Spring Hill Rehabilitation and Nursing Center

Inspectors wroteBased on a review of policy, observation and staff interview, it was determined that the facility failed to properly label and date food products, maintain kitchen equipment in a sanitary condition, properly store chemicals, and properly restrain hair creating the potential for cross contamination in the Main Kitchen of the facility.

Inspectors wroteBased on facility requirements according to Affordable Care Act (ACA) review of Payroll Based Journal (PBJ) Staffing Data Reports, and staff interviews, it was determined that the facility failed to electronically submit accurate direct care staffing information for one of the last four quarters (Quarter 1 2026).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to offering the COVID-19 vaccination for five of five residents (discharged Resident R9 and Resident's R12, R55, R56 and R57).

Inspectors wroteBased on review of facility documentation, observations, and staff interview, it was determined that the facility failed to make certain that equipment was in safe operating condition for two of two crash carts (First Floor Crash Cart and Second Floor Crash Cart).

Inspectors wroteBased on review of facility policies, resident clinical records, resident council group interviews, resident and staff interviews, it was determined that the facility failed to uphold residents right to vote for two of five sampled residents (Resident R27 and Resident R37), and failed to ensure that care was provided in a manner which maintained resident dignity for one of two residents (Resident R46).

Inspectors wroteBased on review of facility policy, resident trust account balances, closed resident records, and staff interviews it was determined that the facility to obtain an authorization to open a resident fund account for one four closed resident records (Closed resident record CR66) and failed to ensure residents have access to their funds for one of three sampled resident records (Resident R18).

Inspectors wroteBased on review of facility policy, resident records, resident and staff interviews it was determined that the facility failed to provide residents with their quarterly banking statements for two of four sampled resident records (Resident R56 and R57).

Inspectors wroteBased on review of facility policy, resident trust account balances, closed resident records, and staff interviews it was determined that the facility failed to convey resident funds and close accounts upon discharge within 30 days for one of four closed resident records (Closed resident record CR66).

Inspectors wroteBased on review of the residents' personal funds account and facility surety bond, it was determined that the facility failed to ensure that the facility surety bond designee was only to the residents of the facility.

Inspectors wroteBased on Based on document review, clinical record review, and staff interview, it was determined that the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice of non-coverage (SNF-ABN) form to inform those residents of items and services no longer deemed eligible for coverage under Medicare Part-A for two of three sampled resident records (Residents R4 and R57).

Inspectors wroteBased on review of facility policy, documentation, and staff interviews it was determined that the facility failed to protect residents from neglect for two of three residents (Resident R4 and R8).

Inspectors wroteBased on review of facility policy, resident clinical records and staff interviews it was determined that the facility failed to update the care plan for a resident experiencing weight loss one of five sampled residents (Resident R30).

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility failed to implement care and services to maintain activities of daily living (communication) for two of three residents reviewed (Resident R4 and R44).

Inspectors wroteBased on review of facility policy, clinical records, resident council group interview, staff and resident interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for one of five sampled residents (Resident R28).

Inspectors wroteBased on the review of facility policy, clinical records, observation, and interviews with staff and resident, it was determined that the facility failed to make certain that residents received the necessary services to prevent/treat pressure ulcers (injuries to the skin and underlying tissue resulting from prolonged pressure to the skin) for two of three residents (Residents R3 and R11) and failed to follow a physician order during a dressing change observation for one of three residents (Resident R56).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide supervision with meals to monitor for signs and symptoms of dysphagia and failed to make certain that residents were provided appropriate treatment and care in accordance with professional standards of practice for two of six residents (Residents R1 and Resident R8).

Inspectors wroteBased on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (G- Tube, a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for two of two residents (Residents R3, and R4).

Inspectors wroteBased on review of facility policy, clinical records, staff interview, and observations, it was determined that the facility failed to provide appropriate respiratory care for one of two residents (R8). Findings Include: Review of facility policy Oxygen Administration dated 5/1/26, indicated oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences. The resident's care plan shall identify the interventions for oxygen therapy, based upon assessment and orders. Review of facility policy Comprehensive Care Plans dated 3/16/26, indicated the facility will develop and implement a comprehensive person-centered care plan for each resident. [...]

