Wellsprings Care Center

Inspectors wroteBased on observations, record review and interviews, the facility failed to protect three (#3, #5 and #7) out of three residents from physical abuse out of 11 sample residents. Specifically, the facility failed to:-Protect Resident #3 from physical abuse by Resident #6; -Protect Resident #5 from physical abuse by Resident #6; and, -Protect Resident #7 from physical abuse by Resident #5.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#9) of three residents reviewed for accident hazards received adequate supervision out of 11 sample residents. Specifically, the facility failed to assess, educate, and initiate care plan interventions for Resident #9.

Inspectors wroteBased on record review and interviews, the facility failed to protect one (#1) of three residents from misappropriation of property out of three sample residents. Specifically, the facility failed to protect Resident #1 from misappropriation of property and exploitation by a facility employee.

Inspectors wroteBased on observations and interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in the main kitchen. Specifically, the facility failed to ensure:-Perishable foods were discarded after the date of expiration; and, -Perishable foods were labeled and dated.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents were not responsible to purchase items or services for which payment was made under Medicaid or Medicare. Specifically, the facility failed to ensure routine hygiene items such as hand soap in the resident rooms were provided at no cost to the residents. I. Facility admission agreementThe facility's admission agreement, dated 2018, was received from the nursing home administrator (NHA) on 9/8/25 at 10:41 a.m. It read in pertinent part,Services (items) covered under Medicaid/Medicare: Routine personal hygiene items and services, as needed, to meet your needs, including, but not limited to: hygiene supplies, comb, brush, soap, and disinfecting soaps or specialized cleansing agents when indicated to treat special skin. II. ObservationsOn 9/9/25 at 10:03 a.m. room [ROOM NUMBER] was observed. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide a clean, comfortable and homelike environment for residents in two of four hallways and two of four shower rooms. Specifically, the facility failed to:-Ensure Resident #4's window blinds and walls were cleaned and maintained and the resident's bed was in good condition;-Ensure bath towels were available for resident use in shower rooms; and,-Ensure residents' rooms were free from debris and odors and appropriate personal hygiene items were available.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the environment was free of accidents and hazards for three (#48, #68 and #5) of four residents reviewed for accidents/hazards out of 39 sample residents. Specifically, the facility failed to: -Ensure Resident #48 and Resident #68 were re-assessed to determine if they were safe to smoke independently; -Ensure staff were consistently implementing the care planned fall interventions for Resident #5; and, -Ensure Resident #5's fall care plan was updated with all fall interventions.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease on three of four hallways. Specifically, the facility failed to:-Ensure enhanced barrier precautions (EBP) were followed during a transfer for Resident #49, who had an indwelling medical device (Foley catheter); -Ensure enhanced barrier precautions (EBP) were followed during resident care for Resident #47, who had an indwelling medical device (enteral feeding tube); and,-Ensure staff performed hand hygiene consistently during medication administration for Resident #31, Resident #14 and Resident #24.

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to:-Ensure the first floor north shower gurney pad was smooth, cleanable, in good repair, and cleaned according to manufacturing instructions; and, -Ensure the residents' shower rooms were maintained in a safe, sanitary and working conditions.

Inspectors wroteBased on record review and interviews, the facility failed to ensure two (#27 and #43) of six residents reviewed for abuse out of 39 sample residents were kept free from abuse. Specially, the facility failed to protect Resident #27 and Resident #43 from physical abuse by Resident #48.

Inspectors wroteBased on record review and interviews, the facility failed to notify the state mental health agency promptly after a significant change in the resident's mental condition for one (#7) of four residents out of 39 sample residents. Specifically, the facility failed to notify the state mental health agency authority of Resident #7's necessity for inpatient psychiatric hospitalization.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent (%). Specifically, the facility had a medication error rate of 8%, or two errors out of 25 total opportunities for error.

Inspectors wroteBased on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in two of four medication carts. Specifically, the facility failed to:-Ensure residents' medications were labeled and dated appropriately with the resident's name, the date the medication was opened and the expiration date, as applicable; and,-Ensure over-the-counter (OTC) medications stored in medication carts were not expired.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents received the required therapy services which were ordered by the physician for one (#74) of three residents reviewed for therapy services out of 39 sample residents. Specifically, the facility failed to ensure Resident #74 received specialized rehabilitative services as ordered on admission to the facility, to maintain the resident's highest practicable level of physical, mental, functional and psycho-social well-being.

