Springs Road Healthcare

In the surveyor’s words

From the most serious findings on record at Springs Road Healthcare, in the surveyor’s own words.

• Actual harm, isolatedF600Jul 19, 2022

  Based on observation, interview and record review, the facility failed to ensure two of the two residents (Resident 1 and 2) were free from abuse when: 1.The facility did not document, identify and initiate an investigation of Resident 1 ' s complaint of alleged abuse during transfer. 2. Licensed Therapist A was yelling, saying the F word, and telling Resident 2 to deal with the pain during Resident 2's transfer. These failures resulted in Resident 1's suffering from pain, feeling upset and scared and further potential abuse when the alleged perpetrator continued to have access to Resident 1 and other vulnerable residents, and eventually resulted in Resident 2 ' s suffering from pain, embarrassment and humiliation. […]

• No harm, potential for more than minimal, widespreadF812Jun 12, 2026

  Based on observation, interview and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for a census of 58 when:1. Dietary Supervisor (DS) and Dietary Aide (DA) 1 were not wearing a beard net while inside the kitchen.2. [NAME] residue was present on the floor surface of the food warmer.3. The top surface of the knife holder had accumulated dust and residue.4. Black residue was present on the floor beneath the dishwasher area.5. Three quarter size hotel pans were stacked wet while stored away.6. Flies were present in the kitchen area and dry storage area.7. […]

• No harm, potential for more than minimal, patternF583Jun 12, 2026

  Based on observation, interview and record review, the facility failed to secure resident medical records containing Protected Health Information (PHI, any individually identifiable health information held, transmitted, or maintained by the health facility), for four Residents (Resident 11, Resident 39, Resident 59, and Resident 69) out of census of 58 residents, when the Treatment Nurse (TN) left printed wound treatment records on top of an unattended cart.This failure had the potential for unauthorized access by visitors, families, and other residents to Resident 11's, Resident 39's, Resident 59's, and Resident 69's medical records containing PHI.Findings: During an observation on 6/9/26 at 9:49 a.m. […]

• No harm, potential for more than minimal, patternF658Jun 12, 2026

  Based on interview and record review the facility failed to ensure services meet professional standards of quality for four residents (Resident 16, Resident 39, Resident 74, and Resident 6) for a census of 18, when:Medications were given without meals, as prescribed for Resident 16, Resident 39, and Resident 74;Medication with a box warning ((also known as black box warning- the strictest, most serious safety alert mandated by the U.S. Food and Drug Administration (FDA [a federal agency of the United States government responsible for protecting public health]) was being administered for Resident 6 without monitoring for side effects to highlight severe, life-threatening, or permanently disabling risks)).These failures had the potential to cause:Residents 16, Resident 39, and Resident 74 to… […]

• No harm, potential for more than minimal, patternF761Jun 12, 2026

  Based on observation, interview, and record review, the facility failed to ensure medications were properly labeled and stored in accordance with the accepted professional principles and current standard of practice for Resident 33 and Resident 22 and for census of 58 when:1. Resident 33 was found to have medications at the bedside.2. An opened, unlabeled box of Lidocaine Patches 5% was found in the medication cart, containing one unopened packet and 2 opened packets; and3. Resident 22's white envelope containing twenty-five dollars in cash were found inside the narcotic box in medication cart.These failures had the potential for diversion of unlabeled medications and risk resident's safety. […]