Inspectors wroteBased on review of facility policy, clinical records, and staff interview it was determined that the facility failed to provide trauma survivors with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for two of two residents (Resident R1 and R33).

Inspectors wroteBased on review of facility policy, personnel records and staff interviews, it was determined that the facility failed to complete annual performance evaluations for two of three nursing staff (Nurse Aide (NA) Employees E2 and E3).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia for one of three residents reviewed (Resident R42).

Inspectors wroteBased on review of facility documents, clinical record review, and resident and staff interview it was determined that the facility failed to provide medically related social services to one of four residents (Resident R29).

Inspectors wroteBased on facility policy, clinical record review, resident interview, and staff interview it was determined that the facility failed to ensure that the pharmacy provided medications timely for one of eight residents reviewed (Resident R46).

Inspectors wroteBased on review of the clinical records and staff interview, it was determined that the facility failed to provide documentation that medication regimen reviews (MRR) were completed and reviewed by the resident's attending physician for one of four residents (Residents R11).

Inspectors wroteBased on review of facility policy, clinical records, staff interview and observation it was determined that the facility failed to prime an insulin pen prior to administration for one of three residents (R55).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly secure a treatment cart while not in use for two of two treatment carts (First Floor Treatment Cart and Second Floor Treatment Cart), failed to properly store medications in one of two medication storage rooms (First Floor Medication Room) and failed to properly store medications in two of four medication carts (First Floor East Hall Medication Cart and Second Floor [NAME] Hall Medication Cart).

Inspectors wroteBased on observations, facility menu, resident interviews, and staff interviews it was determined that the facility failed to follow the displayed menu for two of five observed meals (lunch meal 5/17/26, and lunch meal 5/18/26).

Inspectors wroteBased on observations, and staff interviews it was determined that the facility failed to provide residents food products based on their preferences for one out of five residents (Resident R1).

Inspectors wroteBased on a review of resident clinical records, and staff interview, it was determined the facility failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end of life care for one of two residents (Resident R25).

Inspectors wroteBased on review of Quality Assurance Attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly (August 2025 and April 2026)

Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to utilize appropriate Personal Protective Equipment (PPE) for one of three residents in reverse isolation precautions (Resident R57) failed to prevent cross contamination during a dressing change for one of three residents (Resident R56) and failed to prevent cross contamination during medication administration for one of three residents (Resident R18).

Inspectors wroteBased on observations, and staff interview it was determined that the facility failed to maintain a fully functioning resident call bell system for one of two nursing units (second floor nursing unit).

Inspectors wroteBased on observations, policy review, and staff interviews, it was determined that the facility failed to ensure that its corridors were equipped with firmly secured handrails for one of two nursing floors (1st floor). Findings Include: An observation in the first floor nursing unit on 5/17/26, at 12:48 p.m. revealed that the handrail affixed on the front side of the nursing station was loose to touch. An interview with the housekeeper, Employee E36 on 5/17/26, confirmed the handrail was not secured properly. It was indicated he had been aware since Thursday and was unsure if maintenance was aware. An interview with the Registered Nurse Supervisor, Employee E28, on 5/17/26, at 12:55 p.m. confirmed that the handrails should be securely affixed to the walls. 28 Pa.

Inspectors wroteBased on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide annual training on Effective Communication for two of three staff members (Nurse Aide (NA) Employees E2 and E3).

Inspectors wroteBased on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Abuse, Neglect, and Exploitation for one of three staff members Nurse Aid (NA) Employee E3.

Inspectors wroteBased on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for one of three staff members (Nurse Aide (NA) Employee E3).

Inspectors wroteBased on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Infection Control for one of three staff members (Nurse Aide (NA) Employee E3).

Inspectors wroteBased on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Compliance and Ethics for one of three staff members (Nurse Aide (NA) Employee E3).

Inspectors wroteBased on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to ensure that two of three sampled Nurse Aides received a minimum of 12 hours of in-service education per year (NA Employee's E2 and E3).

