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 a revisit survey completed on May 19, 2025, it was determined that Spring Hill Rehabilitation and Nursing Center failed to correct the deficiencies cited during the survey of April 8, 2025, under the requirements of the 28 Pa, Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on a review of staffing documents provided by the facility and staff interview it was determined that the facility failed to provide one nurse assistant (NA) per 10 residents on the daylight shift on two of seven days (5/12/25 and 5/17/25), one NA per 11 residents on the second shift on seven of seven days (5/12/25 through 5/18/25) and one NA per 15 residents on the night shift on three of seven days (5/13/25, 5/17/25 and 5/18/25) as required.

Findings include:

A review of facility staffing documents provided by the facility from 5/12/25 through 5/18/25, revealed the facility failed to provide NA on the following shifts as required:

Daylight shift: CensusActual hours Hours required

5/12/257344.7454.75
5/17/257253.4254.00

Evening shift:CensusActual hoursHours required

5/12/257339.6249.77
5/13/257344.0149.77
5/14/257244.3149.09
5/15/257242.1749.09
5/16/257141.6648.41
5/17/257238.1649.09
5/18/257226.6749.09

Night shift:CensusActual hoursHours required

5/13/257326.5936.50
5/17/257232.5936.00
5/18/257226.0536.00

During an interview on 5/19/25 at 4:10 p.m., the Nursing Home Administrator confirmed that the facility failed to provide NA's in the facility on the above shifts as required.

Plan of Correction - To be completed: 06/09/2025

The facility cannot retroactively correct past staffing issues.

To prevent this from reoccurring the Scheduler will be reeducated on staffing Nurses' Aides to include expectations of HPPD and ratio's by the DON/designee. Scheduler will utilize Apploi scheduling assistant for staff to pick up in addition to calling/texting both agency and facility staff. Facility has begun an employee of the month program, monthly employee meal.

The facility will hold staffing meetings 5 days a week, consisting of the NHA, DON, Scheduler and Human Resources to review ratio and PPD compliance for upcoming schedules

DON/designee monitor ratios 5 days a week and ongoing to be provided as needed

Results of the meeting will be forwarded to the facility QAPI committee for further review and recommendations

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on a review of nursing time schedules and staff interview, it was determined that the facility failed to provide a minimum of 3.20 PPD (per patient daily) hours of direct care for each resident on three of seven days (5/12/25, 5/17/25 and 5/18/25).

Findings include:

Review of staffing documents and nursing staff schedules from 5/12/25 through 5/18/25 indicated that the State required PPD minimum hours of 3.20 was not met on the following days:

5/12/25= 2.72 PPD.
5/17/25= 3.10 PPD.
5/18/25= 3.01 PPD.

During an interview on 5/19/25, at 4:10 p.m. the Nursing Home Administrator confirmed that the facility failed to provide a minimum of 3.20 PPD hours of direct care on the above dates as required.

Plan of Correction - To be completed: 06/09/2025

The facility cannot retroactively correct past staffing issues.

To prevent this from reoccurring the Scheduler will be reeducated on the 3.20 to include expectations of HPPD and ratio's by the DON/designee. Scheduler will utilize Apploi scheduling assistant for staff to pick up in addition to calling/texting both agency and facility staff. Facility has begun an employee of the month program, monthly employee meal.

The facility will hold staffing meetings 5 days a week, consisting of the NHA, DON, Scheduler and Human Resources to review ratio and PPD compliance for upcoming schedules

DON/designee monitor ratios 5 days a week and ongoing to be provided as needed

Results of the meeting will be forwarded to the facility QAPI committee for further review and recommendations

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