Letort Spring Nursing and Rehab LLC

Inspectors wroteBased on clinical record reviews, facility provided documents, and staff interviews, it was determined that the facility displayed past-non-compliance in its failure to prevent a significant medication error for one of three residents reviewed (Resident 1).

Inspectors wroteBased on facility policy review, observations, facility documentation review, and staff interviews, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the kitchen, in two of two nourishment refrigerators, on tray service line (main dining room), and tray delivery on one of one units observed (Faith Wing).

Inspectors wroteBased on observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure the residents' right to a clean, comfortable, and homelike environment for one of three lounge rooms observed (Faith East lounge) and for one of 21 resident rooms reviewed (Resident 31).

Inspectors wroteBased on facility policy review, review of medication data sheets, observations, and staff interviews, it was determined that the facility failed to label medications properly in two of two medication carts observed (Faith Short and Love 1) and in one of one medication rooms observed (Faith Wing).

Inspectors wroteBased on review of facility policy, facility documentation review, observations, and resident and staff interviews, it was determined that the facility failed to provide foods that are palatable and at a safe and appetizing temperature.

Inspectors wroteBased on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure staff implement infection control policies to prevent the spread of infection for two of 23 residents observed on enhanced barrier precautions (Residents 11 and 35), and failed to ensure that staff implement appropriate infection control policies to prevent the spread of infection during two of two medication administration observations (Faith Short and Love 1).

Inspectors wroteBased on facility policy, staff interviews, and clinical record reviews, it was determined that the facility failed to provide an explanation of the risks and benefits of psychotropic medications use and obtain consent prior to administering psychotropic medications for one of five residents reviewed for psychotropic medication use (Resident 9).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 21 residents reviewed (Resident 9, 11, and 68).

Inspectors wroteBased on clinical record review, policy review, and staff interview, it was determined that the facility failed to ensure that a baseline care plan, to included the minimum healthcare information necessary to properly care for a resident, was developed and implemented within 48 hours of admission for one of 23 residents reviewed (Resident 2). Findings Include: Facility policy, titled Care Plans - Baseline, revised on April 24, 2025, read, in part, Policy Interpretation and Implementation 1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality of care and must include the minimum healthcare information necessary to properly care for the resident including but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative; b. [...]

Inspectors wroteBased on facility policy review, observations, clinical record review, and staff interview, it was determined that the facility failed to ensure the care plan was reviewed and revised timely for one of 21 residents reviewed (Resident 1).

Inspectors wroteBased on observations, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for three of 21 residents reviewed (Residents 16, 49, and 74).

Inspectors wroteBased on policy review, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to provide necessary services to carry out activities of daily living to maintain good nutrition and personal hygiene for residents' dependent on staff for assistance for two of 21 residents reviewed (Residents 5 and 12).

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to address weight loss in a timely manner for one of four residents reviewed (Resident 1).

Inspectors wroteBased on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide appropriate care and services to residents receiving tube feedings for one of one residents reviewed for tube feeding (Resident 75).

Inspectors wroteBased on observations, facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that respiratory care and services provided were consistent with professional standards of care for two of two residents reviewed for respiratory care (Residents 8 and 89). Findings Include:Review of facility policy, titled Oxygen Therapy revised April 24, 2025, revealed, Policy: A physician must order the oxygen therapy. 1. Verify that there is a physician's order for this procedure. Review of Resident 8's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (lung and airway disease that restricts breathing) and protein-calorie malnutrition (inadequate intake of protein and calories). [...]

Inspectors wroteBased on review of facility policy, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that the residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of one residents reviewed (Resident 10). Findings Include:Review of facility policy, titled Trauma Informed Care and Culturally Competent Care, revised April 22, 2025, revealed, Purpose to address the needs of trauma survivors by minimizing and/or re-traumatization. Resident Assessment 1. Assessment involves an in-depth process of evaluation the presence of symptoms, their relationship to trauma, as well as identification of triggers. [...]

Inspectors wroteBased on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to implement the licensed pharmacist's recommendations for one of five residents reviewed for unnecessary medications (Resident 7). Findings Include:Review of facility policy, titled Medication Regimen Review (Monthly Report), last revised April 22, 2025, revealed G. Recommendations are acted upon and documented by the facility staff and or the prescriber. Review of Resident 7's clinical record revealed diagnoses that included bipolar II disorder (mental health disorder with depressive episodes alternating with hypomanic episodes) and major depressive disorder (persistent feelings of intense sadness, worthlessness, and loss of interest in activities). Review of Resident 7's physician orders revealed the following orders: [...]

Inspectors wroteBased on facility policy review, staff interview, and observations, it was determined that the facility failed to ensure that it was free from a medication error rate of five percent or greater based on two medication errors out of 29 opportunities.

