A list of the most recent deficiencies for Spring Hill Care and Rehab. 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? |
|---|---|---|---|---|
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-11-07 | 2023-12-08 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-07 | 2023-12-08 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-11-07 | 2023-12-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-11-07 | 2023-12-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-07 | 2023-12-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-07 | 2023-12-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-07 | 2023-12-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-07 | 2023-12-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-07 | 2023-12-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-11-07 | 2023-12-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-07 | 2023-12-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-07 | 2023-12-08 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-04 | 2023-11-02 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2023-10-04 | 2023-11-02 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-10-04 | 2023-11-02 | 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 | 2023-10-04 | 2023-11-02 | 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 | 2023-10-04 | 2023-11-02 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-10-04 | 2023-11-02 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-10-04 | 2023-11-02 | 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 | 2023-10-04 | 2023-11-02 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-10-04 | 2023-11-02 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2022-03-16 | 2022-04-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-03-16 | 2022-04-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-03-16 | 2022-04-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-16 | 2022-04-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-16 | 2022-04-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-03-16 | 2022-04-15 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-02-03 | 2022-03-04 | 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 | 2022-02-03 | 2022-03-04 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-02-03 | 2022-03-04 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-02-03 | 2022-03-04 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-02-03 | 2022-03-04 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2020-03-16 | 2020-04-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-03-16 | 2020-04-24 | 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 | 2020-03-16 | 2020-04-24 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-03-16 | 2020-04-24 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-02-11 | 2020-03-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-02-11 | 2020-03-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-02-11 | 2020-03-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-02-11 | 2020-03-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-11 | 2020-03-13 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2020-02-11 | 2020-03-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-11 | 2020-03-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-02-11 | 2020-03-13 | N |
