Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Spring Lake Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to conduct accurate PASRR screenings for residents with mental disorders, leading to missed Level II evaluations. A resident was readmitted without mental health diagnoses, despite using psychotropic medication. Another resident with PTSD was not referred for Level II screening, and a third resident's PASRR did not reflect all mental health diagnoses. The facility did not follow its policy to notify state authorities of significant changes in residents' mental conditions.
The facility failed to post appropriate oxygen use signage in 23 resident rooms where oxygen was administered. Observations revealed the absence of such signs, despite the presence of no smoking signs outside the facility and on oxygen storage rooms. Interviews with facility leadership indicated a misunderstanding regarding the necessity of additional signage, and the facility lacked a specific policy on oxygen signage.
A resident was not adequately informed or encouraged to participate in activities, despite expressing interest and having a care plan that required such interventions. Additionally, the facility failed to coordinate communication for another resident and did not post necessary safety signs in rooms where procedures were administered. The facility lacked a policy for signage, impacting safety standards.
A resident with dementia and other health conditions was observed eating lunch with his fingers in a high-traffic hallway, assisted by staff standing over him. The resident was placed there for monitoring, as requested by his daughter, but the DON acknowledged this could be a dignity concern. The facility lacked a policy on dignified dining.
The facility did not ensure timely submission of MDS assessments for two residents. A resident's death assessment was completed but not submitted, and another resident's discharge assessment was delayed. Staff attributed the issue to a switch in electronic medical records systems.
A resident expressed willingness to participate in activities if invited, but the facility failed to inform or encourage them, resulting in minimal engagement. The resident's care plan required invitations and assistance for activities, yet documentation showed limited participation. The Activity Director acknowledged documentation gaps, and the facility's policy on individual activities was not effectively implemented.
A facility failed to coordinate communication with a dialysis center for a resident with end-stage renal disease. Despite providing transportation, the facility did not ensure the completion of communication forms from the dialysis center, which are crucial for documenting treatment details. Staff interviews revealed a lack of policy and difficulties in obtaining necessary information, leading to incomplete documentation and inadequate collaboration as required by the contract.
The facility failed to securely store medications, leaving them accessible to unauthorized individuals. On the 800-hall, a thermal cooler with Lacto Probiotic was left unattended on a medication cart. On the 200-hall, a medication cart was left unlocked and out of view while insulin was administered to a resident, contrary to facility policy.
A facility failed to initiate timely Enhanced Barrier Precautions (EBP) for a resident with surgical wounds admitted for rehabilitation. Despite the facility's policy requiring EBP for residents with wounds, the resident did not have any signage indicating EBP. Interviews with the ADON/ICP and DON confirmed the oversight, with the DON citing high turnover as a contributing factor.
A resident was observed eating lunch in a high-traffic hallway while seated in a wheelchair, with staff assisting him in a manner that raised dignity concerns. The resident required assistance with personal care, and staff placed him in the hallway for monitoring. The DON acknowledged the potential dignity issue, and the facility lacked a policy on dignified dining.
A survey found that a delayed egress exit door in the main dining room of a facility failed to close and latch properly, as required by NFPA 101. The maintenance director acknowledged the issue, which was observed during a facility tour. This deficiency highlights a lapse in maintaining functional egress systems for safety.
The facility failed to maintain smoke barrier integrity as required by NFPA 101. During a tour, an unsealed penetration and untested blowout patching were observed above the smoke door and ceiling by room 106. The maintenance director acknowledged these issues, noting that the barrier was not sealed to the deck.
An oxygen concentrator in the rehab area was found with an outdated PCREE certification from July 2021, indicating non-compliance with NFPA 99 standards. The maintenance director confirmed the concentrator was provided by a rental company, suggesting a lapse in oversight of equipment maintenance and certification.
