Wellsprings Care Center

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from the wrongful use of the resident's belongings or money.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Resident Rights Deficiencies

Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Resident Assessment and Care Planning Deficiencies

Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.

Pharmacy Service Deficiencies

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.

Quality of Life and Care Deficiencies

Provide or get specialized rehabilitative services as required for a resident.

Resident Rights Deficiencies

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.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Environmental Deficiencies

Have enough outside ventilation via a window or mechanical ventilation, or both.

Resident Assessment and Care Planning Deficiencies

Provide care by qualified persons according to each resident's written plan of care.

Resident Rights Deficiencies

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.

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

A complaint survey, prompted by #CO39923, #CO39992, #CO40085, Incident #40057, and Incident #40104 was conducted on 6/3/25 to 6/4/25. Three deficiencies were cited. Based on observations and interviews the facility failed to provide a safe, clean, sanitary and comfortable homelike environment throughout the facility in three out of four hallways. Specifically the facility failed to: -Ensure resident rooms were clean and odor free;-Ensure the residents had clean bed linens and privacy curtains; -Ensure the dining room and common areas were clean; and,-Ensure the facility was free from institutional odors.Findings include:I. Facility policy and procedureThe Homelike Environment policy, revised February 2021, was provided by the nursing home administrator (NHA) on 6/4/25 at 12:24 p.m. The policy read in pertinent part, "Residents are provided with a safe, clean, comfortable and homelike environment."The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics included a clean, sanitary and orderly environment, clean bed and bath linens that are in good condition, and pleasa.. Based on record review and interviews, the facility failed to ensure three (#1, #2 and #5) of three residents reviewed for abuse out of 12 sample residents were kept free from abuse.Specifically, the facility failed to:-Ensure Resident #2 and Resident #5 were kept free from physical abuse from each other; and,-Ensure Resident #1 was kept free from physical abuse by Resident #2.Findings include:I. Facility policy and procedureThe Abuse policy and procedure, dated 5/3/23, was provided by the nursing home administrator (NHA) on 6/4/22 at 12:24 p.m. It revealed in pertinent part, "The facility does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends, or any other individuals. If a resident experiences a behavior change resulting in aggression toward other residents, the facility will implement interventio.. Based on record review and interviews, the facility failed to notify the resident representative when there was a significant change in the resident' s condition for two (#7 and #8) of three residents reviewed out of 12 sample residents.Specifically, for Resident #7 and Resident #8, the facility failed to:-Keep the resident' s current designated representative' s name and contact information updated in the resident' s record; and,-Make additional attempts or try alternative methods to contact the representative when the representative was not reachable.Findings include:I. Facility policy and procedureThe Change of Condition policy, dated 2/29/24, was provided by the nursing home administrator (NHA) on 6/4/25 at 12:24 p.m. It read in pertinent part, "The resident, attending physician and legal representative or interested family member are notified when changes in condition or certain events occur. Communication with the IDT (interdisciplinary team) and caregivers is also important to ensure that consistency and ..