Deficiencies per Year
80
60
40
20
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 81
Capacity: 98
Deficiencies: 52
Mar 17, 2025
Visit Reason
The inspection was conducted as a renewal licensing inspection with multiple visits in 2025, including follow-ups and enforcement actions due to violations found.
Findings
Multiple violations were found including confidentiality breaches, improper medication administration and storage, inadequate staff training, unsafe resident equipment, sanitation issues, and failure to follow emergency procedures. Several repeat violations were noted. Enforcement actions including fines and provisional licensing were issued.
Complaint Details
The complaint investigation involved allegations of resident abuse, neglect, and inadequate supervision resulting in injury and death of resident #2, as well as a heat exposure incident involving resident #1. The investigation found substantiated verbal and physical abuse by a staff person and resident-to-resident abuse resulting in fatal injury. Additional concerns included failure to report incidents timely and inadequate supervision during extreme heat conditions.
Deficiencies (52)
| Description |
|---|
| 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 and accessible. |
| Resident-home contracts were not signed by residents or lacked documentation of opportunity to sign. |
| Quality management meetings were not held quarterly as required. |
| Multiple cameras were found operating without proper signage or policy in resident areas. |
| 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 administration and resident care topics. |
| Resident bedside mobility devices were not properly secured or covered, creating entrapment hazards. |
| Poisonous materials were unlocked and accessible to residents in janitor closets. |
| 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 resident telephones. |
| Furniture and equipment such as boilers were not maintained in good repair. |
| Resident bed linens and blankets were stained and not clean. |
| Residents did not have operable lamps or lighting at bedside. |
| Resident bedroom carpets were stained and not properly maintained. |
| Emergency procedures did not include contact information for each resident’s designated person and were not posted conspicuously. |
| Residents did not evacuate to a public thoroughfare or fire-safe area within designated time during fire drills. |
| Residents did not evacuate to designated meeting places during fire drills. |
| Resident medical evaluations were not completed within required timeframes. |
| Menus were not posted one week in advance as required. |
| First aid kits in vehicles lacked required contents such as thermometers. |
| Residents self-administering medications were not properly assessed or medication storage was unsecured. |
| Medication records lacked required documentation including medication lists, administration times, and staff initials. |
| Staff administering medications had not completed required Department-approved medication administration training. |
| Prescription medications and syringes were not kept locked in resident rooms. |
| Discontinued and expired medications were found in medication carts and not properly disposed. |
| Medications were not stored properly according to sanitation and manufacturer instructions. |
| Medication disposal was not performed according to Department of Environmental Protection and Federal regulations. |
| Procedures for safe storage, access, security, distribution and use of medications were not fully implemented. |
| Medication records did not include all required information such as dosage, route, and administration times. |
| The home did not follow prescriber's orders for medication administration and wound care. |
| Resident records were not kept confidential; assignment sheets and logs were accessible in memory care unit. |
| The home failed to comply with applicable health and safety laws regarding food manager certification coverage. |
| Resident-home contracts were not signed by residents in memory care unit. |
| Direct care staff did not complete required resident rights training. |
| Resident bedside mobility devices were not compliant with safety regulations and were replaced after family notification. |
| Poisonous materials were unlocked and accessible in memory care unit. |
| Sanitary conditions were not maintained; stained pads on shower chairs were found. |
