Spring Meadows Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Spring Meadows Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 26, 2023

  Based on policy review, facility investigation review, weather website review, medical record review, and interview, the facility failed to ensure a safe environment with adequate supervision to prevent elopement for 1 of 6 (Resident #5) sampled residents reviewed for elopement/wandering behaviors. The facility's failure to ensure residents were adequately supervised resulted in Immediate Jeopardy when Resident #5, who had severe cognitive impairment, exited the facility unsupervised, when a visitor entered the building through the front door of the facility and Resident #5 walked out of the door before it had closed, and was found by staff sitting on the front porch of the facility. The resident was unsupervised and out of the facility for approximately 58 minutes. […]

• Immediate jeopardy, isolatedF609Jul 25, 2022

  Based on weather website review, policy review, medical record review, observation, and interview, the facility failed to report incidents of elopement for 2 of 7 sampled residents (Resident #45 and #87) reviewed for wandering and elopement. The facility's failure to report incidents of elopement to the State Survey Agency resulted in Immediate Jeopardy when Resident #45, a vulnerable, severely cognitively impaired resident, exited the facility without staff knowledge or supervision and was found approximately 94.6 feet from the New Wing North exit door, standing in the parking lot on a cold January day, out of sight of the staff for approximately five to ten minutes and when Resident #87 a vulnerable, moderately cognitively impaired resident exited the facility without staff knowledge or… […]

• Immediate jeopardy, isolatedF610Jul 25, 2022

  Based on policy review, job description review, facility investigation review, medical record review, observation, and interview, the facility failed to ensure incidents of elopement, staff-to-resident abuse, and drug diversions were thoroughly investigated for 5 of 10 sampled residents (Resident #45, #87, #19, #68, and #90) reviewed for wandering/elopement behaviors and at risk for abuse. The facility's failure to thoroughly investigate incidents of elopement resulted in Immediate Jeopardy when Resident #45, a cognitively impaired resident at risk for wandering/elopement, exited the facility without staff knowledge, walked approximately 94.6 feet from the facility, and was found standing in the parking lot in the back of the facility and when Resident #87 a vulnerable, moderately… […]

• Immediate jeopardy, isolatedF689Jul 25, 2022

  Based on weather website review, policy review, facility investigation review, medical record review, observation, and interview, the facility failed to ensure a safe environment and provide adequate supervision to prevent elopement for 2 of 7 sampled residents (Resident #45 and #87) reviewed for elopement/wandering behaviors. Resident #45, who had severely impaired cognition, was at risk for wandering, and was a fall risk, exited the facility without staff knowledge through the New Wing North exit door on a cold January day, walked approximately 94.6 feet and was found by staff standing in the parking lot for an undetermined amount of time. […]

• Immediate jeopardy, isolatedF835Jul 25, 2022

  Based on policy review, Board of Examiners for Nursing Home Administrators (BENHA) review, job description review, and interview, the facility Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain the highest practicable well-being of cognitively impaired residents with wandering behaviors. Administration failed to provide oversight to monitor and provide a safe resident environment for cognitively impaired residents with wandering behaviors, to report, and investigate incidents of elopement. […]