Spring Creek Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents' drug regimens were free from unnecessary drugs by failing to ensure blood glucose levels were monitored as ordered by a physician for 2 out of 11 sampled residents. Specifically, the facility failed to perform ordered blood glucose checks for 2 residents receiving insulin when the residents were sleeping. The facility failed to document a blood glucose check for one resident on multiple days, and during one incident, it was documented that they ran out of testing supplies. Resident Identifiers: 2 and 4. 1. Resident 2 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including type 2 diabetes mellitus. [...]

Inspectors wroteBased on interview and record review, it was determined the facility failed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility experienced a sewage flood, and residents were observed coming into contact with the sewage water. Resident Identifiers: 2 and 6. On 7/28/2026, the surveyor reviewed video footage recorded by a staff member during the sewage backup incident on 7/19/2026. The video showed standing sewage water covering portions of the second-floor hallway, with wet bath towels and bedsheets laid across the corridor to soak up the wastewater. The footage also demonstrated water flooding both sides of the hallway and sewage leaking down through the first-floor ceiling into a facility administrative office. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide housekeeping and maintenance services necessary for a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Specifically, the facility failed to maintain the main sewer plumbing line in good repair, resulting in raw sewage containing urine and feces backing up through shower drains and toilet bases into resident rooms and corridors. This required the main building water supply to be shut off for over 6 hours, exposing residents to unsanitary conditions, hazardous biohazardous waste, and noxious fumes. Resident Identifiers: 2, 6, and 7. [...]

Inspectors wroteBased on interview and record review, it was determined the facility did not ensure that each resident received care and services in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, for 1 out of 11 sampled residents, the facility failed to ensure a resident received a prescribed antidiabetic medication, as ordered by the physician. Resident Identifier 4. Resident 4 was admitted to the facility on [DATE], with a diagnosis which included type 2 diabetes mellitus, chronic diastolic heart failure, chronic respiratory failure, and obesity. Resident 4's physician order, initiated 2/2/26, ordered staff to administer Tradjenta Oral Tablet 5 mg by mouth one time a day. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that each resident was supervised to prevent accidents. Specifically, for 1 out of 11 sampled residents, a resident who was assessed as being unsafe to leave the facility unsupervised had eloped from the facility. Resident Identifier: 1Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia, altered mental status, and schizophrenia. A Community Risk Assessment, dated 9/11/2025, indicated Resident 1 did not know the facility address/phone number, was unaware of basic traffic laws, and lacked awareness of surroundings and safety concerns (inclement weather, road hazards, emergency vehicles, or bike lanes). An Elopement Risk Assessment identified Resident 1 as At-Risk due to exit-seeking behaviors, poor compliance with safety instructions, and non-cooperation with safety plans. [...]

Inspectors wroteBased on interview and record review, it was determined the facility failed to ensure that each resident was free of any significant medication errors. Specifically, for 1 out of 11 sampled residents, the facility failed to administer a prescribed dose of long-acting insulin, due to the medication being unavailable and the staff failed to access the facility's emergency medication supply. Resident Identifier 4. Resident 4 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, chronic diastolic heart failure, chronic respiratory failure, and obesity. A physician order, initiated on 2/26/26 at 6:00 AM, prescribed Insulin Glargine Solostar Subcutaneous Solution Pen-injector 300 units/mL, to inject 50 units subcutaneously once daily. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not develop and implement a comprehensive person-centered care plan consistent with the resident's rights that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment. Specifically, for 4 out of 33 sampled residents, a resident's care plan was not updated to reflect the resident's activities of daily living requirements as they related to the resident's toileting needs; a resident did not have a behavioral health care plan that addressed the resident behavior of disrobing in public; a resident did not have a care plan initiated that addressed the resident's activity preferences and needs; and care plan interventions were not updated after a resident's falls. Resident identifiers: 24, 31, 49, and 54.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that the resident's environment was as free of accident hazards as was possible and each resident received supervision and assistance devices to prevent accidents. Specifically, for 3 out of 33 sampled residents, two residents had falls while being repositioned by staff and one resident caught his hair on fire with a lighter that another resident gave him. Resident identifiers: 22, 24, and 54.