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to document a physician order for hospice services for one of one resident reviewed for hospice services (Resident 8). Findings Include:Review of the facility policy, titled Hospice Program, last reviewed April 22, 2025, failed to reveal that a physician order must be obtained for hospice services. Review of the clinical record for Resident 8 revealed clinical diagnoses that included chronic obstructive pulmonary disease (progressive irreversible lung disease causing chronic coughing, wheezing, and severe shortness of breath) and protein-calorie malnutrition (severe nutritional deficiency from inadequate intake of protein, calories, or both). [...]

Inspectors wroteBased on facility policy review, clinical record review, facility documentation review, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for three of three residents reviewed (Residents 1, 2, and 3) which resulted in actual harm as evidenced by two hospital transfers for seizure activity for one of three residents reviewed (Resident 1).

Inspectors wroteBased on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to provide pharmaceutical services to accurately acquire, receive, dispense, and administer drugs to meet the needs of each resident for two of three residents reviewed (Residents 1 and 2), which resulted in actual harm as evidenced by two hospital transfers for seizure activity for one of three residents reviewed (Resident 1).

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to prevent accident and hazards for one of 10 residents reviewed (Resident 2).

Inspectors wroteBased on clinical record review, observation, and staff interview, it was determined that the facility failed to provide adaptive feeding devices for one of 10 residents reviewed (Resident 1).

Inspectors wroteBased on clinical record review, observations, facility document review, staff interviews, and facility policy review, it was determined that the facility displayed past non-compliance by failing to implement interventions, supervision, and effective safety measures to prevent elopement of a resident identified as being at risk for elopement and exhibiting exit seeking behaviors (Resident 1). Resident 1 was found approximately one half mile from the facility approximately 17.5 hours following his elopement with injury to his forehead. This failure placed an additional 16 residents, who were identified as being at risk on their elopement risk evaluations, in an immediate jeopardy situation (Residents 2, 4, 5, 6, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, and 20).

Inspectors wroteBased on facility policy review, clinical record review, and staff and resident representative interviews, it was determined that the facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status for three of six residents reviewed for nutrition or hydration (Residents 17, 28, and 58). This failure resulted in harm for Resident 17, as evidenced by significant weight loss.

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to provide a notice of transfer for two of six residents reviewed for hospitalization (Residents 28 and 53 ), and failed to provide five of six residents reviewed for transfers with a notice of transfer that included the required information (Residents 1, 28, 52, 58, and 69).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to provide a copy of the facility's bed-hold notice upon transfer or discharge from the facility for two of six residents reviewed for transfer or discharge (Residents 28 and 53), and failed to provide bed-hold notices that included the required information for five of six residents reviewed for transfer or discharge (Residents 1, 28, 52, 58, and 69).

Inspectors wroteBased on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the residents right to participate in the care planning process for one of 18 resident's reviewed (Resident 4), and the facility failed to review and revise the resident plan of care for three of 18 residents reviewed (Residents 28, 37, and 58).

Inspectors wroteBased on clinical record review, policy review, and staff interviews, it was determined that the facility failed to adequately monitor possible side effects and target behaviors for two of five residents reviewed for unnecessary psychotropic medications (Residents 53 and 58).

Inspectors wroteBased on review of select facility documentation and staff interviews, it was determined that the facility failed to utilize kitchen equipment in accordance with professional standards for food service safety in the main kitchen.

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 30 residents reviewed (Residents 17, 28, and 58).

Inspectors wroteBased on observation, policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide care and services to promote healing and prevent infection in accordance with professional standards for one of two residents reviewed for pressure ulcers (Resident 2).

Inspectors wroteBased on record review, observation, and staff interviews, it was determined that the facility failed to prevent accident and hazards for two of 18 residents reviewed (Residents 35 and 47.)

Inspectors wroteBased on clinical record review, resident and staff interviews, and facility document review, it was determined that the facility failed to ensure residents are assisted with obtaining routine dental care for one of one residents reviewed for dental care (Resident 52).

Inspectors wroteBased on observations, facility policy review, and staff interviews, it was determined that the facility failed to ensure staff implemented infection control policies to prevent the spread of infection by using PPE (personal protective equipment) in two of four resident care areas reviewed (Love one and Love two), and failed to handle potentially contaminated items to decrease the possibility for transmission of a infectious disease for one of one unit treatment carts observed (Love unit treatment cart). Findings Include: Review of facility policy, Transmission-Based (Isolation) Precautions, last reviewed January 17, 2025, revealed that, Contact precautions refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. [...]

