Inspection Report — Mar 17, 2025
Monitoring
Census: 81
Capacity: 98
Citations: 55
Date: Mar 17, 2025
Visit Reason
The visit was a renewal inspection of Spring Mill Senior Living to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Complaint Details
The complaint investigation involved allegations of verbal aggression and physical injury between residents #2 and #3 in the secured dementia care unit, resulting in resident #2's hospitalization and death due to head trauma. Additional concerns included a resident (#1) suffering heat exposure due to inadequate supervision and staff communication failures. The investigation found failures in reporting, communication, and resident care practices.
Findings
Multiple deficiencies were found including issues with confidentiality of resident records, contract signatures, quality management meetings, privacy violations due to cameras, staff qualifications, training deficiencies, resident personal equipment safety, medication administration and storage, sanitary conditions, emergency procedures, and record keeping. Several repeat violations were noted.
Citations (55)
The home's current violation report was not posted in a conspicuous and public place.
Memory care resident assignment sheets including resident toileting logs were unlocked, unattended, and accessible.
Resident-home contracts were not signed by residents or signatures were missing.
Quality management meetings were not held quarterly as required.
Multiple cameras were found throughout the home without proof they were inoperable and not recording.
Direct care staff person did not have a valid high school diploma or equivalent.
Direct care staff person did not receive required annual training including medication self-administration and resident rights.
Resident bedside mobility devices were not properly attached or covered, creating entrapment hazards.
Poisonous materials were unlocked and accessible to residents in the janitor's closet.
Sanitary conditions were not maintained in resident rooms and common areas.
Trash outside the home was not kept in covered receptacles and the dumpster area was unclean.
Emergency telephone numbers were not posted on or by telephones in resident apartments.
Furniture and equipment such as boilers were not in good repair.
Resident bed linens and blankets were stained and not clean.
Residents did not have operable lamps or sources of lighting at bedside.
Carpet in resident bedroom was stained and not clean.
Emergency procedures did not include contact information for each resident’s designated person.
Emergency procedures were not posted in a conspicuous and public place.
Residents did not evacuate to a public thoroughfare or fire-safe area within the designated time during fire drills.
Residents did not evacuate to a designated meeting place during fire drills.
Resident medical evaluations were not completed within required timeframes.
Menus were not posted one week in advance.
First aid kit in resident transport vehicle did not include a thermometer.
Residents self-administering medications were not properly assessed for ability to self-administer.
Medications stored in resident rooms were not locked and secure.
Resident medication records did not include current lists of medications.
Staff person administered medications without completing required medication administration training.
Prescription medications, OTC medications, CAM and syringes were not kept locked.
Discontinued and expired medications were not properly removed from medication carts.
Medications were stored in an unorganized manner and expired medications were present.
Medications were destroyed improperly by throwing into trash.
Controlled substances were not stored under double lock as required.
Medication records did not document administration times, doses, or staff initials.
The home did not follow prescriber's orders for blood sugar checks and wound care.
Resident records were not kept confidential; assignment sheets and charts were accessible and unattended.
Staff person was verbally abusive and rough with residents; complaints were not reported timely.
Trash cans in kitchens and bathrooms were not kept covered.
Residents personal equipment such as bed enabler bars were not compliant with safety regulations.
Poisonous materials were unlocked and accessible to residents in memory care unit.
Sanitary conditions were not maintained; stained pads on shower chairs were observed.
Trash outside the home was not kept in covered receptacles and the dumpster area was unclean.
Residents did not evacuate to designated meeting places during fire drills.
Menus were not posted one week in advance.
Residents self-administering medications were not properly assessed for ability to self-administer.
Resident medication records did not include current lists of medications.
Medications and syringes were not kept locked in resident rooms.
Discontinued medications were not removed from medication carts.
Medication carts contained expired medications and loose pills.
Medication storage was not in accordance with sanitation and manufacturer instructions.
Blood glucose readings were not accurately recorded on medication administration records.
Medication records did not document administration times and staff initials.
Staff administered medications without completing required medication administration training.
Resident #1 suffered injury due to altercation between residents; resident #1 suffered heat exposure and was hospitalized; concerns about staff communication and reporting were noted.
Soap dispensers in shared bathrooms were not properly labeled and unsecured hygiene items were present.
Resident medical evaluations were not completed timely and monitoring systems were not in place.