Inspectors wroteBased on interview and record review, the facility did not ensure that residents who have not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. In addition, the facility did not ensure that as needed (PRN) psychotropics were limited to 14 days. Specifically, for 3 out of 33 sampled residents, a resident was prescribed an antipsychotic as a treatment for dementia, a resident was prescribed an antipsychotic as treatment for delusional disorder related to dementia, a resident was prescribed a selective serotonin reuptake inhibitor for depression and the resident did not have a diagnosis for depression. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not establish an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 5 out of 33 sampled residents, a nurse preparing medications used their bare hand to touch the medication and the medication fell on the medication cart and was administered to a resident. Resident's with a peripherally inserted central catheter (PICC) line, urinary catheter, feeding tube, and wound care did not have Enhanced Barrier Precautions (EBP) signage posted on their door and personal protective equipment (PPE) was not available. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that when the facility transferred a resident that the transfer was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider. The information provided to the receiving provider must include contact information of the practitioner responsible for care of the resident; resident representative information; Advance Directive information; all special instructions or precautions for ongoing care; comprehensive care plan goals; and all other necessary information to ensure a safe and effective transition of care. Specifically, for 1 out of 33 sampled residents, a resident's medical record did not contain the information that was provided to the receiving provider when the resident was transferred to a local hospital for evaluation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that that services provided met professional standards of quality. Specifically, for 1 out of 33 sampled residents, a resident's nasogastric (NG) tube feed did not have the formula bag labeled with the rate of infusion or the nurse initials who initiated the infusion. Resident identifier: 173.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Specifically, for 2 out of 33 sampled residents, a resident had a urinary catheter collection bag kept above the level of the bladder. In addition, a resident had a urinalysis (UA) test completed with no follow up and the resident required treatment for a urinary tract infection (UTI). Resident identifiers: 2 and 60.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. Specifically, for 1 out of 33 sampled residents, a resident was provided water flushes via his nasogastric (NG) tube that exceeded the physician orders. Resident identifier: 173.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, for 1 out of 33 sampled residents, a peripherally inserted central catheter (PICC) line had no physician orders for intravenous fluids, flushes or dressing changes, and had no indication for continued use for one resident. Resident identifier: 9.

Inspectors wroteBased on interview and record review, the facility did not provide routine and emergency drugs to its residents. Specifically, for 1 out of 33 sampled residents, a resident that was prescribed a hormone based chemotherapy, antipsychotics, selective serotonin reuptake inhibitor, antibiotic, anticoagulant, and a liquid protein did not have those medications available for administration due to pending delivery. Resident identifier: 62.

Inspectors wroteBased on interview and record review, the facility did not ensure that the pharmacist reported irregularities to the attending physician, the facility's Medical Director (MD), and the Director of Nursing (DON) were acted upon. In addition, the attending physician must document in the resident's medical record that the identified irregularity had been reviewed and what, if any, action had been taken to address it. Specifically, for 1 out of 33 sampled residents, a pharmacy recommendation was not acted upon by the MD and the MD did not document the identified irregularity and what action was taken in the resident's medical record. Resident identifier: 62.

Inspectors wroteBased on observation and interview, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with accepted professional principles, and included the expiration date when applicable. Specifically, for 2 out of 33 sampled residents, four opened insulin injector pens were not labeled with open dates and they were in the medication cart available for resident use. Resident identifiers: 7 and 24.

Inspectors wroteBased on interview and record review it was determined, for 3 of 38 sampled residents, that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, a resident was not assessed after a car accident during a facility transport, a hospice resident who fell and experienced a fracture did not have an x-ray completed timely, and a hospice resident was taken off of his antipsychotic medication abruptly and behaviors escalated. Resident identifiers: 19, 170 and 173.

