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Deficiency Records for Spring Creek Healthcare Center
View the most recent health deficiencies and inspection results for Spring Creek Healthcare Center. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Spring Creek Healthcare Center. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2025-02-03 | 2025-03-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-02-03 | 2025-03-27 | 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 | 2025-02-03 | 2025-03-27 | 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 | 2025-02-03 | 2025-03-27 | N |
| 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 | 2025-02-03 | 2025-03-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-02-03 | 2025-03-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2025-02-03 | 2025-03-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-02-03 | 2025-03-27 | 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 | 2025-02-03 | 2025-03-27 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2025-02-03 | 2025-03-27 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2025-02-03 | 2025-03-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-02-03 | 2025-03-27 | 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 | 2025-02-03 | 2025-03-27 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-01-11 | 2024-03-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-11 | 2024-02-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-11 | 2024-02-12 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-01-11 | 2024-02-12 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-01-11 | 2024-02-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-11 | 2024-02-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-11 | 2024-02-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-11 | 2024-02-12 | N |
| Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised. | Health | 2024-01-11 | 2024-02-12 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-01-11 | 2024-02-12 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-01-11 | 2024-02-12 | N |
| Keep signed and dated reports of x-rays and other diagnostic services in the residents record. | Health | 2024-01-11 | 2024-02-12 | 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 | 2024-01-11 | 2024-02-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-11 | 2024-02-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-11 | 2024-02-12 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-01-11 | 2024-02-12 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2022-04-13 | 2022-06-23 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-04-13 | 2022-06-23 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-04-13 | 2022-06-23 | N |
| Keep signed and dated reports of x-rays and other diagnostic services in the residents record. | Health | 2022-04-13 | 2022-06-23 | N |
| Keep complete, dated laboratory records in the resident's record. | Health | 2022-04-13 | 2022-06-23 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-04-13 | 2022-06-23 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-04-13 | 2022-06-23 | 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 | 2022-04-13 | 2022-06-23 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-13 | 2022-06-23 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-04-13 | 2022-06-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-13 | 2022-06-23 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-04-13 | 2022-06-23 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-04-13 | 2022-06-23 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-04-13 | 2022-06-23 | N |
| Post nurse staffing information every day. | Health | 2022-04-13 | 2022-06-23 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-04-13 | 2022-06-23 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-04-13 | 2022-06-23 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-04-13 | 2022-06-23 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-04-13 | 2022-06-23 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-04-13 | 2022-06-23 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-04-13 | 2022-06-23 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-04-13 | 2022-06-23 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-04-13 | 2022-06-23 | N |
| Keep all essential equipment working safely. | Health | 2022-04-13 | 2022-06-23 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-13 | 2022-06-23 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-04-13 | 2022-06-23 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-04-13 | 2022-06-23 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-04-13 | 2022-06-23 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-04-13 | 2022-06-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-13 | 2022-06-23 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-04-13 | 2022-06-23 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-04-13 | 2022-06-23 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-04-13 | 2022-06-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-13 | 2022-06-23 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2022-04-13 | 2022-06-23 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | Health | 2022-04-13 | 2022-06-23 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2022-04-13 | 2022-06-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-04-13 | 2022-06-23 | N |
| Respond appropriately to all alleged violations. | Health | 2022-04-13 | 2022-06-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-13 | 2022-06-23 | N |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2022-04-13 | 2022-06-23 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2022-04-13 | 2022-06-23 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-13 | 2022-06-23 | 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 | 2022-04-13 | 2022-06-23 | 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 | 2022-04-13 | 2022-06-23 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-04-13 | 2022-06-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-04-13 | 2022-06-23 | 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 | 2022-04-13 | 2022-06-23 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2022-04-13 | 2022-06-23 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-04-13 | 2022-06-23 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-04-13 | 2022-06-23 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-04-13 | 2022-06-23 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-04-13 | 2022-06-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-13 | 2022-06-23 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-04-13 | 2022-06-23 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-04-13 | 2022-06-23 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-04-13 | 2022-06-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-13 | 2022-06-23 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-13 | 2022-06-23 | 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 | 2022-04-13 | 2022-06-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-13 | 2022-06-23 | 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 | 2022-04-13 | 2022-06-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-13 | 2022-06-23 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-04-13 | 2022-06-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-13 | 2022-06-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-13 | 2022-06-23 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-04-13 | 2022-06-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-13 | 2022-06-23 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-04-13 | 2022-06-23 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-04-13 | 2022-06-23 | N |
| 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 | 2022-04-13 | 2022-06-23 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-04-13 | 2022-05-28 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-04-13 | 2022-05-28 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-04-13 | 2022-05-28 | N |