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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on May 14, 2026, it was determined that Spring Hill Rehabilitation and Nursing Center, had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(a)(1)-(2), 416.54(a)(1)-(2), 418.113(a)(1)-(2), 441.184(a)(1)-(2), 482.15(a)(1)-(2), 483.475(a)(1)-(2), 483.73(a)(1)-(2), 484.102(a)(1)-(2), 485.542(a)(1)-(2), 485.625(a)(1)-(2), 485.68(a)(1)-(2), 485.727(a)(1)-(2), 485.920(a)(1)-(2), 486.360(a)(1)-(2), 491.12(a)(1)-(2), 494.62(a)(1)-(2) STANDARD Plan Based on All Hazards Risk Assessment:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2)

[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:]

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.*

(2) Include strategies for addressing emergency events identified by the risk assessment.

* [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
(2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.

*[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.
(2) Include strategies for addressing emergency events identified by the risk assessment.

*[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients.
(2) Include strategies for addressing emergency events identified by the risk assessment.

Observations:
Name: - Component: -- - Tag: 0006

Based on document review and interview, it was determined the facility failed to maintain an emergency preparedness plan that included a facility and community based risk assessment.

Findings include:

1. Documentation review on May 14, 2026, at 9:05 a.m., revealed that the facility and community based risk assessment using an all-hazards approach was not updated in the emergency preparedness plan within the last twelve months.

Interview with the Facility Administrator and Maintenance Director on May 14, 2026, at 1:00 p.m., confirmed a risk assessment was not updated for the emergency preparedness plan within the last twelve months.

Plan of Correction - To be completed: 06/30/2026

Facility Maintenance Director or designee will complete an updated facility risk assessment and will be placed in the facility EP manual. Monthly audits will be completed to ensure all parts of the EP manual are up to date and current. Facility Maintenance Director will be educated by Administrator or designee on facility risk assessments needing to be completed every two years and records updated/kept in EP manual and then reviewed in facility quarterly Quality Assurance meetings with IDT team.

403.748(c)(1), 416.54(c)(1), 418.113(c)(1), 441.184(c)(1), 482.15(c)(1), 483.475(c)(1), 483.73(c)(1), 484.102(c)(1), 485.542(c)(1), 485.625(c)(1), 485.68(c)(1), 485.727(c)(1), 485.920(c)(1), 486.360(c)(1), 491.12(c)(1), 494.62(c)(1) STANDARD Names and Contact Information:

§403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1).

[(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:]

(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [facilities].
(v) Volunteers.

*[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [hospitals and CAHs].
(v) Volunteers.

*[For RNHCIs at §403.748(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Next of kin, guardian, or custodian.
(iv) Other RNHCIs.
(v) Volunteers.

*[For ASCs at §416.45(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.

*[For Hospices at §418.113(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Hospice employees.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Other hospices.

*[For HHAs at §484.102(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.

*[For OPOs at §486.360(c):] The communication plan must include all of the following:
(2) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Volunteers.
(iv) Other OPOs.
(v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA).

Observations:
Name: - Component: -- - Tag: 0030

Based on documentation review of the facility's Emergency Preparedness (EP) Plan, it was determined the facility failed to include updated names and contact information.

Findings include:

1. Interview and documentation review of the facility EP plan on May 14, 2026, at 9:35 a.m., revealed the EP Plan did not include updated and accurate names and contact information for (i) Staff and (ii) Resident physicians.

Interview with the Facility Administrator and Maintenance Director on May 14, 2026, at 1:00 p.m., confirmed the listed EP plan deficiency.

Plan of Correction - To be completed: 06/30/2026

Facility Maintenance Director or designee will update the EP manual to reflect correct and current contact information for staff and resident physicians. Monthly audits will be completed to ensure all parts of the EP manual are up to date and current. Facility Maintenance Director will be educated by Administrator or designee on ensuring all contact information for facility staff an physicians is kept and updated to current designees of the facility. EP manual and audits will be reviewed in the quarterly Quality Assurance meetings with IDT team.

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID# 192902
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 14, 2026, it was determined that Spring Hill Rehabilitation and Nursing Center was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a two-story, Type II (222), fire resistive building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Exit Signage:

This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.

Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0293

Based on observation and interview it was determined the facility failed to maintain Exit signage in three instances, affecting three of seven smoke compartments..

Findings Include:

1. Observation on May 14, 2026, revealed the following Exit sign deficiencies:

a) 9:45 a.m., the Exit sign above the door to the stairwell in the Main Lobby had a defective battery;
b) 10:35 a.m., the Exit sign above the exit door leading to the Patio in the East Hall had a defective battery;
c) 10:45 a.m., the Exit sign above the the doors to the West Hall had a defective battery.

