Springfield Senior Living Community.

“Staff person assigned as Power of Attorney and executor of a resident's estate, which is prohibited. Legal entities, administrators, and staff of the residence cannot hold power of attorney or guardianship of residents or their estates.”

“Resident #2 did not receive required assistance with bladder management as indicated in their assessment and support plan. The resident smelled of urine at approximately 9:00 am on 02/19/26.”

“Direct care staff person C received only one hour of annual training relating to job duties during training year 2025, falling significantly short of the 16 hours required. This is a repeat violation from 01/22/25 and 11/03/25.”

“Direct care staff person C did not receive required training in: medication self-administration, instruction on meeting resident needs per assessment, care for residents with dementia/cognitive/neurological impairments, infection control and hygiene, assisted living service needs, safe management techniques, and care for residents with mental illness or intellectual disability. Direct care staff person D did not receive training in medication self-administration and assisted living service needs. This is a repeat violation from 01/22/25 and 11/03/25.”

“Staff person C did not receive required annual training in resident rights, the Older Adult Protective Services Act, and falls and accident prevention during training year 2025. This is a repeat violation from 01/22/25 and 11/03/25.”

“Staff person C received zero hours of dementia-specific training during training year 2025, failing to meet the requirement of at least 2 hours of dementia-specific training annually.”

“On 02/18/26 at approximately 11:00 am, the bathroom floor in room B-318 was sticky with a strong odor of urine, indicating unsanitary conditions were not maintained.”

“The bathrooms in rooms #B-117 and #B-312 do not have operable outside windows, and the ventilation fans are inoperable, failing to meet bathroom ventilation requirements.”

“The center stairwell connected to the SDCU had several cracks in the wall and ceiling, indicating surfaces were not in good repair and posed potential hazards.”

“Emergency telephone numbers for the nearest hospital and fire department were not posted on or by the telephone in room #C-220, in violation of requirements to post emergency contact information by all telephones with outside lines.”

“When an allegation of abuse involving staff was reported, the residence failed to immediately suspend the two staff persons involved (Staff A and B). Instead, they continued to work multiple shifts after the incident was reported to the Department.”

“A resident requiring assistance with personal hygiene had not been showered or bathed since their arrival at the facility.”

“Two staff persons (A and B) handled a resident roughly during a shower, picking up and dragging the resident to the bathroom against the resident's objections despite the resident's stated medical condition and explicit refusal. This caused the resident physical pain and mental anguish. The resident also feared retaliation for reporting the incident.”

“When an allegation of abuse involving staff was reported, the residence failed to immediately suspend the two staff persons involved (Staff A and B). Instead, they continued to work multiple shifts after the incident was reported to the Department.”

“A resident requiring assistance with personal hygiene had not been showered or bathed since their arrival at the facility.”

“Two staff persons (A and B) handled a resident roughly during a shower, picking up and dragging the resident to the bathroom against the resident's objections despite the resident's stated medical condition and explicit refusal. This caused the resident physical pain and mental anguish. The resident also feared retaliation for reporting the incident.”

“Direct care staff person B does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry, which is required for direct care staff qualifications. This is a repeat violation.”

“Direct care staff person B received only 11.50 hours of annual training relating to job duties during training year 2024, falling short of the required 16 hours. This is a repeat violation.”

“Direct care staff person A did not receive training in medication self-administration and care for residents with mental illness or intellectual disability during the 2024 training year. Direct care staff person B did not receive training in medication self-administration, instruction on meeting resident needs as described in assessment documents, and infection control and hygiene principles during the 2024 training year.”

“Direct care staff person B does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry, which is required for direct care staff qualifications. This is a repeat violation.”

“Direct care staff person B received only 11.50 hours of annual training relating to job duties during training year 2024, falling short of the required 16 hours. This is a repeat violation.”

“Direct care staff person A did not receive training in medication self-administration and care for residents with mental illness or intellectual disability during the 2024 training year. Direct care staff person B did not receive training in medication self-administration, instruction on meeting resident needs as described in assessment documents, and infection control and hygiene principles during the 2024 training year.”

“Staff person A did not receive orientation on job duties before providing direct care. Staff person B did not receive orientation on job duties before providing direct care.”

“An unlabeled, undated and uncovered large white container of brown rice was present in the dry storage area.”

“Staff person A did not receive orientation on fire safety topics including evacuation procedures, staff duties during emergencies, designated meeting places, smoking safety procedures, fire extinguisher location and use, smoke detectors and fire alarms, and emergency notification procedures on their first day of work.”

