Sinking Spring Skilled Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Sinking Spring Skilled Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jan 8, 2026

  Based on facility policy review, clinical record review, observation, and resident and staff interviews, it was determined the facility failed to ensure that residents were free from physical and mental abuse for one of seven sampled residents. (Resident 1) This failure resulted in an Immediate Jeopardy situation.Findings include: Review of the facility policy entitled, Abuse Prohibition, last reviewed April 17, 2025, revealed that the facility prohibited abuse, mistreatment, and neglect for all residents. The policy further defined abuse as willful infliction, meaning the individual acted deliberately, not that the individual must have intended to inflict injury or harm. […]

• Actual harm, isolatedF550Jan 8, 2026

  Based on facility policy review, clinical record review, and resident and staff interview, it was determined that the facility failed to provide care and services in a manner that respected each resident's dignity and preferences to promote quality of life, resulting in psychosocial harm for one of seven sampled residents. (Resident 1)Findings include: Review of the facility policy entitled, Treatment: Considerate and Respectful, reviewed February 21, 2025, revealed that residents were to be groomed as they wished to be groomed, which included maintaining the resident's personal preference regarding hair style and length. Clinical record review revealed that Resident 1 had diagnoses that included chronic pain syndrome, major depressive disorder, and anxiety. […]

• Actual harm, isolatedF600Mar 27, 2025

  Based on facility policy review, clinical record review, review of facility documentation, and resident interview, it was determined that the facility failed to ensure that residents were free from mental and/or physical abuse for two residents (Residents 1 and 2), which resulted in psychosocial harm for one of seven residents reviewed. (Resident 1) Findings include: Review of the facility policy entitled, Abuse Prohibition, last reviewed February 21, 2025, revealed that instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. […]

• Actual harm, isolatedF600Oct 27, 2022

  Based on review of facility policy, clinical record review, review of facility documentation, and resident and staff interviews, it was determined that the facility failed to prevent neglect that resulted in a serious injury and actual harm, (bilateral fractured shoulders), for one of seven sampled residents who was dependent on staff for assistance with transfers. (Resident 132) Findings include: Review of the facility policy entitled Injury Prevention Lifts and Injury-Reducing Devices Manual, dated October 13, 2022, revealed that when utilizing lifts it was advisable to have two staff present to stabilize and support the resident. Clinical record review revealed that Resident 132 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF684Oct 22, 2021

  Based on clinical record review and staff interview, it was determined that the facility failed to provide care and treatment in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident 205). This deficiency is cited as past noncompliance. Findings include: Clinical record review revealed that Resident 205 was admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Clinical record documentation also reflected that the resident had a [CONDITION(S)]. (A [CONDITION(S)] is a surgically created opening through the neck into the trachea - the windpipe - into which a tube is placed. Once the [CONDITION(S)] is created and a [CONDITION(S)] tube inserted, the person breathes through this tube. […]