Spencer Post Acute Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Spencer Post Acute Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF880Sep 14, 2021

  Based on observation, interview and record review, the facility failed to establish adequate measures to mitigate the spread of the Covid-19 virus. In the Northshire building, residents that tested positive for Covid-19 were not separated from the population that was still testing negative. A plastic barrier was taped on to the door frames of those that were positive but the negative residents continued to remain in their rooms and doors were left open. The findings constituted an Immediate Jeopardy (IJ) to resident health and safety. The facility reported a census of 64 residents. Findings include: According to a Report of Covid-19 positive cases provided by the Administrator, on 8/19/21 a staff person tested positive and the first positive resident case was on 8/24/21. […]

• Immediate jeopardy, isolatedF678May 20, 2024

  Based on clinical record review, staff interviews, personnel records and facility policy review on [DATE] the facility staff failed to implement CPR (cardiopulmonary resuscitation) for one of five residents sampled (Resident #1), who was found unresponsive with no pulse or respirations and desired CPR. This resulted in immediate jeopardy to the residents health and safety. The facility identified a census of 53 current residents, 13 of which were identified by the facility with a request for CPR at the time of cardiopulmonary or respiratory arrest. The facility was notified of the Immediate Jeopardy (IJ) and given the IJ template on [DATE] at 12:15 PM. The immediacy had been removed on [DATE] when the facility provided staff education and review of their policy. […]

• Immediate jeopardy, isolatedF760Oct 30, 2023

  Based on document review, observation, record review, and staff interviews the facility failed to protect a resident from a significant medication error. A nurse committed to giving 37 units of Aspart insulin (Novolog) to Resident #47 at 9:45 AM after drawing it up from a vial, then put the vial back into the medication cart. Resident #47 has an order that reads Levemir Subcutaneous Solution 100 UNIT/ML inject 37 units subcutaneously in the morning for 1 of 4 residents reviewed (Resident #47). The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of October 25, 2023 on October 25th, 2023 at 4:40 P.M. The Facility Staff removed the Immediate Jeopardy on October 26, 2023 through the following actions: a. […]

• Actual harm, isolatedF684Jun 4, 2026

  Based on observation, record review, and staff interview, the facility failed to provide adequate assessment and timely intervention to assure 2 of 3 residents (Resident #1 and #2) received prompt treatment for a change in condition. Resident #1 had urinary tract infection (UTI) symptoms on the weekend of 5/16-17/26 and the facility failed to notify the physician or initiate any other interventions related to the symptoms. Resident #1 had difficulty catching her breath after the evening meal on [DATE] and needed staff to intervene for the resident to clear it. According to the clinical record the resident sat where she could be observed for a half hour and then went to bed. The clinical record lacked documentation the staff monitored her after going to bed. […]

• No harm, potential for more than minimal, patternF628Aug 14, 2025

  Based on clinical record review, interviews, and facility policy, the facility failed to ensure bed hold notice was signed by residents and or the resident's responsible person when residents transferred out of the facility for 4 of 4 residents reviewed (Residents #2, #4, #5 and #9). The facility reported a census of 67 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #4 documented reentry to the facility on 2/20/25 for a short term hospital stay. Review of the Clinical Census report for Resident #4 revealed the following information:a. 11/25/24- hospital leaveb. 12/3/24- activec. 2/9/25- hospital d. 2/11/25- active Review of the Progress Notes for Resident #4 revealed the following:a. […]