A list of the most recent deficiencies for Wellspring Health 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-08-30 | 2022-10-20 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-08-30 | 2022-10-20 | 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 | 2022-08-30 | 2022-10-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-30 | 2022-10-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-30 | 2022-10-20 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-08-30 | 2022-10-20 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-08-23 | 2022-10-20 | 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 | 2022-08-23 | 2022-10-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-08-23 | 2022-10-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-23 | 2022-10-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-23 | 2022-10-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-08-23 | 2022-10-20 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-08-23 | 2022-10-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-08-23 | 2022-10-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-23 | 2022-10-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-23 | 2022-10-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-08-23 | 2022-10-20 | 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 | 2022-07-19 | 2022-08-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-29 | 2022-02-09 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-12-29 | 2022-02-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-29 | 2022-02-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-12 | 2021-12-17 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-11-12 | 2021-12-17 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-12 | 2021-12-17 | Y |
| 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 | 2021-11-12 | 2021-12-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-12 | 2021-12-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-31 | 2021-04-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-03-31 | 2021-04-28 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2021-03-31 | 2021-04-28 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-03-31 | 2021-04-28 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-03-31 | 2021-04-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-31 | 2021-04-28 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-04 | 2019-05-17 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-04-04 | 2019-05-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-04-04 | 2019-05-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-04 | 2019-05-17 | 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 | 2019-04-04 | 2019-05-17 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-04-04 | 2019-05-17 | 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 | 2019-04-04 | 2019-05-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-04 | 2019-05-17 | 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 | 2019-04-04 | 2019-05-17 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2019-04-04 | 2019-05-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-04 | 2019-05-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-04 | 2019-05-17 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-04-04 | 2019-05-17 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-04-02 | 2019-05-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-04-02 | 2019-05-17 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-04-02 | 2019-05-17 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-04-02 | 2019-05-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-02 | 2019-05-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-02 | 2019-05-17 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-04-02 | 2019-05-17 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2019-04-02 | 2019-05-17 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-04-02 | 2019-05-17 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-04-02 | 2019-05-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-02 | 2019-05-17 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-03-08 | 2018-04-09 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-03-08 | 2018-04-09 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-03-08 | 2018-04-09 | N |
| Respond appropriately to all alleged violations. | Health | 2018-03-08 | 2018-04-09 | 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 | 2018-03-08 | 2018-04-09 | 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 | 2018-03-08 | 2018-04-09 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-03-08 | 2018-04-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-08 | 2018-04-09 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-03-06 | 2018-04-09 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-03-06 | 2018-04-09 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-03-06 | 2018-04-09 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-03-06 | 2018-04-09 | 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 | 2018-03-06 | 2018-04-09 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-03-06 | 2018-04-09 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2018-03-06 | 2018-04-09 | 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 | 2018-03-06 | 2018-04-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-03-06 | 2018-04-09 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-03-06 | 2018-04-09 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-03-06 | 2018-04-09 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2018-03-06 | 2018-04-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-03-06 | 2018-04-09 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-03-06 | 2018-04-09 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2018-03-06 | 2018-04-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-03-06 | 2018-04-09 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-03-06 | 2018-04-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-03-06 | 2018-04-09 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2018-03-06 | 2018-04-09 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-03-06 | 2018-04-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-03-06 | 2018-04-09 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2018-03-06 | 2018-04-09 | N |