Inspectors wroteBased on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Behavioral Health for two of three staff members (Nurse Aide (NA) Employee E2 and NA Employee E3).

Inspectors wroteBased on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of three residents sampled with facility-initiated transfers (Residents R5) and failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for two of three resident hospital transfers (Residents R5 and R6).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications in three of four medication carts (first floor East Medication Cart, first floor [NAME] Medication Cart and second floor [NAME] Medication Cart).

Inspectors wroteBased on review of facility policies and clinical records, resident and staff interviews, it was determined that the facility failed to provide effective pain management for one of five residents reviewed (Resident R1), which resulted in excessive pain, poor sleeping, and decreased level of functioning of activities of daily living, causing harm to Resident R1.

Inspectors wroteBased on a review of facility policy, review of clinical records, resident interviews, and staff interviews, it was determined that the facility failed to ensure that residents are free from misappropriation of property for five of seven residents (Resident R1, R2, R3, R4, and R5).

Inspectors wroteBased on review of facility policy, resident clinical record, incident reports, reports submitted to the State, and staff interview it was determined that the facility failed to report allegations of misappropriation of resident belongings for five of seven residents (Resident R1, R2, R3, R4, and R5).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interview, it was determined that the facility failed to conduct a thorough investigation for allegations of misappropriation of resident belongings for five of seven residents (Resident R1, R2, R3, R4, and R5).

Inspectors wroteBased on review of job description, clinical records, observations, and staff interviews, it was determined that the Director of Nursing (DON) failed to timely and effectively manage five allegations of misappropriation of resident belongings that included narcotic diversion for five of five residents (Resident R1, R2, R3, R4, and R5).

Inspectors wroteBased on a review of facility policy, observations, and resident interviews, it was determined that the facility failed to ensure that residents rights were maintained in having beds in working order for residents to maintain the highest level of functioning for one of two residents (Resident R1).

Inspectors wroteBased on reviews of facility policy, employee files, facility documentation, and staff interviews, it was determined that the facility failed to verify current, valid license from licensing and registration boards to verify any disciplinary actions prior to employment for one of two employees (Registered Nurse Employee E1).

Inspectors wroteBased on facility policy, clinical record review, resident interview, and staff interview it was determined that the facility failed to ensure that the pharmacy provided medications timely for one of two residents reviewed (Resident R1).

Inspectors wroteBased on a review of facility documents and interviews with staff it was determined that the facility failed to provide the State Agency with access to facility investigation, causing a delay in the survey process.

Inspectors wroteBased on reviews of facility policy, employees files, facility documentation, and staff interviews, it was determined that the facility failed to ensure annual abuse and neglect prevention training was completed for five of seven staff members (Nurse Aide (NA) Employee E1, Registered Nurse (RN) Employee E3, NA Employee E4, RN Employee E6, and the Director of Nursing (DON) identified in an incident of reported neglect. The facility also failed to provide annual abuse and neglect training for 88 of 90 current Facility Employees for 12 of 12 months (January through [DATE]). The facility also failed to screen employees for a potential history of abuse by completing pre-employment criminal background checks for one of seven employees (Licensed Practical Nurse (LPN) Employee E2). [...]

Inspectors wroteBased on review of facility policy, clinical records, staff interviews, resident interviews, and observations it was determined that the facility failed to ensure that residents were free from neglect and failed to timely and effectively manage 12 allegations of resident neglect, which created an Immediate Jeopardy situation for 12 of 12 residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, and R12).

Inspectors wroteBased on review of facility policy, resident and staff interviews, and observations, it was determined that the facility failed to have sufficient nursing staff to provide nursing related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, which created an Immediate Jeopardy situation for 12 of 12 residents residing on one of two halls (West Hall) for Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, and R12). Findings Include:Review of the facility policy Resident Rights dated 9/22/25, indicated all residents will be treated with respect, and dignity. Residents have the right to reside and receive services in the facility. The residents have the right to a safe, clean, comfortable and homelike environment including but not limited to receiving treatment and support for daily living. [...]

Inspectors wroteBased on review of facility documentation and staff and resident interviews, it was determined that the facility failed to maintain the facilities elevator (Main elevator) in safe operating condition for 11 of 11 days (January 6, 2026, through January 14, 2026).

