Spring Lake Skilled Nursing And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs for 2 (#10, #86) of 40 sampled residents reviewed. The facility failed to follow physician's orders for Resident #10 and Resident #86. Findings:Review of Resident #10's medical records revealed an admit date of 10/21/2025 including the following diagnoses, in part: type 2 diabetes mellitus with diabetic polyneuropathy, chronic respiratory failure with hypoxia, and enterocolitis due to clostridium difficile recurrent (11/01/2025).Review of Resident #10's Physician's orders revealed an order dated 11/10/2025 for Fluconozole 50mg (milligram) by mouth once daily for 7 days.Review of Resident #10's November medication administration record failed to reveal Fluconazole 50mg once daily x 7 days was administered for the full 7 days. Further review revealed the first dose of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews, observations and interviews, the facility failed to provide services that met professional standards for 1 (#113) of 40 residents in the sample. The facility failed to ensure safe medication administration practices by leaving medications at the bedside.Findings:Review of facility's Self-Administration of Medications policy with a Revision date of December 2016 revealed in part:Policy StatementResidents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.Policy Interpretation and Implementation1. As part of their overall evaluation, the staff with the assistance from the practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident.2. In addition to general evaluation of decision-making capacity, the interdisciplinary team will perform an assessment of Self Administration of Medications Form, or equivalent including (but not limited to) the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews and interviews, the facility failed to provide ADL (activities of daily living) for 2 (#17, #131) of 3 (#17, #31, #131) residents reviewed for ADL care of dependent residents. The facility failed to trim and clean Resident #17's fingernails and bathe/shower Resident #131. Findings: Review of the facility's Care of Fingernails/Toenails policy revised 10/2010 included in part:PurposeThe purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infectionsGeneral Guidelines1. Nail care includes daily cleaning and regular trimming.4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. Review of Facility's Shower/Tub Bath policy and procedure revised October 2010 revealed in part: Documentation - The following information should be recorded on the resident's ADL record and/or in the resident's medical record: 1. The date and time the shower/tub bath was performed. 5. If the resident refused the shower/tub bath, the reason (s) why and the intervention taken. 6. The signature and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to maintain acceptable parameters of nutritional status by failing to follow up with the physician in a timely manner to implement the registered dieticians (RD) recommendation for 1 (#99) of 6 (#1, #16, #25, #86, #99 and #132) residents reviewed for nutrition. Findings:Review of Resident #99's medical record revealed an admission date of 08/28/2025 with the following diagnoses, not limited to, muscle wasting and atrophy, type 2 diabetes mellitus without complications, mild protein-calorie malnutrition, muscle weakness (generalized) and need for assistance with personal care.Review of Resident #99's weights revealed a significant 17.93% (33 pounds) weight loss in 73 days from dates 08/29/2025 (184 pounds) and 11/10/2025 (151 pounds).Review of Resident #99's physician orders for dates 09/01/2025 through 12/03/2025 failed to reveal recommendations from S7RD and S8RD were implemented:On 09/16/2025 S8 RD recommended: three times a day house shake supplements for 90 days.On 11/20/2025 S7RD recommended: two times a day house shake…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews, observations, and interview, the facility failed to provide specialized care needs for the provision of respiratory care including tracheostomy care and tracheal suctioning, in accordance with professional standards of practice for 1 (#117) of 1 (#117) resident reviewed for respiratory care. The facility failed to date and store hand held nebulizer mask and tubing in a covered bag. Findings: Review of Facility's policy and procedure for oxygen administration revised February 2025 revealed in part: 6. Nebulizer tubing will be changed within 7-10 days, or if visibly soiled. 6. Store nebulizer equipment in a covered device (i.e. plastic bag, kangaroo pouch) between uses.Review of Resident #117's medical records revealed an admit date of 11/05/2025 with the following diagnoses, in part: severe persistent asthma uncomplicated and chronic systolic (congestive) heart failure. Review of Resident #117's physician's orders revealed an order dated 11/25/2025 for Budesonide-Formoterol Fumarate Inhalation Aerosol 160-4.5 mcg(microgram)/Act(actuation)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation and interviews the facility failed to ensure residents who were unable to complete their ADL (Activities of Daily Living) received the necessary services to maintain proper grooming for 1 (#48) of 3 (#2, #34, #48) residents reviewed for ADL. The facility failed to ensure Resident #48 received nail care. Findings: Review of Resident #48's medical diagnoses revealed the following, but not limited to cerebral infarction, type 2 diabetes mellitus with diabetic neuropathy, and systemic lupus erythematosus. Review of Resident #48's September 2024 physician orders dated 05/08/2024 revealed: Activity as tolerated. Licensed nurse may clip and trim diabetic finger and toenails as indicated. Review of Resident #48's quarterly MDS (Minimum Data Sets) dated 07/08/2024 revealed a BIMS (Brief Interview of Mental Status) was 15 out of 15 indicating cognitively intact. Review of Resident #48's care plan revealed resident has an ADL self-care performance deficit and requires assistance with ADL. Observation on 09/23/2024 at 11:03 A.M. revealed Resident #48 sitting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews the facility failed to accurately submit mandatory direct care staffing information to Centers for Medicare and Medicaid Services (CMS) for the Fiscal Year (FY) Quarter 3 2024 (April 1-June 31). Findings: Review of the facility's Payroll Based Journal (PBJ) Staffing Data Report for FY Quarter 3 2024 (April 1-June 31) revealed triggers for the following: One Star Staffing Rating and Excessively Low Weekend Staffing. During an interview on 09/25/2024 at 12:30 p.m. S1 Administrator reported he did not understand why the facility triggered for low staffing. S1 Administrator reported he is the only person at the facility that submits agency invoices to the corporate office. S1 Administrator further reported the corporate office submits the PBJ data to the CMS system.