Inspection Reports for
Spring Lake Skilled Nursing and Rehabilitation
8622 LINE AVENUE, SHREVEPORT, LA, 71106
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Inspection Report — Dec 3, 2025
Annual Inspection CMS
Date: Dec 3, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and to evaluate the quality of care and services provided by Spring Lake Skilled Nursing and Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to develop and implement comprehensive care plans, failure to follow physician orders for medication administration, failure to provide services meeting professional standards, failure to provide adequate assistance with activities of daily living, failure to maintain nutritional status, and failure to provide appropriate respiratory care.
Deficiencies (7)
Failed to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes for 2 residents.
Failed to follow physician's orders for medication administration for Resident #10, including delayed and incomplete administration of Fluconazole.
Failed to maintain PICC line dressing properly for Resident #86; dressing was loose and discolored and not changed as ordered.
Failed to ensure safe medication administration practices by leaving medications at the bedside for Resident #113 without proper evaluation and authorization.
Failed to provide adequate activities of daily living care, including trimming fingernails for Resident #17 and bathing Resident #131.
Failed to maintain acceptable nutritional status by not timely implementing dietitian recommendations for Resident #99.
Failed to provide appropriate respiratory care for Resident #117, including failure to date and store nebulizer mask and tubing in a covered bag as per policy.
Report Facts
Residents reviewed: 40
Residents reviewed for ADL care: 3
Weight loss percentage: 17.93
Weight loss in pounds: 33
Days for medication ordered: 7
Days medication received: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 Director of Nursing | Director of Nursing | Confirmed medication administration issues for Resident #10 and medication at bedside for Resident #113 |
| S5 LPN | Licensed Practical Nurse | Confirmed PICC line dressing issues for Resident #86 |
| S6 NP | Nurse Practitioner | Reported not being notified of Resident #99's weight loss or dietitian recommendations |
| S3 LPN | Licensed Practical Nurse | Acknowledged nebulizer mask and tubing undated and not stored properly for Resident #117 |
Inspection Report — Sep 25, 2024
CMS
Date: Sep 25, 2024
Visit Reason
The inspection was conducted to assess compliance with care standards, including activities of daily living assistance and accuracy of direct care staffing data submission.
Findings
The facility failed to ensure proper nail care for a diabetic resident requiring assistance with activities of daily living and failed to accurately submit mandatory direct care staffing information to CMS for Fiscal Year Quarter 3 2024.
Deficiencies (2)
Failed to ensure Resident #48 received nail care despite diabetic condition and physician orders allowing licensed nurse to clip and trim nails.
Failed to accurately submit mandatory direct care staffing information to CMS for Fiscal Year Quarter 3 2024, resulting in triggers for One Star Staffing Rating and Excessively Low Weekend Staffing.
Report Facts
Residents reviewed for ADL: 3
Residents affected by nail care deficiency: 1
Fiscal Year Quarter: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 DON | Director of Nursing | Reported on nail care services and confirmed Resident #48's diabetic status and missed nail care |
| S3 NP | Nurse Practitioner | Performs nail care on residents every 60 days; last service date 08/19/2024 |
| S1 Administrator | Administrator | Reported on staffing data submission process and lack of understanding of low staffing triggers |
Inspection Report — Jun 5, 2024
Annual Inspection CMS
Date: Jun 5, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to comprehensive care planning, pressure ulcer care, and pain management for residents.
Findings
The facility failed to develop and implement a comprehensive care plan for one resident, did not perform timely skin and wound evaluations for pressure ulcers, and failed to administer prescribed pain medication for one resident, resulting in minimal harm or potential for actual harm.
Deficiencies (3)
Failed to develop and implement a complete care plan that meets all the resident's needs, with measurable timetables and actions.
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing, including failure to perform skin and wound evaluation upon admission and weekly.
Failed to provide safe, appropriate pain management by not administering pain medication as ordered for a resident.