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including Coronavirus Disease 2019 (COVID-19). Specifically, the facility did not have an infection control tracking and trending program, a resident with pneumonia was walking in the hallway without a mask, a nurse touched the medications during administration, hand hygiene was not used during meal times, silverware that was used to close a meal tray cart door was then given to a resident for use, food items were transported through the hallways uncovered, and staff did not wear Personal Protective Equipment (PPE) appropriately when entering an isolation room. Resident identifiers: 6, 20, 35, 40, 52 and 64.

Inspectors wroteBased on observation, interview and record review it was determined, for 10 of 38 sampled residents, that the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of lift, recognizing each resident's individuality. Specifically, residents were called by nicknames, desserts were served in disposable cups, a sign was hung at the nurses station for residents, residents at the same table were not served at the same time and staff were talking loudly. Resident identifiers: 6, 18, 23, 31, 32, 43, 45, 52, 62 and 319.

Inspectors wroteBased on interview, it was determined that the facility did not employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. Specifically, the facility did not employ a qualified dietary manager or a full time qualified dietitian that possesses one or more of the following credentials: Certified Dietary Manager, Registered Dietitian, Certified Food Service Manager, a Food Service Management Certificate, 2 or more years of experience in a nursing facility setting as a food service director and has completed a course of study in food safety and management, or an associates degree or higher with coursework in food service, hospitality, or restaurant management. Findings Include: On 1/8/24 at 7:05 AM, an interview was conducted with the Dietary Manager (DM). [...]

Inspectors wroteBased on interview and record review, it was determined that the facility did not ensure that each resident receives and the facility provides food prepared by methods that conserve nutritive value, flavor, and appearance. Specifically, multiple residents complained about the food during the initial pool interview process and multiple grievances were filed by residents about the quality of the food served by the facility. Resident identifiers: 1, 11, 13, 20, 23, 36, and 50.

Inspectors wroteBased on observation and interview, it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the facility served three residents beverages in plastic cups that were not clean and facility staff served residents hot chocolate without completing hand hygiene. Resident Identifiers: 38, 62, 7, 57, 319, and 61. Finding Include: On 1/9/24 at 11:50 AM, an observation was made of the Resident Advocate (RA) 1 and the Minimum Data Set Coordinator (MDSC). The RA 1 and MDSC pushed a three level cart that held juice on the top level, small plastic cups on the mid level and large plastic cups on the bottom level. All the small cups were observed to be clean. Three of the large cups on the bottom were observed to be dirty with a light brown sediment. [...]

Inspectors wroteBased on record review and interview it was determined, for 5 of 38 sample residents, that the facility did not maintain medical records on each resident that were complete, accurately documented, and readily accessible. Specifically, resident's influenza consent and declination records were not included in the medical record. Resident identifiers: 29, 34, 6, 1, and 21.

Inspectors wroteBased on interview and record review, it was determined, the facility did not ensure that the antibiotic stewardship program included antibiotic use protocols and a system to monitor the antibiotic use. Specifically, the facility did not have infection control tracking and trending completed for the previous year.

Inspectors wroteBased on observation, interview and record review it was determined, for 2 of 38 sampled residents, the facility did not offer a therapeutic diet when there was a nutritional problem and the health care provider orders a therapeutic diet. Specifically, residents with physician's orders for liberalized renal diets were not provided the appropriate diet. Resident identifiers: 23 and 170.

Inspectors wroteBased on observation and interview, the for 1 out of 38 sampled residents, the facility was not in accordance with currently accepted professional principles and included the Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. Specifically, there was documentation of narcotics that were wasted with one nurse and a second nurse did not witness the waste. Resident identifier: 19.

Inspectors wroteBased on interview and record review it was determined, for 1 of 38 sampled residents, that the facility did not file in the resident's clinical record signed and dated reports of radiological services. Specifically, a resident's x-ray was not located in the medical record. Resident identifier: 19.

Inspectors wroteBased on interview and record review, it was determined that for 2 of 38 sampled residents, that the facility did not ensure that each resident receives and the facility provides food prepared in a form designed to meet individual needs. Specifically, residents were served food that they were unable to chew due to missing teeth, received double portions of all food served at a meal instead of double portions of protein, and were served diet textures inappropriate for their swallowing ability. Resident Identifiers: 64 and 23.

