Spencer Post Acute Rehabilitation Center

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to provide adequate assessment and timely intervention to assure 2 of 3 residents (Resident #1 and #2) received prompt treatment for a change in condition. Resident #1 had urinary tract infection (UTI) symptoms on the weekend of 5/16-17/26 and the facility failed to notify the physician or initiate any other interventions related to the symptoms. Resident #1 had difficulty catching her breath after the evening meal on [DATE] and needed staff to intervene for the resident to clear it. According to the clinical record the resident sat where she could be observed for a half hour and then went to bed. The clinical record lacked documentation the staff monitored her after going to bed. She was later discovered in respiratory distress and transferred to the hospital in critical condition. [...]

Inspectors wroteBased on clinical record reviews, staff interviews and policy review, the facility failed to put effective interventions in place and provide adequate nursing supervision to prevent accident and injuries from falls for 1 of 1 residents reviewed (Resident #2). Resident #2 had a risk for falls with a history of repeated falls. Resident #2 had his thirteenth fall on 3/15/25 in a three-month period of time.

Inspectors wroteBased on clinical record review, interviews, and facility policy, the facility failed to ensure bed hold notice was signed by residents and or the resident's responsible person when residents transferred out of the facility for 4 of 4 residents reviewed (Residents #2, #4, #5 and #9). The facility reported a census of 67 residents.

Inspectors wroteBased on observation, Medication Administration Record (MAR), policy review, and staff interview the facility failed to provide appropriate infection prevention practices when providing care to a resident with a catheter, with wound care, and a resident with an enteral tube, that was on Enhanced Barrier Precautions (EBP) for 5 of 7 reviewed (Resident #4, #7, #9, #14 and #38). The facility reported a census of 67 residents.

Inspectors wroteBased on resident and staff interviews, and policy review, the facility failed to have ready and reasonable access to personal funds upon request for 1 of 17 residents reviewed (Resident #10). The facility reported a census of 67. Findings Include:In an interview on 8/11/2025 12:55 PM, Resident #10 reported that if she wanted personal funds during the weekend, she had to plan to get money from the office on Friday. In an interview on 8/12/2025 at 9:25 AM, Resident #10 reported she could not remember when or which staff she asked for personal funds. Resident #10 stated, when I asked they told me that I had to wait for the office manager to be here. In an interview on 8/14/2025 at 8:38 AM, Staff C, Certified Medication Assistant/Certified Nurse Assistant (CMA/CNA) reported if a resident requested personal funds she would go to the Business Officer Manager (BOM). [...]

Inspectors wroteBased on clinical record review and staff interview the facility failed to identify non-pharmacological interventions and targeted behaviors on the care plan related to high risk medications in 2 out of 5 sampled residents reviewed (Resident #4 and #21). The facility reported a census of 67 residents.

Inspectors wroteBased on observations, clinical record review and staff interview the facility failed to revise and update care plans to include a new order for oxygen usage on the comprehensive care plan for 1 of 17 residents reviewed (Resident #9). The facility reported a census of 67 residents. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #9 documented diagnoses of anemia, cancer and malnutrition. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Observation on 8/11/2025 at 11:36 AM currently wearing oxygen sitting up in bed. Observation on 8/12/2025 at 12:27 PM currently sleeping in bed with oxygen concentrator on via nasal cannula and running. Review of August Medication Administration Record (MAR) lacked orders for oxygen usage. Review of current Physician Orders lacked an order for oxygen usage. [...]

Inspectors wroteBased on clinical record review, resident and staff interviews and facility policy review the facility failed to have a physicians order to administer medications prior to administering medications to 1 of 1 residents reviewed (Resident #70). The facility reported a census of 67 residents.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure residents with significant weight loss were immediately identified, and assessed for nutritional needs for 1 of 2 resident's reviewed (Resident #21). The facility reported a census of 67 residents.

Inspectors wroteBased on observations, clinical chart review and staff interview the facility failed to implement policies and procedures regarding the technical aspect of feeding tubes by pushing enteral medication with a syringe into enteral tube for 1 of 1 residents (Resident #9). The facility reported a census of 67 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that residents who required dialysis received services, consistent with professional standards of practice by communication with the dialysis center for 1 resident on dialysis (Resident #3). The facility reported a census of 67 residents.

Inspectors wroteBased on observation, Medication Administration Record - Treatment Administration Record (MAR-TAR), Electronic Health Record (EHR) review, and staff interviews the facility failed to provide 2 of 31 medications as ordered resulting in a medication error rate of 6.45. The facility reported a census of 67 residents.

