Deficiency Records for Springcreek Rehabilitation and Nursing Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Springcreek Rehabilitation and Nursing Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-10-11 | 2023-10-25 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-10-11 | 2023-10-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-11 | 2023-10-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-11 | 2023-10-25 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-10-11 | 2023-10-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-10-11 | 2023-10-25 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-10-11 | 2023-10-25 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-10-11 | 2023-10-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-11 | 2023-10-25 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2023-10-11 | 2023-10-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-11 | 2023-10-25 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2023-10-11 | 2023-10-25 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2023-10-11 | 2023-10-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-11 | 2023-10-25 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-22 | 2023-07-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-22 | 2023-07-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-22 | 2023-07-18 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-06-22 | 2023-07-18 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-06-22 | 2023-07-18 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-06-22 | 2023-07-18 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-18 | 2023-01-15 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-08-23 | 2022-09-27 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-08-23 | 2022-09-27 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2022-08-23 | 2022-09-27 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-08-23 | 2022-09-27 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-08-23 | 2022-09-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-08-23 | 2022-09-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-23 | 2022-09-27 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-08-23 | 2022-09-27 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-08-23 | 2022-09-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-23 | 2022-09-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-23 | 2022-09-27 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-23 | 2022-09-27 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-23 | 2022-09-27 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-08-23 | 2022-09-27 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-08-23 | 2022-09-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-08-23 | 2022-09-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-23 | 2022-09-27 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-08-23 | 2022-09-27 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-08-23 | 2022-09-27 | N |
| Report COVID19 data to residents and families. | Health | 2022-08-23 | 2022-09-27 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-08-23 | 2022-09-27 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-08-23 | 2022-09-27 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-23 | 2022-09-27 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-08-23 | 2022-09-27 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-08-18 | 2022-09-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-18 | 2022-09-27 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-08-18 | 2022-09-27 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-08-18 | 2022-09-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-18 | 2022-09-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-04-28 | 2022-05-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-28 | 2022-05-16 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-04-28 | 2022-05-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-09 | 2021-11-29 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-11-09 | 2021-11-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-08 | 2021-09-24 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-06-11 | 2021-07-02 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-24 | 2021-06-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-05-24 | 2021-06-25 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-05-24 | 2021-06-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-24 | 2021-06-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-24 | 2021-06-25 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-05-24 | 2021-06-25 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-05-24 | 2021-06-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-24 | 2021-06-25 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-05-24 | 2021-06-25 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-05-24 | 2021-06-25 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-05-24 | 2021-06-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-24 | 2021-06-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-05-24 | 2021-06-25 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-05-24 | 2021-06-25 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-05-19 | 2021-06-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-05-19 | 2021-06-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-19 | 2021-06-25 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-05-19 | 2021-06-25 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-05-19 | 2021-06-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-19 | 2021-06-25 | N |
