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

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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 onsite revisit survey completed on March 6, 2026, it was determined that Spring Hill Rehabilitation and Nursing Center corrected the deficiencies cited during the survey of January 22, 2026, under the requirements of 42 CFR, Part 483, Subpart B, Requirements for Long Term Care Facilities, however, remains noncompliant with deficiencies cited under 28 Pa Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.\~\~




 Plan of Correction:


§ 211.12(f.1)(3) LICENSURE Nursing services. :State only Deficiency.
(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 the facility's staffing worksheet, provided by the facility for the time period of 2/17/26, through 3/3/26, and staff interviews, it was determined that the facility failed to provide one Nurse Assistant (NA) per 10 residents on the daylight shift for 11 on 15 days (2/17/26, 2/18/26, 2/20/26, 2/21/26, 2/23/26, 2/25/26, 2/26/26, 2/27/26, 2/28/26, 3/1/26, and 3/1/26), one NA per 11 residents on the evening shift doe eight of 15 days (2/17/26, 2/18/26, 2/19/26, 2/20/26, 2/23/26, 2/26/26, 2/27/26, and 3/2/26) and one Na per 15 residents on the night shift for seven of 15 days (2/17/26, 2/19/26, 2/20/26, 2/22/26, 2/24/26, 2/27/26 and 3/1/26) as required

Findings include:
During a review of the facility's staffing worksheet, provided by the facility for the time period of 2/17/26, through 3/3/26, the following was revealed:
Date Census Actual Hours Minimum Hours
Daylight shift
2/17/26 62 38.25 46.50
2/18/26 62 37.00 46.50
2/20/26 61 44.65 45.75
2/21/26 61 36.74 45.75
2/23/26 60 44.72 45.00
2/25/26 60 42.97 45.00
2/26/26 61 45.17 45.75
2/27/26 60 37.51 45.00
2/28/26 60 30.05 45.00
3/1/26 61 28.83 45.75
3/2/26 61 44.62 45.75
Evening shift
2/17/26 62 30.76 42.27
2/18/26 62 26.83 42.27
2/19/26 62 32.45 42.67
2/20/26 61 30.92 41.59
2/23/26 60 30.34 40.91
2/26/26 61 36.55 41.59
2/27/26 60 40.08 40.91
3/2/26 61 36.63 41.59
Night shift
2/18/26 62 24.80 31.50
2/19/26 61 30.43 30.50
2/20/26 61 22.94 30.50
2/22/26 60 27.32 30.00
2/24/26 61 23.13 30.50
2/27/26 60 29.63 30.50
3/1/26 61 30.38 30.50

During an interview on 3/4/26, at 3:20 pm the Nursing Home Administrator confirmed that for the time period of 2/17/26, through 3/3/26, the facility failed to provide one NA per 10 residents on the daylight shift for 11 of 15 days, one NA per 11 residents on the evening shift for eight of 15 days, and one NA per 15 residents on the night shift for seven of 15 days as required.





 Plan of Correction - To be completed: 03/24/2026

P5520
1. Residents had no ill effects from not meeting the staffing ratios for nurse aides.
2. Facility has increased the utilization of agency staff, implemented bonuses for staff to pick up vacant shifts and are continuing to actively hire additional staff.
3. Staffing coordinator was educated on the state staffing ratios for nurse aides.
4. Staffing coordinator or designee will audit the ratios daily through the use of the state staffing sheet. Results will be reviewed through the QA/QI process until substantial compliance is met.

§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:

Based on a review of the facility's staffing worksheet, provided by the facility for the time period of 2/17/26, through 3/3/26, and staff interviews, it was determined that the facility failed to provide one Licensed Practical Nurse (LPN per 40 residents on the night shift for two of 15 days (2/18/26, and 2/20/26) as required.

Findings include:

A review of the facility's staffing worksheet , provided by the facility, for the time period of 2/17/26, through 3/3/26, revealed the following:
Date Census Actual Hours Minimum Hours
Night shift
2/18/26 62 7.83 11.63
2/20/26 61 7.95 11.44

During an interview on 3/4/26, at 3:20 pm the Nursing Home Administrator confirmed that the facility failed to provide one LPN per 40 residents on the night shift for two of 15 days as required.





 Plan of Correction - To be completed: 03/24/2026

P5530
1. Residents had no ill effects from not meeting the staffing ratios for Licensed Practical Nurses (LPNs).
2. Facility has increased the utilization of agency staff, implemented bonuses for staff to pick up vacant shifts and are continuing to actively hire additional staff.
3. Staffing coordinator was educated on the state staffing ratios for Licensed Practical Nurses (LPNs).
4. Staffing coordinator or designee will audit the ratios daily through the use of the state staffing sheet. Results will be reviewed through the QA/QI process until substantial compliance is met.

§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(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 the facility's staffing worksheet, provided by the facility for the time period of 2/17/26, through 3/3/26, and staff interviews, it was determined that the facility failed to provide each resident a daily minimum of 3.2 hours of direct nursing care (PPD) for three of 15 days (2/17/26, 2/18/26, and 2/28/26) as required.

Findings include:
A review of the facility's staffing worksheet, provided by the facility, for the time period of 2/17/26, through 3/3/26, revealed the following:

PPD
Date Census Actual PPD hours Minimum PPD hours
2/17/26 62 2.97 3.2
2/18/26 62 2.58 3.2
2/28/26 60 3.06 3.2

During an interview on 3/4/26, at 3:20 pm the Nursing Home Administrator confirmed that the facility failed to provide the minimum 3.2 hours of direct nursing care for each resident for three of 15 days as required.





 Plan of Correction - To be completed: 03/24/2026

P5640
1. Residents had no ill effects from not meeting the state minimum number of general nursing hours to each resident in a 24-hour period.
2. Facility has increased the utilization of agency staff, implemented bonuses for staff to pick up vacant shifts and are continuing to actively hire additional staff.
3. Staffing coordinator was educated on the state minimum number of general nursing hours to each resident in a 24-hour period of a 3.20 PPD.
4. Staffing coordinator or designee will audit the ratios daily through the use of the state staffing sheet. Results will be reviewed through the QA/QI process until substantial compliance is met.


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