Pennsylvania Department of Health
SPRING HILL REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

SPRING HILL REHABILITATION AND NURSING CENTER
Inspection Results For:

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SPRING HILL REHABILITATION AND NURSING CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on an Abbreviated Survey in response to two complaints, completed on August 5, 2026, it was determined that Spring Hill Rehabilitation and Nursing Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.25(k) REQUIREMENT Pain Management:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations:
Based on a review of clinical records, facility policy, and staff interviews, it was determined that the facility failed to provide pain management consistent with professional standards of practice for one of three residents (Resident R1).

Findings include:

Review of facility policy "Pain Management" dated 5/1/26, indicated that facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The interventions for pain management will be incorporated into the components of the comprehensive care plan, addressing conditions or situations that may be associated with pain or may be included as a specific pain management need or goal.

Review of the clinical record indicated Resident R1 was admitted to the facility on 1/16/25.

Review of Resident R1's Minimum Data Set (MDS - a period assessment of care needs) dated 4/10/26, indicated diagnoses of heart failure, arthritis, and chronic pain.

Review of Resident R1's physician order dated 11/26/25, indicated MS Contin oral tablet extended release 15 mg (milligram) (Morphine sulfate), give 15 mg by mouth at bedtime for chronic pain.

Review of Resident R1's physician order dated 11/26/25, indicated MS Contin oral tablet extended release 30 mg (Morphine sulfate), give 30 mg by mouth two times a day for chronic pain hold for sedation.

Review of Resident R1's physician order dated 7/3/26, indicated Oxycodone HCl oral tablet 5 mg, give 10 mg by mouth every 8 hours as needed for moderate to severe pain hold for sedation.

Review of Resident R1's physician order dated 1/8/25, indicated Tylenol Extra Strength oral tablet 500 mg (Acetaminophen), give 1000 mg by mouth three times per day for pain do not exceed 3 grams in 24 hours.

Review of Resident R1's physician order dated 10/12/23, indicated Non-pharmacological intervention(s) used before PRN (as needed) pain medication, or before PRN anti-depressant, anti-anxiety, anti-psychotic, or sedative/hypnotic medication - Document by number: (1) Reposition for comfort (2) massage (3) involve in activity/alternative activity to divert (4) provide quiet setting with reduced stimuli (5) relaxation technique (6) music (7) remove from area (8) direction/distraction (10) ambulate (11) provide food/drink (12) educated (13) one: one (14) other, document PN (progress note) as needed.

Review of Resident R1's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for July 2026failed to indicate any non-pharmacological interventions for the use of pain medications.

Review of Resident R1's clinical progress notes for July 2026, failed to indicate any non-pharmacological interventions for the use of pain medications.

During an interview completed on 8/5/26, at 1:12 p.m. the Director of Nursing (DON) confirmed that Resident R1's clinical record failed to indicate any documented non-pharmacological interventions for the use of pain medication and that the facility failed to provide pain management consistent with professional standards of practice for one of three residents (Resident R1).

28 Pa. Code 211. 10(c) Resident care policies
28 Pa. Code 211.12(d)(1) Nursing services

Plan of Correction - To be completed: 09/09/2026

Affected resident R1 orders have been adjusted to have the correct non-pharmacological interventions and supplemental documentation for pain management.

All pain orders were reviewed and non-pharmacological interventions and supplemental documentation was added. Residents had no ill effects from not having non-pharmacological interventions in the EMAR

Education was provided to Rns and LPNs by DON or designee as well as providers on inputting orders and to include non-pharmacological interventions.

Orders will be reviewed in AM clinical meeting daily for 4 weeks to ensure any orders requiring non-pharmacological interventions are present and supplemental documentation is being completed.

Will be reviewed as part of facility Quality Assurance.

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