The Reserve at Spring Hill

In the surveyor’s words

From the most serious findings on record at The Reserve at Spring Hill, in the surveyor’s own words.

• Actual harm, isolatedF684May 20, 2026

  Based on policy review, medical record review, hospital record review and interview, the facility failed to ensure residents received the necessary treatment and services consistent with professional standards of practice to promote healing and prevent infection for residents determined to be at risk of skin breakdown for 1 of 3 (Resident #85) sampled residents reviewed for wounds. Resident #85 was admitted to the facility on [DATE], and readmitted on [DATE], with a right elbow surgical site wound and the use of a single use negative pressure wound therapy system dressing (Named system that uses vacuum suction to promote healing, generally kept in place for 7 to 14 days) covered by a soft splint. […]

• No harm, potential for more than minimal, patternF755May 20, 2026

  Based on facility policy review, medical record review, review of the Controlled Drug Use Record, and interview, the facility failed to properly document narcotic medications signed in error or wasted, and failed to ensure drug destruction sheets were signed by 2 nurses for 3 of 4 (November 2025, December 2025 and January 2026) months reviewed. The findings include: 1. Review of the facility policy titled, Disposal of Medications and Medication-Related supplies, dated 11/18, revealed .When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason .It is destroyed in the presence of two licensed facility personnel as permitted by the regulations, and the disposal is documented on the accountability record/book… […]

• No harm, potential for more than minimal, patternF756May 20, 2026

  Based on facility policy review, medical record review, and interview, the facility failed to provide evidence of a Monthly Regimen Review or physician acknowledgement of recommendations for 4 of 5 sampled residents (Residents #5, #6, #14, and #32) reviewed for unnecessary meds. The findings include: 1. Review of the facility policy titled, Medication Regimen Review, dated 1/1/2025, revealed .Medication Regimen Review (MRR), or Drug Regimen Review, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication .Review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities… […]

• No harm, potential for more than minimal, isolatedF569May 20, 2026

  Based on facility policy review, resident trust fund account review, medical record review, and interview, the facility failed to refund the resident's funds within 30 days of death or discharge for 2 of 2 (Resident #73 and #74) sampled residents reviewed for personal funds. The findings include: 1. Review of the facility policy titled, Resident Personal Funds, dated [DATE], revealed .Upon the discharge, eviction, or death of a resident with a personal fund deposited with the facility, the facility will convey within 30 days the resident's funds and final account of those funds to the resident, or in the case of death, the individual or probate jurisdiction administering the resident's estate, in accordance with State Law. 2. […]

• No harm, potential for more than minimal, isolatedF656May 20, 2026

  Based on facility policy review, medical record review, observation, and interview, the facility failed to implement care plan interventions for 1 of 13 (Resident #28) sampled residents reviewed for falls. The findings include: 1. Review of the facility policy titled, Comprehensive Care Plans, dated 01/16/2026, revealed .facility to develop and implement a comprehensive person-centered care plan for each resident.services that are identified in the resident's comprehensive assessment and meet professional standards of quality .Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions. 2. […]