Report Facts
License Capacity: 98
Residents Served: 81
Residents Served: 86
Residents Served: 88
Total Daily Staff: 101
Total Daily Staff: 105
Total Daily Staff: 106
Total Daily Staff: 112
Waking Staff: 76
Waking Staff: 79
Waking Staff: 80
Waking Staff: 84
Fine Per Resident Per Day: 3
Fine Per Resident Per Day: 5
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 264
Calculated Fine Per Day: 440
Calculated Fine Per Day: 440
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in abuse and mistreatment findings involving residents #1 and #2 | |
| Staff person B | Named in medication administration training deficiency and abuse investigation | |
| Staff person C | Named in abuse investigation involving resident #1 | |
| Staff person D | Named in training deficiencies including resident rights and medication training | |
| Staff person F | Named in medication disposal violation | |
| Staff person G | Named in medication administration training deficiency | |
| Director of Memory Care | Named in multiple findings including confidentiality, medication training, and bed enabler bar compliance | |
| Executive Director | Named in multiple findings including abuse investigation, training, and compliance monitoring | |
| Director of Health and Wellness | Named in medication administration, training, and compliance monitoring | |
| Assistant Director of Health and Wellness | Named in medication administration, training, and compliance monitoring | |
| Director of Maintenance | Named in findings related to equipment repair, safety, and fire drills | |
| Director of Culinary | Named in findings related to food safety, menus, and sanitation |
Inspection Report — Aug 26, 2024
Complaint Investigation
Census: 84
Capacity: 98
Citations: 6
Date: Aug 26, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation to review compliance with resident care, confidentiality, staffing, assessments, and record-keeping requirements.
Complaint Details
The visit was complaint-related, triggered by allegations of neglect and mistreatment. Residents reported long wait times for assistance, including one incident where a resident waited 45 minutes to over an hour after ringing a call pendant, resulting in an accident. Staff disciplinary actions and re-education were implemented. The complaint was substantiated based on observations and records.
Findings
The inspection found multiple deficiencies including unlocked nursing office compromising resident record confidentiality, delayed staff response to resident call pendants resulting in neglect, disrespectful treatment of residents by staff, inadequate medication administration staffing, incomplete resident assessments and support plans, and missing incident reports in resident records. Plans of correction were accepted and later implemented.
Citations (6)
Nursing office was observed unlocked and unsecured, risking resident record confidentiality.
Residents experienced long wait times for staff response to call pendants, resulting in neglect and humiliation.
Resident was treated without dignity and respect; staff engaged in personal conversations and used obscenities during interactions.
No trained medication administration staff present from 5:06 am to 6:37 am on 8/17/2024 due to staff leaving early without coverage.
Resident initial assessments and support plans were incomplete or not filed timely in resident records.
Resident record did not include a copy of the incident report for an incident on 7/30/2024 at time of inspection.
Report Facts
Residents served: 84
Total licensed capacity: 98
Staffing hours - Total Daily Staff: 111
Staffing hours - Waking Staff: 83
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 12
Call bell response time: 45
Call bell response time: 62
Medication administration staffing gap: 91
Inspection Report — Jun 11, 2024
Follow-Up
Census: 92
Capacity: 98
Citations: 9
Date: Jun 11, 2024
Visit Reason
The inspection visit was an unannounced partial inspection conducted due to an incident, specifically a follow-up to verify the implementation of a previously submitted plan of correction.
Complaint Details
The visit was triggered by an incident involving alleged abuse by staff person A toward residents, which was not reported timely to the Department. The investigation substantiated the abuse allegations.
Findings
The facility was found to have multiple deficiencies related to resident abuse, failure to report abuse timely, inadequate staff training and orientation, incomplete annual medical evaluations, and incomplete support plan signatures. The submitted plan of correction was determined to be fully implemented as of the inspection date.
Citations (9)
Two incidents of alleged abuse by staff person A toward residents were not reported timely to the Department.
Resident 1 was physically abused by staff person A who took away the resident's walker and poked the resident despite requests to stop.
Resident 2 was left naked and alone in the shower despite requiring assistance, and verbally abused by staff person A.
Staff person B did not complete required orientation on fire safety and emergency preparedness prior to providing care.
Staff person B did not complete orientation within 40 hours on resident rights, emergency medical plan, and mandatory reporting of abuse and neglect.
Staff person B did not complete the direct care training competency test prior to providing care.
Staff person B completed only 9.75 hours of annual training in 2023, less than the required 12 hours.
Resident 1's most recent medical evaluation was not current as required annually.
Residents 1 and 2 did not properly sign and date their support plans as required.
