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Inspection visit

Health inspection

SPRING CREEK REHABILITATION AND NURSING CENTERCMS #3950741 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

395074 03/11/2025 Spring Creek Rehabilitation and Nursing Center 1205 South 28th Street Harrisburg, PA 17111
F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of select facility grievances, review of the menu and select facility recipes, observation, completion of one meal test tray, and resident and staff interviews, it was determined that the facility failed to provide foods that are palatable, attractive, and at appetizing temperatures at one of one meal observed. Residents Affected - Few Findings include: Review of facility grievance log from January 2025, revealed a grievance filed on January 16, 2025, that stated, Resident stated meals are frequently cold. Chicken noodle soup last evening was cold, and bowl was only half full. Also stated tomato soup Monday evening was cold and watery. Review of facility grievance log from January 2025, revealed another grievance filed on January 16, 2025, on behalf of another resident, that states, French toast and bacon was cold when received this morning. Resident stated food is frequently cold. Review of facility menu on March 11, 2025, revealed the lunch menu consisted of Chicken with Lemon Pepper, Fluffy Steamed Rice, Peas & Carrots, and Fruit Jello & Topping. Review of the recipe that was provided for Lemon Pepper Chicken, read, in part, Place chicken in a roasting pan, brush with oil and rub well with seasoning, bake at 350 [degrees Fahrenheit - F] for 45-60 minutes until chicken begins to brown. Review of the recipe that was provided for Steamed Rice, read, in part, Place rice in stock pot or kettle, add water. Bring water to a boil, reduce heat, cover pot & simmer rice 20-25 minutes until done, rice tender, water absorbed & internal temperature of 140 [degrees Fahrenheit]. Fluff rice with service fork, add margarine & season with salt & pepper. The recipe also contained an alternate steamer method for the cooking process. A test tray was completed on March 11, 2025, at 1:17 PM, with Employee 10 (Food Service Director) that included the Chicken with Lemon Pepper, Fluffy Steamed Rice, Peas &Carrots, Fruit Jello (without topping), Milk, and Coffee. The test tray was placed on a meal cart and delivered to [NAME] 3 unit with other trays being delivered at that time; 18 minutes had elapsed between with the test tray was prepared from the service line and presented for evaluation. Employee 10 took temperatures of the food items at the time the test tray was served for evaluation. At that time, the chicken had a recorded highest temperature of 121.4 degrees F and the rice had a recorded highest temperature of 114.7 F; both the chicken and rice were not at appetizing Page 1 of 2 395074 395074 03/11/2025 Spring Creek Rehabilitation and Nursing Center 1205 South 28th Street Harrisburg, PA 17111
F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few temperatures. In addition, the chicken was opaque white in color, not browned, and tasted and appeared under seasoned. The rice tasted and appeared under seasoned, as well as undercooked. The surveyor discussed the results of the test tray with Employee 10. During an interview with Resident 2 on March 11, 2024, at 1:20 PM, he revealed his lunch lacked flavor and wasn't warm enough. He further revealed that his food is never warm enough. During an interview with the Nursing Home Administrator and the Director of Nursing on March 11, 2025, at 2:18 PM, the surveyor revealed the concern with food palatability and the test tray results. No further information was provided. 28 Pa. Code 201.14. Responsibility of licensee 395074 Page 2 of 2

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Citations

1 citation 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.

  • 0804GeneralS&S Dpotential for harm

    F804 - Food and drink

    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

FAQ · About this visit

Common questions about this visit

What happened during the March 11, 2025 survey of SPRING CREEK REHABILITATION AND NURSING CENTER?

This was a inspection survey of SPRING CREEK REHABILITATION AND NURSING CENTER on March 11, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at SPRING CREEK REHABILITATION AND NURSING CENTER on March 11, 2025?

Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature."

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

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