Inspectors wroteBased on observations and interviews, the facility failed to ensure adequate outside ventilation by means of windows, or mechanical ventilation for two out of four shower rooms. Specifically, the facility failed to ensure ventilation fan covers were kept clean and operational in the resident shower rooms.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that services provided or arranged in accordance with the resident's plan of care were delivered by individuals who have the skills, experience and knowledge to do a particular task or activity for four (#2, #4, #6 and #7) of seven residents out of 11 sample residents. Specifically, the facility failed to: -Ensure Resident #2, Resident #5, Resident #6 and Resident #7's post fall assessments were completed timely by a qualified person and documented in the residents medical record.

Inspectors wroteBased on observations and interviews the facility failed to provide a safe, clean, sanitary and comfortable homelike environment throughout the facility in three out of four hallways. Specifically the facility failed to: -Ensure resident rooms were clean and odor free; -Ensure the residents had clean bed linens and privacy curtains; -Ensure the dining room and common areas were clean; and, -Ensure the facility was free from institutional odors.

Inspectors wroteBased on record review and interviews, the facility failed to notify the resident representative when there was a significant change in the resident's condition for two (#7 and #8) of three residents reviewed out of 12 sample residents. Specifically, for Resident #7 and Resident #8, the facility failed to: -Keep the resident's current designated representative's name and contact information updated in the resident's record; and, -Make additional attempts or try alternative methods to contact the representative when the representative was not reachable.

Inspectors wroteBased on record review and interviews, the facility failed to ensure three (#1, #2 and #5) of three residents reviewed for abuse out of 12 sample residents were kept free from abuse. Specifically, the facility failed to: -Ensure Resident #2 and Resident #5 were kept free from physical abuse from each other; and, -Ensure Resident #1 was kept free from physical abuse by Resident #2.

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, clean, sanitary, and comfortable environment throughout the facility. Specifically, the facility failed to: -Ensure resident rooms were clean, sanitary and odor-free; -Ensure the resident common areas were clean and odor-free; -Ensure residents' bed sheets were changed regularly and when soiled; and, -Ensure residents had hand towels available for use in their rooms.

Inspectors wroteBased on record review and interviews, the facility failed to ensure three (#12, #14 and #23) of five residents reviewed for abuse out of 23 sample residents were kept free from abuse. Specifically, the facility failed to: -Prevent Resident #12 from being sexually abused by Resident #13; -Prevent Resident #14 and Resident #23 from being physically abused by Resident #13; and, -Implement a care plan focus to assess and monitor Resident #13 for inappropriate behavior when he had a known history of violent aggression and other inappropriate behaviors.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#7) of one resident out of 23 sample residents was protected from exploitation and misappropriation of property. Specifically, the facility failed to prevent a staff member from taking $5,060 from Resident #7.

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to: -Ensure the resident's second floor smoking patio was free from debris and the fire blanket was visible; -Ensure the outdoor refuse area was free from debris and items were properly disposed of; and, -Ensure a resident's room was free of long standing stains on the floor. I. Facility policy and procedure The Homelike Environment policy, revised February 2021, was provided by the quality mentor (QM) on 12/4/24 at 12:30 p.m. The policy revealed in pertinent part, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for one (#1) of six residents reviewed out of 11 sample residents. Specifically, the facility failed to ensure Resident #1, who was dependent on staff for bathing, received her scheduled showers.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#6) of one resident out of 11 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to: -Ensure Resident #6 was weighed weekly per physician orders; and, -Ensure Resident #6's care plan was updated to include new weight monitoring interventions related to his diagnosis of atrial fibrillation and heart failure. I. Resident status Resident #6, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), depression, atrial fibrillation (irregular heartbeat), high blood pressure and heart failure. [...]