Failure to Conduct Accurate PASRR Screenings
Penalty
Summary
The facility failed to obtain an accurate Pre-Admission Screening and Resident Review (PASRR) for a resident prior to their re-admission. The resident was initially admitted and later readmitted without any mental health diagnoses recorded. However, the resident's medication administration record indicated the use of psychotropic medication for anxiety, and the care plan noted a risk for adverse reactions related to psychotropic medication use. An updated Level I PASRR later revealed diagnoses of anxiety disorder, depressive disorder, adjustment disorder, and a history of PTSD, but still concluded that a Level II PASRR was not required. Additionally, the facility did not ensure that residents with mental illness or suspected mental illness were referred for Level II screening. One resident had a Level I PASRR that did not indicate a need for Level II screening despite having a diagnosis of PTSD and experiencing related symptoms such as nightmares and anxiety. The Director of Nursing stated that the resident did not qualify for a Level II PASRR because they were stable and did not exhibit behaviors. Another resident's Level I PASRR indicated anxiety disorder but did not check depressive disorder, despite the resident having diagnoses of anxiety, major depressive disorder, and adjustment disorder. The Director of Nursing stated that a Level II screen was not needed because the resident's dementia diagnosis was not primary or secondary. The facility's policy requires notification to the state mental health authority for significant changes in residents with mental disorders, but this was not adhered to in these cases.
Plan Of Correction
1. Resident #98's PASRR has been updated to accurately reflect the physical and mental condition of the resident. Resident #15 has been discharged from the facility. Resident #96 has been referred for a Level II PASRR. 2. Director Of Nursing/Social Services Director/Designee have completed a review of current facility residents to verify PASRR accurately reflects the resident and has been submitted for a Level II review if indicated. Follow up based on findings. 3. Staff Development Coordinator/Designee has provided education for Inter Disciplinary Team related to PASRR requirements. 4. Director Of Nursing/Social Services Director/Designee to complete monitoring of admission and readmission residents using the morning meeting process to verify PASRR accuracy and has been referred for a Level II if applicable for a period of 3 months, then quarterly as needed or until substantial compliance is achieved. Findings to be reviewed during the monthly Quality Assurance and Performance Improvement Committee Meeting. Modifications implemented as indicated.
Failure to Post Oxygen Use Signage in Resident Rooms
Penalty
Summary
The facility failed to ensure appropriate cautionary and safety signs indicating the use of oxygen were posted in 23 out of 23 randomly observed rooms where oxygen was administered. During observations on two separate days, it was noted that there were no oxygen use signs near the resident rooms, although no smoking signs were posted outside the facility and on the oxygen storage rooms. Interviews with the Nursing Home Administrator, the Director of Nursing, and the President of Clinical Services revealed a misunderstanding that no additional oxygen signage was necessary due to the existing no smoking signs. The facility lacked a specific oxygen policy related to the posting of oxygen signs.
Plan Of Correction
1. Signage was updated to reflect use inside the facility. 2. Administrator/Designee completed observation of facility entrances to verify signage stating usage is present. 3. Regional Support Team member provided education for the facility Inter Disciplinary Team related to signage posting requirements. 4. Administrator/Designee will observe the facility entrances to verify in use signage in place weekly x 4, then as needed until substantial compliance is achieved. Findings to be reviewed during the monthly Quality Assurance and Performance Improvement Committee Meeting. Modifications implemented as indicated.
Deficiencies in Resident Activities and Safety Signage
Penalty
Summary
The facility failed to provide adequate and appropriate health care by not assisting and providing activities per preference to a resident. The resident expressed a willingness to participate in activities but was not informed or invited by the staff. Observations revealed that the activity calendar was placed too high for the resident to see, and there was a lack of documentation regarding the resident's participation in activities. The resident's care plan indicated a need for encouragement and assistance to attend activities, but these interventions were not effectively implemented. Additionally, the facility failed to coordinate communication with a center for another resident. There was a lack of documented evidence of collaboration of care and communication between the nursing facility and the unit. This included participation in care conferences and the review of control policies and procedures, which are essential for ensuring comprehensive care for the resident. Furthermore, the facility did not ensure appropriate cautionary and safety signs were posted in 23 randomly observed rooms where certain procedures were administered. Despite having no smoking signs outside the facility, there were no specific signs indicating the use of certain procedures inside the facility. The facility lacked a policy related to the posting of these signs, which is necessary for maintaining safety standards.