| Trash outside the home was not properly contained; debris and broken chairs were found near dumpster. |
| Residents did not evacuate to designated meeting places during fire drills; education and new procedures planned. |
| Menus were not posted one week in advance. |
| Residents self-administering medications were not properly assessed for ability and need for reminders. |
| Resident medication records did not include all prescribed medications or had expired medications. |
| Medication administration records lacked documentation of glucose readings and insulin units administered. |
| Medication administration records lacked staff initials at time of administration. |
| Medication carts contained discontinued, expired, or improperly stored medications. |
| Resident #1 suffered injury due to altercation with another resident resulting in hospitalization and death; heat exposure incident was not reported timely. |
| Nurse station was left unlocked and unattended with resident charts accessible. |
| Resident #2 was physically abused by another resident resulting in injury and death; heat exposure incident occurred with inadequate supervision. |
| Unlabeled used bar soap was found in shared resident bathroom. |
| Resident medical evaluations were not completed annually or timely. |
Report Facts
Fine Per Resident: 3
Fine Per Resident: 5
Fine Per Resident: 5
Census at Inspection: 88
Total Daily Staff: 101
Waking Staff: 76
License Capacity: 98
Residents Served: 81
Residents Served in Dementia Unit: 14
Current Residents in Hospice: 7
Residents 60 Years or Older: 81
Residents with Mobility Need: 20
Total Daily Staff: 105
Waking Staff: 79
Residents Served: 86
Residents Served in Dementia Unit: 15
Current Residents in Hospice: 4
Total Daily Staff: 106
Waking Staff: 80
Residents Served: 86
Residents Served in Dementia Unit: 16
Current Residents in Hospice: 5
Total Daily Staff: 112
Waking Staff: 84
Residents Served: 88
Residents Served in Dementia Unit: 18
Current Residents in Hospice: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Care Manager | Named in abuse and mistreatment findings involving residents #1 and #2 |
| Staff person B | Healthcare Coordinator | Involved in complaint investigation and abuse findings |
| Staff person C | Involved in abuse incident with resident #1 and staff person A | |
| Director of Memory Care | Director of Memory Care | Named in multiple findings including confidentiality, medication administration training, and bed enabler bar compliance |
| Executive Director | Executive Director | Named in multiple findings including enforcement actions, training, and compliance monitoring |
| Director of Health and Wellness | Director of Health and Wellness | Named in medication administration, training, and compliance monitoring |
| Assistant Director of Health and Wellness | Assistant Director of Health and Wellness | Named in medication administration, training, and compliance monitoring |
| Director of Culinary | Director of Culinary | Named in findings related to food safety and sanitation |
| Director of Maintenance | Director of Maintenance | Named in findings related to facility maintenance, safety, and fire drills |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 98
Deficiencies: 57
Mar 17, 2025
Visit Reason
The inspection was conducted as a renewal licensing inspection with multiple visits between March and August 2025, including complaint and incident investigations.
Findings
The facility was found to have multiple violations including confidentiality breaches, improper medication administration and storage, inadequate staff training, sanitary issues, improper emergency procedures, and resident abuse allegations. Several repeat violations were noted. The facility was issued a first provisional license with required plans of correction and follow-up inspections.
Complaint Details
Complaint investigation included allegations of resident abuse by staff and other residents, inadequate supervision leading to resident injury and heat stroke, and failure to report incidents to the Department. Multiple interviews and investigations were conducted. Staff person A was found to have been rough and impatient, leading to resident injury and death. Resident #1 suffered heat stroke due to inadequate supervision. Incident reporting was delayed. Confidentiality breaches were noted. Plans of correction include staff training, monitoring, and policy updates.