Inspectors wroteBased on interview and record review it was determined, for 1 of 38 sampled residents, that the facility did not ensure that each resident received the food and drink that accommodates the resident allergies, intolerance's, and preferences Specifically, a resident reported that she could not digest dark chicken meat and had asked not to receive it. Resident identifier: 36.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that a feeding assistant had completed a state-approved training course before providing feeding assistance to residents. Specifically, for 1 out of 38 sampled residents, the Resident Advocate (RA) was providing feeding assistance to a resident without having completed a state-approved training course. Resident identifier: 64.

Inspectors wroteBased on interview and record review it was determined, for 1 of 38 sampled residents, that each resident did not receive adequate supervision to prevent accidents. Specifically, a resident's neurological assessments were not completed after sustaining falls. Resident identifier: 173.

Inspectors wrote15. Resident 22 was initially admitted to the facility on [DATE] and again on 1/19/22 with diagnoses which included idiopathic peripheral autonomic neuropathy, endocarditis and heart valve disorders, history of COVID-19, major depressive disorder, muscle weakness, osteoarthritis of the left hip, and generalized anxiety disorder. On 3/29/22 at 2:25 PM an interview with resident 22 was conducted. Resident 22 stated that the facility was dysfunctional. Resident 22 stated that she had wounds on her legs which were painful. Resident 22 stated that she did not feel like she received good care at this facility. Resident 22's medical records were reviewed on 4/4/22 Resident 22 had an order that started on 2/10/22 and it stated wound care to right lower extremity, clean wound with wound cleaner or NS [normal saline], pat dry with gauze. [...]

Inspectors wroteBased on record review and interview it was determined for 14 of 51 sample residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency. Specifically, entity reports of multiple abuse allegations were not submitted to the State Survey in a timely manner.

Inspectors wroteBased on interview and record review it was determined that in response to allegations of abuse, neglect, exploitation, or mistreatment the facility failed to have evidence that all alleged violations were thoroughly investigated for 14 of 51 sample residents. Specifically, based on a review of Entity Reports, filed with the State Survey Agency (SSA), between 8/22/21 and 3/31/22, the facility has submitted multiple initial Entity Reports with no subsequent final investigation report. Multiple instances of resident to resident physical, verbal and sexual abuse occurred with an insufficient investigation. This was determined to have occurred at an Immediate Jeopardy level. Resident identifiers: 4, 6, 14, 16, 18, 20, 23, 25, 31, 37, 49, 51, 53, and 111. NOTICE: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined for 9 of 51 sample residents, that the facility did not ensure that all residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, residents had pressure ulcers that were not treated as ordered and one resident's that was not examined by a physician, and residents who underwent change of condition that were not treated timely.

Inspectors wrote8. Resident 38 was admitted to the facility on [DATE] with diagnoses that included a history of cerebral infarction, cardiomyopathy, difficulty walking, depression, anxiety, and a history of falls. On 3/27/22 at 3:30 PM, resident 38 was interviewed. Resident 38 stated that he'd fallen 6 or 7 times at the facility, with part of the problem being that he needed new glasses. Resident 38 stated that he wanted to leave the facility to go to an assisted living facility. On 4/13/22, resident 38's medical record review was completed. On 12/20/21 at 3:03 AM, an administration note revealed that resident 38 was on alert charting for a fall. Nursing notes revealed the following: a. On 12/13/21 at 10:44 AM, resident 38 had a fall note. Patient had no neuro problem or any discomfort at this time. Patient still walks around the hall way. Will continue to monitor. b. [...]

