A list of the most recent deficiencies for Wellsprings Post Acute Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-29 | 2023-12-12 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-29 | 2023-12-12 | Y |
| Post nurse staffing information every day. | Health | 2023-11-29 | 2023-12-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-29 | 2023-12-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-07 | 2023-12-02 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-11-07 | 2023-12-02 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-11-07 | 2023-12-02 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-11-07 | 2023-12-02 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-11-07 | 2023-12-02 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-29 | 2023-11-20 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-10-29 | 2023-11-20 | Y |
| Report COVID19 data to residents and families. | Health | 2023-10-29 | 2023-11-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-01 | 2023-11-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-01 | 2023-11-16 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-01 | 2023-11-16 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-10-17 | 2023-11-02 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-10-17 | 2023-11-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-05 | 2023-10-17 | Y |
| Post nurse staffing information every day. | Health | 2023-09-13 | 2023-10-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-13 | 2023-10-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-25 | 2023-08-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-17 | 2023-08-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-17 | 2023-08-10 | Y |
| Provide appropriate foot care. | Health | 2023-07-17 | 2023-08-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-14 | 2023-08-04 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-07-05 | 2023-07-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-05 | 2023-07-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-05 | 2023-07-27 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-06-16 | 2023-07-07 | Y |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2023-06-16 | 2023-07-07 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-06-16 | 2023-07-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-14 | 2023-06-23 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-04-17 | 2023-05-07 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-04-11 | 2023-05-03 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-12 | 2023-04-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-21 | 2023-03-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-21 | 2023-03-21 | Y |
| List the names and contact information of those in the facility. | Fire Safety | 2023-01-30 | 2023-02-27 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-01-30 | 2023-02-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-01-30 | 2023-02-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-01-30 | 2023-02-27 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-01-30 | 2023-02-27 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-01-30 | 2023-02-27 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-01-30 | 2023-02-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-30 | 2023-02-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-01-30 | 2023-02-27 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-01-30 | 2023-02-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-30 | 2023-02-27 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-01-30 | 2023-02-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-01-30 | 2023-02-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-30 | 2023-02-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-30 | 2023-02-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-01-30 | 2023-02-27 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-20 | 2023-02-20 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-01-20 | 2023-02-20 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-01-20 | 2023-02-20 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-01-20 | 2023-02-20 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-01-20 | 2023-02-20 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-01-20 | 2023-02-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-20 | 2023-02-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-20 | 2023-02-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-20 | 2023-02-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-20 | 2023-02-20 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2023-01-20 | 2023-02-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-20 | 2023-02-20 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-01-20 | 2023-02-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-20 | 2023-02-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-20 | 2023-02-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-01-20 | 2023-02-20 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-01-20 | 2023-02-20 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-01-20 | 2023-02-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-20 | 2023-02-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-20 | 2023-02-20 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-01-20 | 2023-02-20 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-01-20 | 2023-02-20 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-01-20 | 2023-02-20 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-02-01 | 2023-02-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-27 | 2023-02-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-27 | 2023-02-03 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-11-21 | 2022-12-21 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-11-21 | 2022-12-21 | Y |
| Report COVID19 data to residents and families. | Health | 2022-11-30 | 2022-12-09 | Y |
| Provide appropriate foot care. | Health | 2022-10-18 | 2022-11-17 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-10-11 | 2022-11-11 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-09-23 | 2022-10-24 | Y |
| Keep all essential equipment working safely. | Health | 2022-09-23 | 2022-10-24 | Y |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2022-09-23 | 2022-10-24 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-30 | 2022-09-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-30 | 2022-09-09 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-08-01 | 2022-09-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-28 | 2022-09-02 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-07-28 | 2022-09-02 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-07-28 | 2022-09-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-21 | 2022-08-25 | Y |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2022-06-29 | 2022-07-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-08 | 2022-02-18 | N |
| Report COVID19 data to residents and families. | Health | 2022-02-08 | 2022-02-18 | N |
| Post nurse staffing information every day. | Health | 2021-11-14 | 2021-11-26 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-11-15 | 2021-11-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-15 | 2021-11-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-29 | 2021-11-04 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-07-24 | 2019-08-23 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-07-24 | 2019-08-23 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-07-24 | 2019-08-23 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-07-24 | 2019-08-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-07-24 | 2019-08-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-24 | 2019-08-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-24 | 2019-08-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-24 | 2019-08-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-07-24 | 2019-08-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-07-24 | 2019-08-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-07-24 | 2019-08-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-07-12 | 2019-08-12 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-07-12 | 2019-08-12 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-07-12 | 2019-08-12 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-07-12 | 2019-08-12 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-07-12 | 2019-08-12 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-07-12 | 2019-08-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-07-12 | 2019-08-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-12 | 2019-08-12 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-07-12 | 2019-08-12 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-07-12 | 2019-08-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-07-12 | 2019-08-12 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-07-12 | 2019-08-12 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-07-12 | 2019-08-12 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-07-12 | 2019-08-12 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-07-12 | 2019-08-12 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-07-12 | 2019-08-12 | N |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2019-07-12 | 2019-08-12 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2019-07-12 | 2019-08-12 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-07-12 | 2019-08-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-12 | 2019-08-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-07-12 | 2019-08-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-12 | 2019-08-12 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-07-12 | 2019-08-12 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-07-12 | 2019-08-12 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-07-12 | 2019-08-12 | N |
| Have enough backup water supply for essential areas of the nursing home. | Health | 2019-07-12 | 2019-08-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-07-15 | 2018-08-15 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-07-15 | 2018-08-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-07-15 | 2018-08-15 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-07-15 | 2018-08-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-07-15 | 2018-08-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-07-15 | 2018-08-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-07-15 | 2018-08-15 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-07-15 | 2018-08-15 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2018-07-15 | 2018-08-15 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2018-07-15 | 2018-08-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-07-15 | 2018-08-15 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-07-15 | 2018-08-15 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2018-07-15 | 2018-08-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-15 | 2018-08-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-07-15 | 2018-08-15 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2018-07-15 | 2018-08-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-15 | 2018-08-15 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-07-15 | 2018-08-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-07-15 | 2018-08-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-07-15 | 2018-08-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-07-15 | 2018-08-15 | N |
