Spring City Care and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Spring City Care and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF600Feb 27, 2024

  Based on facility policy, facility investigations police reports, medical record review and interview, the facility failed to protect a resident's right to be free from abuse for 6 of 20 (Resident #23, #24, #7, #8, #10 and #11) residents reviewed for abuse. The facility failed to protect Resident #23, a cognitively impaired female resident, from sexual abuse when Resident #24, a cognitively impaired male resident, made sexual advances toward Resident #23 causing mental distress, which resulted in actual harm to Resident #23 and when the facility failed to protect Resident (#7, #8, #10, #11) from resident-to-resident physical abuse. […]

• No harm, potential for more than minimal, widespreadF812Mar 1, 2023

  Based on facility policy review, manufacturer recommendations, observation, and interview, the facility failed to ensure the appropriate chemical sanitization ratio of a 3 compartment sink used for cleaning and sanitizing cooking equipment, failed to maintain a clean and sanitary work area in the dish room, and in 1 of 1 nourishment rooms which had the potential to affect 82 of 84 residents. The findings include: Review of the facility policy titled, Environment, revised 9/2017, showed .All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition .The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls .The Dining Services Director will ensure .proper procedures… […]

• No harm, potential for more than minimal, isolatedF550May 6, 2026

  Based on facility policy review, medical record review, observations, and interviews the facility failed to maintain dignity for 3 residents (Resident #25, #45, and #62) of 8 residents reviewed.The findings include: Review of the facility policy's titled, Assistance with Meals, dated 1/31/2025, revealed .Residents shall receive assistance with meals in a manner that meets the individual needs of each resident .Residents who cannot feed themselves will be fed with .dignity . Medical record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Mood Disorder, and Unspecified Protein-Calorie Malnutrition. […]

• No harm, potential for more than minimal, isolatedF641May 6, 2026

  Based on review of the Resident Assessment Instrument Manual 3.0 (RAI), medical record review, interview, and observation, the facility failed to accurately complete Minimum Data Set (MDS) assessments for 5 residents (Resident #32, # 62, #2, #59, and #27) of 20 residents reviewed for MDS assessments. The findings include: Review of the Centers for Medicare and Medicaid Services Long Term Care Facility RAI 3.0 User's Manual Version 1.20.1, dated 11/2025, revealed .A1500 .Preadmission Screening and Resident Review (PASRR) .Code .yes .if PASRR Level II screening determined that the resident has a serious mental illness . SECTION L .ORAL/DENTAL STATUS .This item is intended to record any dental problems present .check all that apply .obvious broken natural teeth . […]

• No harm, potential for more than minimal, isolatedF677May 6, 2026

  Based on medical record review, observation's, and interview's, the facility failed to provide assistance for activities of daily living (ADL) for 1 dependent resident (Resident #42) of 26 residents sampled for ADL care.The findings include:Review of the facility's policy titled Activities of Daily Living (ADLs) dated 1/30/2026, revealed .For residents who are unable to perform their own activities of daily living, the facility will provide the needed assistance for completion of cares .Medical record review revealed Resident #42 was admitted to the facility on [DATE] with diagnoses including Dementia, Stroke, and Schizophrenia.Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #42 scored a 4 on the Brief Interview for Mental Status (BIMS) assessment… […]