Report Facts
License Capacity: 98
Residents Served: 92
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 5
Residents 60 Years or Older: 92
Residents with Mobility Need: 26
Annual Training Hours Completed by Staff Person B: 9.75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in multiple abuse and neglect findings involving residents 1 and 2; suspended and terminated following investigation. | |
| Staff person B | Named in findings related to incomplete fire safety orientation, incomplete emergency medical plan training, failure to complete direct care competency test prior to providing care, and insufficient annual training hours; terminated. | |
| Executive Director | Responsible for reporting abuse allegations, educating staff, monitoring compliance, and overseeing corrective actions. | |
| Director of Health and Wellness | Involved in reporting abuse allegations and support plan compliance; received re-education. | |
| Director of Memory Care | Received re-education on abuse reporting and support plan development. | |
| Business Office Manager | Conducted audits of staff training and education files and monitors compliance. |
Inspection Report — May 29, 2024
Complaint Investigation
Census: 93
Capacity: 98
Citations: 0
Date: May 29, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.
Complaint Details
The visit was complaint-related and incident-related; no deficiencies or citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 93
License Capacity: 98
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 19
Hospice Current Residents: 8
Residents Age 60 or Older: 93
Residents with Mobility Need: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dean Gray | Department Representative | On-site representative during inspection |
Inspection Report — Apr 11, 2024
Complaint Investigation
Census: 93
Capacity: 98
Citations: 5
Date: Apr 11, 2024
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 04/11/2024 to review compliance and the submitted plan of correction.
Complaint Details
The visit was complaint-related as indicated by the inspection information section specifying 'Reason: Complaint'.
Findings
The inspection identified multiple deficiencies including incomplete criminal background checks for a staff member, missing resident signatures on support plans, lack of documentation of no objection statements for admission to the secured dementia care unit, delayed completion of initial support plans, and incomplete documentation of resident communication methods. All deficiencies had plans of correction accepted and were implemented by 06/21/2024.
Citations (5)
Staff member A hired did not have documentation of a background check completed until after hire.
Resident 1 participated in the development of the support plan but did not sign the support plan.
Resident 1 and Resident 2 admitted to the Secure Dementia Care Unit lacked documentation that they and their designated persons had not objected to the admission.
Resident 1 did not have the initial support plan completed within 72 hours of move-in or within 72 hours prior to move into Secure Dementia Unit.
Resident 1's record showed language as English, but staff interviews indicated the resident speaks Swedish and communicates with gestures and facial expressions, which was not documented.
Report Facts
License Capacity: 98
Residents Served: 93
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 18
Current Hospice Residents: 3
Residents Age 60 or Older: 92
Residents with Mobility Need: 40
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Inspection Report — Jan 29, 2024
Renewal
Census: 89
Capacity: 98
Citations: 17
Date: Jan 29, 2024
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements and verify the implementation of a previously submitted plan of correction.
Findings
The inspection identified multiple deficiencies related to resident confidentiality, privacy, staff training, resident personal equipment, sanitary conditions, surfaces, furniture and equipment, lighting, annual medical evaluations, medication storage and administration, follow prescriber's orders, additional assessments, and support plan documentation. All deficiencies had accepted plans of correction with proposed completion dates and were noted as implemented by the report date.
Citations (17)
Narcotics logbook was unlocked, unattended, and accessible on the medication cart.
Medication administered to a resident in the presence of other residents, violating privacy.
Direct care staff received less than the required 12 hours of annual training.
Direct care staff did not receive required training on meeting residents' needs as described in assessment tools.
Direct care and ancillary staff did not receive required annual training in fire safety, emergency preparedness, and falls prevention.
Bedside mobility devices were not securely attached and covered with loose pillowcases posing hazards.
Crumbs, spills, and food particles found in memory care kitchen refrigerator; strong odor of feces in a resident's bathroom due to soiled underwear.
Rubber threshold cover was not flush causing tripping hazard; baseboard detached in resident's bathroom.
Memory care kitchen cabinet door off hinges; inoperable washer and dryer; missing dresser drawer in resident's bedroom.
Residents did not have operable bedside lamps accessible.
Residents' annual medical evaluations were not completed within required timeframes.
Loose pills found in medication cart in memory care unit.
Medication prescribed for a resident was not available in the home for administration.
Resident glucometer readings were inaccurately documented and glucometers were not calibrated correctly.
Medications prescribed for a resident were not administered as ordered.
Resident assessments were not completed annually or upon significant change as required.
Resident support plans did not document the need for bedside mobility devices or special dietary needs.