Inspectors wroteBased on review of facility policy, observations, resident interviews, and staff interviews, it was determined that the facility failed to accommodate the needs for four of five residents (Residents R1, R13, R14, and R18).

Inspectors wroteBased on review of personnel records and staff interview, it was determined that the facility failed to complete annual performance evaluation at least once every 12 months for two of two nurse aide (NA) personnel records (NA Employee E1, and E4).

Inspectors wroteBased on review of facility policy, facility documents and staff interviews, it was determined that the facility failed to provide Communication training to four of five direct care facility staff reviewed (Employees E1, E3, E4, and E6).

Inspectors wroteBased on review of facility policy, facility documents and staff interviews, it was determined that the facility failed to provide Resident Rights training to four of five direct care facility staff reviewed (Employees E1, E3, E4, and E6).

Inspectors wroteBased on review of facility policy, facility documents and staff interviews, it was determined that the facility failed to provide Abuse and Neglect training to five of seven direct care facility staff reviewed (Employees E1, E3, E4, E6, and Director of Nursing).

Inspectors wroteBased on review of facility policy, facility documents and staff interviews, it was determined that the facility failed to provide Quality Assurance and Performance Improvement (QAPI) training to five of five direct care facility staff reviewed (Employees E1, E2, E3, E4, and E6).

Inspectors wroteBased on review of facility policy, facility documents and staff interviews, it was determined that the facility failed to provide Infection Control training to four of five direct care facility staff reviewed (Employees E1, E3, E4, and E6).

Inspectors wroteBased on review of facility policy, facility documents and staff interviews, it was determined that the facility failed to provide Compliance and Ethics training to four of five direct care facility staff reviewed (Employees E1, E3, E4, and E6).

Inspectors wroteBased on review of facility policy, personnel records, and staff interview it was determined that the facility failed to ensure that two of two sampled Nurse Aides (NA) received a minimum of 12 hours of in-service education per year (NA Employee E1, and E4).

Inspectors wroteBased on review of facility policy, facility documents and staff interviews, it was determined that the facility failed to provide Behavioral Health training to four of five direct care facility staff reviewed (Employees E1, E3, E4, and E6).

Inspectors wroteBased on a review of facility job descriptions, facility documents, personnel files, and staff interviews, it was determined the facility failed to ensure that staff renewed their nurse aide registration to allow individuals to work as a nurse aide for two of 28 nurse aides (NA) reviewed (NA Employee E15, and E16).

Inspectors wroteBased on review of job descriptions, clinical records, observations, and staff interviews, it was determined that the Nursing Home Administrator 1(NHA) and the Director of Nursing 1 (DON) failed to timely and effectively manage 12 allegations of resident neglect and failed to maintain sufficient nursing staff to provide resident care and treatment, which created an Immediate Jeopardy situation for 12 of 12 residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, and R12), and failed to ensure annual abuse and neglect prevention training was completed for five of seven staff members (Nurse Aide (NA) Employee E1, Registered Nurse (RN) Employee E3, NA Employee E4, RN Employee E6, and the Director of Nursing (DON) identified in an incident of reported neglect, and failed to provide documentation of annual abuse and neglect training for 90 of 90 current Facility Employees for 12 of [...]

Inspectors wroteBased on review of facility policy, resident clinical records and staff interviews it was determined that the facility failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for two of two residents (Resident R16 and R17).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to maintain proper infection control practices related to the care of clean linen, which created the potential for cross-contamination for one of two nursing floors (Second floor).

Inspectors wroteBased on review of facility documentation, staff and resident interview it was determined that the governing body failed to implement policies regarding the management of the operation of the facility by failing to respond to vendor invoices and failing to respond to facility requests payment for outstanding bills.

Inspectors wroteBased on review of facility policy, clinical records, resident and staff interview it was determined that the facility failed to follow physician orders with doctor's appointments and lab work for four of five residents reviewed (Resident R1, R2, R3, and R4).

Inspectors wroteBased on review of facility policy, clinical records and staff interview it was determined that the facility failed to provide ADL's (activities of daily living) for one of five residents reviewed (Resident R5).

