Wellspring Health Center

In the surveyor’s words

From the most serious findings on record at Wellspring Health Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 28, 2025

  Based on review of the medical record, review of the Emergency Medical Services (EMS) report, staff interviews, review of witness statements, review of door repair invoices, review of maintenance work orders, review of facility Self-Reported Incident (SRI), review of hospital records and review of the facility policy, the facility failed to provide adequate supervision to prevent an elopement from the Memory Care Unit (MCU) of one resident (#45) who ambulated through a door on the MCU with a malfunctioning alarm and into the East side stairwell where Resident #45 fell down 11 cement stairs. […]

• Actual harm, isolatedF689Feb 18, 2026

  Based on record review, staff interview, review of the facility's investigation and policy review, the facility failed to provide adequate physical assistance for a resident who was dependent on staff for toileting, personal hygiene, and bed mobility. Actual Harm occurred on 01/19/26 at approximately 6:00 P.M. when one staff member was providing incontinent care to Resident #39 while in bed. Certified Nursing Assistant (CNA) #250 rolled Resident #39 to his left side and the resident fell from the bed onto the floor. Resident #39 had fractures to his right humerus (upper arm bone), right coronoid (elbow), left femur (upper leg bone), and left patella (kneecap). This affected one (Resident #39) of three residents reviewed for falls. […]

• Actual harm, isolatedF686Mar 31, 2021

  Based on closed medical record review, staff interview, and review of the National Pressure Injury Advisory Panel (NPIAP) guidelines on pressure ulcers, the facility failed to ensure a resident who was assessed at risk had interventions to prevent the development of pressure ulcers. Actual harm occurred to Resident #63 when she developed three (3) Stage III pressure ulcers (full thickness tissue loss; subcutaneous fat may be visible, but bone, tendon or muscle are not exposed; slough may be present but does not obscure the depth of tissue loss.) to the coccyx, and right and left buttocks. This affected one (#63) of three residents reviewed for in-house acquired pressure ulcers. The facility identified eight current residents with pressure ulcers. […]

• No harm, potential for more than minimal, widespreadF812Dec 4, 2025

  Based on observation, interview, facility policy and document review, and the Food and Drug Administration 2022 Food Code, the facility failed to ensure meals were prepared and food was stored in accordance with professional standards for food safety. This had the potential to affect 38 residents who received meals from the kitchen. The facility census was 40. 1. A facility policy titled, Sanitation - Dish and Utensil Procedure Guideline, dated 03/19/2019, specified, The following guidelines provides an overview of routine cleaning services and the general frequency of various cleaning tasks. The policy specified, 6. Dishes and utensils shall be air dried before storage. Do not towel dry, and 10. Cutting boards need to be washed and sanitized between each use. […]

• No harm, potential for more than minimal, widespreadF880Aug 30, 2022

  Based on staff interview, review of the Centers for Medicare and Medicaid Services (CMS) memo, review of the infection control log, and policy review, the facility failed to implement a program to prevent Legionella (a type of pneumonia caused by bacteria). This had the potential to affect all residents at the facility. The facility census was 46. Findings include Review of the facility policy packet titled, Water Program, dated 12/29/17 included a plan to reduce the risk for growing and spreading Legionella. Maintenance will provide a continuous review of the water management system. The water management program revealed no evidence of a water management team, roles of the team, no evidence of a description of the building water system. […]