Deficiency Records for Spring Grove Rehabilitation and Healthcare Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Spring Grove Rehabilitation and Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure each resident receives an accurate assessment. | Health | 2023-08-15 | 2023-09-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-15 | 2023-09-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-15 | 2023-09-08 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-08-15 | 2023-09-08 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-08-15 | 2023-09-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-15 | 2023-09-08 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-08-15 | 2023-09-08 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-08-15 | 2023-09-08 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-08-15 | 2023-09-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-03 | 2023-01-03 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-07-23 | 2021-08-12 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-07-23 | 2021-08-12 | Y |
| Ensure that smoke control systems are tested and documented in accordance with established engineering principles. | Fire Safety | 2021-06-03 | 2021-07-21 | N |
| Provide activities to meet all resident's needs. | Health | 2021-06-03 | 2021-06-30 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-06-03 | 2021-06-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-03 | 2021-06-30 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-06-03 | 2021-06-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-03 | 2021-06-30 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-06-03 | 2021-06-30 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2021-06-03 | 2021-06-30 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2021-06-03 | 2021-06-30 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2021-06-03 | 2021-06-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-03 | 2021-06-27 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-06-03 | 2021-06-20 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-07-30 | 2019-09-10 | N |
| Respond appropriately to all alleged violations. | Health | 2019-07-30 | 2019-09-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-07-30 | 2019-09-10 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-07-30 | 2019-09-10 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-07-30 | 2019-09-10 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-07-30 | 2019-09-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-30 | 2019-09-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-07-30 | 2019-09-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-30 | 2019-09-10 | N |
