Deficiency Records for The Springs Skilled Nursing and Therapy
Updated as of March 01, 2024
A list of the most recent deficiencies for The Springs Skilled Nursing and Therapy. 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? |
|---|---|---|---|---|
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-24 | 2023-09-12 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-08-24 | 2023-09-12 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-06-19 | 2023-07-12 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-06-19 | 2023-07-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-04-18 | 2023-05-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-18 | 2023-05-17 | 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 | 2023-04-18 | 2023-05-17 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-04-18 | 2023-05-17 | N |
| Provide activities to meet all resident's needs. | Health | 2023-04-18 | 2023-05-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-18 | 2023-05-17 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-04-18 | 2023-05-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-18 | 2023-05-17 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-04-18 | 2023-05-17 | N |
| 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 | 2023-04-18 | 2023-05-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-18 | 2023-05-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-18 | 2023-05-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-18 | 2023-05-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-18 | 2023-05-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-18 | 2023-05-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-18 | 2023-05-17 | 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 | 2023-04-18 | 2023-05-17 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-18 | 2023-05-17 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-04-18 | 2023-05-17 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-04-18 | 2023-05-17 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-04-18 | 2023-05-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-04 | 2022-12-06 | 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 | 2022-11-04 | 2022-12-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-21 | 2022-10-05 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-08-24 | 2022-08-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-07-26 | 2022-08-30 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-07-26 | 2022-08-30 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-07-26 | 2022-08-30 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-07-26 | 2022-08-30 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-07-26 | 2022-08-30 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-07-26 | 2022-08-30 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-07-26 | 2022-08-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-26 | 2022-08-30 | 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 | 2022-07-26 | 2022-08-30 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-07-26 | 2022-08-30 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-07-26 | 2022-08-30 | 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 | 2022-07-26 | 2022-08-30 | 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 | 2022-07-26 | 2022-08-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-26 | 2022-08-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-26 | 2022-08-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-07-26 | 2022-08-30 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-26 | 2022-08-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-26 | 2022-08-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-26 | 2022-08-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-26 | 2022-08-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-26 | 2022-08-30 | Y |
| 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 | 2022-07-26 | 2022-08-30 | 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 | 2022-07-26 | 2022-08-30 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-26 | 2022-08-30 | 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 | 2022-07-26 | 2022-08-30 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-07-26 | 2022-08-30 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-07-28 | 2022-08-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-07-28 | 2022-08-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-20 | 2022-02-25 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-09-10 | 2021-09-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-10 | 2021-09-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-10 | 2021-09-18 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-09-10 | 2021-09-18 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-10 | 2021-09-18 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-07-28 | 2021-08-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-28 | 2021-08-18 | 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 | 2021-07-28 | 2021-08-18 | 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 | 2021-07-28 | 2021-08-18 | 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 | 2021-07-28 | 2021-08-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-07-28 | 2021-08-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-29 | 2021-05-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-29 | 2021-05-09 | 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 | 2021-04-29 | 2021-05-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-15 | 2021-05-09 | 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 | 2021-03-15 | 2021-05-09 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-03-15 | 2021-03-24 | 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 | 2021-03-15 | 2021-03-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-03-15 | 2021-03-24 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-03-15 | 2021-03-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-15 | 2021-03-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-15 | 2021-03-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-15 | 2021-03-24 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-03-15 | 2021-03-24 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-03-15 | 2021-03-24 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-03-15 | 2021-03-24 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-03-15 | 2021-03-24 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-03-15 | 2021-03-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-15 | 2021-03-24 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-10-31 | 2019-12-03 | 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 | 2019-10-31 | 2019-12-03 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-10-31 | 2019-12-03 | N |
| 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 | 2019-10-31 | 2019-12-03 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-10-31 | 2019-12-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-29 | 2019-12-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-10-29 | 2019-12-03 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-10-29 | 2019-12-03 | N |
