facility census was 46.

Inspectors wroteBased on observation, record review, facility policy review, and interview, the facility failed to provide a homelike environment for three residents (#07, #29, and #30) out of three residents reviewed. The facility census was 46.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that resident medical records provided an accurate depiction of resident medication administration. This affected one resident (Resident #353) of 17 residents reviewed for medications. The facility census was 46.

Inspectors wroteBased on observation, policy review and staff interview, the facility failed to ensure that medications were secured inside the medication carts and did not have loose medications, personal items, food and discontinued blood glucose monitoring test fluids were not stored in the carts. The facility also failed to ensure the medications rooms were clean, orderly and in good repair. This affected three of four medication carts and two of two medications rooms. This had the potential to affect all 64 residents residing in the facility.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain a clean sanitary environment for food preparation. This had the potential to affect all 64 residents residing in the facility as all residents consumed meals from the kitchen.

Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to thoroughly investigate falls and ensure the physician ordered and care planned interventions for fall preventions were in place. This affected four (#5, #10, #20 and #25) of four residents reviewed for accidents. The facility policy was 64.

Inspectors wroteBased on record review, observation and staff interview, the facility failed to ensure geri chairs were clean. This affected two (Residents #10 and #34) of 24 residents reviewed for environment. In addition, the facility failed to secure and/or repair a ripped transition strip to the threshold of the third floor dining and activity area. This had the potential to affect all 30 the residents residing on the third floor (Residents #1, #2, #4, #6, #10, #11, #12, #14, #19, #20, #21, #22, #23, #25, #30, #31, #32, #33, #34, #36, #38, #39, #90, #91, #92, #93, #247, #248, #249 and #250). The facility census was 64.

Inspectors wroteBased on record review, observation, staff interview and review of facility policy, the facility failed to transport a resident in his reclining chair in a dignified manner. This affected one (Resident #25) of four residents reviewed for accidents. The facility census was 64.

Inspectors wroteBased on observation, record review, review of facility policy and staff interviews, the facility failed to ensure call lights were within reach of the residents. This affected three (#19, #30 and #90) of seventeen residents investigated in the final sample. The facility census was 64.

Inspectors wroteBased on record review, family interview, review of facility policy and staff interviews, the facility failed to notify a resident and/or resident representative of a resident's significant weight loss. This affected one (#34) of five residents reviewed for nutrition. The facility identified five residents who had significant weight loss or gain. The facility census was 64.

Inspectors wroteBased on record review and staff interview, the facility failed to notify the resident and/or resident's representative and the Office of the State Long-Term Care Ombudsman in writing upon the resident's transfer to the hospital. This affected three (Residents #5, #17 and #20) of three residents reviewed for hospitalization. The facility census was 64.

Inspectors wroteBased on record review, staff interview, and review of facility policy, the facility failed to provide the resident and/or resident's representative with written notification of the facility's bed hold policy upon the resident's transfer to the hospital. This affected three (Residents #5, #17, #20) of three residents reviewed for hospitalization. The facility census was 64.

Inspectors wroteBased on record review and staff interview, the facility failed to complete a Preadmission Screening and Resident Review (PASARR) when admitting a resident with mental illness. This affected one (#30) of seventeen residents reviewed in the final sample. The facility census was 64.

Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to care plan a seat belt and update a resident's potential for alteration in skin integrity care plan with interventions to prevent the development of pressure ulcers. This affected two (#19 and #39) of 17 residents who were reviewed for care plans in the final sample.

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to serve resident liquids thickened according to the physician's order. This affected one (Resident #39) of one residents reviewed for hydration. The facility census was 64.

Inspectors wroteBased on record review, observation, staff interview and policy review, the facility failed to maintain appropriate infection prevention regarding tube feeding and failed to utilize appropriate hand hygiene during a wound care treatment. This affected one (Resident #38) of four residents observed for pressure ulcer treatments and one ( Resident #77) of two residents observed with a tube feed. The facility identified seven residents with pressure ulcers and three residents who utilize tube feed. The facility census was 64.