Report Facts
License Capacity: 98
Residents Served: 89
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 5
Resident Diagnosed with Mental Illness: 1
Resident Diagnosed with Intellectual Disability: 1
Resident with Mobility Need: 26
Resident with Physical Disability: 1
Inspection Report — Jul 31, 2023
Complaint Investigation
Census: 86
Capacity: 98
Citations: 14
Date: Jul 31, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial inspection on 07/31/2023.
Complaint Details
The inspection was complaint-driven and incident-related, with a follow-up plan of correction submission required and accepted.
Findings
Multiple deficiencies were identified including unsecured poisonous materials accessible to residents, malfunctioning exit gate blocking egress, medication administration errors, incomplete medical evaluations, and inadequate resident support plans. Plans of correction were accepted and implemented by 09/28/2023.
Citations (14)
Colgate toothpaste labeled 'poisonous if swallowed' was unlocked and accessible in resident #1's bathroom.
The gate in the memory care courtyard was malfunctioning and blocked exit egress.
A private duty aide administered medications without required medication administration training.
Medication was not placed in resident #3's hand, mouth, or other route as ordered by the prescriber.
Pharmacy label for resident #2's Levothyroxine did not include a change of directions sticker for administration.
No notation in resident #2's file documenting anxiety or reason for Lorazepam administration on specified dates.
Medication administration record for resident #2 lacked initials of staff administering Lorazepam on specified dates.
Resident #3 was administered Acetaminophen at an incorrect time and missed Melatonin doses.
Resident #2 was improperly handled during transfer, resulting in being dropped onto bed.
Resident #1's medical evaluation did not indicate the need for a secure dementia care unit.
No documentation that resident #4 and designated person did not object to admission to the secure dementia care unit.
Resident #4's initial support plan was completed late; resident #5's support plan lacked completion date.
Resident #5's support plan did not identify supervision and mobility needs.
Resident #5 and designated person were not involved in the development of the support plan.
Report Facts
License Capacity: 98
Residents Served: 86
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 18
Hospice Residents: 5
Residents Age 60 or Older: 76
Residents with Mobility Need: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Named in the finding related to improper handling of resident #2 during transfer. |
Inspection Report — Mar 27, 2023
Complaint Investigation
Census: 84
Capacity: 98
Citations: 4
Date: Mar 27, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at Spring Mill Senior Living to review compliance with resident care and record-keeping requirements.
Complaint Details
The visit was complaint-related and included incident investigation. The submitted plan of correction was fully implemented as of May 5, 2023.
Findings
The inspection found deficiencies related to inadequate staffing and supervision in the memory care unit, incomplete medical evaluations lacking special health or dietary needs, and missing incident reports in resident records. Plans of correction were accepted and implemented by early May 2023.
Citations (4)
Resident 1 did not receive extensive supervision as required by his/her support plan due to lack of available direct care staffing in the memory care unit.
On the date of inspection, 18 residents were present in the memory care area with only two staff members on duty, one of whom was asleep during a combined break, resulting in inadequate staffing coverage.
Resident 1's medical evaluation did not include special health or dietary needs of the resident.
Resident 1's record did not include a copy of the incident reports for the individual at the time of inspection due to an ongoing investigation.
Report Facts
License Capacity: 98
Residents Served: 84
Memory Care Capacity: 22
Memory Care Residents Served: 18
Current Residents in Hospice: 1
Residents Age 60 or Older: 84
Residents with Mobility Need: 30
Residents with Physical Disability: 2
Staffing - Total Daily Staff: 114
Staffing - Waking Staff: 86
Staff on Duty in Memory Care: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Health and Wellness | Assistant Director of Health and Wellness | Responsible for staffing memory care and personal care units, re-education on care plans, scheduling breaks, and auditing medical evaluations and incident reports. |
| Executive Director | Executive Director | Monitors monthly staffing schedules, audits resident charts quarterly, and ensures incident reports are filed and sent to DHS. |
Inspection Report — Jun 29, 2022
Renewal
Census: 61
Capacity: 98
Citations: 0
Date: Jun 29, 2022
Visit Reason
The inspection was conducted as a renewal licensing inspection of the Spring Mill Senior Living facility.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 61
License Capacity: 98
Secured Dementia Care Unit Capacity: 22
Residents Served in Dementia Care Unit: 17
Hospice Residents: 7
Residents with Mobility Need: 25
Residents with Physical Disability: 2
Residents Diagnosed with Mental Illness: 1
Residents 60 Years or Older: 61
Inspection Report — Apr 6, 2022
Follow-Up
Census: 69
Capacity: 98
Citations: 2
Date: Apr 6, 2022
Visit Reason
The inspection was a follow-up review conducted on 04/06/2022 to verify the implementation of a previously submitted plan of correction related to an incident.