“Staff person A did not complete required 40-hour orientation training including resident rights, emergency medical plan, mandatory reporting of abuse and neglect, reportable incidents, safe management techniques, and core competency training in person-centered care, communication/problem solving/relationship skills, and nutritional support.”

“Mouse droppings covered approximately 2 one-foot by one-foot square tiles in the back storage area of the kitchen under a wire shelving unit at 10:39 AM.”

“At 9:39 AM an electrical outlet was missing the internal receptacle with a faceplate partially covering the opening allowing exposure to internal wiring. At 10:49 AM, 3 ceiling tiles in the 1st floor nursing area were stained brown from water damage and 1 tile showed black circular stain with apparent mold.”

“Two fire extinguishers in the basement have not been inspected by a fire safety expert since an unspecified past date.”

“A resident does not have access to a source of light that can be turned on/off at bedside as required. This was a repeat violation.”

“Staff member A made disrespectful comments to a resident stating "you people are always wanting something" when the resident requested assistance, violating the requirement to treat residents with dignity and respect. This was a repeat violation. Staff member was terminated.”

“The floor transition in front of the recreation hall has flooring peeling up in three places, posing a tripping hazard for residents. This was a repeat violation.”

“Staff member made disrespectful comments to a resident. The allegation of abuse was not reported to the local Area Agency on Aging until after the required timeframe.”

“The residence did not report an incident involving disrespectful comments made by staff to a resident to the Department within 24 hours as required.”

“Direct Care Staff Person A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry as required. This was a repeat violation.”

“A resident's bed is equipped with a bedside mobility device with dangerous openings: 12 inches in width between the rail and 6.5 inches from the pocket to the top bar in height, posing a risk of entrapment. This was a repeat violation.”

“A first floor window located across from the elevator was open and did not have a screen, creating a safety hazard.”

“The elevator located in the center of the building is not operational, making it unusable for residents.”

“The residence validated two theft incidents but failed to inform other residents or their designated persons of possible thefts that may have occurred throughout the residence, as required by regulation.”

“Emergency notification systems in two living units were in disrepair: one unit had a missing cord and another unit's button did not send out an alert.”

“Operable automatic smoke detectors were not present in certain living units.”

“The residence did not have a smoke detector or automatic fire alarm system that was interconnected in the attic area.”

“The residence did not have documentation of an annual fire safety inspection conducted by a fire safety expert for compliance with PA 2800 regulations; the documentation provided referenced PA 2600 regulations instead.”

“The medical evaluation for a resident did not include documentation of special health or dietary needs, with that section of the form left blank.”

“A resident was smoking in their room on the first-floor hall in the B wing, which is not the designated smoking area (the courtyard outside). This is a repeat violation from 10/22/2024 and 08/20/2024.”

“Five bottles of prescription medications, five boxes of OTC medications, and a box of another medication belonging to an Independent Living resident were unlocked, unattended, and accessible on a dresser in a shared bedroom. This is a repeated violation.”

“Prescription medications, OTC medications, CAM and syringes were not kept in a locked area or container as required.”

“Medical evaluation was not completed within the required timeframe prior to or after admission. Documentation showed the evaluation was completed after the allowable deadline.”

“Multiple sanitary condition violations observed: resident bathroom toilet bowl contained black fuzzy mold with hair and trash in sink; office chair present in shower with white stain; clogged sink filled with water in special care unit janitor closet with strong urine smell.”

“Wall next to window in special care unit resident living unit had three openings with vents on floor and trash/drywall pieces creating tripping and cutting hazards. Doorknob to this resident living unit was missing and the unit was accessible to residents.”

“Medical evaluation was not completed within the required timeframe prior to or after admission. Documentation showed the evaluation was completed after the allowable deadline.”

“Multiple sanitary condition violations observed: resident bathroom toilet bowl contained black fuzzy mold with hair and trash in sink; office chair present in shower with white stain; clogged sink filled with water in special care unit janitor closet with strong urine smell.”

“Wall next to window in special care unit resident living unit had three openings with vents on floor and trash/drywall pieces creating tripping and cutting hazards. Doorknob to this resident living unit was missing and the unit was accessible to residents.”

“Two living units do not have individual control of heating and cooling because the vents have been removed from the wall in both units.”

“One living unit does not have a functioning flush toilet in the bathroom. Another living unit's toilet leaks water into a bucket when flushed.”

“Toilet paper was not available for the toilet in the bathroom of a resident living unit.”

