Spring Mill Health Campus

In the surveyor’s words

From the most serious findings on record at Spring Mill Health Campus, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Nov 15, 2021

  Based on observation, record review and interview, the facility failed to implement adequate supervision measures to prevent a cognitively impaired resident deemed at risk for elopement from exiting the building. The resident left the building unattended around 3:30 a.m. on 11/2/21 and was found by security on rounds at a nearby office park and taken to the local hospital for evaluation. The facility is located within 1 mile of a major interstate and adjacent to a busy 4 lane road. (Resident D) The immediate jeopardy began on 11/2/21 when the resident had exited the facility without supervision. The alarm to the second floor door he exited was activated. The door to the outside was on the same alarm, so no secondary alarm went off as the resident left the facility. […]

• Actual harm, isolatedF684Jun 21, 2023

  Based on record review and interview, the facility failed to ensure a resident received the necessary treatment and services related to insulin administration for 1 of 3 residents reviewed for insulin administration. (Resident B) The deficient practice was corrected on 6/9/23, prior to the start of the survey, and was therefore past noncompliance. The facility identified the concern, completed an audit of residents who received insulin, and provided an inservice for staff on confirming and discontinuing Physician's orders. Finding includes: Closed record review for Resident B was completed on 6/20/23 at 9:38 a.m. […]

• Actual harm, isolatedF740Jun 27, 2022

  Based on observation, interview and record review, the facility failed to ensure to follow up with the nurse practitioner's (NP) orders for obtaining outside behavioral health services which resulted in a resident displaying continued tearfulness and emotional distress. (Resident 28) Finding includes: On 6/20/22 at 2:15 p.m., Resident 28 indicated she was in need of outside resources for mental health and depression. She indicated she had ongoing, worsening depression symptoms. During the interview, it was noted she had increased tearfulness and crying. On 6/21/22 at 3:33 p.m., the resident had noted tearfulness and she asked again if the facility had made any appointments with an outside psychological service. […]

• Actual harm, isolatedF686Apr 19, 2021

  Based on record review and interview, the facility failed to ensure a resident who was admitted with an open area received the necessary treatment and services to promote healing related to the lack of treatment, assessment and monitoring which resulted in an unstageable pressure ulcer 4 days later. (Resident C) The facility also failed to assess and obtain treatments for pressure ulcers in a timely manner for 3 of 5 residents reviewed for pressure ulcers. (Residents C, B and D) Findings include: 1. The closed record for Resident C was reviewed on 4/14/21 at 2:21 p.m. The resident was admitted to the facility on [DATE] and discharged to the hospital on 2/10/21. The resident did not return to the facility. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF692Apr 19, 2021

  Based on record review and interview, the facility failed to ensure residents maintained acceptable parameters of nutritional status related to weekly weights not obtained, meal consumption records not completed, and the Registered Dietitian's (RD) recommendations not followed for residents who were nutritionally at risk, which resulted in a significant weight loss (Resident C) and potential for weight loss (Resident E) for 2 of 5 residents reviewed for nutrition. Findings include: 1. The closed record for Resident C was reviewed on 4/14/21 at 2:21 p.m. The resident was admitted to the facility on [DATE] and discharged to the hospital on 2/10/21. The resident did not return to the facility. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]