Inspectors wroteBased on observations and interviews, the facility failed to maintain a clean and sanitary homelike environment for residents on three of four units. Specifically, the facility failed to: -Ensure residents experienced a clean and sanitary homelike environment with living spaces free from odors, dirt, debris and soiled areas; and, -Ensure that mouse droppings were removed and the surfaces were properly sanitized from possible rodent contamination.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the kitchen. Specifically, the facility failed to: -Ensure staff wore hair restraints to prevent hair from contacting food; -Ensure the freezer was within appropriate operating range to maintain frozen foods solid; -Ensure dry goods were stored in sealed containers to prevent rodents; -Ensure staff practiced appropriate hand hygiene and glove use when necessary during food preparation activities; and, -Ensure food in the nourishment refrigerator was dated.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure garbage and refuse was properly disposed of and the dumpster lid was closed to prevent harborage to pests and insects. Specifically, the facility failed to: -Ensure all dumpster lids were closed and not overflowing with garbage; and, -Ensure garbage was cleaned up around and under dumpsters.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for two out of four units in the facility. Specifically, the facility failed to: -Ensure high touch areas were cleaned appropriately by the housekeeping staff; -Ensure proper proper disinfectant times were utilized by staff; -Ensure housekeeping staff performed hand hygiene while cleaning resident rooms; -Ensure each resident was provided with hand hygiene prior to meals; -Ensure hand sanitizer dispensers were operational; and, -Ensure resident laundry was covered while being transported in the hallways.

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to: -Ensure resident rooms, dining rooms, hallways, and the elevator were free from debris and food; -Ensure the dumpsters were closed at all times and the area was free from debris, food, and trash; -Ensure kitchen was free from mice droppings and dry storage was stored properly; and, -Ensure the entrance to the facility was free from extinguished cigarette butts disposed on the ground.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure four residents (#27, #39, #212 and #6) of six residents reviewed for abuse were kept free from abuse out of 37 sample residents. Specifically, the facility failed to ensure Residents #27, #39, #212 and #6 were kept free from physical abuse from Resident #49.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent. Specifically, the facility had a medication error rate of 17.24%, which was five errors out of 29 opportunities for error.

Inspectors wroteBased on record review and interviews, the facility failed to provide bed hold documentation for residents being discharged to the hospital for one (#27) of two residents reviewed for the bed hold policy out of 37 sample residents. Specifically, the facility failed to provide Resident #27 with an appropriate bed hold notification when being transferred to the hospital on [DATE] and 11/29/23.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one resident (#8) of four reviewed for dialysis care out of 37 sample residents received dialysis services consistent with professional standards of practice. Specifically, the facility failed to communicate with the dialysis center when the communication form was not completed.

Inspectors wroteBased on observation and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly on one of four medication carts. Specifically, the facility failed to: -Ensure insulin (medication used for blood glucose control) pens were labeled with resident name and open dates; -Ensure medications were not left unattended on the medication cart; -Ensure medications were disposed of properly; and, -Ensure medication carts were kept clean.

Inspectors wroteBased on observations, interviews, document review, and facility policy review, the facility failed to maintain proper kitchen sanitation when Dietary Aide (DA) #1 continued to wash dishes using a low temperature dish machine without ensuring the proper sanitizer concentration. The facility further failed to maintain a log of refrigerator and freezer temperatures. These deficient practices had the potential to affect all residents residing in the facility who received food from the kitchen.

Inspectors wroteBased on interviews, record reviews, document review, and facility policy review, it was determined the facility failed to report an allegation of staff-to-resident abuse to the state survey agency (SSA) within two hours after the allegation was made for 1 (Resident #3) of 4 sampled residents reviewed for abuse. On 10/31/2022 at approximately 6:30 AM, Resident #3 alleged that Certified Nursing Assistant (CNA) #1 yelled at the resident and made an inappropriate hand gesture toward the resident. The facility did not report the allegation to the SSA until 11:29 AM, approximately five hours after the resident made the allegation.

Inspectors wroteBased on observation, interviews, record review, document review, and facility policy review, the facility failed to protect 1 (Resident #3) of 4 residents from further potential abuse while an abuse allegation investigation was being conducted. On 10/31/2022, at approximately 7:43 AM, Registered Nurse (RN) #1 sent Certified Nursing Assistant (CNA) #1 home after Resident #3 reported that CNA #1 yelled at the resident and made an inappropriate hand gesture by raising the middle finger. However, the facility allowed CNA #1 to return to work at 9:22 AM before an investigation was completed.