Spring Creek Healthcare Center

Inspectors wroteBased on observation, interview, and document review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe consistent manner. This deficient practice was evidenced by the following: On 04/09/2025 from 9:59 AM until 10:37 AM the surveyor, who was accompanied by the Director of the Kitchen (DOK), observed the following in the kitchen: 1. In the first refrigerator, there was baked ziti in a metal container covered with clear plastic wrap. It was dated 3/8/25. The DOK said the baked ziti was probably misdated, however she will throw it away. 2. In the first refrigerator there was a loaf of rye bread dated 3/13/25 and a loaf of raisin bread dated 3/24/25. The DOK said the bread is good for 30 days in the refrigerator. [...]

Inspectors wroteBased on observation, interview, and pertinent facility documentation, it was determined that the facility did not maintain the dignity of a resident specifically, by transporting the resident backward in a geriatric chair (specialized, high-backed reclining chair designed to provide comfort, support, and mobility for individuals with limited mobility) down the hallway. This deficiency was identified in 1 of the 36 residents (Resident # 2) reviewed. This deficient practice was evidenced by the following: On 01/13/2025 at 10:15 AM, the surveyor observed Certified Nurse Aide #1, pulling the resident in a geriatric chair backward down the third-floor hallway. During an interview with the surveyor on 04/14/2025 at 11:22 AM, the Licensed Practical Nurse/Unit Manager #1 said that residents should not be pushed backward in their geriatric chairs as it is a dignity concern. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain a clean, safe and sanitary environment for 2 of 3 units, the second floor and the third floor. This deficient practice was evidenced by the following: During initial tour on 04/09/2025 at 10:56 AM surveyor #1 observed the wall behind bed 1 in room [ROOM NUMBER], which had two strips of black sticky tape with what appeared to be white foam on them that looked to have been used to anchor an object to the wall. During a room visit on 04/10/2025 in room [ROOM NUMBER], bed 2, surveyor #1 observed broken trim with sharp edges along the center of the wall behind the resident's bed. The resident was unsure of how long the trim had been broken. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to develop and implement a care plan that meets the medical needs identified on the comprehensive assessment care for 1 of 24 residents reviewed for comprehensive care plans, Resident #36. This deficient practice was evidenced by the following: A review of Resident # 36's admissions record revealed that, Resident #36 was admitted with but not limited to Chronic Obstructive Pulmonary Disease (an ongoing lung condition caused by damage to the lungs), and Major Depressive Disorder. There was no order for Atrial Fibrillation (rapid heart rhythm) until brought to the facilities attention by the surveyor. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide respiratory care consistent with professional standards of practice by not storing a nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) mask properly and failed to document the use of oxygen in Electronic Medical Record (EMR) for 1 of 2 residents (Resident #67) reviewed for Respiratory Care. The deficient practice was evidenced by the following: During the initial tour on 04/09/2025 at 10:09AM, Resident #67 was observed sitting in the wheelchair with oxygen in use via a nasal cannula (tubing that delivers oxygen through the nose). The surveyor also observed a nebulizer mask laying open to air on the resident's bed. [...]

Inspectors wroteCOMPLAINT # NJ168251 Based on interviews, medical record review, and review of other pertinent facility documentation on 10/17/23 and 10/18/23, it was determined that the facility failed to follow their policies and procedures for a facility-initiated discharge. A resident (Resident #3) was involved in an altercation with another resident and was sent to the hospital for a behavioral evaluation. When the resident was discharged from the hospital, the facility would not permit the resident to return to the facility. The deficient practice was identified for Resident #3, 1 of 6 residents reviewed and was evidenced by the following: According to the admission Record, Resident #3 was admitted to the facility on [DATE] with diagnoses which included but were not limited to: [...]

Inspectors wroteBased on observation, interview and review of facility documentation, it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses, b.) properly wash hands and c.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination. This deficient practice was evidenced by the following: On 03/27/2023 at 9:40 AM, the surveyor toured the kitchen, in the presence of the Regional Food Service Director (RFSD) and the Food Service Director (FSD) and observed the following: The surveyor observed an unlabeled box filled with seven logs of frozen ground beef in the freezer. [...]