Findings
The submitted plan of correction was determined to be fully implemented, with the facility ensuring resident participation in support plan development and proper documentation of refusals to sign support plans.
Citations (2)
Resident #1 was not provided an opportunity to participate in the development of their support plans.
Resident #1 did not sign the support plan and the facility failed to document the refusal or inability to sign.
Report Facts
License Capacity: 98
Residents Served: 69
Secured Dementia Care Unit Capacity: 21
Residents Served in Dementia Care Unit: 12
Total Daily Staff: 91
Waking Staff: 68
Residents with Mobility Need: 22
Residents with Physical Disability: 2
Inspection Report — Feb 7, 2022
Follow-Up
Census: 70
Capacity: 98
Citations: 5
Date: Feb 7, 2022
Visit Reason
The inspection was a follow-up visit to review the submitted plan of correction related to an incident at the facility.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing deficiencies related to resident care, abuse, direct care staff training, self-administration of medication, and prescription medication administration.
Citations (5)
Resident #1 did not receive required total physical assistance with transferring and repositioning every two hours as indicated in the resident’s assessment and support plan.
Resident #1 was neglected when staff failed to return the pendant alert button, preventing the resident from calling for assistance, resulting in the resident sliding out of bed onto the floor and not being checked between midnight and 6am.
Direct care staff person A provided unsupervised ADL services without completing the required Department-approved direct care training and competency test.
Resident #1 was self-administering medications contrary to the resident’s assessment and support plan which indicated the resident was not capable of self-administering medications.
Resident #1’s morning medications were administered by a private hire companion aide not employed by the facility, contrary to regulations requiring administration by approved staff.
Report Facts
License Capacity: 98
Residents Served: 70
Memory Care Capacity: 22
Memory Care Residents Served: 12
Current Hospice Residents: 2
Total Daily Staff: 91
Waking Staff: 68
Inspection Report — Dec 13, 2021
Renewal
Census: 71
Capacity: 98
Citations: 9
Date: Dec 13, 2021
Visit Reason
The inspection was conducted as a renewal, provisional licensing inspection of Spring Mill Senior Living on 12/13/2021 and 12/14/2021.
Findings
The inspection identified multiple deficiencies related to resident privacy, medication storage and administration, annual medical evaluations, and medication record keeping. Plans of correction were accepted for all cited deficiencies with specified completion dates.
Citations (9)
The home has video recording on the premises without signs indicating that images are being recorded.
An unlocked, unattended poisonous sanitizer was accessible to residents in the memory care common area.
Resident #1's most recent annual medical evaluation was not completed timely.
Resident #2 was unable to identify how much and when medications are to be taken, indicating inability to self-administer safely.
Expired insulin belonging to resident #3 was found on the medication cart past the discard date.
Medications prescribed as needed (PRN) for residents #4, #5, #6, and #7 were not available in the home.
Medication Administration Records for residents #3 through #10 did not indicate date and time of medication administration for prescribed medications.
Resident #2 and #5 had prescribed medications that were not available in the home.
Resident #10's prescribed device was not changed as ordered, and medication dosing did not match sliding scale requirements.
Report Facts
License Capacity: 98
Residents Served: 71
Memory Care Capacity: 22
Memory Care Residents Served: 11
Hospice Residents: 5
Residents 60 Years or Older: 70
Residents with Mobility Need: 18
Notice — Sep 11, 2021
Capacity: 98
Citations: 0
Date: Sep 11, 2021
Visit Reason
This document serves as a renewal notification and license issuance for the Personal Care Home 'Spring Mill Senior Living' following receipt of the renewal application dated June 1, 2021. It also advises that an annual inspection will be conducted within the next twelve months as required by regulation.
Findings
The Department issued a regular license in response to the renewal application and confirmed the facility's compliance with applicable regulations. No inspection findings or deficiencies are reported in this document.
Report Facts
Maximum licensed capacity: 98
Secure Dementia Care Unit capacity: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report — Jun 17, 2021
Follow-Up
Census: 60
Capacity: 98
Citations: 3
Date: Jun 17, 2021
Visit Reason
The inspection was conducted as a follow-up to review the submitted plan of correction related to an incident and behavioral assessments at the facility.