Inspectors wroteBased on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for five of six residents (Residents R2, R3, R4, R5, and R6).

Inspectors wroteBased on facility policy, clinical record review, facility documents, observation, and staff interview, it was determined that the facility failed to ensure proper hand hygiene for enhanced barrier precautions (EBP) in eight of eight resident rooms with EBP signage on the doors (Rooms 104, 108, 202, 216, 220, 221, 222, and 223).

Inspectors wroteBased on review of facility policy, review of clinical records, resident and staff interviews, it was determined that the facility failed to afford residents the right to self-administer medication for one of three residents (Resident R1).

Inspectors wroteBased on review of facility policy, observations and staff interview it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for 12 out of 15 resident rooms (Rooms 102, 107, 114, 116, 119, 204, 206, 208, 216, 224, 225, and 226), and one out of two resident common rooms (Second Floor).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to follow a physician order for one out of three residents (Resident R2) and failed to make certain that residents were provided appropriate treatment and care for one of three residents (Residents R1).

Inspectors wroteBased on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and assistance to prevent accidents for two of three residents (Resident R1 and R2).

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to accommodate the proper linen needs for three of five residents (Residents R2, R3, and R9).

Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff interview, it was determined the facility failed to provide to provide appropriate care and services to residents receiving tube feedings for four of five residents reviewed (Residents R6, R7, R5, and R8) and failed to adhere to tube site dressing care for one of four residents (R8).

Inspectors wroteBased on a review of facility documents, observations, and staff interviews, it was determined that the facility failed to maintain a homelike environment for one of two floors (First Floor).

Inspectors wroteBased on review of facility policy, facility documents, clinical records, and resident and staff interviews, it was determined that the facility failed to make certain residents were free from neglect and mistreatment by giving the wrong medication to a resident after resident refusal for one of three residents (Resident R4).

Inspectors wroteBased on review of facility policies, resident records and staff interview, it was determined the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of three residents (Resident R5).

Inspectors wroteBased on review of facility policy, observation, clinical record, and staff interview, it was determined that the facility failed to make certain that residents are free of significant medication errors for one of three residents (Resident R4).

Inspectors wroteBased on facility policy, clinical record review, observation, and staff interviews, it was determined that the facility failed to prevent cross contamination with residents' personal toiletries for two of five bathrooms on the First Floor (Rooms 107, and 118).

Inspectors wroteBased on facility policy review, observations, resident council group interview, resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for one of two shower rooms (One-West), one clean utility room (One-East) and four out of five resident rooms (Resident R22, R46, R61, and Resident R63) and the facility failed to maintain an adequate supply the following day of wash clothes, towels, and blankets readily available for two of two nursing units.

Inspectors wroteBased on observations and resident and staff interviews, it was it was determined that the facility failed to make certain that residents were provided appropriate treatment and care for three of four residents (Resident R16, R23, R52 and R128).

Inspectors wroteBased on review of facility policy, nursing staff personnel records, nurse training documentation and staff interview, it was determined that the facility failed to ensure that nursing staff received annual in-service education for three out of five sampled nursing personnel records (Registered Nurse (RN) Employee E16 , Licensed Practical Nurse (LPN) Employee E25, and Registered Nurse (RN) Employee E26).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to implement pharmaceutical services to ensure accurate provision of medications for one of four residents (Residents R51 and Resident R128).

Inspectors wroteBased upon review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that any irregularities submitted in the medication regimen reviews (MRR) by pharmacy were acted upon timely for two out of two residents (Resident R2 and R69).

Inspectors wroteBased on facility policy, clinical record review, and staff interview it was determined the facility failed to ensure PRN orders for psychotropic drugs are limited to 14 days, and failed to monitor the effectiveness or adverse consequences of psychotropic medication use for one of three residents (Resident R2) reviewed. Findings Include: Review of facility policy Use of Psychotropic Medications dated 12/9/24, indicated this policy is to ensure that residents only receive psychotropic mediations when other nonpharmacological interventions are clinically contraindicated. Additionally, these medication should only be used to treat the resident's medical symptoms and not used for disciple or staff convenience. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. [...]