Plan Of Correction
Preparation and/or execution of this Plan of Correction does not constitute admission or agreement by the provider of the truth of the items alleged or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared solely because it is required by the provision of Federal and State Laws, code section 1280 and 42 CFR 483.1. 1. Resident #71 has been discharged from the facility. Resident #36 has been discharged from the facility. Signage was updated to reflect use inside the facility. 2. Activities Director/Designee has completed a review of current facility residents to confirm that activities are provided per preference. Director of Nursing/Designee has conducted a review of current facility residents to verify communication is completed as required. Follow up based on findings. Administrator/Designee completed observation of facility entrances to verify signage stating usage is present. 3. Staff Development Coordinator/Designee has provided education to activity staff related to assisting and providing resident's preferred activities. Staff Development Coordinator/Designee has completed education for current facility licensed nurses related to communication requirements. Regional Support Team member provided education for the facility Inter Disciplinary Team related to signage posting requirements. 4. Activities Director/Designee to monitor residents to verify that activities are provided per preference using a random sample of 10 residents weekly x 3 months then as needed until substantial compliance is achieved. Director of Nursing/Staff Development Coordinator/Unit Manager/Designee to complete monitoring of residents to verify communication documentation is present weekly x 3 months, then as needed until substantial compliance is achieved. Administrator/Designee observed the facility entrances to verify in use signage in place weekly x 4, then as needed until substantial compliance is achieved. Findings to be reviewed during the monthly Quality Assurance and Performance Improvement Committee Meeting. Modifications implemented as indicated.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for a resident, who was observed eating lunch with his fingers while seated in a high-traffic hallway. Two staff members were seen adjusting the resident in his wheelchair, with one assisting him with his meal while standing over him. The resident, who has diagnoses including type 2 diabetes mellitus, dementia, and anxiety, requires assistance with personal care. Interviews with staff revealed that the resident is placed in the hallway during meals for monitoring purposes, as requested by his daughter, but the Director of Nursing acknowledged that this arrangement could be a dignity concern. The facility lacked a policy related to dignified dining.
Plan Of Correction
Preparation and/or execution of this Plan of Correction does not constitute admission or agreement by the provider of the truth of the items alleged or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared solely because it is required by the provision of Federal and State Laws code section 1280 and 42 CFR 483.1. 1. Resident #7's plan of care has been updated to reflect the dining preferences of the resident/resident representative. The resident's representative has received information specific to dignified dining, who verbalized understanding. 2. Director of Nursing (DON)/Designee has completed observation of current facility residents while dining to verify dignity is maintained. Follow up based on findings. 3. Staff Development Coordinator (SDC)/Designee has completed education for current facility employees related to maintaining resident dignity while dining. 4. Director Of Nursing/Assistant Director Of Nursing/Unit Manager/Designee to complete random observations of residents while dining to ensure dignity is maintained. Observations will contain 10 residents/week x 3 months, then as needed until substantial compliance is achieved. Findings to be reviewed during the monthly Quality Assurance and Performance Improvement Committee Meeting. Modifications implemented as indicated.
Failure to Submit Timely MDS Assessments
Penalty
Summary
The facility failed to ensure accurate and timely completion of resident assessments for two residents. Resident #27 was admitted to the facility and later died there. An MDS assessment for death in the facility was completed but not submitted. Resident #82 was admitted and later discharged to the hospital. The last MDS assessment submitted for this resident was an admission assessment, and the discharge assessment was not submitted until a later date. Staff E, a Resident Care Specialist I RN, confirmed that Resident #27's MDS assessment should have been submitted and acknowledged that the discharge MDS assessment for Resident #82 was delayed. The staff member attributed these issues to a switch in electronic medical records systems, which caused them to work in two systems simultaneously.
Plan Of Correction
1. Residents #27 & #82's assessments were transmitted on. 2. Minimum Data Set (MDS) Coordinator/Designee has completed a review of facility resident Minimum Data Set assessments completed over the last 30 days to verify completed & transmitted timely. Follow up based on findings. 3. Staff Development Coordinator/Designee has completed education with current facility Minimum Data Set employees related to timely Minimum Data Set completion/submission. 4. Minimum Data Set Coordinator/Designee to complete monitoring to verify assessments completed/transmitted timely weekly x 3 months or until substantial compliance is achieved. Findings to be reviewed during the monthly Quality Assurance and Performance Improvement Committee Meeting. Modifications implemented as indicated.
