Health inspection·March 21, 2025

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on facility policy review, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one of 10 residents reviewed (Resident 2). Findings include: Review of facility policy, titled Administering Medications last revised December 2012, read, in part, Medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time frame. Review of Resident 2's clinical record revealed diagnoses that included pancreatitis (inflammation of the pancreas that can cause swelling, pain, and changes in how an organ or tissues work), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), and hypertension (high blood pressure). Review of Resident 2's physician orders revealed an order for Creon Oral Capsule (a medication that contains digestive enzymes to aid in the breakdown of food), give four capsules by mouth three times a day with meals. The administration times for the medication were noted as 7:30 AM, 11:30 AM, and 5:30 PM daily, consistent with the mealtimes on the nursing unit. Review of Resident 2's care plan revealed a focus area Nutritional Care Plan: at risk for malnutrition related to chronic disease and increased metabolic needs, with a start date of March 13, 2025, with an intervention for administer medications and obtain labs as ordered, with a start date of March 13, 2025. Observation on the South 1 Nursing Unit on March 20, 2025, at 9:30 AM, revealed Resident 2's call light was on above his room. During an interview with Resident 2 on March 20, 2025, between 9:33 AM and 9:44 AM, he revealed that he had stomach issues, and he required a medication called Creon with meals. He further revealed he had his call light on because he still hasn't received the medication, despite that it should have been served with his breakfast meal around 7:30 AM. He stated that he was requesting to have his medication, as well as a lactose free milk to have the medication with some cereal. During an interview with Employee 1 (Registered Nurse Unit Manager) on March 20, 2025, at 9:46 AM, (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395074 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spring Creek Rehabilitation and Nursing Center 1205 South 28th Street Harrisburg, PA 17111 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)