Report Facts
Residents sampled: 4
Residents receiving pain medication sampled: 3
Pain level: 7
Wound size: 9
Wound size: 5.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S4 MDS Nurse | Acknowledged Resident #1's care plan was incomplete | |
| S2 Corporate Nurse | Reported Skin & Wound Evaluations should be completed every 7 days | |
| S2 DON | Acknowledged Resident #1 did not have Skin & Wound Evaluation completed upon admission and weekly | |
| S3 LPN | Licensed Practical Nurse | Reported not knowing why Resident #1 did not receive prn pain medication on specified dates |
| S1 DON | Director of Nursing | Acknowledged Resident #1 did not receive prn pain medication on specified dates after reviewing May MAR |
Inspection Report — Aug 9, 2023
Complaint Investigation CMS
Date: Aug 9, 2023
Visit Reason
The inspection was conducted following a complaint investigation regarding the treatment of Resident #102 by a Certified Nursing Assistant (S6CNA), specifically allegations of rough handling and failure to respect the resident's dignity.
Complaint Details
The complaint investigation focused on Resident #102's report of rough treatment by S6CNA, including pushing and rough handling during brief changes. Multiple staff interviews confirmed awareness of the issue, but the facility failed to take adequate corrective action. Resident's Responsible Party also reported discomfort with S6CNA. The facility did not offer alternative CNA assignments or inform residents about male CNAs changing briefs.
Findings
The facility failed to treat Resident #102 with respect and dignity, as evidenced by multiple interviews and record reviews indicating rough treatment by S6CNA. Additionally, the facility failed to provide sufficient nursing staff hours on multiple weekend days and did not ensure Medical Director or designee attendance at quarterly Quality Assessment and Assurance meetings.
Deficiencies (3)
Failed to treat Resident #102 with respect, dignity, and care, including rough handling by S6CNA during brief changes.
Failed to provide enough nursing staff every day to meet the needs of every resident; insufficient staffing hours on 8 of 25 weekend days reviewed.
Failed to ensure Medical Director or designee attended quarterly Quality Assessment and Assurance Committee meeting for second quarter of 2023.
Report Facts
Weekend staffing hours provided: 238
Weekend staffing hours provided: 267
Weekend staffing hours provided: 249
Weekend staffing hours provided: 260
Weekend staffing hours provided: 247
Weekend staffing hours provided: 214
Weekend staffing hours provided: 226
Weekend staffing hours provided: 230
Weekend days with insufficient staffing: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (S6CNA) | Named in rough treatment of Resident #102 during brief changes | |
| Administrator (S1Administrator) | Aware of rough treatment allegations and involved in meetings regarding Resident #102's care | |
| Therapy Staff (S7Therapy, S8Therapy) | Reported Resident #102's distress and rough treatment by S6CNA | |
| Physical Therapy Assistant (S9PTA) | Reported Resident #102's upset state and awareness of Administrator's knowledge | |
| Certified Occupational Therapist Assistant (S10COTA) | Reported knowledge of rough handling by S6CNA and Administrator's awareness | |
| Assistant Director of Nursing (S11ADON) | Reported need for retraining S6CNA but no knowledge of rough handling reports | |
| Director of Nursing (S2DON) | Reported facility did not offer alternative CNA and no knowledge of rough handling | |
| Director of Nursing (S2 Director of Nursing) | Verified lack of Medical Director or designee signature on QAA Committee meetings |
Inspection Report — Jun 21, 2023
CMS
Date: Jun 21, 2023
Visit Reason
The inspection was conducted to evaluate whether the facility provided sufficient nursing staff every day to meet the needs of every resident and to have a licensed nurse in charge on each shift.
Findings
The facility failed to ensure there was a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each resident's basic needs. Specifically, the facility did not provide the minimum required staffing hours for 4 of 26 weekend days reviewed in Fiscal Year Quarter 1 2023.
Deficiencies (1)
Failure to provide enough nursing staff every day to meet the needs of every resident and to have a licensed nurse in charge on each shift.
Report Facts
Staffing hours provided: 245.85
Staffing hours provided: 262.34
Staffing hours provided: 265.48
Staffing hours provided: 274.6
Weekend days reviewed: 26
Weekend days with insufficient staffing: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 Director of Nursing | Director of Nursing | Interviewed regarding staffing pattern reports and acknowledged insufficient staffing |
| S2 Regional President | Regional President | Interviewed regarding staffing pattern reports and acknowledged insufficient staffing |
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