Inspectors wroteHARM 2. Resident 29 was initially admitted to the facility on [DATE] and again on [DATE] with diagnoses which included type 2 diabetes mellitus, chronic obstructive pulmonary disease, cerebral infarction, acute myocardial infarction, unspecified dementia, anxiety disorder, and low back pain. On [DATE] at 11:15 AM an interview with resident 29 was conducted. Resident 29 stated that the staff rarely changed the dressing for his wounds. Resident 29 stated that the last time his dressings for his wounds were changed and cleaned was 3 days ago. On [DATE] an interview with resident 29's family member was conducted. Resident 29's family member stated that once resident 29 returned from the hospital on [DATE], they noticed that resident 29 was always lying in the same position. [...]

Inspectors wrotePOTENTIAL FOR HARM 5. Resident 43 was admitted to the facility on [DATE], with diagnoses that included alcohol dependence, peripheral neuropathy, hyperlipidemia, anxiety, depression, muscle weakness, lack of coordination, club foot and insomnia. On 3/30/22 at 2:51 PM, an interview with resident 43 was conducted. Resident 43 stated that his depression was getting worse, and he had asked the Administrator for a referral to get mental health counseling. Resident 43 stated that he asked the Administrator because there was no Social Worker or Resident Advocate working in the facility. Resident 43 stated that he asked for these services three weeks ago and had not heard anything yet. On 4/5/22 at 9:33 AM, a follow-up interview with resident 43 was conducted. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that 3 of 51 sample residents maintained acceptable parameters of nutritional status. Specifically, three residents experienced weight loss without timely interventions. The findings for all three residents were determined to have occurred at a harm level. Resident identifiers: 29, 32, and 49.

Inspectors wroteBased on observation, interview, and record review, it was determined, for 4 of 51 sample residents, that the facility did not ensure that pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, a residents were not given pain medication prior to a wound care treatment and residents with consistent high pain scores were given no additional pain management.

Inspectors wroteBased on observation, interview and record review, the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. These findings resulted in harm to multiple residents. In addition, staff and resident interviews revealed that staffing levels were not appropriate for the residents' needs. Resident identifiers: 4, 16, 17, 18, 19, 22, 27, 28, 29, 37, 40, 41, 43, 44, 46, 47, 49, 51, 57, 61 and 111.

Inspectors wrotePOTENTIAL FOR HARM 5. On 4/7/22 at 2:03 PM, an interview was conducted with the laundry staff (LS). A Spanish speaking SSA representative assisted in translating for the interview with the LS. The LS stated that one day in December the facility Administrator (ADM) made her work as a Nurse Assistant (NA). The LS stated that she started work at 6:00 AM with laundry and housekeeping duties and then at 5:00 PM she transitioned to being a NA until approximately 10:00 PM. The LS stated that she was told to pass water and when a resident pressed the call light to just go and see what the resident wanted. The LS stated that she was left alone on the 2nd floor for 3 hours with no other aide until agency arrived. The LS stated that there were some residents that she had to change their diaper. The LS stated that she had no training as a nursing assistant. [...]

Inspectors wrotePOTENTIAL FOR HARM 6. Resident 43 was admitted to the facility on [DATE], with diagnoses that included alcohol dependence, peripheral neuropathy, hyperlipidemia, anxiety, depression, muscle weakness, lack of coordination, club foot and insomnia. On 3/30/22 at 2:51 PM, an interview with resident 43 was conducted. Resident 43 stated that his depression was getting worse, and he asked the Administrator for a referral to get mental health counseling. Resident 43 stated that he asked the Administrator because there was not a Social Worker or Resident Advocate in the facility. Resident 43 stated that he asked for this three weeks ago and had not heard anything yet. On 4/5/22 at 9:33 AM. a follow-up interview with resident 43 was conducted. Resident 43 stated that he had to take care of this himself by talking to the Medical Doctor about this, and called a mental health provider himself. [...]

Inspectors wroteBased on interview and record review it was determined, for 11 out of 51 sample residents, that the facility did not provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, two residents with mental health disorders required hospitalization after attempting suicide due to lack of interventions and behavioral health services, a resident with suicidal ideation (SI) eloped and was hospitalized due to lack of interventions and behavioral health services, and a resident with memory deficits had multiple incidents of distressing behaviors without interventions or services provided. The deficient practice identified was found to have occurred at a harm level. [...]