Failure to Facilitate Resident Participation in Activities
Penalty
Summary
The facility failed to provide activities according to the preferences of a resident, identified as Resident #71, who expressed a willingness to participate in activities if invited. During an observation and interview, the resident mentioned that they were not informed about activities and would likely attend if asked. The resident was observed in their room with a television on and was unaware of the activity calendar placed on a bulletin board in their room. Staff interviews revealed that the resident did not attend activities but went to therapy, and the activity department was supposed to visit the resident's room. The resident's care plan indicated a need for invitations, assistance, and encouragement to attend programs of interest, such as music programs, card games, and social visits. The care plan also included interventions like offering seating close to program leaders and providing 1:1 leisure visits. Despite these interventions, the resident's activity task documentation showed minimal participation in activities over the past 30 days, with only a few instances of engagement in entertainment and friendly visits. The Activity Director acknowledged the lack of documentation for the resident's participation in a recent music program and mentioned that the resident was on isolation for a period, which may have affected their ability to attend activities. The facility's policy on individual activities stated that such activities should be provided for residents who do not wish to attend group activities, making use of each resident's physical and mental abilities. However, the facility did not adequately document or facilitate the resident's participation in activities, as evidenced by the lack of recorded engagement and the resident's own statements about not being informed or invited to activities. The Director of Nursing mentioned that the facility conducts welcoming meetings and shows new residents the activity calendar, but the follow-up on these procedures appeared insufficient in this case.
Plan Of Correction
1. Resident #71 has been discharged from the facility. 2. Activities Director/Designee has completed a review of current facility residents to confirm that activities are provided per preference. Follow up based on findings. 3. Staff Development Coordinator/Designee has provided education to the Activity staff related to assisting and providing residents preferred activities. 4. Activities Director/Designee to monitor residents to verify that activities are provided per preference using a random sample of 10 residents weekly x 3 months, then quarterly as needed or until substantial compliance is achieved. Findings to be reviewed during the monthly Quality Assurance and Performance Improvement Committee Meeting. Modifications implemented as indicated.
Failure to Coordinate Dialysis Communication
Penalty
Summary
The facility failed to coordinate communication with a dialysis center for a resident requiring dialysis services. The resident, who has end-stage renal disease and is dependent on renal dialysis, was observed not feeling well and expressed uncertainty about attending dialysis. Despite the facility providing transportation, there was a lack of completed communication forms from the dialysis center, which are essential for documenting medications given, vital signs, and any changes in condition. The forms for specific dates were incomplete, and there was no evidence in the progress notes that the facility attempted to contact the dialysis center for the missing information. Interviews with staff revealed that the communication forms were not consistently completed by the dialysis center, and there was no policy in place for dialysis communication. The Director of Nursing acknowledged difficulties in obtaining completed forms from the dialysis center and noted the absence of a facility policy for dialysis. The contract between the facility and the dialysis center requires the interchange of information and collaboration of care, which was not adequately fulfilled, as evidenced by the incomplete communication forms and lack of documented communication efforts.
Plan Of Correction
1. Resident #36 has been discharged from the facility. 2. Director Of Nursing/Designee has conducted a review of current facility residents to verify communication is completed as required. Follow up based on findings. 3. Staff Development Coordinator/Designee has completed education for licensed nurses related to communication requirements. 4. Director Of Nursing/Staff Development Coordinator/Unit Manager/Designee to complete monitoring of residents to verify communication documentation is present weekly x 3 months, then as needed until substantial compliance is achieved. Findings to be reviewed during the monthly Quality Assurance and Performance Improvement Committee Meeting. Modifications implemented as indicated.
Medication Storage and Security Deficiency
Penalty
Summary
The facility failed to ensure medications were stored securely and were inaccessible to unauthorized personnel, visitors, and residents. During an observation of medication administration on the 800-hall, a thermal cooler was found on top of a medication cart with a bottle of over-the-counter medication labeled Lacto Probiotic. The staff member indicated that the Lacto Probiotic was left unattended on the cart because it needed to be refrigerated during the medication pass. This indicates a failure to adhere to the facility's policy that requires medications to be stored safely and securely. Additionally, on the 200-hall, a medication cart was left unlocked and unattended while a staff member administered insulin to a resident. The cart was moved from the resident's doorway to the nursing station for verification of the insulin amount, and then back to the area outside the resident's room. During the administration of the insulin, the cart was not visible to the staff, leaving it unsecured. The facility's policy mandates that medication carts be locked when not in direct view of the nurse administering medication, which was not followed in this instance.
Plan Of Correction
1. Identified medications were relocated to an appropriate storage area. 2. Director of Nursing/Designee have completed a review of medication carts to ensure medications were stored in a safe manner and inaccessible to unauthorized personnel. Follow up based on findings. 3. Staff Development Coordinator/Designee has completed education with licensed nurses related to medication storage standards. 4. Director of Nursing/Staff Development Coordinator/Unit Manager/Designee to observe medication carts to verify medications are stored in a safe manner and inaccessible to unauthorized personnel daily x 2 weeks, 3 x/ week x 2 weeks, weekly x 4, then monthly as needed or until substantial compliance is achieved. Findings to be reviewed during the monthly Quality Assurance and Performance Improvement Committee Meeting. Modifications implemented as indicated.