Inspectors wroteBased on review of facility policy, facility scheduled mealtimes, resident council group interview, and staff interviews it was determined that the facility failed to ensure the provision of a nourishing (satisfying to the resident) evening snack when greater than 14 hours elapsed from the supper meal to breakfast the next day for residents including three of three residents sampled (Residents R73, R377, and R378), and failed to [NAME] resident group acceptance of a meal span of greater than 14 hours.

Inspectors wroteBased on a review of facility documents, and resident and staff interview, it was determined that the facility failed to provide specialized rehabilitative services for three of three residents (Resident R16 and R237). Findings Include: Review of the facility policy Therapy Evaluation dated 12/9/24, stated the licensed therapist will perform an initial resident evaluation upon physician referral and any reevaluation where indicated. The Rehabilitation Department will be notified when a physician order is written for therapy evaluation and treatment. Review of the facility policy Therapy Treatment Procedures for Therapeutic Exercise dated 12/9/25, stated it is the facility's policy to provide therapy treatment procedures for therapeutic exercise as necessary. Review of the clinical record revealed that Resident R16 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on review of clinical records and staff interview it was determined that the facility failed to employ a full time social worker.

Inspectors wroteBased on review of facility policy, Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all of the required committee members for three of four quarters (April 2024 through June 2024 and July 2024 through December 2024).

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to follow enhanced barrier precautions for two of five residents (Resident R13 and R68), failed to prevent cross contamination during a dressing change for one of three residents (Resident R68), and failed to implement an infection control program that included a system of surveillance that included tracking, trending and mapping to identify possible communicable diseases or infections for one of six months (January 2025).

Inspectors wroteBased on a review of select facility policy and staff interview, it was determined the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections (Mid-October 2024, to 2/21/25).

Inspectors wroteBased on review of facility policy, closed clinical records, resident fund account statements and staff interview it was determined that the facility failed to convey resident funds in accordance with State law and closed accounts upon discharge in a timely manner for one out of two sampled records (Closed Resident Record CR984).

Inspectors wroteBased on review of facility policy, review of facility provided documents, clinical records, and staff interview, it was determined that the facility failed to thoroughly investigate to rule out potential neglect for two of four residents (Resident R23 and R24).

Inspectors wroteBased on review of facility policy, resident records, admissions documentation, billing documents, resident and staff interviews it was determined that the facility failed to maintain admission documentation for two of four sampled residents (Resident R32 and Resident R57) and failed to provide a comprehensive review of resident admission rights, policies, and payment requirements for two of four residents (Resident R62 and R66).

Inspectors wroteBased on review of facility policies, resident records and staff interview, the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two out of three residents sampled with facility-initiated transfers (Resident R47 and R76).

Inspectors wroteBased on review of resident clinical records, and staff interviews, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for two of two residents (Resident R47, and R76). Findings Include: Review of Resident R47's clinical record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of intellectual disabilities, dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident R47's clinical record revealed that the resident was transferred to the hospital on 3/17/25, and returned to the facility on 3/20/25. [...]

Inspectors wroteBased on review of resident clinical records, and staff interviews, it was determined that the facility failed to provide evidence that a written notification of the facility bed hold policy was provided to the resident upon transfer to the hospital for two of two residents (Resident R47 and R76). Findings Include: Review of Resident R47's clinical record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of intellectual disabilities, dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). [...]

Inspectors wroteBased on review of facility policy, clinical record review, observations and staff interviews, it was determined that the facility failed to provide language assistance services to maintain activities of daily living (ADLs) for communication for one of two residents (Resident R177).

Inspectors wroteBased on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for two of three residents (Residents R13 and Resident R35).

Inspectors wroteBased on review of facility policies and clinical records, observations, and resident and staff interviews, it was determined that the facility failed to provide effective pain management for one of four residents reviewed (Resident R16).

Inspectors wroteBased on review of resident clinical records and staff interviews, it was determined that the facility failed to maintain a complete record of a dialysis contract for one of two sampled residents (Resident R22).

Inspectors wroteBased on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents (Resident R278).