Inspectors wroteBased on interview, record review, and observation, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, multiple system failures were identified during the survey, and the facility was found to be in non-compliance with F600, F609, F610, F684, F686, F689, and F740 at an Immediately Jeopardy level, indicating substandard quality of care. In addition, the facility was found to have been cited at a harm level for F580, F644, F688, F692, F697, F710, F725, F726, F741, F742, F745, F770, and F841. Resident identifiers: 1, 2, 4, 6, 14, 16, 17, 18, 19, 20, 22, 23, 25, 27, 28, 29, 30, 31, 32, 37, 38, 38, 39, 40, 41, 43, 44, 46, 47, 49, 51, 53, 55, 57, 61 and 111.

Inspectors wroteBased on interview, record review, and observation, the facility did not appoint an administrator who reported to, and is accountable to the governing body. In addition, the governing body did not establish and implement policies regarding the management and operation of the facility. Specifically, multiple system failures were identified during the survey, and the facility was found to be in non-compliance with F600, F609, F610, F684, F686, F689, and F740 at an Immediately Jeopardy level, indicating substandard quality of care. In addition, the facility was found to have been cited at a harm level for F580, F644, F688, F692, F697, F710, F725, F726, F741, F742, F745, F770, and F841. Resident identifiers: 1, 2, 4, 6, 14, 16, 17, 18, 19, 20, 22, 23, 25, 27, 28, 29, 30, 31, 32, 37, 38, 38, 39, 40, 41, 43, 44, 46, 47, 49, 51, 53, 55, 57, 61 and 111.

Inspectors wroteBased on interview, observation, and record review, the facility did not ensure that the medical director implemented resident care policies, and coordinated care in the facility. Multiple system failures were identified during the survey, and the facility was found to be in non-compliance with F600, F609, F610, F684, F686, F689, and F740 at an Immediately Jeopardy level, indicating substandard quality of care. In addition, the facility was found to have been cited at a harm level for F580, F644, F688, F692, F697, F710, F725, F726, F741, F742, F745, and F770. Resident identifier: 61.

Inspectors wroteBased on interview, record review, and observation, the facility did not present a Quality Assurance and Performance Improvement (QAPI) plan to the State Agency. In addition, multiple system failures were identified during the survey, and the facility was found to be in non-compliance with F600, F609, F610, F684, F686, F689, and F740 at an Immediately Jeopardy level, indicating substandard quality of care. In addition, the facility was found to have been cited at a harm level for F580, F644, F688, F692, F697, F710, F725, F726, F741, F742, F745, F770, and F841.

Inspectors wroteBased on interview and record review, the facility did not ensure that the Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of correction to correct identified quality deficiencies. Specifically, multiple system failures were identified, and the facility was found to be in non-compliance with F600, F609, F610, F684, F686, F689, and F740 at an Immediately Jeopardy level, indicating substandard quality of care. In addition, the facility was found to have been cited at a harm level for F580, F644, F688, F692, F697, F710, F725, F726, F741, F742, F745, F770, and F841. In addition, the QAA meetings were not being conducted, nor was the Medical Director involved in the QAA process. Resident identifiers: 1, 2, 4, 6, 14, 16, 17, 18, 19, 20, 22, 23, 25, 27, 28, 29, 30, 31, 32, 37, 38, 38, 39, 40, 41, 43, 44, 46, 47, 49, 51, 53, 55, 57, 61 and 111.

Inspectors wroteBased on interview and record review, the facility did not ensure that the Quality Assessment and Assurance (QAA) committee met quarterly and as needed to identifying issues with respect to which quality assessment and assurance activities are necessary. In addition, the Medical Director was not involved in the QAA process. Specifically, multiple system failures were identified, and the facility was found to be in non-compliance with F600, F609, F610, F684, F686, F689, and F740 at an Immediately Jeopardy level, indicating substandard quality of care. In addition, the facility was found to have been cited at a harm level for F580, F644, F688, F692, F697, F710, F725, F726, F741, F742, F745, F770, and F841. Resident identifiers: 1, 2, 4, 6, 14, 16, 17, 18, 19, 20, 22, 23, 25, 27, 28, 29, 30, 31, 32, 37, 38, 38, 39, 40, 41, 43, 44, 46, 47, 49, 51, 53, 55, 57, 61 and 111.