Failure to Implement Timely Enhanced Barrier Precautions
Penalty
Summary
The facility failed to initiate timely Enhanced Barrier Precautions (EBP) for a resident admitted with surgical wounds. The resident, who was in the facility for rehabilitation following hip repair surgery, had two dressings on the left lower extremity but did not have any signage indicating EBP. This oversight was identified during an observation and interview with the resident, who confirmed the absence of EBP measures. Interviews with the Assisted Director of Nursing/Infection Control Preventionist (ADON/ICP) and the Director of Nursing (DON) revealed that the facility's policy required EBP for residents with wounds, including surgical wounds. The ADON/ICP acknowledged that the resident should have been placed on EBP upon admission. The DON admitted awareness of the issue and attributed it to the high turnover of admissions and discharges, indicating a need for improvement in implementing EBP for residents with wounds.
Plan Of Correction
1. Resident #345's plan of care was updated to include enhanced barrier precautions. 2. Director of Nursing/Designee have completed a review of current facility residents to confirm enhanced barrier precautions are implemented if indicated. Follow up based on findings. 3. Staff Development Coordinator/Designee has conducted education with licensed nurses related to implementation of enhanced barrier precautions. 4. Director of Nursing/Staff Development Coordinator/Unit Manager/Designee to complete monitoring of facility residents to verify enhanced barrier precautions are implemented if indicated daily x 4 weeks, weekly x 4 weeks, then monthly as needed or until substantial compliance is achieved. Findings to be reviewed during the monthly Quality Assurance and Performance Improvement Meeting. Modifications implemented as indicated.
Dignity Concern in Resident Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for a resident, identified as Resident #7, who was observed eating lunch in a high-traffic hallway while seated in a wheelchair. Two staff members were seen adjusting the resident in his chair, with one assisting him with his meal while standing over him. The resident's admission record indicated a need for assistance with personal care, and interviews with staff revealed that the resident was placed in the hallway for monitoring during meals. The Director of Nursing acknowledged that seating the resident in the hallway could be a dignity concern, and it was noted that the facility lacked a policy related to dignified dining.
Plan Of Correction
1. Resident #7's plan of care has been updated to reflect the dining preferences of the resident/resident representative. The residents representative has received information specific to dignified dining, who verbalized understanding. 2. Director of Nursing/Designee has completed observation of current facility residents while dining to verify dignity is maintained. Follow up based on findings. 3. Staff Development Coordinator/Designee has completed education for current facility employees related to maintaining resident dignity while dining. 4. Director of Nursing/Assistant Director of Nursing/Unit Manager/Designee to complete random observations of residents while dining to ensure dignity is maintained. Observations will contain 10 residents/week x 3 months, then as needed until substantial compliance is achieved. Findings to be reviewed during the monthly Quality Assurance and Performance Improvement Committee Meeting. Modifications implemented as indicated.
Delayed Egress Door Malfunction
Penalty
Summary
The facility was found to have a deficiency related to the maintenance of delayed egress exit doors, as observed during a survey conducted on February 11, 2025. During a tour of the facility with the maintenance director, it was noted that the delayed egress exit door from the main dining room failed to close and latch properly when tested. This issue was identified as a failure to comply with the requirements set forth in NFPA 101, which governs the safety and functionality of egress doors in healthcare facilities. The maintenance director, who was present during the observation, acknowledged that the door should have closed and latched automatically but required assistance to do so. This indicates a lapse in the facility's adherence to safety protocols, as the door's inability to function correctly could impede safe egress in an emergency situation. The deficiency was documented based on both observation and interview, highlighting the importance of maintaining functional egress systems to ensure the safety of residents and staff. The findings were discussed with both the maintenance director and the facility administrator during the exit conference on the same day. The report does not mention any specific residents being directly affected by this deficiency, nor does it provide details on any immediate consequences resulting from the door's malfunction. However, the failure to maintain the door in accordance with NFPA 101 standards represents a significant oversight in the facility's safety measures.
