Elim Wellspring Health Care Center

In the surveyor’s words

From the most serious findings on record at Elim Wellspring Health Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF908Mar 11, 2021

  Based on observation, interview, and document review, the facility failed to maintain tub equipment in a safe operating condition, which had the potential to effect all 14 residents residing on the Skyview unit. Findings include: During observations of the Skyview Unit, on 3/10/21, at 10:08 a.m. the following environmental concerns were noted: the bath tub (MasterCare brand) seat cushion had a worn vinyl and exposed foam to both front outer edge corners, along with cracked vinyl and exposed foam to the seams of the middle oval cutout section. In addition, the seat had approximately four inches of cracked vinyl and exposed foam to the left front edge. The leg rest cushion had numerous areas of cracked vinyl with exposed foam along the surface and sides. […]

• No harm, potential for more than minimal, isolatedF880Dec 18, 2025

  Based on observation, interview and record review, the facility failed to follow standard precautions (infection prevention practices that apply to all residents, regardless of suspected or confirmed diagnosis or presumed infection status and includes use of gloves before potential contact with blood) to prevent the potential for spread of blood borne infections for 1 of 2 residents (R67) who were reviewed for point-of-care testing using a blood glucose monitor. Findings include:R67's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition with a diagnosis of diabetes and use of insulin.R67's orders dated 7/11/25, directed staff to monitor his blood glucose four times a day.During observation on 12/17/25 at 8:45 a.m., registered nurse (RN)-A prepared to perform R67's… […]

• No harm, potential for more than minimal, isolatedF755Nov 5, 2024

  Based on interview and document review, the facility failed to properly account for 34 tablets of hydromorphone (a controlled narcotic pain medication) for 1 of 3 residents (R1) reviewed for controlled medications. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE] indicated diagnoses of infection of multiple sites of the spine, septicemia (infection in the blood) and low back pain. The MDS also indicated R 1 had recent spinal surgery and she had received scheduled and as needed pain medication. […]

• No harm, potential for more than minimal, isolatedF580Nov 3, 2022

  Based on Interview and document review, the facility failed to ensure resident families and/or representatives were updated timely for a change in condition related to a fall for 1 of 2 residents (R34) reviewed for falls. Findings include R34's quarterly Minimum Data Set (MDS) dated [DATE], included severed cognitive deficit with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R34's care plan listed problem of cognition/mood dated 10/10/22, indicated R34, Relies on family to assist with major decision making prn [as needed], and directed staff to, Encourage family support and involvement. When interviewed on 10/31/22, at 12:14 p.m. R34's responsible family member (FM)-A stated, R34 had a fall on 9/30/22, at around 1:00 a.m. The facility did not notify him until 9/30/22 around 3:30 p.m. […]

• No harm, potential for more than minimal, isolatedF609May 31, 2022

  Based on interview and document review, the facility failed to ensure incidents of alleged abuse were reported immediately, within two hours, to the State Agency (SA) for 1 of 3 residents (R1) reviewed for allegations of abuse who obtained a significant injury from a fall. Findings include: R1's Face Sheet undated indicated R1 admitted on [DATE], with recent fracture of right femur, dementia, repeated falls and aged related [CONDITION(S)]. R1's Care Plan with start date of 5/20/22, indicated R1 was a fall risk related to fall prior to admission resulting in a right hip fracture requiring surgical repair, pain, impaired mobility, medications, new environment and diagnoses. […]