Inspectors wroteBased on interview, observation and record review the facility did not notify the physician for 3 of 51 sample residents after the residents experienced a significant change in condition or a need to alter treatment. Specifically, one resident who needed wound care did not see a provider and declined to the point of death, a resident who left the faciity on leave did not have needed medications, and abnormal vital signs were not provided to the physician. The findings for resident 61 were determined to have occurred at a harm level. Resident identifiers: 17, 40, and 61.

Inspectors wroteBased on interview and record review it was determined for 2 of 51 sampled residents that the facility did not incorporate the recommendations from the Pre-admission Screening Resident Review (PASRR) Level II into the resident's assessment, care planning and transitions of care. Specifically, a PASRR Level II evaluation identified that residents needed mental health services and the facility did not arrange for those services. The findings for residents 46 and 49 were determined to have occurred at a harm level. Resident identifiers: 46 and 49.

Inspectors wroteBased on observations, interviews, and record review it was determined that the facility did not ensure a 3 of 51 sample resident with limited range of motion received appropriate treatment and services to increase their range of motion and to prevent further decrease in range of motion. Specifically, a resident who arrived to the facility with the ability to walk was not provided with treatment and services to increase their range of motion or to prevent further decrease in range of motion and the facility did not provide a restorative nurse assistant (RNA) to residents. This finding resulted in a harm deficiency for resident 29. Resident identifiers: 29, 30, and 55.

Inspectors wroteBased on interview and record review, the facility did not ensure that for 2 of 51 sample residents, the medical care was supervised by a physician. Specifically, appropriate oversight for wound care was not provided, and resident 61 subsequently passed away. The findings for resident 61 were determined to have occurred at a harm level. Resident identifiers: 17 and 61.

Inspectors wroteBased on interview, observation and record review, the facility did not ensure that 2 of 51 sample residents who displayed or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. Specifically, a resident expressing suicidal ideations was not treated appropriately. This finding was determined to have occurred at a harm level. In addition, one resident was not assisted in making an appointment with a mental health provider, despite multiple requests. Resident identifiers: 43 and 49.

Inspectors wroteBased on interview and record review it was determined for 4 of 51 sample residents that the facility did not obtain laboratory services to meet the needs of its residents. Specifically, resident had orders to obtain lab draws that were not completed. The findings for resident 61 were determined to have occurred at a harm level. Resident identifiers: 2, 17, 30, and 61.

Inspectors wroteBased on interview, the facility did not designate a registered nurse to serve as the director of nursing on a full time basis.

Inspectors wroteBased on record review, the facility did not conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there was, or the facility plans for, any change that would require a substantial modification to any part of this assessment. Specifically, the facility did not accurately assess the residents' needs, nor did they comply with their assessment.

Inspectors wroteBased on observation, interview, and record review it was determined, for 4 of 51 sample residents, that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. [...]

Inspectors wroteBased on interview and record review, the facility did not designate one or more individuals as the infection preventionist who are responsible for the facility's infection control program.

Inspectors wrote2. Resident 18 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included respiratory failure, type II diabetes mellitus, obesity, peripheral vascular disease, primary hypertension, spinal stenosis, cervical disc degeneration, depression, and bilateral osteoarthritis of the knee. On 4/1/22 at 3:25 PM, resident 18 was interviewed. Resident 18 stated that he had fallen from a Hoyer lift while at the facility. Resident 18 stated that the higher capacity Hoyer was not able to go up and down so staff used a Hoyer that was rated 8 pounds above his weight, which was not sufficient for a safe transfer. On 4/13/22, resident 18's record review was completed. On 11/16/21 at 8:00 PM, an incident note revealed that resident 18 fell from the Hoyer lift while being transferred to bed. [...]

