Deficiency Records for Spring Creek Rehabilitation and Nursing Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Spring Creek 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? |
|---|---|---|---|---|
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-10-24 | 2023-11-08 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-07-25 | 2023-08-17 | N |
| 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. | Fire Safety | 2023-07-25 | 2023-08-17 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-07-25 | 2023-08-17 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-07-25 | 2023-08-17 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-07-25 | 2023-08-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-25 | 2023-08-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-25 | 2023-08-17 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-07-25 | 2023-08-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-25 | 2023-08-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-25 | 2023-08-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-26 | 2023-08-08 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-07-13 | 2023-08-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-07-13 | 2023-08-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-13 | 2023-08-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-13 | 2023-08-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-07-13 | 2023-08-08 | 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 | 2023-07-13 | 2023-08-08 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-07-13 | 2023-08-08 | N |
| 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. | Health | 2023-07-13 | 2023-08-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-13 | 2023-08-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-13 | 2023-08-08 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-07-13 | 2023-08-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-06 | 2023-06-12 | Y |
| 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 | 2023-05-15 | 2023-05-31 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-05-15 | 2023-05-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-15 | 2023-05-31 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-07-28 | 2022-08-30 | 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 | 2022-07-28 | 2022-08-30 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-07-28 | 2022-08-30 | 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 | 2022-07-28 | 2022-08-30 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-07-28 | 2022-08-30 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-07-28 | 2022-08-30 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-07-28 | 2022-08-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-28 | 2022-08-30 | 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 | 2022-07-28 | 2022-08-30 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-07-28 | 2022-08-30 | N |
| Provide activities to meet all resident's needs. | Health | 2022-07-28 | 2022-08-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-28 | 2022-08-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-28 | 2022-08-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-28 | 2022-08-30 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-07-28 | 2022-08-30 | N |
| 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. | Health | 2022-07-28 | 2022-08-30 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-07-28 | 2022-08-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-28 | 2022-08-30 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-07-28 | 2022-08-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-07-28 | 2022-08-30 | Y |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2022-07-13 | 2022-08-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-07-13 | 2022-08-30 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-07-13 | 2022-08-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-07-13 | 2022-08-30 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-07-13 | 2022-08-30 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-07-13 | 2022-08-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-07-13 | 2022-08-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-13 | 2022-08-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-07-13 | 2022-08-30 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-07-13 | 2022-08-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-07-13 | 2022-08-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-07-13 | 2022-08-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-07-13 | 2022-08-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-07-13 | 2022-08-30 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-07-13 | 2022-08-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-13 | 2022-08-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-13 | 2022-08-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-07-13 | 2022-08-30 | N |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-07-01 | 2022-07-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-07 | 2022-07-06 | 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 | 2022-06-07 | 2022-07-06 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-06-07 | 2022-07-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-06 | 2022-05-31 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-03-29 | 2022-04-20 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-29 | 2022-04-20 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-03-29 | 2022-04-20 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-03-29 | 2022-04-20 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-03-29 | 2022-04-20 | Y |
| 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 | 2022-03-23 | 2022-04-20 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-02-28 | 2022-04-20 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-03-04 | 2022-03-17 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-02-25 | 2022-03-17 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-10 | 2022-01-05 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-22 | 2021-11-30 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-10-22 | 2021-11-30 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-10-22 | 2021-11-30 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2021-10-22 | 2021-11-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-06-24 | 2021-08-23 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-06-24 | 2021-08-01 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-06-24 | 2021-08-01 | 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 | 2021-06-24 | 2021-08-01 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-06-24 | 2021-08-01 | 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 | 2021-06-24 | 2021-08-01 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-06-24 | 2021-08-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-06-24 | 2021-08-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-24 | 2021-08-01 | 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 | 2021-06-24 | 2021-08-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-06-24 | 2021-08-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-24 | 2021-08-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-24 | 2021-08-01 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-06-24 | 2021-08-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-24 | 2021-08-01 | 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 | 2021-06-24 | 2021-08-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-06-24 | 2021-08-01 | N |
| Post nurse staffing information every day. | Health | 2021-06-24 | 2021-08-01 | 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 | 2021-06-24 | 2021-08-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-06-24 | 2021-08-01 | 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 | 2021-06-24 | 2021-08-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-06-24 | 2021-08-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-24 | 2021-08-01 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-06-24 | 2021-08-01 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-06-24 | 2021-08-01 | N |
| 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. | Health | 2021-06-24 | 2021-08-01 | Y |
| Use approved construction type or materials. | Fire Safety | 2021-06-29 | 2021-08-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-06-29 | 2021-08-01 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-06-29 | 2021-08-01 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-06-29 | 2021-08-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-29 | 2021-08-01 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-06-29 | 2021-08-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-29 | 2021-08-01 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2021-06-29 | 2021-08-01 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2021-06-29 | 2021-08-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-29 | 2021-08-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-06-29 | 2021-08-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-04-08 | 2021-04-22 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-03-19 | 2021-04-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-19 | 2021-04-16 | Y |