Deficiencies (57)
| Description |
|---|
| 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 not properly documented. |
| Quality management meetings were not held quarterly as required. |
| Multiple cameras were found operating in resident areas without proper signage or proof they were not recording. |
| Direct care staff did not have proper qualifications or training. |
| Resident personal equipment such as bedside mobility devices were not properly secured or covered. |
| Poisonous materials were unlocked and accessible to residents. |
| 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 resident telephones. |
| Furniture and equipment such as boilers were not maintained in good repair. |
| Resident bedsheets and carpets were stained and not clean. |
| Residents did not have operable lamps or lighting at bedside. |
| Emergency procedures did not include contact information for each resident’s designated person and were not posted conspicuously. |
| Residents did not evacuate to designated meeting places during fire drills and evacuation times exceeded limits. |
| Resident medical evaluations were not completed timely or annually as required. |
| Menus were not posted one week in advance. |
| First aid kits in vehicles lacked required contents. |
| Residents self-administering medications were not properly assessed or medication storage was unsecured. |
| Resident medication records were incomplete or inaccurate. |
| Staff administering medications lacked current Department-approved training. |
| Medications and syringes were not kept locked in resident rooms. |
| Discontinued or expired medications were not properly removed or destroyed. |
| Medication storage and administration procedures were not consistently followed. |
| Resident records lacked recent photographs. |
| Memory care resident assignment sheets were unlocked and accessible. |
| Food manager certified staff were not scheduled during all food preparation hours. |
| Resident-home contracts were unsigned by residents. |
| Direct care staff did not complete required resident rights training. |
| Bedside mobility devices were not properly secured or covered, creating entrapment hazards. |
| Poisonous materials were unlocked and accessible in memory care unit. |
| Sanitary conditions were not maintained; stained shower chair pad observed. |
| Trash outside the home was not properly contained; debris and broken chairs found near dumpster. |
| 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 and need for reminders. |
| Resident medication storage was unsecured in apartments. |
| Resident medication records were incomplete or inaccurate. |
| Staff administering medications lacked current Department-approved training. |
| Medications and syringes were not kept locked in resident rooms. |
| Discontinued medications were not removed from medication carts. |
| Medication storage was not organized and contained expired or loose pills. |
| Medication disposal was not done in a safe manner according to regulations. |
| Controlled substances were not stored under double lock as required. |
| Medication records lacked documentation of administration times and staff initials. |
| Resident #1 was exposed to heat and suffered heat stroke; incident was not reported timely to the Department. |
| Resident records were not kept confidential; nurse station was unlocked and accessible. |
| Resident #2 was physically abused by resident #3 resulting in fatal injury; resident #1 was found with heat stroke due to inadequate supervision. |
| Residents were not treated with dignity and respect; staff person A was accused of rough and impatient care. |
| Trash cans in kitchens were uncovered. |
| Bathroom fans were not operating properly in multiple resident rooms. |
| Thermometer was missing in deep freezer in main kitchen. |
| Food was stored in unsealed containers. |
| Lint accumulated in lint traps of dryers. |
| Resident #18 medication record did not indicate units of insulin administered per sliding scale. |
| Resident #9 blood sugar checks and wound care orders were not followed as prescribed. |
Report Facts
Fine Per Resident: 3
Fine Per Resident: 5
Fine Per Resident: 5
Census at Inspection: 88
License Capacity: 98
Residents Served: 81
Residents Served: 86
Residents Served: 88
Residents Served: 86
Residents Served: 88
Residents Served: 15
Residents Served: 16
Residents Served: 18
Residents Served: 4
Residents Served: 5
Residents Served: 7
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
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Care Manager | Named in resident abuse and mistreatment findings |
| Staff person B | Healthcare Coordinator | Involved in resident abuse investigation and medication administration training violation |
| Staff person C | Involved in resident abuse incident | |
| Staff person D | Named in training violations and resident rights training non-compliance | |
| Staff person F | Involved in medication disposal violation | |
| Staff person G | Named in medication administration training violation | |
| Director of Memory Care | Responsible for medication training audits and resident assignment confidentiality | |
| Director of Maintenance | Named in multiple findings including bed enabler bars, bathroom fans, and fire drill education | |
| Executive Director | Named in multiple findings including abuse investigation, training, and compliance monitoring | |
| Director of Health and Wellness | Named in medication administration, abuse investigation, and compliance monitoring | |
| Assistant Director of Health and Wellness | Named in medication administration, abuse investigation, and compliance monitoring |
Inspection Report
Renewal
Census: 81
Capacity: 98
Deficiencies: 34
Mar 17, 2025
Visit Reason
The inspection was a renewal licensing inspection conducted to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The facility was found to have multiple violations including confidentiality breaches, contract signature issues, quality management plan deficiencies, privacy violations related to surveillance cameras, direct care staff qualification issues, training deficiencies, resident personal equipment hazards, medication administration and storage problems, sanitary condition concerns, emergency preparedness issues, and record keeping deficiencies. Plans of correction were proposed with various completion dates.
