Complete Care at Springbrook

In the surveyor’s words

From the most serious findings on record at Complete Care at Springbrook, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF584May 1, 2026

  Based on observation and interview, it was determined that the facility failed to ensure a safe, clean, and comfortable homelike environment for the residents. This was evident for multiple areas within the facility observed during the annual survey. The findings include: 1.On 04/27/2026 at 07:31 AM, an observation of the dining room revealed the wall across from the door to the basement stairs by the kitchen door, which had a hole in the wall that was approximately 4 inches long and 2 inches wide. […]

• No harm, potential for more than minimal, patternF638May 1, 2026

  Based on medical record review and staff interview, it was determined the facility staff failed to complete a quarterly Minimum Data Set (MDS) assessment within 14 days after the assessment reference date. This was evident for 6 (Resident #22, # 41, #80, #47, #58, and #69 ) of 7 residents reviewed during the annual survey. The findings include: 1, The Minimum Data Set (MDS) is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on these individualized needs, and that the care is provided as planned to meet the needs of each resident. […]

• No harm, potential for more than minimal, patternF640May 1, 2026

  Based on review of Minimum Data Set (MDS) Assessment material and interview with facility staff, it was determined that the facility failed to transmit MDS assessments within 14 days of completion of the assessment. This was evident for 5 (Resident #22, #41, #80, #47 and #58 ) of 7 residents reviewed during the annual survey. The findings include: 1.On 4/28/2026 at 12:05 PM information from the Centers for Medicare and Medicaid (CMS) regarding transmission of Minimum Data Set (MDS) Assessments were reviewed. […]

• No harm, potential for more than minimal, patternF641May 1, 2026

  Based on observations, Resident and staff interviews and surveyor record reviews it was determined that the facility failed to code Minimum Data Set (MDS) Assessments accurately for Residents. This finding was found to be evident in 2 (Resident #13 and #23) out of 2 Residents reviewed for falls and continence. The findings include:The Minimum Data Set (MDS) is a federally mandated, standardized clinical assessment tool used in Medicare/Medicaid-certified nursing homes to evaluate a Resident's functional, medical, psychosocial, and cognitive status, including skin and health conditions, nutrition, continence, medications, treatments, and active diagnoses. […]

• No harm, potential for more than minimal, patternF803May 1, 2026

  Based on observation and interview, it was determined that the facility failed to ensure residents were served meals according to their meal ticket. This was evident for 11 (Resident #14, #19, #30, #39, #41, #51, #58, #66, #70, #87, and #92) of 83 trays observed during the lunch meal tray lineThe findings include:On 04/29/2026 at 11:35 AM, an observation of the kitchen lunch tray line revealed [NAME] (Staff #15) started to plate the food. On 04/29/2026 at 12:07 PM, Resident #19's meal ticket was placed on the tray and [NAME] (Staff #16) noted that it indicated the resident was supposed to receive garlic egg noodles as the main food item for the meal. [NAME] (Staff #15) indicated they did not have any garlic egg noodles. […]