Complaint Details
The visit was incident-related due to a reported abuse incident involving staff and a resident. The complaint was substantiated as the facility failed to report the incident timely.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing failure to report an abuse incident timely and inadequate behavioral assessments and support plans for a resident with significant behavioral changes.
Citations (3)
Failure to report an incident of abuse to the Department within 24 hours as required.
Failure to complete additional assessments for a resident with significant behavioral changes.
Failure to document aggressive behavior in the resident's support plan despite documented behavioral changes.
Report Facts
License Capacity: 98
Residents Served: 60
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 10
Hospice Current Residents: 6
Residents Age 60 or Older: 60
Residents with Mobility Need: 12
Inspection Report — Apr 21, 2021
Complaint Investigation
Census: 67
Capacity: 98
Citations: 3
Date: Apr 21, 2021
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulations at Spring Mill Senior Living.
Complaint Details
The visit was complaint-related, with a follow-up type of Plan of Correction (POC) submission. The submitted plan of correction was fully implemented as of the inspection date.
Findings
The inspection identified deficiencies related to orientation of agency staff, medication administration documentation, and preadmission cognitive screening for a resident in the secured dementia care unit. Plans of correction were submitted and determined to be fully implemented.
Citations (3)
Failure to provide documentation that agency staff received orientation on fire safety and emergency preparedness prior to or during the first work day.
Medication administration record for Resident #1 did not include staff initials for certain medication administrations on specified dates and times.
Resident #1 admitted to the secured dementia care unit did not have a written cognitive preadmission screening completed within 72 hours prior to admission.
Report Facts
License Capacity: 98
Residents Served: 67
Memory Care Capacity: 22
Memory Care Residents Served: 10
Resident Mobility Need: 11
Resident Physical Disability: 1
Total Daily Staff: 78
Waking Staff: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Claire Mendez | Signed the letter regarding the plan of correction implementation. | |
| Director of Health & Wellness | Responsible for maintaining orientation records, auditing narcotic log book, and auditing resident files for cognitive pre-screening. | |
| Assistant Director of Health & Wellness | Re-inserviced on Regulation 231c related to cognitive preadmission screening. | |
| Executive Director | Responsible for reviewing compliance at Quality Assurance meetings. |
Inspection Report — Mar 16, 2021
Complaint Investigation
Census: 54
Capacity: 98
Citations: 6
Date: Mar 16, 2021
Visit Reason
The inspection was conducted as a complaint investigation with multiple unannounced partial inspections and an on-site visit to address allegations and concerns at Spring Mill Senior Living.
Complaint Details
The complaint investigation was triggered by concerns related to resident abuse and neglect, specifically regarding the failure to provide timely CPR to resident #1 who was found unresponsive and subsequently died. Additional complaints involved resident record access and medication administration practices.
Findings
The inspection found multiple deficiencies including abuse related to failure to provide timely CPR to a resident who became unresponsive, denial of resident record access, failure to provide CPR by trained staff, medication refusal documentation issues, unsafe physical environment hazards, and unapproved medication administration by a private duty caregiver.
Citations (6)
Resident #1 was found unresponsive with dark brown coffee ground emesis; staff failed to initiate CPR promptly.
Resident record access was denied to family without proper written approval until April 9, 2021.
Two agency staff failed to render CPR assistance to resident #1 in accordance with training.
Iron support jetting out five inches on second floor landing created a tripping hazard.
Resident #1 and #2 refused multiple prescribed medications without documented physician response.
Private duty caregiver administered medications without completing Department-approved medication administration course.
Report Facts
Inspection Dates: 9
License Capacity: 98
Residents Served: 54
Secured Dementia Care Unit Capacity: 22
Residents Served in Dementia Unit: 9
Staffing Hours: 64
Waking Staff Hours: 48
Medication Refusals: 20
Inspection Report — Jan 8, 2021
Complaint Investigation
Census: 75
Capacity: 98
Citations: 0
Date: Jan 8, 2021
Visit Reason
The inspection was conducted as a complaint investigation with multiple off-site inspection dates from 01/08/2021 to 01/25/2021.
Complaint Details
The inspection was complaint-related and unannounced, with an exit conference held on 01/13/2021. No deficiencies or citations were substantiated.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 98
Residents Served: 75
Memory Care Capacity: 22
Memory Care Residents Served: 17
Hospice Current Residents: 4
Hospice Capacity: 20
Residents Age 60 or Older: 74
Residents with Mobility Need: 17
Residents with Physical Disability: 1
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