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Inspection visit

Inspection

Spencer Post Acute Rehabilitation CenterCMS #16544928 citations on this visit
28 citations recorded

Citations

28 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0291GeneralS&S Fpotential for harm

    Install emergency lighting that can last at least 1 1/2 hours.

  • 0567GeneralS&S Dpotential for harm

    F567 - The resident has a right to manage his or her financial affairs

    Honor the resident's right to manage his or her financial affairs.

  • 0605GeneralS&S Dpotential for harm

    F605 - Respect and Dignity

    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

  • 0628GeneralS&S Epotential for harm

    F628 - Documentation

    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

  • 0656GeneralS&S Dpotential for harm

    F656 - Comprehensive Care Plans

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0684GeneralS&S Dpotential for harm

    F684 - Quality of care

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0692GeneralS&S Dpotential for harm

    F692 - Assisted nutrition and hydration

    Provide enough food/fluids to maintain a resident's health.

  • 0693GeneralS&S Dpotential for harm

    F693 - Assisted nutrition and hydration

    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

  • 0698GeneralS&S Dpotential for harm

    F698 - Dialysis

    Provide safe, appropriate dialysis care/services for a resident who requires such services.

  • 0759GeneralS&S Dpotential for harm

    F759 - Medication Errors

    Ensure medication error rates are not 5 percent or greater.

  • 0760GeneralS&S Dpotential for harm

    F760 - Residents are free of any significant medication errors

    Ensure that residents are free from significant medication errors.

  • 0803GeneralS&S Dpotential for harm

    F803 - Menus and nutritional adequacy

    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

  • 0842GeneralS&S Dpotential for harm

    F842 - Resident-identifiable information

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  • 0880GeneralS&S Epotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

  • 0883GeneralS&S Dpotential for harm

    F883 - Influenza and pneumococcal immunizations

    Develop and implement policies and procedures for flu and pneumonia vaccinations.

  • 0161GeneralS&S Fpotential for harm

    Use approved construction type or materials.

  • 0222GeneralS&S Epotential for harm

    Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

  • 0321GeneralS&S Fpotential for harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  • 0324GeneralS&S Fpotential for harm

    Provide properly protected cooking facilities.

  • 0331GeneralS&S Fpotential for harm

    Construct fire resistant interior walls.

  • 0346GeneralS&S Fpotential for harm

    Follow proper procedures when the fire alarm was out of service for more than 4 hours.

  • 0354GeneralS&S Fpotential for harm

    Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

  • 0363GeneralS&S Epotential for harm

    Install corridor and hallway doors that block smoke.

  • 0712GeneralS&S Fpotential for harm

    F712 - Frequency of physician visits

    Have simulated fire drills held at unexpected times.

  • 0761GeneralS&S Epotential for harm

    F761 - Labeling of Drugs and Biologicals

    To conduct inspection, testing and maintenance of fire doors by qualified individuals.

  • 0918GeneralS&S Fpotential for harm

    F918 - Bathroom Facilities

    Have generator or other power source capable of supplying service within 10 seconds.

  • 0920GeneralS&S Epotential for harm

    F920 - Dining and Resident Activities

    Ensure proper usage of power strips and extension cords.

  • 0922GeneralS&S Fpotential for harm

    F922 - Establish procedures to ensure that water is available to essential areas

    Meet requirements for the use and maintenance of medical gas equipment.

FAQ · About this visit

Common questions about this visit

What happened during the August 14, 2025 survey of Spencer Post Acute Rehabilitation Center?

This was a inspection survey of Spencer Post Acute Rehabilitation Center on August 14, 2025. The surveyor cited 28 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Spencer Post Acute Rehabilitation Center on August 14, 2025?

Yes, 28 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Install emergency lighting that can last at least 1 1/2 hours."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.