Springmeade Healthcenter

In the surveyor’s words

From the most serious findings on record at Springmeade Healthcenter, in the surveyor’s own words.

• Actual harm, isolatedF686Apr 3, 2025

  Based on observation, resident interview, staff interviews, medical record review, physician wound documentation review, hospital documentation review, National Pressure Injury Advisory Panel (NPIAP) guidleine review, and policy review, the facility failed to transcribe and implement treatment orders timely for the treatment of pressure ulcers for two (#68 and #80) residents. Actual harm occurred to one resident (#68) when wound care orders were not timely implemented on admission, and the resident received no treatment or intervention from the facility for pressure areas that were present on admission. Resident #68 was admitted with a Stage 2 pressure ulcer to the sacrum/coccyx area on 01/31/25 and received no treatment until 02/04/25, after the wound increased to an unstageable wound. […]

• No harm, potential for more than minimal, widespreadF804Apr 3, 2025

  Based on observation, resident interviews, family interview, staff interview, and policy review the facility failed to ensure meals were served to residents at a safe temperature and palatable. This affected four (#12, #45, #55 and #70) of five residents reviewed for food. This had the potential to affect all the residents . The facility identified there were not any residents who could not eat anything by mouth. The census was 87. Findings included: Interview on 03/24/25 at 11:21 A.M., with Resident #55 revealed his meals were often served cold. His daughter added this was also a concern of hers because he already has a poor appetite. Interview on 03/24/25 at 1:41 P.M., with Resident #45 revealed when he ate in his room the food was cold. Breakfast and dinners were the worst. […]

• No harm, potential for more than minimal, widespreadF812Apr 3, 2025

  Based on observation, staff interview and policy review, the facility failed to ensure the kitchen was a clean environment and food was served in a safe manner. This affected all of the residents. The facility identified all the residents received meals from the kitchen. The census was 87. Findings included: Observation of the kitchen on 03/24/25 at 8:35 A.M., revealed there were five panels of lights in the ceiling in the dishwasher area, and three sets of five lights in the ceiling that ran from one side of the kitchen area to the other side that had a grey flaky substance either inside of the light panel or on the outside of the light panel. There was a vent on the far end of the dishwasher area that had a thick black substance on the outside of it. […]

• No harm, potential for more than minimal, widespreadF880Apr 3, 2025

  Based on staff interviews, observations, record review, review of infection tracking, policy review, Centers for Disease (CDC) guidelines review, review of testing documentation, review of water testing results and water testing staff interviews, the facility failed to wear proper Personal Protective Equipment (PPE) when providing resident care for residents in Enhanced Barrier Precautions (EBP), failed to ensure complete hand hygiene during a dressing change, failed to timely monitor infection tracking and monitoring was accurately and timely maintained, the facility failed to provide updated policies to address Legionella, and provide scheduled monitoring procedures of at risk water systems and provide a system approach to a positive Legionella testing. […]

• No harm, potential for more than minimal, widespreadF880Jun 23, 2022

  Based on review of the facility water management program, staff interview, and review of a Centers for Medicare and Medicaid Services Survey and Certification memo, the facility failed to ensure preventive measures for Legionella were completed according to their water management plan. This had the potential to affect all 95 residents at the facility. The facility census was 95. Findings include: Review of the facility binder titled Water Management Program for Building/Water Systems, dated 2021, revealed the facility was to obtain water temperatures weekly. Interview on 06/23/22 at 8:03 A.M. with the Maintenance Supervisor #755 confirmed the facility was not obtaining weekly water temperatures as per their water management program. […]