The Springs Skilled Nursing and Therapy

In the surveyor’s words

From the most serious findings on record at The Springs Skilled Nursing and Therapy, in the surveyor’s own words.

• Actual harm, patternF600Mar 15, 2021

  Based on observation, interview, and record review, it was determined the facility failed to ensure residents were free from neglect when it failed to: ~ Provide supervision to prevent resident to resident altercations for one (#3) of two residents reviewed for supervision. This had the potential to affect 50 residents who resided on the 300 and 400 halls; and ~ Carry the resident call light system pagers for the 300 and 400 halls. This had the potential to affect 42 of 50 residents who resided on the 300 and 400 halls. Findings: The facility's policy on abuse and neglect, revised 12/28/17, documented, . The facility will not tolerate mistreatment, neglect, or abuse of residents . […]

• Actual harm, patternF689Mar 15, 2021

  Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent resident to resident altercations for two (#3 and #6) of two residents reviewed for supervision. From 12/13/20 through 03/09/21, resident #3 had physical altercations with other residents that resulted in bruising, scratching, and hitting. Three residents expressed fear of physical aggression from resident #3. This had the potential to affect 50 residents who resided on the 300 and 400 halls. Findings: 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's care plan, revised 08/23/20, documented the resident had a focus concern of impaired cognitive function related to [MEDICAL CONDITION]. […]

• Actual harm, patternF725Mar 15, 2021

  Based on observation, interview, and record review, it was determined the facility failed to have sufficient staff to meet the needs of the residents. The failure to have adequate staff contributed to actual harm situations related to neglect, supervision to prevent resident to resident altercations, pain management, and pharmacy services. This had the potential to affect 89 of 89 residents who resided at the facility. Findings: 1. The facility failed to provide supervision to prevent resident to resident altercations for two (#3 and #6) of two resident reviewed for supervision. From 12/13/20 through 03/09/21, resident #3 had physical altercations with other residents that resulted in bruising, scratching, and hitting. Three residents expressed fear of physical aggression from resident #3. […]

• Actual harm, isolatedF689Apr 18, 2023

  Based on observation, record review, and interview, it was determined the facility failed to ensure residents received supervision to prevent falls for three (#10, 15, and #33) of five residents who were reviewed for accidents related to falls. Res #15 had a fall on 03/17/23. Hospital records related to this fall documented the resident sustained a right femoral neck fracture. The DON reported 68 residents had fallen in the previous six months. Findings: A facility policy, titled Fall Awareness Program, revised on 02/28/23, read in part, .11. Review the fall at the next Safety committee meeting and gain input for interdisciplinary team meeting members for other possible interventions to prevent falls. Make sure to update and revise plan of care as indicated. 1. […]

• Actual harm, isolatedF697Mar 15, 2021

  Based on interview and record review, it was determined the facility failed to provide pain management for one (#8) of three sampled residents who were reviewed for pain. The resident had suffered a femur fracture with subsequent surgical repair, and while at the facility, experienced pain of eight out of 10, on a zero to 10 scale, and was not provided any pain medication. The facility identified 26 residents as having pain concerns. Findings: The facility's policy and procedure on pain, revised 09/10/07, documented, . An individualized pain assessment is a vital first step in pain management . Failure to properly assess pain can lead to its under-treatment . Pain complaints may be screened by a licensed practical nurse . Pain should be assessed in all residents . […]