Interview with the Facility Administrator and Maintenance Director on May 14, 2026, at 1:00 p.m., confirmed the Exit signage deficiencies.

Plan of Correction - To be completed: 06/30/2026

Facility Maintenance Director or designee will replace the batteries for the exit signs above the door to the stairwell In the main lobby, above the exit door leading to the patio in the East Hall, and above the door to the West hall. Weekly audits will be completed for 4 weeks and then monthly thereafter by Maintenance Director or designee to ensure all exit sign batteries are in working condition and illuminated. Facility maintenance director will be educated by Administrator or designee on keeping exit sign batteries checked and signs in working order. Audits will be reviewed in the quarterly Quality Assurance meetings with IDT team.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures in one instance, affecting one of seven smoke compartments.

Findings include:

1. Observation on May 14, 2026, at 10:45 a.m., revealed the main entry door to Dietary/Kitchen failed to close latch when tested.

Interview with the Facility Administrator and Maintenance Director on May 14, 2026 at 1:00 p.m., confirmed the listed hazardous area enclosure deficiency.

Plan of Correction - To be completed: 06/30/2026

Facility Maintenance Director or designee will repair the main entry door to the Dietary/Kitchen area. Weekly random audits will be completed for 4 weeks and then monthly thereafter by Maintenance Director or designee to ensure doors throughout the facility are closing and latching appropriately. Facility maintenance director will be educated by Administrator or designee on ensuring facility doors, especially those that lead to hazardous areas, are closing and latching appropriately. Audits will be reviewed in the quarterly Quality Assurance meetings with IDT team.

NFPA 101 STANDARD Cooking Facilities:

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on documentation review, observation, and interview, it was determined the facility failed to maintain the kitchen hood in two instances, affecting one of seven smoke compartments.

Findings include:

1. Document review, observation, and interview on May 14, 2026, revealed the following kitchen hood deficiencies:

a) 8:50 a.m., the facility failed to perform one of two semi-annual kitchen fire suppression system inspections in the last twelve months;
b) 9:25 a.m., the facility failed to have one of two semi-annual kitchen hood cleanings performed in the last twelve months.

Interview with the Facility Administrator and Maintenance Director on May 14, 2026, at 1:00 p.m., confirmed the kitchen hood deficiencies.

Plan of Correction - To be completed: 06/30/2026

Facility Maintenance Director or designee will have the fire suppression system inspection and kitchen hood cleaning completed in Dietary/Kitchen area. Semi annual audits will be completed by Maintenance Director or designee to ensure all testing in kitchen is on schedule with the semi annual schedule of testing required. Facility maintenance director will be educated by Administrator or designee on ensuring facility kitchen inspections and cleanings are completed semi-annually as required and that ongoing schedule with contractor is maintained. Audits will be reviewed in the quarterly Quality Assurance meetings with IDT team.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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.

Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0761

Based on documentation review and interview, it was determined the facility failed to perform the required annual fire door assembly inspection, affecting the entire facility.

Findings include:

1. Review of documentation on May 14, 2026, at 9:25 a.m., revealed the facility lacked documentation for an annual fire door assembly inspection.

Interview with the Facility Administrator and staff on May 14, 2026, at 1:00 p.m., confirmed the facility lacked documentation showing that an annual fire door assembly inspection had been completed.

Plan of Correction - To be completed: 06/30/2026

Facility Maintenance Director or designee will have the annual fire door assembly inspection completed. Annual audits will be completed by Maintenance Director or designee to ensure fire door assembly inspections are completed annually as required. Facility maintenance director will be educated by Administrator or designee on ensuring facility fire door assembly inspections are completed annually as required and that ongoing schedule with contractor is maintained. Audits will be reviewed in the quarterly Quality Assurance meetings with IDT team.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to maintain the electrical wiring systems and equipment in one instance, affecting one of seven smoke compartments.

Findings include:

1. Observation on May 14, 2026, at 11:20 a.m., revealed there was a refrigerator and coffee pot plugged into a power-strip extension cord in the DON's office.

Interview with the Facility Administrator and Maintenance Director on May 14, 2026, at 1:00 p.m., confirmed the listed electrical wiring system deficiency.

Plan of Correction - To be completed: 06/30/2026

Facility Maintenance Director or designee removed power strip from office immediately upon finding. Weekly audits will be completed by Maintenance Director or designee to ensure office staff is not using power strips to plug personal electronics into. Facility maintenance director and IDT managers will be educated by Administrator or designee on ensuring no personal electronics are being plugged into power strips in offices. Audits will be reviewed in the quarterly Quality Assurance meetings with IDT team.

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