“Medical evaluation for a resident does not include documentation of tuberculin skin test administration with negative results within 2 years, or chest X-ray results if positive. The tuberculin test area on the form is listed as unknown and was not administered within 15 days of admission.”

“A resident who self-administers medications had several unlocked, unattended medications stored in their living unit, including medicated items, in violation of the requirement that self-administered medications be kept locked in a safe and secure location.”

“Two living units do not have individual control of heating and cooling because the vents have been removed from the wall in both units.”

“One living unit does not have a functioning flush toilet in the bathroom. Another living unit's toilet leaks water into a bucket when flushed.”

“Toilet paper was not available for the toilet in the bathroom of a resident living unit.”

“Medical evaluation for a resident does not include documentation of tuberculin skin test administration with negative results within 2 years, or chest X-ray results if positive. The tuberculin test area on the form is listed as unknown and was not administered within 15 days of admission.”

“A resident who self-administers medications had several unlocked, unattended medications stored in their living unit, including medicated items, in violation of the requirement that self-administered medications be kept locked in a safe and secure location.”

“Resident #2's and Resident #3's records did not contain statements signed by the residents acknowledging receipt of resident rights and complaint procedures. This is a repeat violation.”

“The residence's copy of 55 Pa. Code Chapter 2800 was not posted in a conspicuous and public place in the residence.”

“From 11:00 PM to 7:00 AM on 01/19/25, with 54 residents present, no staff persons in the residence were trained in first aid and certified in obstructed airway techniques and CPR, violating the 1:35 ratio requirement.”

“There is no copy of the quarterly account of financial transactions in resident #1's record for the period of 10/01/24 to 12/31/24. Documentation was requested but not provided until after 4:00 PM, indicating records were kept off-site.”

“Staff person C, whose first day of work was 01/24/2025, did not receive orientation in fire safety and emergency preparedness topics including evacuation procedures, staff duties, designated meeting place, smoking safety, fire extinguisher location and use, smoke detectors and fire alarms, and emergency notification procedures. This is a repeat violation.”

“Two of the facility's elevators were not operational. One elevator in the lobby was reset and made operable on 3/24/2025. The second elevator in the center of the building was not operable due to oil in the pit and required repair by the elevator vendor.”

“A resident did not have access to a source of light that could be turned on/off at bedside. This was a repeat violation.”

“A resident had a portable space heater that was plugged into an electrical socket in the home. This was a repeat violation.”

“Poisonous materials (Comet cleaner with bleach and Listerine mouthwash) were observed unlocked, unattended, and accessible to residents at the SCU nurses station. Not all residents were assessed as capable of safely using or avoiding poisonous materials. This was a repeat violation from 09/05/24 and 02/12/24.”

“Sanitary conditions were not maintained in Resident #1's room. Clothes had not been washed for two weeks with dirty clothes scattered throughout the room and an overloaded laundry basket. A clear plastic bag containing linens and other items with visible fecal stains was on the floor. Additionally, several areas of dried smeared feces were observed on the bathroom floor.”

“Evidence of pest infestation was found throughout the facility including: gnats in the water tank used for cleaning the food steam table; mouse droppings under the water boiler basin; unidentified insects in flour bins and powdered thickener bins; mouse droppings on container lids, dirty dishes, and to-go containers; mouse droppings and a desiccated mouse on a glue trap in the storage area; mouse droppings on the closet floor in resident room #303; and reports of live mice observed in the SCU and running along hallway walls. This was a repeat violation from 8/20/24 and 5/31/24.”

“Floors, walls, ceilings, windows, doors and other surfaces were not maintained in good repair and free of hazards. A rectangular hole measuring approximately 6 inches by 4 inches was located by the Christmas trees/elevator at the end of B hall in the SCU. In SCU room B319, open junction boxes with exposed wires were present in an unlocked unoccupied room creating an unsafe area for residents who wander in the SCU.”

“Furniture and equipment were not in good repair. The closet doors in rooms #303 and #305 did not work properly, preventing residents from hanging their clothes and closing the doors. The wheels of the closet doors were not rolling properly along the track and required repair.”

“Resident #2's bed did not have a pillow, failing to provide the required clean bed linens, pillows, and blankets for each resident in their living unit.”

“The residence's copy of 55 Pa. Code Chapter 2800 was not posted in a conspicuous and public place in the residence.”

“There is no copy of the quarterly account of financial transactions in resident #1's record for the period of 10/01/24 to 12/31/24. Documentation was requested but not provided until after 4:00 PM, indicating records were kept off-site.”

“Resident #2's and Resident #3's records did not contain statements signed by the residents acknowledging receipt of resident rights and complaint procedures. This is a repeat violation.”

