Springhurst Health Campus

In the surveyor’s words

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

• Immediate jeopardy, isolatedF755Mar 23, 2026

  Based on interview and record review, the facility failed to correctly transcribe the hospital's discharge orders for 1 of 3 residents reviewed for accuracy of physician orders for a newly admitted resident. This deficient practice resulted in a resident not having a diagnosis of diabetes identified and not receiving his hospital discharged ordered insulin for five (5) days, which contributed to the resident having elevated (high) blood glucose, diminished cognitive levels, lethargy and being sent out to the local hospital. The resident was sent out to the local hospital on 2-13-26, at the request of the family. He was subsequently admitted to the local hospital the same date for altered mental status, possibly related to dehydration, infection or diabetic ketoacidosis. […]

• No harm, potential for more than minimal, widespreadF725Jun 17, 2025

  Based on interview and record review, the facility failed to ensure sufficient nursing staff to provide activities of daily living (ADL) care, skin care treatments, and maintain residents' dignity. This deficient practice had the potential to affect 61 of 61 residents in the facility. Findings include: A confidential interview was conducted with a resident. They indicated there were not enough staff in the facility to help them. They forgot about them when they pressed their call light, and it made them feel unimportant. An interview was conducted with Resident P on 6/10/25 at 1:23 p.m. She indicated it took thirty minutes for staff to help her, after she pressed her call light. An interview was conducted with Resident S on 6/11/25 at 11:27 a.m. […]

• No harm, potential for more than minimal, patternF677Jun 17, 2025

  Based on observation, interview, and record review, the facility failed to assist dependent residents with shaving per preference and provide activities of daily living (ADL) care in a timely manner for 4 of 7 residents reviewed for activities of daily living. (Resident E, Resident G, Resident L, and Resident J) Findings include: 1. The clinical record for Resident E was reviewed on 6/16/2025 at 1:20 p.m. The diagnoses included, but were not limited to, urinary tract infection and depression. A Minimum Data Set (MDS) assessment, dated 5/14/2025, indicated Resident E was cognitively intact, utilized an indwelling urinary catheter, and needed substantial/maximal assistance with toileting hygiene, upper and lower body dressing, and personal hygiene. […]

• No harm, potential for more than minimal, isolatedF550Jun 17, 2025

  2. The clinical record for Resident F was reviewed on 6/11/25 at 10:30 a.m. His diagnoses included, but were not limited to, Parkinson's disease. An interview was conducted with Family Member 4 on 6/11/25 at 10:38 a.m. She indicated there was an incident involving Resident F and CRCA (Certified Resident Care Assistant) 15 in March 2025 in his room. Resident F had bowel issues. It wasn't a happy situation, and CRCA 16 had to clean it up. CRCA 16 said it was gross right in front of him. They filed a grievance about it. Family Member 4 received a call back afterwards, stating the facility would be doing more staff training. The grievance log for the past six months was provided by Clinical Support on 6/12/25 at 10:48 a.m. […]

• No harm, potential for more than minimal, isolatedF558Jun 17, 2025

  Based on observation, interview, and record review, the facility failed to ensure a resident's call light was within reach for 1 of 1 resident reviewed for call light accessibility. (Resident 218) Findings include: During an observation and interview with Resident 218 on 6/11/25 at 9:59 a.m., Resident 218 was sitting in a wheelchair in the middle of her room. The call light was on the other side of the room on the floor beside her bed. Resident 218 indicated when staff would get her up during the day, she could never reach her call light and had no way of contacting staff when she needed help. […]