Plan Of Correction
Preparation and/or execution of this Plan of Correction does not constitute admission or agreement by the provider of the truth of the items alleged or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared solely because it is required by the provision of Federal and State Laws code section 1280 and 42 CFR 483.1. 1. Identified doors repaired, currently closing/latching as intended. 2. Maintenance Director/Designee completed observation of other facility exit doors to verify delayed egress maintained. 3. Administrator provided education for current facility Maintenance Department regarding egress doors. 4. Maintenance Director/Designee to complete monthly preventative maintenance testing of exit doors to verify delayed egress maintained. Findings to be reviewed at the monthly QAPI Committee Meeting. Modifications as indicated based on findings. Preparation and/or execution of this Plan of Correction does not constitute admission or agreement by the provider of the truth of the items alleged or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared solely because it is required by the provision of Federal and State Laws code section 1280 and 42 CFR 483.1. 1. Identified doors repaired, currently closing/latching as intended. 2. Maintenance Director/Designee completed observation of other facility exit doors to verify delayed egress maintained. 3. Administrator provided education for current facility Maintenance Department regarding egress doors. 4. Maintenance Director/Designee to complete monthly preventative maintenance testing of exit doors to verify delayed egress maintained. Findings to be reviewed at the monthly QAPI Committee Meeting. Modifications as indicated based on findings.
Failure to Maintain Smoke Barrier Integrity
Penalty
Summary
The facility failed to maintain the continuity of smoke barriers in accordance with NFPA 101 standards. During a facility tour conducted on February 11, 2025, between 1:00 p.m. and 4:00 p.m., it was observed that there was an unsealed penetration in the smoke barrier above the smoke door by room 106. Additionally, there was an untested blowout patching in the smoke barrier above the ceiling in the same area. These deficiencies were identified through both observation and interview with the maintenance director. The maintenance director acknowledged the presence of the unsealed penetration and the untested blowout patching during the tour. He stated that he had already removed several blowout patches but admitted that this particular one had not been addressed, and the barrier was not sealed to the deck. These findings were reviewed with both the maintenance director and the administrator during the exit conference on the same day.
Plan Of Correction
1. Identified unsealed penetration & smoke barrier has been sealed. Identified untested blowout patching in the smoke barrier above the ceiling has been removed/repaired. 2. Maintenance Director/Designee completed observation of other facility smoke barriers to verify they are maintained in accordance with NFPA 101. 3. The administrator provided education for current facility Maintenance Department regarding smoke barrier maintenance. 4. Maintenance Director/Designee to complete monthly observation of smoke barriers to verify they are maintained in accordance with NFPA 101. Findings to be reviewed at the monthly QAPI Committee Meeting. Modifications as indicated based on findings.
Outdated Certification of Oxygen Concentrator
Penalty
Summary
The facility failed to maintain patient care related electrical equipment (PCREE) in accordance with NFPA 99 standards. During a facility tour, it was observed that an oxygen concentrator in the rehabilitation area had an outdated PCREE certification, with the last certification dated July 2021. This indicates that the equipment had not been tested or certified for compliance for a significant period, contrary to the requirements that all PCREE be tested before being put into service and after any repair or modification. The maintenance director, who was present during the tour, acknowledged that the concentrator was provided by a rental company. This suggests a lapse in the facility's oversight of equipment maintenance and certification, particularly for equipment sourced externally. The findings were discussed with the maintenance director and the administrator during the exit conference, highlighting the facility's failure to adhere to established protocols for electrical equipment testing and maintenance.
Plan Of Correction
1. Identified concentrator was removed from service, PCREE certification service completed. 2. Maintenance Director/Designee completed observation of other facility concentrators to verify PCREE certification is completed as required. 3. The administrator provided education for current facility Maintenance Department regarding PCREE maintenance requirements. 4. Maintenance Director/Designee to complete monthly observation of facility concentrators to ensure PCREE certification is completed as required. Findings to be reviewed at the monthly QAPI Committee Meeting. Modifications as indicated based on findings.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 120 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Winter Haven
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vivo Healthcare Winter Haven | 1 mi | ★★★★★ | 0 | 0 |
| Winter Haven Health And Rehabilitation Center | 2.1 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Winter Haven | 2.7 mi | ★★★★★ | 0 | 0 |
| Oak Haven Rehab And Nursing Center | 2.8 mi | ★★★★★ | 4 | 0 |
| Lake Mariam Health And Rehabilitation Center | 2.8 mi | ★★★★★ | 4 | 2 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Spring Lake Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.