“From 11:00 PM to 7:00 AM on 01/19/25, with 54 residents present, no staff persons in the residence were trained in first aid and certified in obstructed airway techniques and CPR, violating the 1:35 ratio requirement.”

“Staff person C, whose first day of work was 01/24/2025, did not receive orientation in fire safety and emergency preparedness topics including evacuation procedures, staff duties, designated meeting place, smoking safety, fire extinguisher location and use, smoke detectors and fire alarms, and emergency notification procedures. This is a repeat violation.”

“Resident #4 does not have access to a source of light that can be turned on/off at bedside. This is a repeat violation from 05/31/2024 and 12/22/2023.”

“There was an unlabeled, undated pitcher of juice in the refrigerator of the Special Care Unit. This is a repeat violation from 12/22/2023.”

“Direct care staff person A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. This is a repeat violation from 12/22/2023.”

“Resident #1's bed was equipped with a bedside mobility device not properly attached to the bed frame, secured only with loose straps, creating potential entrapment zones. Resident #2's bed was equipped with a bedside mobility device that exceeded FDA guidelines for entrapment areas and was not covered.”

“Sanitary conditions were not maintained. The toilet bowl in resident room #311 was smeared with feces inside and outside. The bottom of the freezer in the food pantry was covered with brown stained ice. The freezer section of a stand-alone refrigerator in the Special Care Unit had streaked discoloration. The freezer in the 1st floor kitchen had cardboard boxes and a plastic bag stored on top. This is a repeat violation.”

“The doorknob in the electrical room closet in the Special Care Unit was not working properly and would not close; glass debris inside posed a hazard to SCU residents. Exposed wires were found on the wall near the juice table in the first-floor food pantry. This is a repeat violation.”

“The freezer in the food pantry on the first floor was covered with ice on one side of the wall and on the bottom due to a clogged water drainage system.”

“The mattress on the bed for resident #3 was sagging in the middle and not in good repair. This is a repeat violation from 12/22/2023.”

“Multiple poisonous materials were found unlocked, unattended, and accessible to residents throughout the facility, including in the Memory Care Supervisor Office, nurse station, and resident rooms. Items included hand sanitizer, toothpaste, deodorant, cleaners, and other products with poison control labels. Not all residents, including those in the secure care dementia unit, were assessed as capable of safely recognizing and using these materials.”

“Two residents did not have access to a source of light that can be turned on/off at bedside.”

“Two medications were found unlocked, unattended, and accessible in resident rooms on 9/4/2024.”

“Two loose pills were observed in the drawer of the medication cart in the memory care unit on 9/4/2024 at 12:37 pm.”

“Two over-the-counter medications (Milk of Magnesia and Biofreeze topical pain relief) in resident rooms lacked pharmacy labels.”

“A resident prescribed as-needed pain medication every 12 hours did not have the medication available in the residence on 9/4/2024. Description was cut off but indicates medication storage procedure issues.”

“Staff treated a resident disrespectfully by telling her she "talks too much," saying "nobody wants to work with you," calling her a "piece of work," and using profane language ("Jesus Christ, what's your problem now?").”

“A strong odor of urine was present in a bathroom at 12:23 pm, with brown streaks of feces on the outside of the toilet and an overflowing trash can with wet incontinence products. This was a repeat violation from 5/31/2024.”

“Active bed bugs were found in resident rooms. This was a repeat violation from 5/31/2024.”

“Fresh cigarette smoke was detected in the bathroom of a resident room at 12:23 pm, indicating smoking outside of the designated smoking room.”

“A medication prescribed for a resident was kept in the residence's medication cart despite being discontinued.”

“A resident's August 2024 medication administration record did not include the diagnosis or purpose for prescribed medications.”

“Medication administration records did not include the initials of the staff person who administered medications at the time of administration. One resident's record lacked initials for controlled substance administration on two dates, and another resident's record lacked initials for three medication administrations.”

“Resident #1 did not receive required assistance with dressing and care of clothes as indicated in their assessment and support plan. The resident was observed still dressed in pajamas.”

“Resident #1 did not receive required assistance with personal hygiene as indicated in their assessment and support plan. A strong odor of urine was present near the bed in the resident's room, and the resident was in bed unable to communicate their needs.”

“Resident #2 reported that staff members are rude, scream when asked for assistance, and raise their voices when spoken to. Resident #2 indicated this behavior is common among all care staff and that the treatment is consistent, causing the resident to be hesitant to request needed assistance.”

