The Springs Healthcare Center at the Carlotta

In the surveyor’s words

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

• Actual harm, isolatedF686Jun 27, 2024

  Based on interview and record review, the facility failed to provide treatment and services consistent with the professional standards of practice, to prevent progression of pressure injuries (PI-damage to the skin and underlying tissue due to prolonged pressure) for two of three sampled residents (Residents 1 and 2) when: 1. For Resident 2, a consistent weekly skin assessment was not completed to evaluate the changes in the resident's redness to the coccyx identified on admission. In addition, the facility failed to initiate treatment for Resident 2's redness to the coccyx upon admission. These failures resulted in Resident 2's coccyx (tailbone) redness to worsen into a Stage 3 pressure injury (full thickness tissue loss). 2. […]

• No harm, potential for more than minimal, patternF812Jun 6, 2025

  Based on observation, interview, and record review, the facility failed to maintain a sanitary environment, store, and prepare food in accordance with professional standards for food service safety when: 1. Multiple large plastic pans stacked in the storage rack were wet; and 2. Four containers of five pounds (lbs - a unit of measurement) low fat cottage cheese were stored in the refrigerator beyond the use-by-date. These failures had the potential to result in cross contamination (bacteria were unintentionally tranferred from one substance or object to another with harmfull effect) and foodborne illnesses (illnesses that result from ingesting contaminated food) for 40 of 40 medically compromised residents who received food from the kitchen. Findings: 1. […]

• No harm, potential for more than minimal, patternF814Jun 6, 2025

  Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly when one re-cycle dumpster lid was widely open, bags of trash were piled and was overflowing one trash container causing the lid not to close, and multiple debris and trash were on the ground. This failure had the potential to attract pests and rodents that can be a source of communicable diseases. Findings: On June 3, 2025, at 11:36 a.m., a concurrent observation and interview was conducted with the Dietary Manager (DM), during inspection of the outside garbage storage area. […]

• No harm, potential for more than minimal, patternF880Jun 6, 2025

  Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented for four of 40 residents reviewed (Residents 17, 92, 11 and 195), when: 1a. For Resident 17, on Enhanced Barrier Precaution (EBP - an infection control precaution using the Protective Personal Equipment (PPE) such as gown and gloves during high contact resident care activities) the Physical Therapist (PT- healthcare professional who helps individuals improve their movement and functions through various therapies) did not wear the proper PPE when transferring Resident 17 from the wheelchair to the bed; 1b. For Resident 92, on EBP, the Certified Nursing Assistant (CNA) did not wear proper PPE when providing care and changing bed linens; 2. […]

• No harm, potential for more than minimal, isolatedF880Jan 28, 2026

  Based on observation, interview, and record review, the facility failed to ensure staff were wearing the N95 Respirator (a tight fitting disposable mask that filters out at least 95% of airborne particles including virus') they were approved to wear during Fit Testing (testing that determines the exact make and model of the N95 mask to be worn) for two out of three staff.This failure had the potential for the spread of COVID-19 (A contagious virus spread through respirator droplets) to other residents and staff in the facility. Findings: On January 28, 2026, at 10:05 a.m., an observation of a sign at the facility entrance indicated, . (The facility) currently (has) Covid cases in the building .we ask that you wear a mask during your visit . […]