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Deficiency Records for Three Springs Sr Living and Rhab
A list of the most recent deficiencies for Three Springs Sr Living and Rhab. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Three Springs Sr Living and Rhab. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-06-26 | 2024-07-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-06-26 | 2024-07-05 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-06-26 | 2024-07-05 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-06-14 | 2024-07-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-06-14 | 2024-07-02 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2024-06-14 | 2024-07-02 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-09-13 | 2023-09-27 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-09-13 | 2023-09-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-09-13 | 2023-09-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-13 | 2023-09-27 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-09-13 | 2023-09-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-13 | 2023-09-27 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-09-13 | 2023-09-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-13 | 2023-09-27 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2023-09-13 | 2023-09-27 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-26 | 2022-11-17 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-26 | 2022-09-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-26 | 2022-09-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-08-26 | 2022-09-19 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-08-19 | 2022-09-07 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-08-19 | 2022-08-31 | N |
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