Complaint Details
Complaint investigation related to allegations of resident abuse and neglect. Resident #1 and #2 reported concerns about staff person A being rough and impatient, resulting in injury to resident #2. Resident #1 experienced heat exposure due to inadequate supervision outside. The home failed to report the heat exposure incident to the department. Staff person A resigned during the investigation. The facility was cited for failure to treat residents with dignity and respect and failure to report incidents timely.
Deficiencies (34)
| Description |
|---|
| The home's current violation report was not posted in a conspicuous and public place in the home. |
| Memory care resident assignment sheets including resident toileting logs were unlocked, unattended, and accessible in the memory care unit activities room. |
| Resident-home contracts were not signed by residents and lacked documentation of opportunity to sign. |
| Quality management meetings were not held quarterly as required; only two meetings were held since 1/1/2024. |
| Multiple cameras were found throughout the home, some operating without proof of policy or signage, violating privacy. |
| Direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Direct care staff person did not receive required annual training on multiple topics including medication self-administration, dementia care, infection control, and fire safety. |
| Resident bedside mobility devices were not properly attached or covered, creating entrapment hazards. |
| Poisonous materials were unlocked and accessible to residents in the secured dementia care unit janitor's closet. |
| Sanitary conditions were not maintained including urine odor and unclean kitchenette drawer. |
| Trash outside the home was not kept in covered receptacles; dumpster lids were missing and trash was scattered. |
| Emergency telephone numbers were not posted on or by telephones in resident apartments. |
| Furniture and equipment including boilers were not in good repair; boiler was leaking. |
| Resident bed linens and blankets were stained and not clean. |
| Residents did not have operable lamps or sources of lighting that could be turned on at bedside. |
| Bedroom carpets had large stains and were not clean. |
| Home's written emergency procedures did not include contact information for each resident’s designated person. |
| Emergency procedures were not posted in a conspicuous and public place in the home. |
| 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 away from the building or within the fire-safe area during fire drills. |
| Resident medical evaluations were not completed within required timeframes prior to or after admission. |
| Menus were not posted one week in advance as required. |
| First aid kit in the bus used to transport residents did not include a thermometer. |
| Resident assessments did not identify ability to self-administer medications; some residents self-administered without proper assessment. |
| Medications stored in resident rooms were unlocked and accessible, not kept locked as required. |
| Resident medication records did not include current lists of all prescribed medications. |
| Staff person administered medications without completing Department-approved medication administration training. |
| Prescription medications, OTC medications, CAM and syringes were not kept locked in resident rooms. |
| Discontinued and expired medications were kept in the medication cart and not properly removed. |
| Medications were not stored in an organized manner; loose pills and expired medications were found in medication carts. |
| Discontinued medications were not destroyed in a safe manner according to regulations. |
| Controlled substances were not stored under double lock as required. |
| Medication records did not include required information such as administration times and staff initials. |
| The home did not follow prescriber's orders; blood sugar checks and wound care were not performed as ordered. |
Report Facts
Census at inspection: 88
Total daily staff: 112
Waking staff: 84
License capacity: 98
Fine amount: 1144
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in abuse and resident dignity violation findings | |
| Staff person B | Named in abuse investigation and medication administration training violation | |
| Staff person C | Named in abuse investigation | |
| Director of Memory Care | Director of Memory Care | Named in multiple findings including confidentiality, medication administration, and resident contract compliance |
| Executive Director | Executive Director | Named in multiple findings including abuse investigation, medication administration, and overall compliance monitoring |
| Director of Health and Wellness | Director of Health and Wellness | Named in medication administration, training, and compliance monitoring |
| Assistant Director of Health and Wellness | Assistant Director of Health and Wellness | Named in medication administration, training, and compliance monitoring |
| Director of Culinary | Director of Culinary | Named in food safety and sanitation findings |
| Director of Maintenance | Director of Maintenance | Named in findings related to equipment repair, safety, and fire drills |
Inspection Report
Monitoring
Census: 81
Capacity: 98
Deficiencies: 55
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.
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.
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.
Deficiencies (55)
| Description |
|---|
| 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
Complaint Investigation
Census: 84
Capacity: 98
Deficiencies: 6
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.
