Spring Mill Senior Living.

“Staff person A alleged witnessing staff person B shouting, cursing at residents, and neglecting to provide incontinence care on multiple occasions. The facility failed to report this suspected abuse to the local area agency on aging in a timely manner as required by the Older Adult Protective Services Act.”

“The facility failed to report an incident of suspected abuse (staff person B shouting, cursing at residents, and neglecting incontinence care) to the Department's personal care home regional office within 24 hours as required.”

“At approximately 5:00 PM, resident records were unlocked, unattended, and accessible in the Healthcare med suite on the 2nd floor, violating confidentiality requirements.”

“Two incidents of suspected resident abuse were not reported to the local area agency on aging in a timely manner. First incident: resident hitting another resident with a closed fist on their arm on an unspecified date at 5:30 AM was reported to staff the evening of that date but not reported to the agency until 3:00 PM on a later date. Second incident: staff member tore off a resident's incontinence brief in view of others on an unspecified date during morning shift but was not reported to the agency until 3:40 PM on a later date.”

“Two incidents were not reported to the Department within 24 hours as required. First incident: resident hitting another resident with a closed fist was not reported to the department until a later date (specific date not clearly indicated in violation text). Second incident: staff member tearing off resident's incontinence brief in front of others was not reported to the department until a later date (specific date not clearly indicated in violation text).”

“A resident with dementia and aggression struck another resident with a closed fist on their arm, causing the victim's glasses to become askew. The aggressive resident subsequently attempted to hit staff members during interventions. Following this incident, the victim vividly remembered the attack and attempted to barricade themselves in their room to feel safe. The aggressive resident had exhibited prior incidents of aggression, including throwing a walker toward other residents.”

“The home's current violation report dated 2024 was not posted in a conspicuous and public place in the home.”

“Memory care resident assignment sheets including resident toileting logs were unlocked, unattended, and accessible on a table in the memory care unit activities room. This is a repeat violation.”

“The resident-home contract for resident 1 was not signed by the resident and there was no indication the resident was given the opportunity to sign.”

“The home's policy/plan for Quality Management requires meetings quarterly, but the home only conducted two quality management meetings.”

“The home's policy/plan for Quality Management requires meetings quarterly, but the home only conducted two quality management meetings.”

“The home's current violation report dated 2024 was not posted in a conspicuous and public place in the home.”

“Memory care resident assignment sheets including resident toileting logs were unlocked, unattended, and accessible on a table in the memory care unit activities room. This is a repeat violation.”

“The resident-home contract for resident 1 was not signed by the resident and there was no indication the resident was given the opportunity to sign.”

“The home's current violation report dated 2024 was not posted in a conspicuous and public place in the home.”

“Memory care resident assignment sheets including resident toileting logs were unlocked, unattended, and accessible on a table in the memory care unit activities room. This is a repeat violation.”

“The home's current violation report dated 2024 was not posted in a conspicuous and public place in the home.”

“Memory care resident assignment sheets including resident toileting logs were unlocked, unattended, and accessible on a table in the memory care unit activities room. This is a repeat violation.”

“The resident-home contract for resident 1 was not signed by the resident and there was no indication the resident was given the opportunity to sign.”

“The home's policy/plan for Quality Management requires meetings quarterly, but the home only conducted two quality management meetings.”

“The home's policy/plan for Quality Management requires meetings quarterly, but the home only conducted two quality management meetings.”

“The resident-home contract for resident 1 was not signed by the resident and there was no indication the resident was given the opportunity to sign.”

“The home's current violation report dated 2024 was not posted in a conspicuous and public place in the home.”

“Memory care resident assignment sheets including resident toileting logs were unlocked, unattended, and accessible on a table in the memory care unit activities room. This is a repeat violation.”

“The nursing office was observed unlocked and unsecured, which compromises the confidentiality of resident records stored there.”

“Residents experienced prolonged delays in call bell response times (45 minutes and 1 hour 2 minutes), resulting in incontinence accidents and humiliation. This constitutes neglect through failure to respond to residents' needs for toileting assistance in a timely manner.”

“Staff member engaged in a verbal altercation with a resident using obscenities and yelling, failing to treat the resident with dignity and respect.”

“From 5:06 am to 6:37 am, there was no trained medication administration staff available to provide services. A medication technician left before a replacement arrived, leaving only untrained caregivers to cover medication administration needs for residents requiring as-needed medications.”

“A resident admitted on 6/30/2024 did not have a completed initial assessment on file at the time of inspection, which was beyond the required 15-day timeframe.”