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide evidence that education was provided to Residents and/or their Representatives on the risks, benefits, or side effects of the influenza vaccine for two of five residents reviewed for immunizations (Residents 8 and 25). Findings Include: Review of facility policy, titled Influenza Vaccination with an implementation date of April 7, 2022, and a last review date of January 17, 2025, revealed, in part, 5. Prior to the administration of the influenza vaccine, the person receiving the immunization, or his/her legal representative, will be provided with a copy of CDC's current vaccine information statement relative to the influenza vaccination. 6. [...]

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide evidence that education was provided to Residents and/or their Representatives on the risks, benefits, or side effects of the COVID-19 vaccine for two of five residents reviewed for immunizations (Residents 8 and 25). Findings Include: Review of facility policy, titled COVID-19 Vaccination with a last revised date of June 19, 2023, and a last review date of January 17, 2025, revealed 26. The resident's medical record will include documentation of the following: a. Education to the resident or resident representative regarding the risks, benefits, and potential side effects of the COVID-19 vaccine; b. Each dose of the vaccine administered to the resident, or c. If the resident did not receive the COVID-19 vaccine due to medical contraindication or refusal. [...]

Inspectors wroteBased on clinical record review, review of Centers for Disease Control and Prevention guidance, facility documentation review, and staff interviews, it was determined that the facility failed to implement infection control practices to prevent or limit the spread of infectious disease for 13 of 17 residents reviewed for skin conditions (Residents 2, 4, 5, 7, 8, 9, 10, 11, 13, 14, 15, 16, and 17).

Inspectors wroteBased on clinical record review, observation, policy review, staff interview, and facility document review, the facility failed to protect the resident's right to be free from physical abuse by a staff member for one of three residents reviewed for abuse (Resident 1).

Inspectors wroteBased on clinical record review, staff interviews, and facility document review, it was determined that the facility failed to provide care and services in accordance with professional standards of practice for one of 18 residents reviewed for skin issues (Resident 18).

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to timely notify hospice of a change in condition for one of six residents reviewed (Resident 1). Findings Include: Review of facility policy, titled Notification of Changes, revised August 29, 2023, revealed, The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: .Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. Review of the facility's hospice contract with Resident 1's hospice provider, most recently dated August 26, 2013, revealed Facility shall immediately notify Hospice when: a. [...]

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure proper monitoring and timely implementation of interventions to maintain acceptable parameters of nutritional status for four of 17 residents reviewed (Residents 22, 23, 45, and 57), resulting in actual harm as evidenced by continued weight loss after a significant weight loss was documented for two of 17 residents reviewed (Residents 22 and 45).

Inspectors wroteBased on facility policy review and staff interview, it was determined that the facility failed to develop a Water Management Program for the prevention, detection, and control of water-borne contaminants, such as Legionella, a bacteria that may cause Legionnaires' Disease (a serious type of pneumonia). Findings Include: Review of facility policy, titled Water Management Program, dated October 23, 2022, revealed It is the policy of this facility to establish water management plans for reducing the risk of Legionellosis and other opportunistic pathogens . A water management team has been established to develop and implement the facility's water management program . The Maintenance Director maintains documentation that describes the facility's water system . A risk assessment will be conducted by the water management team annually . [...]

Inspectors wroteBased on observations, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that services were provided with reasonable accommodation of resident need for one of 17 residents reviewed (Resident 6).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for six of 19 residents reviewed (Residents 6, 7, 8, 22, 33, and 41). Findings Include: Review of Resident 6's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), legal blindness (a term to describe severe visual impairment that cannot be corrected with glasses or contact lenses), and generalized anxiety disorder (a mental disorder characterized by feelings of worry, nervousness, or unease). [...]

Inspectors wroteBased on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure the resident's comprehensive plan of care was updated upon changes in the resident's condition for three of 17 residents reviewed (Residents 29, 53, and 60). Findings Include: Review of facility policy, titled Care Plan Revisions Upon Status Change, with a last revised date of April 18, 2023, revealed 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. Review of Resident 29's clinical record revealed diagnoses that included atrial fibrillation (A-fib- an irregular, often rapid heart rate that commonly causes poor blood flow) and hypertension (elevated blood pressure). [...]

Inspectors wroteBased on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for four of 19 residents reviewed (Residents 7, 22, 45, and 67). Findings Include: Review of facility policy, titled Dressing Change Policy, dated January 15, 2017, revealed Remove soiled dressing and discard in a trash bag; .Don non-sterile/sterile gloves (when appropriate) prior to cleansing wound site; Cleanse wound site per physician's order; Wash hands; [NAME] non-sterile/sterile gloves (when appropriate) and apply topical treatment as ordered . [...]

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to consult qualified dietary staff to assess the nutritional needs of residents in the absence of a qualified dietitian for four of 17 residents reviewed (Residents 22, 23, 45, 57).