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (#1) out of 4 (#1, #2, #3, #4) sampled residents reviewed for pressure ulcers and skin conditions. The facility failed to perform a skin and wound evaluation upon admission and weekly for Resident #1. Findings: Review of medical records revealed Resident #1 with an admit date of 04/18/2024 with the following diagnosis, in part: muscle wasting and atrophy, not elsewhere classified/multiples sites, primary generalized (osteo) arthritis, mild protein-calorie malnutrition, Chronic Obstructive Pulmonary Disease/unspecified, muscle weakness (generalized), difficulty walking/not elsewhere classified, unsteadiness on feet, Peripheral Vascular Disease/unspecified, and cellulitis of right lower limb. Review of Resident #1's MDS (Minimum Data Set)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to develop and implement a comprehensive care plan for 1 (#1) out of 4 (#1, #2, #3, #4) sampled residents plan of care reviewed. Findings: Review of medical records revealed Resident #1 with an admit date of 04/18/2024 and discharge date of 05/11/2024 with the following diagnosis, in part: muscle wasting and atrophy, not elsewhere classified/multiples sites, primary generalized (osteo) arthritis, mild protein-calorie malnutrition, Chronic Obstructive Pulmonary Disease/unspecified, muscle weakness (generalized), difficulty walking/not elsewhere classified, unsteadiness on feet, Peripheral Vascular Disease/unspecified, and cellulitis of right lower limb. Review of Resident #1's MDS (Minimum Data Set) admission Assessment revealed a date of 04/21/2024. The comprehensive care plan was initiated on 04/19/2024 with only one problem and approach - activities of daily living (ADL) self-care performance deficit. During an interview on 06/04/2023 at 8:25 a.m. S4 MDS Nurse acknowledged Resident #1's care plan included one problem and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews and interview, the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The facility failed to administer pain medication for 1 (#1) out of 3 (#1, #2, #3) sampled residents receiving pain medication. Findings: Review of medical records revealed Resident #1 with an admit date of 04/18/2024 with the following diagnosis, in part: muscle wasting and atrophy, not elsewhere classified/multiples sites, primary generalized (osteo) arthritis, mild protein-calorie malnutrition, Chronic Obstructive Pulmonary Disease/unspecified, muscle weakness (generalized), difficulty walking/not elsewhere classified, unsteadiness on feet, Peripheral Vascular Disease/unspecified, and cellulitis of right lower limb. Review of Resident #1's Physician's Orders revealed the following orders: - 05/09/24 - hydrocodone-acetaminophen oral tablet 7.5-325mg (milligram) give 1 tablet by mouth every 6 hours as needed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to treat each resident with respect, dignity and care in a manner that promotes maintenance of his or her quality of life, recognizing each resident's individuality for 1 resident (#102) of 3 residents (#62, #102, #106) residents investigated for dignity. Findings: Review of Resident #102's Quarterly MDS (Minimum Data Sets) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 13 which indicated the resident was cognitively intact. Review of Resident #102's clinical record revealed an admission date of 03/02/2023 with the following diagnoses in part: aphasia, hemiplegia affecting the left side, muscle wasting and atrophy, cognitive communication deficit. Review of Occupational Therapy Notes dated 06/30/2023 revealed Resident #102 was feeling mistreated at the facility due to CNAs (Certified Nursing Assistant) not answering the call light. During an interview on 08/07/2023 at 1:49 a.m. Resident #102 reported every time S6CNA…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews and interview, 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. The facility failed to provide the minimum required staffing hours for 8 of 25 weekend days reviewed. Findings: Review on the facility's PBJ (Payroll Based Journal) Staffing Data Report for FY (Fiscal Year) Quarter 2 2023 (January 1 to March 31) revealed the submitted weekend staffing data was excessively low. Review of the facility's staffing pattern reports for weekends from FY Quarter 2 2023 revealed the facility provided 238 hours on 01/08/2023 and were required to provide 268 hours. Further review revealed the facility provided 267 hours on 01/14/2023 and were required to provide 277 hours, provided 249 hours on 01/22/2023 and were required to provide 280 hours, provided 260 hours on 01/29/2023 and were required to provide 261 hours, provided 247 hours on 02/19/2023 and were required to provide 260 hours, provided 214 hours on 02/26/2023 and were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based record reviews and interviews, the facility failed to ensure nursing staff demonstrated competencies to provide care, assure residents' safety, and maintain the residents' highest practicable physical well-being. The facility failed to ensure nursing staff assessed a resident for injury in a timely manner and before the resident was moved following a witnessed fall for 1 (#16) of 3 (#2, #16, #77) residents reviewed for falls. Findings: Review of Resident #16's record revealed an admit date of 11/07/2020 and diagnoses including Paraplegia unspecified, unspecified muscle weakness, lack of coordination, and a history of falling. Review of Resident #16's Minimum Data Set Assessment with an Assessment Reference Date of 05/14/2023 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the resident was cognitively intact. Review of the facility's incident logs revealed Resident #16 had a witnessed fall in his room on 07/09/2023 at 6:58 a.m. Further review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview the provider failed to ensure a Medical Director or designee attended a quarterly QAA (Quality Assessment and Assurance) Committee meeting for the second quarter of the year 2023. Findings: Record review of the provider's quarterly QAA Committee meetings failed to reveal a signature of the Medical Director or designee for the second quarter of the year 2023. During an interview on 08/09/2023 at 4:50 p.m., S2 Director of Nursing reviewed the quarterly QAA Committee meetings that were held on the months of April, May, and June of 2023. S2 Director of Nursing verified a signature was not completed by the Medical Director or designee for the second quarter of 2023 QAA Committee meetings.