“The facility failed to immediately report two incidents of alleged abuse by staff person A toward residents 1 and 2 to the Department's Aging office. Resident 2 sent an email regarding abuse and neglect allegations, and a staff member submitted a statement about abuse toward Resident 1, but the previous Assistant Director of Health and Wellness did not report these to the Executive Director in a timely manner.”

“Two incidents of alleged staff-to-resident abuse were not reported to the Department within 24 hours. The allegations were reported to staff person C but were not reported to the Department until 5/30/2024, causing a significant delay in incident reporting.”

“Staff person A physically abused two residents: Resident 1 by taking away their walker and placing it out of reach, poking the resident on arms, back of neck, and head despite requests to stop, and walking behind the resident to scare them; Resident 2 by leaving them naked and alone in the shower despite requiring assistance.”

“Staff member A was hired without completion of a background check prior to scheduling orientation. A background check was subsequently completed and cleared.”

“Resident 1 participated in the development of his/her support plan but did not sign the support plan.”

“Two residents admitted to the Secured Dementia Care Unit lacked documentation that the resident and designated person have not objected to the admission.”

“Resident 1 admitted to the Secured Dementia Care Unit did not have an initial support plan completed within 72 hours of admission or within 72 hours prior to admission.”

“Resident 1's record lists language as English, however staff interviews indicate the resident speaks Swedish and communicates with gestures and facial expressions. The record does not accurately reflect the resident's actual language or means of communication.”

“Direct Care Staff Person B received only 11 hours of annual training in the training year 2023, falling short of the required 12 hours.”

“The narcotics logbook was unlocked, unattended, and accessible on the Medication Cart A, violating confidentiality requirements for resident records.”

“Staff Person A administered medication to Resident 1 while the resident was sitting in the dining room with two other residents present at the table, violating the resident's right to privacy during medical procedures.”

“Direct Care Staff Person C did not receive training on meeting the needs of the residents as described in the preadmission screening form, assessment tool, medical evaluation and support plan during the training year 2023.”

“Staff Person B did not receive training in fire safety, emergency preparedness procedures, or falls and accident prevention during the training year 2023. Staff Person D did not receive training in emergency preparedness procedures and recognition and response to crises and emergency situations during the training year 2023.”

“Three bedside mobility devices on residents' beds posed hazardous conditions: Resident 2's device had a loose pillowcase covering openings; Resident 3's device was easily pulled out and not securely attached with straps, covered by a loose pillowcase; Resident 4's device was pulled out over 4.5 inches from bedside with insufficient strap security and a loose pillowcase covering.”

“On 1/29/24 at 10:20 am, there were crumbs, spills, food particles, and debris at the bottom of the memory care kitchen refrigerator with splashed food particles inside the door. On 1/30/24 at 11:15 am, there was a strong odor of feces in Resident 5's bathroom caused by two soiled pairs of underwear on the sink.”

“Resident #2 is prescribed Lorazepam 1mg tab as needed for anxiety. On 07/19/23 at 2am and 07/30/23 at 11am, there is no notation in the resident file that they were experiencing anxiety and the reason for the medication administration was not recorded.”

“Colgate toothpaste with manufacturer's label indicating "poisonous if swallowed" was unlocked and accessible in resident #1's bathroom. Not all residents of the home, including resident #1, have been assessed capable of recognizing and using poisons safely.”

“On 07/31/23 at 9:30am, the gate in the memory care courtyard that leads to an exit was blocked, as the gate was malfunctioning and needs repair. A metal plate that engages with the magnetic locking mechanism appears to have rusty bolts that are keeping the plate from being attached securely, which then hits a vinyl post on the other side of the gate, preventing it from opening all the way.”

“On 07/31/2023 at 9:30 am, the gate used for exit from the memory care unit was malfunctioning blocking the egress from the home's courtyard.”

“On 07/31/23 at 1pm, an aide administered medications to resident #2 including Divalproex SOD DR 500mg Tab and Olanzapine 15mg tablet. The private duty aide is not a staff person who has completed the medication administration training as specified in § 2600.190.”

“On 07/31/23 at 1:00 pm, the home did not place the medication in the resident's hand, mouth or other route as ordered by the prescriber, in accordance with the limitations specified in subsection (b)(4) for resident #3, who requires this assistance to take Acetaminophen 325mg.”

“The pharmacy label for resident #2's Levothyroxine 112mcg, take 1 tablet by mouth once daily does not include a change of directions sticker for administration. The pharmacy label indicates take 1 tablet daily at 8am.”

“Resident #2 is prescribed Lorazepam 1 mg tab, take 1 tablet by mouth twice a day as needed for anxiety. Resident #2's July 2023 medication administration record does not include the initials of the staff person who administered Lorazepam 1mg tab on 07/19/23 at 2 am and 07/30/23 at 11 am.”