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.
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.
Deficiencies (6)
| Description |
|---|
| 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
Follow-Up
Census: 92
Capacity: 98
Deficiencies: 9
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.
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.
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.
Deficiencies (9)
| Description |
|---|
| 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
Complaint Investigation
Census: 93
Capacity: 98
Deficiencies: 0
May 29, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The visit was complaint-related and incident-related; no deficiencies or citations were found, indicating no substantiated issues.
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
Complaint Investigation
Census: 93
Capacity: 98
Deficiencies: 5
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.
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.
Complaint Details
The visit was complaint-related as indicated by the inspection information section specifying 'Reason: Complaint'.
Deficiencies (5)
| Description |
|---|
| 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
Renewal
Census: 89
Capacity: 98
Deficiencies: 17
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.
Deficiencies (17)
| Description |
|---|
| 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
Complaint Investigation
Census: 86
Capacity: 98
Deficiencies: 14
Jul 31, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial inspection on 07/31/2023.
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.
Complaint Details
The inspection was complaint-driven and incident-related, with a follow-up plan of correction submission required and accepted.
Deficiencies (14)
| Description |
|---|
| 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
Complaint Investigation
Census: 84
Capacity: 98
Deficiencies: 4
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.
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.
Complaint Details
The visit was complaint-related and included incident investigation. The submitted plan of correction was fully implemented as of May 5, 2023.
Deficiencies (4)
| Description |
|---|
| 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
Renewal
Census: 61
Capacity: 98
Deficiencies: 0
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
Follow-Up
Census: 69
Capacity: 98
Deficiencies: 2
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.
Deficiencies (2)
| Description |
|---|
| 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
Follow-Up
Census: 70
Capacity: 98
Deficiencies: 5
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.
Deficiencies (5)
| Description |
|---|
| 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
Renewal
Census: 71
Capacity: 98
Deficiencies: 9
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.
Deficiencies (9)
| Description |
|---|
| 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
Capacity: 98
Deficiencies: 0
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
Follow-Up
Census: 60
Capacity: 98
Deficiencies: 3
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.
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.
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.
Deficiencies (3)
| Description |
|---|
| 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
Complaint Investigation
Census: 67
Capacity: 98
Deficiencies: 3
Apr 21, 2021
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulations at Spring Mill Senior Living.
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.
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.
Deficiencies (3)
| Description |
|---|
| 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
Complaint Investigation
Census: 54
Capacity: 98
Deficiencies: 6
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.
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.
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.
Deficiencies (6)
| Description |
|---|
| 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
Complaint Investigation
Census: 54
Capacity: 98
Deficiencies: 6
Mar 16, 2021
Visit Reason
The inspection was conducted as a complaint investigation following multiple licensing inspections between March and April 2021 due to violations found at the facility.
Findings
The inspection found multiple violations including abuse resulting in a resident's death, failure to provide timely access to resident records, failure of staff to provide CPR in accordance with training, tripping hazards on the premises, refusal of medication documentation issues, and unlicensed medication administration by a private caregiver.
Complaint Details
The inspection was complaint-driven, triggered by allegations related to resident care and compliance issues. The complaint was substantiated by findings including abuse and neglect leading to a resident's death and other regulatory violations.
Deficiencies (6)
| Description |
|---|
| Resident #1 was found unresponsive with coffee ground emesis and without breathing; staff failed to initiate CPR until paramedics arrived. |
| Family was denied timely access to resident #1's records 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 causing a tripping hazard. |
| Resident #1 and #2 refused multiple prescribed medications without documented physician response. |
| Private duty personal caregiver administered medications without completing Department-approved medication administration course. |
Report Facts
License Capacity: 98
Residents Served: 54
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 9
Staffing Hours: 64
Waking Staff: 48
Medication Refusals: 20
Tripping Hazard Projection: 5
Inspection Report
Complaint Investigation
Census: 75
Capacity: 98
Deficiencies: 0
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.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related and unannounced, with an exit conference held on 01/13/2021. No deficiencies or citations were substantiated.
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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