Spring Lake Skilled Nursing and Rehabilitation

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF656Dec 3, 2025

  Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs for 2 (#10, #86) of 40 sampled residents reviewed. The facility failed to follow physician's orders for Resident #10 and Resident #86. Findings:Review of Resident #10's medical records revealed an admit date of 10/21/2025 including the following diagnoses, in part: type 2 diabetes mellitus with diabetic polyneuropathy, chronic respiratory failure with hypoxia, and enterocolitis due to clostridium difficile recurrent (11/01/2025).Review of Resident #10's Physician's orders revealed an order dated 11/10/2025 for Fluconozole 50mg (milligram) by… […]

• No harm, potential for more than minimal, patternF658Dec 3, 2025

  Based on record reviews, observations and interviews, the facility failed to provide services that met professional standards for 1 (#113) of 40 residents in the sample. The facility failed to ensure safe medication administration practices by leaving medications at the bedside.Findings:Review of facility's Self-Administration of Medications policy with a Revision date of December 2016 revealed in part:Policy StatementResidents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.Policy Interpretation and Implementation1. […]

• No harm, potential for more than minimal, patternF677Dec 3, 2025

  Based on record reviews and interviews, the facility failed to provide ADL (activities of daily living) for 2 (#17, #131) of 3 (#17, #31, #131) residents reviewed for ADL care of dependent residents. The facility failed to trim and clean Resident #17's fingernails and bathe/shower Resident #131. Findings: Review of the facility's Care of Fingernails/Toenails policy revised 10/2010 included in part:PurposeThe purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infectionsGeneral Guidelines1. Nail care includes daily cleaning and regular trimming.4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. […]

• No harm, potential for more than minimal, patternF692Dec 3, 2025

  Based on record review and interviews, the facility failed to maintain acceptable parameters of nutritional status by failing to follow up with the physician in a timely manner to implement the registered dieticians (RD) recommendation for 1 (#99) of 6 (#1, #16, #25, #86, #99 and #132) residents reviewed for nutrition. Findings:Review of Resident #99's medical record revealed an admission date of 08/28/2025 with the following diagnoses, not limited to, muscle wasting and atrophy, type 2 diabetes mellitus without complications, mild protein-calorie malnutrition, muscle weakness (generalized) and need for assistance with personal care.Review of Resident #99's weights revealed a significant 17.93% (33 pounds) weight loss in 73 days from dates 08/29/2025 (184 pounds) and 11/10/2025 (151… […]

• No harm, potential for more than minimal, patternF677Sep 25, 2024

  Based on record review, observation and interviews the facility failed to ensure residents who were unable to complete their ADL (Activities of Daily Living) received the necessary services to maintain proper grooming for 1 (#48) of 3 (#2, #34, #48) residents reviewed for ADL. The facility failed to ensure Resident #48 received nail care. Findings: Review of Resident #48's medical diagnoses revealed the following, but not limited to cerebral infarction, type 2 diabetes mellitus with diabetic neuropathy, and systemic lupus erythematosus. Review of Resident #48's September 2024 physician orders dated 05/08/2024 revealed: Activity as tolerated. Licensed nurse may clip and trim diabetic finger and toenails as indicated. […]