“On 06/20/24 at 2:45 pm, a strong odor of urine was present in resident #1's room, indicating unsanitary conditions were not maintained.”

“Violation related to 55 Pa Code § 2800.82c, Class II violation assessed with daily fine of $5 per resident census (36 residents at inspection = $180 per day) if not corrected by mandated date.”

“Department agents requested access to door C in the basement on January 4, 2024 at 9:45 am, but the facility was unable to unlock the door and reported not having a key.”

“On December 30, 2023, the facility experienced a five-hour power outage and basement flood that closed the kitchen for three hours. The facility used emergency food but did not report this incident to the Department within 24 hours as required.”

“On December 22, 2023 at 8:40 am, a binder containing resident medical administration records was unlocked, unattended, and accessible to residents near the dining room.”

“Violation related to 55 Pa Code § 2800.187d, Class II violation assessed with daily fine of $5 per resident census (36 residents at inspection = $180 per day) if not corrected by mandated date.”

“Violation related to 55 Pa Code § 2800.82c, Class II violation assessed with daily fine of $5 per resident census (36 residents at inspection = $180 per day) if not corrected by mandated date.”

“Violation related to 55 Pa Code § 2800.187d, Class II violation assessed with daily fine of $5 per resident census (36 residents at inspection = $180 per day) if not corrected by mandated date.”

“On December 22, 2023 at 8:40 am, a binder containing resident medical administration records was unlocked, unattended, and accessible to residents near the dining room.”

“Department agents requested access to door C in the basement on January 4, 2024 at 9:45 am, but the facility was unable to unlock the door and reported not having a key.”

“On December 30, 2023, the facility experienced a five-hour power outage and basement flood that closed the kitchen for three hours. The facility used emergency food but did not report this incident to the Department within 24 hours as required.”

“Department agents requested access to door C in the basement on January 4, 2024 at 9:45 am, but the facility was unable to unlock the door and reported not having a key.”

“On December 30, 2023, the facility experienced a five-hour power outage and basement flood that closed the kitchen for three hours. The facility used emergency food but did not report this incident to the Department within 24 hours as required.”

“On December 22, 2023 at 8:40 am, a binder containing resident medical administration records was unlocked, unattended, and accessible to residents near the dining room.”

“Violation related to 55 Pa Code § 2800.82c, Class II violation assessed with daily fine of $5 per resident census (36 residents at inspection = $180 per day) if not corrected by mandated date.”

“Violation related to 55 Pa Code § 2800.187d, Class II violation assessed with daily fine of $5 per resident census (36 residents at inspection = $180 per day) if not corrected by mandated date.”

“Direct care staff hours were insufficient on three dates in December 2023. Residents with mobility needs required a minimum of 66 hours of direct care service, but only 54 hours, 49.5 hours, and 54 hours were provided respectively. Staff spent approximately three hours per eight-hour shift on ancillary duties, reducing actual direct care coverage.”

“Waking hours direct care staffing was insufficient on three dates in December 2023. A minimum of 49.5 hours of direct care was required during waking hours, but only 40.5 hours, 36 hours, and 40.5 hours were provided respectively.”

“Indoor temperature in the C-wing of the 3rd floor was 68 degrees Fahrenheit when residents were present, below the required minimum of 70°F. Temperature logs showed readings below 70 degrees in the third-floor hallway and B wing on multiple dates between 3:00 pm and 9:00 pm and 8:00 am and 4:00 pm.”

“A resident room did not have sufficient hot water pressure for use of the bathroom sink and shower. The shower slowly warmed to only a lukewarm 89 degrees Fahrenheit.”

“Two portable space heaters were found in the residence: one providing heat in a resident room and another observed on the floor of a common area in the first-floor B wing. Portable space heaters are prohibited.”

“Violation related to 55 Pa Code § 2800.187d, Class II violation assessed with daily fine of $5 per resident census (36 residents at inspection = $180 per day) if not corrected by mandated date.”

“Department agents requested access to door C in the basement on January 4, 2024 at 9:45 am, but the facility was unable to unlock the door and reported not having a key.”

“On December 30, 2023, the facility experienced a five-hour power outage and basement flood that closed the kitchen for three hours. The facility used emergency food but did not report this incident to the Department within 24 hours as required.”

“On December 22, 2023 at 8:40 am, a binder containing resident medical administration records was unlocked, unattended, and accessible to residents near the dining room.”

“Violation related to 55 Pa Code § 2800.82c, Class II violation assessed with daily fine of $5 per resident census (36 residents at inspection = $180 per day) if not corrected by mandated date.”