Inspectors wroteBased on clinical record review, facility policy and interviews with staff, it was determined that the facility failed to ensure a medication was signed off by a physician prior to administering, and timely provide care and necessary treatment and services for one of two residents (Resident R52).

Inspectors wroteBased on clinical record review and staff and resident interview, it was determined that the facility failed to provide behavioral health interventions for a resident to maintain the highest practicable mental well-being for one of four residents reviewed for behavioral concerns (Resident 16).

Inspectors wroteBased on review of clinical records and staff interview it was determined that the facility failed to provide medically related social services to one of two residents reviewed (Resident R128).

Inspectors wroteBased on review of facility policies, observations, and staff interviews it was determined that the facility failed to properly store medical supplies and biologicals in one of two medication rooms (second floor medication room) and two of four medication carts (first floor west and second floor west medication cart) failed to date open medications in two of four medication carts (first floor west and second floor west medication cart) and treatment medications were found unsecured at a resident's bedside for one of four residents (Resident R69).

Inspectors wroteBased on facility policy, clinical record review and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to the Influenza and Pneumonia vaccine for two of five residents (Resident R13 and R60).

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition in the main kitchen and the facility failed to maintain essential equipment with a dryer not working ( 1 of 2 dryers).

Inspectors wroteBased on review of facility policy, employee personnel records, and staff interview, it was determined that the facility failed to provide training on Abuse, Neglect, and Exploitation on the date of orientation for one out of five sampled records (Physical Therapist Employee E3).

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to properly label and date food products in the walk in freezer and dry storage in the designated main kitchen and failed to maintain sanitary conditions which created the potential for cross contamination (Main Kitchen).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide discharge planning that focuses on the resident's discharge goals and preparation of resident to be active partners in the discharge planning process that focuses on the resident's discharge planning and process for one of three residents (Resident R4).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for two of four residents (Residents R2 and R3).

Inspectors wroteBased on a review of facility policy, clinical record, and staff interview, it was determined that the facility failed to provide medications as ordered by the physician for one of five residents (Resident R5).

Inspectors wroteBased on observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for two of four residents (Residents R1 and R2).

Inspectors wroteBased on review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for one of five residents reviewed (Resident R5).

Inspectors wroteBased on menu, observation, and staff interview, it was determined that the facility failed to follow the portion sizes for one of one meal observed.

Inspectors wroteBased on observation, and staff interview, it was determined that the facility failed to maintain a clean, safe, and homelike environment for three of three resident rooms (rooms [ROOM NUMBER]), and failed to have an ample supply of linen at the staff's immediate disposal on four of five hallways (2East, 2West, 1 East, and 1West). Findings Include: Review of the facility policy Safe and Homelike Environment dated 12/9/24, indicated in accordance with resident's rights, the facility will provide a safe, clean, comfortable, and homelike environment. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. The facility will provide and maintain bed and bath linens that are clean and in good condition. During observations of the Second-floor nursing unit on 12/27/24, at 9:28 a.m. the following was observed: [...]

Inspectors wroteBased on review of facility policy, resident records, admission documentation and staff interview it was determined that the facility failed to disclose and provide to a resident or potential resident prior to time of admission, notice of special characteristics or service limitations of the facility for one of three residents (Closed Resident Record CR1).

Inspectors wroteBased on facility policy, clinical record review and staff interviews, it was determined the facility failed to notify the physician of a medication error for one of three residents. (Resident R1)

Inspectors wroteBased on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to make certain medications were administered as ordered by the physician for one of four residents (Resident R1).

Inspectors wroteBased on review of clinical records, and staff interview, it was determined that the facility failed to implement procedures to ensure availability of prescribed medications for two of three residents (Residents R1, and R2)

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to provide a safe and comfortable environment in one resident room on the 1st floor.

Inspectors wroteBased on a review of facility policies, observations and staff interviews it was determined that the facility failed to maintain kitchen equipment and dry storage area in a clean, sanitary condition, failed to properly monitor food temperatures, and failed to verify the sanitizing temperature of the dish machine in the Main Kitchen (Main Kitchen), which created the potential for cross-contamination and/or food borne illness. Findings Include: Review of facility policy Food Safety Requirements, dated 1/18/24, stated that it is the policy of the facility to procure food from sources approved or considered satisfactory by federal, state, and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. [...]

