Deficiency Records for Spring Hill Rehabilitation and Nursing Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Spring Hill Rehabilitation and Nursing 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? |
|---|---|---|---|---|
| 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 | 2023-12-07 | 2024-01-22 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-07-20 | 2023-09-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-20 | 2023-09-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-20 | 2023-09-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-20 | 2023-09-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-07-20 | 2023-09-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-20 | 2023-09-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-20 | 2023-09-08 | N |
| Respond appropriately to all alleged violations. | Health | 2023-07-14 | 2023-09-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-14 | 2023-09-01 | 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 | 2023-07-14 | 2023-09-01 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-07-14 | 2023-09-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-14 | 2023-09-01 | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2023-07-14 | 2023-09-01 | N |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2023-07-14 | 2023-09-01 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-07-14 | 2023-09-01 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-07-14 | 2023-09-01 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-11-22 | 2023-01-10 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-11-22 | 2023-01-10 | 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 | 2022-10-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-23 | 2022-10-28 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-23 | 2022-10-28 | 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 | 2022-09-23 | 2022-10-28 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-09-23 | 2022-10-28 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-07-20 | 2022-10-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-07-20 | 2022-08-24 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-07-20 | 2022-08-24 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-07-20 | 2022-08-24 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-07-20 | 2022-08-24 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-07-20 | 2022-08-24 | N |
| 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 | 2022-07-20 | 2022-08-24 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-20 | 2022-08-24 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2022-07-20 | 2022-08-24 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-20 | 2022-08-24 | N |
| Respond appropriately to all alleged violations. | Health | 2022-07-20 | 2022-08-24 | N |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2022-07-20 | 2022-08-24 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-07-20 | 2022-08-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-20 | 2022-08-24 | 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 | 2022-07-20 | 2022-08-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-20 | 2022-08-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-20 | 2022-08-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-07-20 | 2022-08-24 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-07-20 | 2022-08-24 | N |
| Post nurse staffing information every day. | Health | 2022-07-20 | 2022-08-24 | 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 | 2022-07-20 | 2022-08-24 | 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 | 2022-07-20 | 2022-08-24 | N |
| Keep complete, dated laboratory records in the resident's record. | Health | 2022-07-20 | 2022-08-24 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-07-20 | 2022-08-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-20 | 2022-08-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-20 | 2022-08-24 | 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 | 2022-07-20 | 2022-08-24 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-07-20 | 2022-08-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-20 | 2022-08-24 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-07-20 | 2022-08-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-07-20 | 2022-08-24 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-07-20 | 2022-08-24 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2022-07-20 | 2022-08-24 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-07-26 | 2022-08-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-26 | 2022-08-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-07-26 | 2022-08-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-07-26 | 2022-08-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-07-26 | 2022-08-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-26 | 2022-08-12 | 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 | 2022-06-06 | 2022-07-27 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-06-06 | 2022-07-27 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2022-06-06 | 2022-07-27 | 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 | 2022-06-06 | 2022-07-27 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-06-06 | 2022-07-27 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-04-08 | 2022-05-01 | 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 | 2022-04-08 | 2022-05-01 | 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 | 2021-09-27 | 2021-11-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-27 | 2021-11-01 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-09-27 | 2021-11-01 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-27 | 2021-11-01 | Y |
| Keep all essential equipment working safely. | Health | 2021-09-27 | 2021-11-01 | 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 | 2021-05-06 | 2021-06-21 | N |
| 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 | 2021-05-06 | 2021-06-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-05-06 | 2021-06-21 | 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 | 2021-05-06 | 2021-06-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-06 | 2021-06-21 | N |
| Dispose of garbage and refuse properly. | Health | 2021-05-06 | 2021-06-21 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-05-06 | 2021-05-31 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-05-06 | 2021-05-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-05-06 | 2021-05-31 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2021-05-06 | 2021-05-31 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2021-05-06 | 2021-05-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-06 | 2021-05-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-05-06 | 2021-05-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-03-01 | 2021-04-01 | Y |
