Three Springs SR Living & Rhab

In the surveyor’s words

From the most serious findings on record at Three Springs SR Living & Rhab, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 3, 2025

  Based on observation, interview and record review the facility failed to supervise a moderately impaired resident with a history of stroke. R3 was left unattended outside and fell from the wheelchair for 1 of 3 residents (R3) reviewed for falls in the sample of 6. This failure resulted in R3 being sent to the hospital after sustaining a black eye and bruising to her forehead from the fall. Findings include: R3's Physician Order Sheet for August 2025 documents diagnosis of atherosclerotic heart disease, cerebral infarction due to thrombosis of left middle cerebral artery, unsteadiness on feet, weakness, need for assistance with personal care, lack of coordination, other abnormalities of gait and mobility, muscle weakness, hemiplegia and hemiparesis following cerebrovascular disease… […]

• Actual harm, isolatedF600Sep 13, 2023

  Based on interview and record review, the facility failed to ensure residents are free from verbal abuse for 1 of 4 residents (R10) reviewed for abuse in the sample of 60. The failure resulted in R10 becoming tearful making her feel terrible. Findings include: R10's Face Sheet, undated, documents R10 was admitted on [DATE] with diagnoses of Congestive Heart Failure, Cerebral Vascular Accident, Atrial Fibrillation, Diabetes, Hypertension. R10's Minimum Data Set (MDS) dated [DATE] documents R10 has no cognitive impairments. MDS documents R10 is independent with mobility and transfers with use of walker. R10's Care Plan updated 6/19/2023 does not document R10 is at risk for abuse. […]

• No harm, potential for more than minimal, widespreadF727Sep 16, 2025

  Based on interview and record review the facility failed to use the services of a registered professional nurse for at least 8 consecutive hours a day, 7 days a week. This has the potential to affect all 66 residents residing in the facility. Findings Include: The facility schedule dated August 11, 2025 through September 11, 2025 was reviewed and on 8/9/25, 8/27/25, 8/29/25, 9/1/25, 9/3/25, 9/6/25, 9/7/25 and 9/8/25 the facility did not have an Registered Nurse providing resident care for 8 Consecutive hours. On 9/12/25 at 9:00 AM V3 (Infection Preventionist) stated she completed the working schedules for the facility, and she scheduled what staff was available. At the time the facility only had 1 Registered Nurse. […]

• No harm, potential for more than minimal, widespreadF812Sep 16, 2025

  Based on interview and record review, the Facility failed to store foods in a manner that prevents foodborne illness. This has the potential to affect all 66 residents living in the Facility.Findings include:On 9/9/25 at 11:30 AM, in the standing refrigerator in the main kitchen, there was a container labeled tartar sauce with the date 8/29. There was a container labeled banana pudding and a pitcher labeled CB (cranberry) juice that were both labeled 9/2. There were two containers, each with 28 individual cups of various colored liquids that were not labeled or dated. […]

• No harm, potential for more than minimal, widespreadF880Dec 13, 2024

  Based on observation, interview, and record review the Facility failed to ensure staff were encouraging COVID-19 positive residents to wear masks and ensure staff don proper personal protective equipment (PPE) to prevent the spread of COVID-19. This has the potential to affect all 63 residents living in the facility. Findings include: 1. The COVID list documents R6 with an onset date of 12/2/2024. R6's Physician Order Sheet for 12/2024 documents a diagnosis of Other specified disorder of kidney and ureter, COVID 19 (12/2/2024), urinary tract infection, unspecified dementia. unspecified severity without behavior disturbances, psychotic disturbances, mood disturbances, GERD, Abnormal weight loss, hypoosmolality and hyponatremia, major depression, insomnia, hypothyroidism. […]