Inspectors wroteBased on observations, staff interviews, Medication Administration Records - Treatment Administration Records (MAR-TAR) and Electronic Health Records (EHR) review the facility failed to ensure the residents were free of significant medication errors to 2 of 6 residents reviewed (Resident #4 and #7). The facility reported a census of 67 residents.

Inspectors wroteBased on observation, policy, Electronic Health Record (EHR) review and staff interview the facility failed to follow the menu and prepare food to meet the residents nutritional needs for 22 of 26 residents (all residents with a regular diet) reviewed. The facility reported a census of 67 residents.

Inspectors wroteBased on resident interview, resident family interviews, staff interview, electronic health records (EHR), document review and policy review the facility failed to maintain medical records on each resident that were complete and accurate by failing to accurately transcribe a physicians order into the EHR for 2 of 8 residents reviewed (Resident #9 and #73). The facility reported a census of 67 residents.

Inspectors wroteBased on clinical record review, staff interviews, Centers for Disease Control and Prevention (CDC) guidelines and facility policy review, the facility failed to screen for eligibility, offer, provide education and document vaccine consent or refusal for the pneumococcal immunization for 1 of 5 resident reviewed (Resident #8) for immunizations. The facility reported a census of 67 residents.

Inspectors wroteBased on Electronic Record Review (EHR), staff interviews, and policy review the facility failed to develop a comprehensive care plan that included problems, goals, or interventions for use of a diuretic or diagnosis of congestive heart failure, develop a comprehensive care plan that was personalized when a resident received hospice care, and did not follow a care plan for 4 of 18 residents reviewed (Resident #3, #20, #43, and #50). The facility reported a census of 53 residents.

Inspectors wroteBased on Electronic Health Records (EHR), policy review, resident interview, and observations the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 5 of 18 residents reviewed (Resident #1, #6, #17, #37, and #106). The facility reported a census of 53 residents.

Inspectors wroteBased on observation and staff interview, the facility failed to post the daily census sheet including the facility resident census and the actual working hours of nurses and nurse aides on duty for the current date. The facility reported a census of 53 residents.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to maintain sanitary practices by failing to keep the ice makers clean and by improperly handling food during meal service. The facility reported a census of 53 residents.

Inspectors wroteBased on observation, record review, policy review, and staff interview the facility failed to provide appropriate infection prevention practices by not covering the clean linen cart when moving between buildings and in hallways at the facility, not disinfecting wheelchair after contaminated during personal cares for a resident with transmission based precautions, not completing hand hygiene and changing gloves in accordance with standards of practice and touched back of medication cards to cups used to distribute medications for 6 of 12 residents reviewed, (Resident #7, #20, #37, #14, #18 and #50). The facility reported a census of 53 residents.

Inspectors wroteBased on clinical policy, observation, and staff interview the facility failed to provide a call light system within reach of a resident in contact precautions and accommodate the needs of a resident with closet door hanging unable to be opened for 2 of 18 residents reviewed, ( Resident #9 and #22). The facility reported a census of 53 residents.

Inspectors wroteBased on observation, clinical record review, staff interviews, and policy review, the facility failed to include psychotropic medications in the baseline care plan for 1 of 18 residents reviewed (Resident #8). The facility reported a census of 53 residents.

Inspectors wroteBased on clinical record review, staff interview and facility policy review, the facility failed to revise a comprehensive care plan for 1 of 18 residents reviewed, (Resident #19). The facility reported a census of 53 residents.

Inspectors wroteBased on clinical record review, staff interview and resident interview, the facility failed to follow physician orders to obtain a resident's weight following admission for 1 of 18 residents reviewed (Resident #106). The facility reported a census of 53 residents.

Inspectors wroteBased on observations, record review and staff interview, the facility failed to provide a Restorative Exercise Program to prevent a worsening of range of motion for 1 of 1 resident reviewed, (Resident #27). The facility reported a census of 53.

Inspectors wroteBased on clinical record review, staff interview and facility policy review, the facility failed to attempt a Gradual Dose Reduction for 2 of 5 residents reviewed, (Residents #14 and #19). The facility reported a census of 53 residents.

Inspectors wroteBased on observation, menu review, clinical record review, staff interviews, and policy review, the facility failed to serve the correct therapeutic diet for one of one resident who was ordered a renal diet, (Resident #15). The facility reported a census of 53 residents.

