Spring Mill Meadows

In the surveyor’s words

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

• Actual harm, isolatedF689May 28, 2025

  Based on interview and record review, the facility failed to ensure a staff member followed the facility policy and procedure related to the use of a gait belt during a transfer which resulted in a resident fall for 1 of 3 residents reviewed for accidents. (Resident B) This deficient practice resulted in an abrasion on the resident's forehead and a fracture of the right femur. The deficient practice was corrected on 5/5/25, prior to the start of the survey, and therefore was past noncompliance. Findings include: During a telephone interview, on 5/27/25 at 8:47 a.m., Resident B's family indicated the resident was a fall risk. He was in the hall, heard a thump, and entered to find the resident on the floor. The resident had blood coming from her head. The CNA did not have a gait belt. […]

• Actual harm, isolatedF684Feb 11, 2025

  Based on interview and record review, the facility failed to ensure a resident received a medication for cancer as ordered, follow-up appointments with an oncologist were scheduled, and the facility's medical director did not discontinue a medication without consulting with the resident's oncologist for 1 of 2 residents reviewed for quality of care. (Resident B) This deficient practice resulted in Resident B having no follow-up oncology care to prevent further spread of the metastasis to the bone related to his prostate cancer. Findings include: An email, dated 1/16/25, indicated there were concerns with Resident B's treatment plan for his metastatic prostate cancer. […]

• Actual harm, isolatedF760Nov 16, 2023

  Based on interview and record review, the facility failed to administer medications to ensure a resident was free from significant medication errors for 1 of 3 residents reviewed regarding medication errors. (Resident G) Resident G required a hospital admission of five days. Finding includes: A document, titled Intake Information, dated 11/2/23, indicated an anonymous complainant had concerns with Resident G having a critically low potassium level and not being treated with the potassium replacement ordered by the Nurse Practitioner (NP). During an interview, on 11/14/23 at 2:45 p.m., the Director of Nursing (DON) indicated Resident G did miss her dose of Potassium liquid, on 10/24/23, after the NP ordered it to be given that day. […]

• No harm, potential for more than minimal, patternF657Aug 5, 2025

  Based on interview and record review, the facility failed to ensure care plan meetings were held quarterly, the residents and the residents' representatives were invited to participate, and to develop a comprehensive care plan related to a PICC line (peripherally inserted central catheter) and enhanced barrier precautions for 4 of 20 residents reviewed for care plans. (Resident 40, 57, 5 and 2)Findings include: 1. During an interview, on 7/30/25 at 10:51 a.m., Resident 40 indicated he had not been to a care plan meeting to discuss his care at the facility. The clinical record for Resident 40 was reviewed on 8/5/25 at 1:40 p.m. […]

• No harm, potential for more than minimal, patternF880Aug 5, 2025

  Based on observation, interview and record review, the facility failed to ensure Personal Protection Equipment (PPE) was used during care for residents on Enhanced Barrier Precautions (EBP), staff removed soiled gloves after cleaning a catheter line and prior to touching items in a resident's environment, to ensure EBP signage was posted, and to properly store a bed pan for 5 of 5 residents reviewed for infection control. (Resident 67, 81, 6, 2 and 5)Findings include:1. During an observation, on 7/31/25 at 8:10 a.m., a sign was posted outside Resident 67's door to indicate the resident was on EBP precautions. During the observation, LPN 1 was observed to perform hand hygiene and put on clean gloves. She was not observed to put on a gown. […]