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:

There are 199 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


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 a complaint, completed on May 1, 2025, it was determined that Spring Hill Rehabilitation and Nursing Center was in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities; however, the facility was not in compliance with the 28. Pa Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

51.3 (g)(1-14) LICENSURE NOTIFICATION:

51.3 Notification

(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.

Observations:

Based on facility reports, and staff interview it was determined that the facility failed to notify the Department of Health of a reportable event.

Findings include:

During clinical record review on 5/1/25, at 9:37 a.m. Resident R1 had an unwitnessed fall on 4/19/25, that resulted in resident receiving a lumbar compression fracture (a type of spinal fracture where the vertebrae collapses).

During clinical record review on 5/1/25, at 10:02 a.m. Resident R1 failed to have a diagnoses of lumbar compression fracture prior to fall on 4/19/25.

During an interview on 5/1/25, at 2:00 p.m. Director of Nursing stated, "She didn't go out to the hospital, so I didn't report a new fracture."

During an interview on 5/1/25, at 2:05 p.m. Nursing Home Administrator and Director of Nursing confirmed that the facility failed to notify the Department of Health of a reportable event.

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

1. Reportable submitted and accepted for identified fall during complaint survey on 5/1/2025.
2. A 30 day look back audit was completed to ensure that no other falls experienced an injury of similar nature and went unreported.
3. NHA to educate DON/designee on events that require a report to be submitted.
4. DON/designee to audit falls and ensure reports are made for any falls with transfer and/or injury daily x 2 weeks, then 2x/week for 2 weeks, and 1x/week for 2 weeks.
5. Results to be submitted to QAPI for review and approval.

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