Inspectors wroteBased on interview, it was determined that the facility failed to provide daily delivery of mail, to include Saturdays. This deficient practice was identified for 7 of 7 residents interviewed during the resident council group meeting (Resident #21, #30, #43, #72, #73, #91 and #100), and was evidenced by the following: On 04/03/23 at 10:30 AM, the surveyor attended a resident council group meeting with Residents #21, #30, #43, #72, #73, #91 and #100. The surveyor interviewed the residents regarding mail delivery and all the residents in attendance told the surveyor that mail was only delivered on Mondays and Fridays, with no other days during the week. On 04/04/23 at 11:45 AM, the surveyor interviewed the Activities Director (AD) regarding mail delivery. [...]

Inspectors wroteBased on observation, interview, and review of medical records and other facility documentation, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS) for 1 of 26 residents reviewed, Resident #54. This deficient practice was evidenced by the following: The surveyor reviewed the admission Record for Resident #54 which reflected that the resident was admitted with diagnoses that included depression and hypertension (high blood pressure). The surveyor reviewed the smoking safety evaluation dated 6/30/22, which indicated that Resident #54 currently smokes. The surveyor reviewed Resident #54's Annual MDS dated [DATE]. The section for current tobacco use was coded as zero (0), indicating that Resident #54 does not currently use tobacco. [...]

Inspectors wroteBased on interview, observation, and record review it was determined the facility failed to maintain professional standards of clinical practice for 1 of 28 residents reviewed (Resident # 206) by failing to document the transfer of a resident to the hospital following a fall. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The nurse practice act for the State of New Jersey states; [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure expired controlled substance (narcotic) medications were detected, removed, and disposed from the emergency (back-up) supply identified for 1 of 1 back up box. This deficient practice was evidenced by the following: On 4/3/23 at 10:30 AM, the surveyor and the Assistant Director of Nursing (ADON) entered the room that contained the narcotic back up medications which was stored in a locked box in a locked room on the second floor. At 10:34 AM, the surveyor with the ADON began the inspection of the narcotic medications in the back up box. At 10:36 AM, in the presence of the ADON, the surveyor observed five patches of Fentanyl 50 microgram/hour (mcg/hr.; [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication observation performed on 3/31/23, the surveyors observed two (2) nurses administer medication to five (5) residents. There were 28 opportunities, and two (2) errors were observed, which calculated to a medication administration error rate of 7.14%. This deficient practice was identified for 2 of 5 residents (Unsampled Resident #1, and Unsampled Resident #2) that were administered medications by 1 of 2 nurses. The deficient practice was evidenced by the following: On 3/31/23 at 8:21 AM, during the medication administration observation, the surveyor observed breakfast meal trays being collected from resident rooms, indicating breakfast had been served and consumed. [...]

Inspectors wroteBased on observations, staff interviews, physician interview, medical record review and review of other pertinent documents, it was determined that the facility failed to a.) recognize and assess the risk factors that placed a resident at risk for serious harm from drug overdose. b.) evaluate a resident's repeated symptoms of opioid intoxication that often occurred after the resident's return from treatment at a methadone clinic from [DATE] to [DATE]. c.) Evaluate the resident's non-compliance and how it may impact other residents. This deficient practice was identified for Resident #101, 1 of 24 residents reviewed for the quality of care provided to the facility residents and was evidenced by the following: [...]

Inspectors wroteBased on observation, interview, medical record review, and review of other facility documentation during a Recertification survey ending on 4/6/21, it was determined that the facility failed to: a.) follow isolation precaution protocols for residents on Transmission-Based Precautions (TBP) on the unit for Persons under observation (PUI) and b.) properly isolate PUI residents from well, non Covid-19 exposed residents as a preventative measure to prevent the transmission of COVID-19. Residents and Health Care Personnel who have been exposed to Covid-19 have the potential to be Covid-19 positive and show no symptoms, thereby spreading this deadly virus. The facility's failure to isolate Resident #4, #45, #104, and #321 from the well, non-exposed residents posed a serious and immediate threat to the safety and wellbeing of the well, non-exposed residents. [...]

Inspectors wroteBased on observation, interview, review of medical record and other pertinent documents, it was determined that the facility did not have a Policy and Procedure to ensure a safe temperature for serving hot beverages to residents. A resident spilled coffee on his/her lap sustaining a second degree burn to both upper thighs. The facility failed to thoroughly investigate and institute in a timely manner staff training and procedures for serving hot beverages in order to mitigate further instances of harm to residents. This deficient practice was identified for Resident #85, 1 of 2 residents reviewed for accidents and hazards and was evidenced by the following. During the initial tour on 03/15/21 at 12:15 PM, the surveyor observed Resident # 85 in bed as the Certified Nursing Assistant (CNA) assisted the resident with lunch. [...]