Inspection Reports for
Spring Mill Meadows

The facility was found deficient in multiple areas including failure to ensure proper interdisciplinary team evaluation and physician orders for medication self-administration, incomplete beneficiary notice documentation, outdated PASARR assessments, delayed baseline care plans, incomplete care plan meetings, failure to follow physician orders for weights and bladder scans, lack of physician order for oxygen use, inadequate documentation of rationale for declined pharmacist recommendations, improper medication labeling, failure to monitor refrigerator temperatures and discard expired food, and lapses in infection control practices including PPE use and equipment storage.

This citation relates to Complaint IN00458980.

The facility failed to ensure a staff member used a gait belt during a transfer, resulting in Resident B falling and sustaining an abrasion and a right femur fracture. The deficient practice was corrected prior to the survey start date.

Complaint IN00455338 had no deficiencies related to allegations. Complaint IN00458980 had federal/state deficiencies cited related to allegations. Complaint IN00459493 had no deficiencies related to allegations.

No deficiencies were found related to complaints IN00455338 and IN00459493. Deficiencies related to complaint IN00458980 were cited involving failure to use a gait belt during resident transfer, resulting in a fall with injury. The deficient practice was corrected prior to the survey.

This citation relates to Complaint IN00451659. The complaint involved failure to provide ordered cancer medication and follow-up oncology care for Resident B, resulting in actual harm.

The facility failed to ensure Resident B received prescribed cancer medication (Nubeqa) as ordered, did not schedule timely follow-up oncology appointments, and the medical director discontinued the medication without consulting the oncologist. This resulted in Resident B having no oncology follow-up care for 15 months, leading to cancer progression and transition to hospice care.

Complaint IN00451659 was substantiated with federal and state deficiencies cited at F684 related to quality of care issues for Resident B involving cancer medication and follow-up care.

The facility failed to ensure a resident with metastatic prostate cancer received ordered cancer medications, had timely follow-up oncology appointments, and the medical director discontinued a high-cost cancer medication without consulting the oncologist, resulting in delayed oncology care and progression of the resident's cancer.

The facility was found not in compliance with Life Safety Code requirements due to one set of smoke barrier doors failing to restrict smoke movement for at least 20 minutes. The doors did not close completely or latch, leaving a one-inch gap, potentially affecting residents, staff, and visitors.

This citation relates to Complaint IN00435561 for transfer issues, Complaint IN00439059 for medication administration, and Complaint IN00429846 for transfer safety.

The facility failed to ensure correct transfer arrangements for a resident, failed to notify physicians as ordered regarding medication parameters and missed doses for multiple residents, and failed to follow physical therapy recommendations for safe resident transfers. These deficiencies were corrected prior to or during the survey.

This citation relates to Complaint IN00429846.

The facility was found deficient in multiple areas including failure to use recommended transfer methods for a resident, delayed AIMS assessments and lack of education on antipsychotic black box warnings, improper medication storage and narcotic reconciliation, failure to assist a resident in obtaining dentures, and inadequate food storage practices in the walk-in freezer.

This survey included investigation of complaints IN00429846, IN00435561, IN00439059, IN00439436, and IN00440642. Deficiencies related to complaints IN00429846, IN00435561, and IN00439059 were cited. Complaints IN00439436 and IN00440642 had no deficiencies cited.

The facility was cited for deficiencies related to discharge planning, quality of care including medication administration and physician notification, accident prevention, psychotropic medication management, medication storage, dental services, and food safety. Some deficiencies were corrected prior to the survey, while others required plans of correction.

This citation relates to Complaint IN00425041 and IN00425093. The complaints involved fraudulent charges on residents' credit cards, with investigations confirming misuse by a housekeeper who was subsequently terminated.

The facility failed to ensure residents' credit cards were kept safe and secure during admission, resulting in fraudulent charges on two residents' credit cards by a housekeeper. The issue was corrected prior to the survey by terminating the implicated employee and implementing staff training on misappropriation of property.

Complaints IN00425041 and IN00425093 were substantiated with federal/state deficiencies cited at F602. Complaint IN00425240 had no deficiencies related to the allegations. The investigation revealed fraudulent use of residents' credit cards by a housekeeper, with charges totaling $602 for Resident B and approximately $300 for Resident C. The housekeeper was terminated prior to the survey.

The facility failed to ensure residents' credit cards were kept safe and secure during admission for 2 of 3 residents reviewed (Residents B and C). Fraudulent charges were made on their credit cards by a housekeeper who was subsequently terminated. The deficient practice was corrected prior to the survey.

The complaint was substantiated and related to medication errors involving Resident G, who had a critically low potassium level and was not treated with the ordered potassium replacement, leading to hospitalization.

The facility failed to administer potassium liquid as ordered to Resident G, resulting in a critically low potassium level and subsequent hospital transfer. The investigation revealed medication rescheduling without notifying the Nurse Practitioner, lack of policy adherence, and medication availability issues.

Complaint IN00421053 was substantiated with federal/state deficiencies cited at F760 related to medication errors. Other complaints investigated showed no deficiencies related to the allegations.

The facility was found to have a significant medication error involving Resident G, who did not receive ordered potassium chloride liquid as prescribed, resulting in a critically low potassium level and hospital admission. Other complaints were found to have no deficiencies related to the allegations.

Complaint IN00418345 was substantiated with federal/state deficiencies cited at F686. Complaints IN00417899, IN00418017, and IN00418427 had no deficiencies related to the allegations.

The facility was found deficient related to Complaint IN00418345 for failing to ensure interventions were used to prevent potential decline of a resident's bilateral heel pressure ulcers. The resident's Prevalon boots and pillows were not in use as ordered, and documentation and care planning for refusal of treatment were inadequate.

This Federal tag relates to Complaint IN00418345.

The facility failed to ensure interventions were used to prevent decline in a resident's bilateral heel pressure ulcers. Observations showed the resident was not wearing prescribed offloading boots and pillows were not used as an alternative. Documentation and care plans were incomplete regarding refusal of treatment and alternative approaches. The resident's wounds were unstageable and had been treated with Betadine daily, but offloading orders were inconsistently applied.

The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements, with deficiencies related to fire alarm system time accuracy, sprinkler head obstructions, and portable fire extinguisher installation height.

The facility was found deficient in multiple areas including failure to monitor daily weights as ordered for a resident with CHF, improper transfer techniques for dependent residents, failure to reweigh and notify physician after significant weight loss, failure to label liquid narcotics properly, and incomplete employee screening and training documentation.

The facility was found deficient in several areas including failure to monitor daily weights as ordered for a resident with congestive heart failure, failure to ensure dependent residents were transferred using proper technique and assist levels, failure to reweigh a resident after significant weight loss and notify the physician, and failure to label liquid narcotics properly in medication carts.

Complaint IN00390136 was substantiated with federal/state deficiencies cited at F583 and F686 related to privacy and pressure ulcer care.

The facility failed to provide privacy for one resident during an examination and failed to ensure off-loading boots were used for one resident with pressure ulcers. The complaint was substantiated with deficiencies related to personal privacy and treatment to prevent pressure ulcers.