Inspectors wroteBased on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food and utilize and monitor equipment in accordance with professional standards for food service safety in the main kitchen and in two of two pantry areas.

Inspectors wroteBased on personnel file review and staff interviews, it was determined that the facility failed to ensure each nurse aide was provided required in-service training consisting of no less than 12 hours per year, which included dementia management and resident abuse prevention, for five of five nurse aide employee records reviewed (Employees 2, 3, 4, 5, and 6). Findings Include: Review of personnel information revealed Employee 2's hire date was February 14, 2022; Employee 3's hire date was May 2, 2016; Employee 4's hire date was June 21, 2022; Employee 5's hire date was September 4, 2012; and Employee 6's hire date was September 18, 2017. Review of facility training records failed to reveal that the aforementioned Employees completed 12 hours of required annual training in the past 12 months. [...]

Inspectors wroteBased on clinical record review and staff interview, it was determined the facility failed to develop a discharge summary that anticipated resident needs and included all required information for one of two discharged residents reviewed (Resident 69). Findings Include: Review of Resident 69's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Review of Resident 69's clinical record revealed she was discharged to her home on December 23, 2023. [...]

Inspectors wroteBased on observation, facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide assistance with activities of daily living (ADL) for dependent residents for one of 19 residents reviewed (Resident 29). Findings Include: Review of facility policy, titled Activities of Daily Living, dated November 26, 2016, revealed The facility will provide care and services for the following activities of daily living: (1) Hygiene- bathing, dressing, grooming and oral care. Review of Resident 29's clinical record revealed diagnoses that included atrial fibrillation (A-fib- an irregular, often rapid heart rate that commonly causes poor blood flow) and hypertension (elevated blood pressure). Review of Resident 29's current ADL care plan, dated December 10, 2023, revealed that Resident 29 is a moderate 1-2 assist for dressing. [...]

Inspectors wroteBased on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to implement a fall intervention for one of six residents reviewed for falls (Resident 29). Findings Include: Review of facility policy, titled Fall Prevention and Management Interventions, dated May 11, 2018, revealed Bedside mat. Review of Resident 29's clinical record revealed diagnoses that included atrial fibrillation (A-fib- an irregular, often rapid heart rate that commonly causes poor blood flow) and hypertension (elevated blood pressure). Review of Resident 29's progress notes revealed a note dated January 22, 2024, stating that Resident 29 had an unwitnessed fall and a new fall intervention would be a fall mat to the left side of Resident 29's bed. [...]

Inspectors wroteBased on facility policy review, observations, clinical record reviews, and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for two of two residents reviewed for respiratory care (Residents 33 and 41). Findings Include: Review of facility policy, titled Noninvasive Ventilation (CPAP [in part]), with an implemented date of April 17, 2023, revealed Definitions: CPAP, or continuous positive airway pressure, is a respiratory therapy intervention used to provide a patent airway during periods of sleep apnea [intermittent airflow blockage during sleep]. It uses air pressure generated by a machine, delivered through a tube into a mask that fits over the nose or mouth and 13. Follow manufacturer instructions for the frequency of cleaning/replacing filters [in part]. [...]

Inspectors wroteBased on observations, facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure there was sufficient staff to ensure residents attained or maintained the highest practicable physical, mental, and psychosocial well-being for one of 19 residents reviewed (Resident 29). Findings Include: Review of facility policy, titled Call Lights: Accessibility and Timely Response, dated October 23, 2022, revealed All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. Review of Resident 29's clinical record revealed diagnoses that included atrial fibrillation (A-fib- an irregular, often rapid heart rate that commonly causes poor blood flow) and hypertension (elevated blood pressure). [...]

Inspectors wroteBased on facility document review and staff interview, it was determined that the facility failed to complete a performance review for nurse aide staff at least once every 12 months for one of five employees reviewed (Employee 6). Findings Include: Review of Employee 6's personnel record revealed a hire date of September 18, 2017, and no evidence of a recent annual performance review. On March 20, 2024, at 8:22 AM, the Nursing Home Administrator confirmed that Employee 6 did not have a recent annual performance review completed. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.19(2) Personnel policies and procedures.

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure an accurate accounting of the disposition of uncontrolled medications during the discharge process for one of two discharged residents reviewed (Resident 68).

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that the physician reviewed and responded to pharmacy review recommendations in a timely manner for one of five residents reviewed for unnecessary medications (Resident 7).

Inspectors wroteBased on facility policy review, review of select facility documentation, observation, completion of a test tray, and resident and staff interviews, it was determined that the facility failed to provide food and beverages that were palatable and at appetizing temperatures for one of one meals tested.