Inspectors wroteBased on clinical record review, staff interviews, personnel records and facility policy review on [DATE] the facility staff failed to implement CPR (cardiopulmonary resuscitation) for one of five residents sampled (Resident #1), who was found unresponsive with no pulse or respirations and desired CPR. This resulted in immediate jeopardy to the residents health and safety. The facility identified a census of 53 current residents, 13 of which were identified by the facility with a request for CPR at the time of cardiopulmonary or respiratory arrest. The facility was notified of the Immediate Jeopardy (IJ) and given the IJ template on [DATE] at 12:15 PM. The immediacy had been removed on [DATE] when the facility provided staff education and review of their policy. [...]

Inspectors wroteBased on observations and staff interview the facility failed to provide for resident ' s dignity during dining when staff engaged in conversation that was not resident focused. The facility reported a census of 54 residents.

Inspectors wroteBased on clinical record review, resident interview, staff interview and facility policy review the facility failed to provide bathing assistance twice weekly for 3 of 3 residents reviewed for bathing (Resident #1, #3 and #5). The facility reported a census of 54 residents.

Inspectors wroteBased on observation, infection control policy and staff interview, the facility failed to provide proper hand hygiene with incontinence care with 2 of 3 residents (Resident #3 and #6) observed. The facility reported a total census of 54 residents.

Inspectors wroteBased on document review, observation, record review, and staff interviews the facility failed to protect a resident from a significant medication error. A nurse committed to giving 37 units of Aspart insulin (Novolog) to Resident #47 at 9:45 AM after drawing it up from a vial, then put the vial back into the medication cart. Resident #47 has an order that reads Levemir Subcutaneous Solution 100 UNIT/ML inject 37 units subcutaneously in the morning for 1 of 4 residents reviewed (Resident #47). The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of October 25, 2023 on October 25th, 2023 at 4:40 P.M. The Facility Staff removed the Immediate Jeopardy on October 26, 2023 through the following actions: a. [...]

Inspectors wroteBased on document review, record review, resident interview and staff interviews the facility failed to provide a comprehensive care plan related to catheterization to a resident with placement of indwelling catheter, a resident with chronic obstructive pulmonary disease / respiratory compromise and a resident with pain to 3 of 5 residents reviewed (Resident #3, #45 and #13). The facility reported a census of 55 residents.

Inspectors wroteBased on document review, electronic health records review, observation, policy review, and staff interviews the facility failed to provide a professional standard of quality by not following physician orders for 3 of 4 residents reviewed (Resident #18, #47, and #207). The facility reported a census of 55 residents.

Inspectors wroteBased on record review, staff and resident interview, the facility failed to assure resident's received baths as planned for 4 of 15 resident's reviewed (Resident #4, #13, #51 and #47 ). The facility reported a census of 55 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to assure functional maintenance programs were completed as planned for 3 of 3 residents reviewed (Resident #4, #13, and #8). The facility reported a census of 55 residents.

Inspectors wroteBased on document review, electronic health records review, observation, policy review, and staff interviews the facility failed to ensure medication error rates are not 5 percent or greater by having a medication error rate of 14.29 percent. The facility reported a census of 55 residents.

Inspectors wroteBased on clinical record review, policy review, resident interview and staff interview, the facility failed to secure medications in a locked compartment, label with open dates and remove medication after expiration date. The facility reported a census of 55 residents.

Inspectors wroteBased on observation, menu review and staff interview, the facility failed to serve food in accordance with professional standards for food safety. The facility reported a census of 55 residents.

Inspectors wroteBased on observation, record review, policy review, and staff interview the facility failed to provide appropriate infection prevention practices when providing personal care for 1 of 1 residents, during medication administration, and failed to review the infection control policy annually with appropriate staff. The facility reported a census of 55 residents.

Inspectors wroteBased on clinical record review, observations, staff interviews, and facility policy review, the facility failed to protect resident from the use of physical restraint that the resident could not remove on their own (Resident #18 and #27). The facility reported a census of 55 residents.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 1 residents (Resident #10) reviewed for PASRR requirements. The facility reported a census of 55 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to review and revise the care plan to reflect the resident's current status for 2 of 15 residents reviewed (Resident #13 and #33). The facility reported a census of 55 residents.

Inspectors wroteBased on document review, Electronic Health Records (EHR), and staff interviews the facility failed to provide dialysis services consistent with professional standards by not completing a post dialysis assessment to 1 of 1 residents reviewed (Resident #20). The facility reported a census of 55 residents.