SPRINGWELL HAVEN, LLC

Official classification

Type A

Official code

87307(a)(2)(B)

Regulation authority

CCR

What the official deficiency says

Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide... living accommodations.. for the residents, staff.. who may reside in the facility...No room commonly used for other purposes shall be used as a sleeping room...This req is not met as evidenced by: Based on observation and interviews conducted, Licensee failed to ensure there is no sleeping/ residing in garage by resident or staff. This poses an immediate health and safety risk to residents in care. *Resident refers to anyone residing at the facility.

Official plan of correction

Licensee to remove the sleeping area in garage and forward proof to LPA by POC due date.

Deadline recorded: Apr 28, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87305(a)

Regulation authority

CCR

What the official deficiency says

Prior to construction or alterations, all facilities shall obtain a building permit. This req is not met as evidenced by: Based on observation, Licensee failed to obtain a building permit for changes made to the garage floor plan which poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee to initiate process for building permit and forward proof to LPA by POC due date.

Deadline recorded: Apr 28, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.695(f)(2)

Regulation authority

HSC

What the official deficiency says

A facility shall have both of the following in place: A set of keys available to facility staff on each shift for use during an evacuation that provides access to all of the following... Based on interviews conducted, Licensee failed to ensure staff have keys to all locked areas which poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee to provide key access to all staff and forward proof to LPA by POC due date.

Deadline recorded: May 11, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above. Facility does not have documentation of required quarterly emergency drills which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/30/2025 Plan of Correction Licensee to conduct drill and forward proof to LPA by POC due date.

Official classification

Type A

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, the licensee did not comply with the section cited above. Facility has not conducted emergency drill which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 10/08/2024 Plan of Correction Licensee to conduct emergency drill and forward proof to LPA by POC due date.

Official classification

Type A

Official code

87628(a)

Regulation authority

CCR

What the official deficiency says

he licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above. Facility staff are performing blood glucose checks which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 10/08/2024 Plan of Correction Facility to submit a plan to discontinue checking blood glucose and forward proof to LPA by POC due date.

Official classification

Type B

Official code

87608(a)(5)(A)

Regulation authority

CCR

What the official deficiency says

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. R3 has two bed rails on bed, at the head and foot of bed, which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 10/21/2024 Plan of Correction Licensee removed rails during visit. CLEARED.

Official classification

Type A

Official code

87465(H)(2)

Regulation authority

CCR

What the official deficiency says

Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. LPA observed multiple medications unsecured which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 10/08/2024 Plan of Correction Licensee to secure noted items and forward proof to LPA by POC due date.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. Two out of five smoke detectors tested are inoperable due to battery issues and hallway smoke detectors have been removed. The pond water is dark and murky. This poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 09/22/2022 Plan of Correction Licensee to ensure all smoke detectors are operational and forward proof to LPA by POC due date. Additionally, please provide a date scheduled for the cleaning of the backyard pond water.

Official classification

Type A

Official code

87608(a)(5)(A)

Regulation authority

CCR

What the official deficiency says

Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in one out of five residents. R1 has two bed rails on the bed, one at the feet and one at the head. This poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 09/22/2022 Plan of Correction Licensee to remove the rails at the foot of the bed and forward proof to LPA by POC due date.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. LPA observed multiple instances of unsecured cleaning supplies and toxins as noted in LIC 809 (photos).This poses an immediate health and safety risk to persons in care. CIVIL PENALTY ASSESSED.

Official plan of correction

POC Due Date: 09/22/2022 Plan of Correction Licensee to secure all noted items and forward proof to LPA by POC due date.

Official classification

Type B

Official code

1569.695(a)(2)

Regulation authority

CCR

What the official deficiency says

Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to..., the facility shall have a plan and supplies available to provide alternative resources during an outage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above. Facility does not have emergency water or food. This was advised to facility during the prior annual in 2021.This poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 10/05/2022 Plan of Correction Licensee to obtain emergency food and water and forward proof to LPA by POC due date.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, the licensee did not comply with the section cited above. R2 was diagnosed with Covid-19 around September 14, 2022 and the case was not reported to the department. This poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 09/22/2022 Plan of Correction Licensee to forward covid script and incident report to the department by POC due date.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirment is not being met as evidenced by: Based on observation, LPAs observed noted area on advisory note dated 10/26/2021 has not been addressed. The side yard has loose tiles over a sinking part of deck presenting a fall hazard. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee to secure/ repair area and forward proof to LPA by POC due date.

Deadline recorded: Nov 19, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

The following shall be stored inacessible to residents with Dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. LPA observed unsecured medications and vitamins in the unlocked caregiver room as well as unsecured cleaning supplies in the unlocked garage. This poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 10/27/2021 Plan of Correction Licensee to secure noted items and forward proof to LPA by POC due date.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. Facility does not have covid precaution/policy posted at facility entrance. LPA gave Licensee an advisory on 08/13/2021 to post signage. During today's visit there is no signage posted. This poses a potential health and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/02/2021 Plan of Correction Licensee to post covid precaution/policy signage at entrance to facility and forward proof to LPA by POC due date.