Spring Lake Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Spring Lake Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF609Apr 23, 2022

  Based on record review, observations, interviews, and facility policy review the facility failed to report to the Adult Protective Services Agency a failure to provide adequate supervision to prevent an unwitnessed and unsupervised exit from the facility for one (#1) of five sampled residents. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was known to ambulate freely through the facility. The resident was able to exit through a receptionist monitored door that did not have adequate supervision by staff to detect a resident from leaving unsupervised. Resident #1 was admitted to the facility after a four-day hospital admission. […]

• Immediate jeopardy, isolatedF610Apr 23, 2022

  Based on record review, observations, interviews, and facility policy review the facility failed to conduct an investigation that determined all factors that led to an elopement of one (#1) of five sampled residents sampled for elopement. This led to a failure to determine education and system changes needed to protect other residents in the building. Resident #1 was admitted to the facility after a four-day hospital admission. She had an episode of [CONDITION(S)] ([CONDITION(S)], or a sudden temporary loss of consciousness) while at an adult day care program and was taken to the hospital then transferred to the facility for short term rehabilitation. She was at risk for falls and was treated in the physical therapy department of the facility for poor safety awareness. […]

• Immediate jeopardy, isolatedF689Apr 23, 2022

  Based on record review, observations, interviews, medical record review and facility policy review the facility failed to ensure adequate supervision was provided to prevent an elopement of one resident (#1) out of five residents sampled for elopement. Resident #1 had diagnoses that included dementia and [CONDITION(S)] with collapse. The resident was known to ambulate freely through the facility. The resident was able to exit through a receptionist monitored door that did not have adequate supervision by staff to detect a resident from leaving unsupervised. Resident #1 was admitted to the facility after a four-day hospital admission. […]

• No harm, potential for more than minimal, patternF645Feb 13, 2025

  Based on record reviews and interviews, the facility failed to obtain an accurate Pre-Admission Screening and Resident Review (PASRR) screen prior to a re-admission for one (#98) resident of thirty sampled residents and failed to ensure residents with Mental Illness or Suspected Mental Illness were referred for Level II screening for two residents (#96 and #15) of thirty sampled residents. Findings included: 1. Review of Resident #98's census information revealed the resident was admitted on [DATE], discharged on [DATE], and readmitted [DATE]. Review of Resident #98's Admission Record revealed the resident was originally admitted on [DATE] and readmitted on [DATE]. The record did not include any mental health diagnoses. […]

• No harm, potential for more than minimal, patternF695Feb 13, 2025

  Based on observations and interviews, the facility failed to ensure appropriate cautionary and safety signs indicating the use of oxygen were posted at 23 out of 23 randomly observed rooms where oxygen was administered. Findings include: During an observation on 2/11/2025 at 2:59 PM, 23 resident rooms where oxygen was observed administered had no oxygen use signage near the resident rooms. During an observation on 2/12/2025 at 4:00 PM, the facility had no smoking signs posted outside the facility next to the front entrance door, but there were no signs addressing the use of oxygen inside the facility. […]