Inspectors wroteBased on review of facility policy, observations, resident council group interview, and resident and staff interviews, it was determined that the facility failed to have an ample linen supply at the staff 's immediate disposal on 3 of 5 halls (2 East, 2 North, and 2 West).

Inspectors wroteBased on review of facility policy, resident council minutes, group and staff interviews, it was determined that the facility failed to provide written response to resident concerns and grievances identified during resident council minutes for six of six months (October 2023, November 2023, December 2023, January 2024, February 2024, and March 2024).

Inspectors wroteBased on observation, and staff interview, it was determined that the facility failed to maintain a clean and homelike environment in two of three nursing hallways on the second floor (2 East and 2 North Hallways). Findings Include: Review of the facility policy Safe and Homelike Environment dated 1/18/24, indicated in accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment, and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Observations on 4/22/24, at 9:12 a.m. indicated the lounge across from room [ROOM NUMBER] with sticky tables, linen bruits and carts, a Hoyer lift, and a Geri-chair (a type of reclining wheelchair). The perimeter of the hallway was covered in grime and had splatter paint marks scattered throughout. Interview on 4/22/24, at 9:15 a.m. [...]

Inspectors wroteBased on review of facility policies, clinical records, facility documents and staff interview, it was determined that the facility failed to ensure that residents received an updated elopement assessment after a discontinued wanderguard, and a neurological assessment after an incident involving a fall for three of six residents (Resident R3, R62 and R271)

Inspectors wroteBased on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for three of five residents (Resident R37, R61, and R272).

Inspectors wroteBased on review of the clinical record and staff interview, it was determined that the facility failed to provide documentation that it acted on the pharmacy recommendations for two of five residents (Resident R21 and R62).

Inspectors wroteBased on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for seven of ten months (July 2023, August 2023, September 2023, October 2023, November 2023, December 2023, and March 2024) and failed to implement enhance barrier precautions for five of six residents (Resident R6, R21, R59, R271, and R272).

Inspectors wroteBased on review of facility policy, observation and staff interview, it was determined that the facility failed to determine it was safe to self-administer medications for one of six residents (Resident R36).

Inspectors wroteBased on facility policy, clinical record reviews and interviews with staff, it was determined that the facility failed to review and revise the comprehensive care plan after a fall for two of six residents (Resident R52 and R62).

Inspectors wroteBased on review of facility policies, clinical records, facility documents and staff interview, it was determined that the facility failed to notify the physician of missed medication doses and failed to follow physicians orders for medication administration for one of five residents (Resident R61).

Inspectors wroteBased on review of facility policies, clinical records, facility documents and staff interview, it was determined that the facility failed to provide care and services for a pressure ulcer for one of five residents (Resident R271).

Inspectors wroteBased on facility policy observation, clinical record review and staff interview, it was determined that the facility failed to provide treatment and services to prevent further decrease in range of motion for one of three residents (Resident R45).

Inspectors wroteBased on review of facility policies, observations, clinical record, and staff interview it was determined that the facility failed to acquire a physician's order correctly for the route of medication administration for two of three residents (Residents R21 and R38) receiving medications via a G-tube (tube placed into the stomach surgically).

Inspectors wroteBased on review of resident clinical records, facility policy and staff interview, it was determined the facility failed to provide consistent and complete communication with the dialysis center for one of two residents reviewed (Resident R43).

Inspectors wroteBased on review of facility documents, facility policy review, and staff interview, it was determined that the facility failed to ensure that all required staff persons were in attendance at quarterly Quality Assurance Process Improvement (QAPI) Committee meetings for one of three quarters reviewed (third quarter, July - September 2023).

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to provide a working call system for resident use to communicate their needs to staff for one of five residents (Resident R13).

Inspectors wroteBased on review of facility policy, observation, and staff interview it was determined the facility failed to store drugs and biologicals in locked compartments in accordance with State and Federal laws for one of two medication carts (Second Floor Unit).