Inspectors wroteBased on interview and record review it was determined that the facility did not provide training to staff that educated on activities that constituted dementia managment, abuse, neglect exploitation and misappropriation of property, procedures for reporting abuse, and resident abuse prevention. Specifically, the facility did not provide dementia management training to facility staff. Resident identifiers: 4 and 14.

Inspectors wroteBased on interview and record review it was determined that the facility did not provide training to staff that was sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year. Resident identifiers: 4 and 14.

Inspectors wrote4. On 4/6/22 at 8:39 AM, resident 17 was observed in the lobby area of the facility with the receptionist. The receptionist stated that resident 17 was going to be leaving soon for an appointment. At 8:40 AM, CNA 18 came to the lobby area and was talking to the resident. The resident responded to CNA 18 in her primary language, which was not English. CNA 18 stated to the receptionist I don't know what the hell she's saying and proceeded to escort the resident out of the building. 5. Resident 4 was admitted to the facility on [DATE] with diagnoses which included hemiplegia affecting right dominant side, paraplegia, traumatic brain injury (TBI), convulsions, chronic pain syndrome, muscle wasting and atrophy, dependence on wheelchair, and a history of falling. On 3/29/22 at 9:10 AM, an interview was conducted with resident 4. Resident 4 stated that last Friday on 3/25/22 at approximately 6: [...]

Inspectors wroteBased on interview, the facility did not ensure that residents were afforded the right to organize and participate in resident groups in the facility. Specifically, no resident council had been formed and held. Resident identifier: 39.

Inspectors wroteBased on interview and record review it was determined, for 5 of 51 sample residents, that the facility did not provide the residents the right to manage his or her financial affairs. Specifically, residents who had authorized the facility to manage any personal funds did not have reasonable access to those funds. In addition, resident's were not provided their allocated 45 dollars each month. Resident identifiers: 31, 37, 38, 47 and 51.

Inspectors wroteBased on interview, the facility did not ensure that 5 of 51 sample residents had their individual financial records available through quarterly statements and upon request. Resident identifiers: 31, 37, 38, 47 and 51.

Inspectors wrote2. On [DATE] at 11:30 AM, an observation was made of resident 21's wheelchair. The arms of the wheelchair were observed to be cracked and peeling, exposing the foam underneath. 3. On [DATE] at 2:06 PM, an interview was conducted with the laundry staff (LS). A Spanish speaking State Survey Agency (SSA) representative was obtained to assist in translating for the interview with the LS. The LS stated that the facility Administrator (ADM) gave her a department budget for housekeeping and laundry supplies of $800 per month. The LS stated that this was not enough money to purchase the required monthly supplies. The LS stated that she use to purchase buckets of detergent and Clorox for the washing machine and it cost $50 and lasted for 22 days. The LS stated that the ADM switched the system and now it utilized little detergent and Clorox bottles. [...]

Inspectors wroteBased on record review and interview it was determined, for 3 of 51 sample residents, that the facility did not ensure the prompt resolution of grievances. The facility did not ensure that grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued. Specifically, grievances were reported with no action taken by Administration to replace missing items or otherwise resolve the grievances. Resident identifiers: 6, 16, and 38.

Inspectors wroteBased on interview and record review, the facility did not appropriately screen employees to ensure that they were free of legal findings regarding abuse, neglect, exploitation, misappropriation of property or mistreatment. Staff identifiers: Staff Members 1, 2, 3 and 4.

Inspectors wroteBased on interview and record review it was determined, for 4 out of 51 sampled residents, that the facility did not ensure that any reasonable suspicion of a crime against any individual who was a resident of the facility was reported immediately to law enforcement, but not later than 2 hours after the suspicion was identified. Specifically, the police were not notified for two sexual abuse investigations. Resident identifiers: 4, 49, 51, and 111.

Inspectors wroteBased on interview and record review, the facility did not develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality of care for 3 of 51 sample residents. Resident identifiers: 61, 111, and 112.

Inspectors wroteBased on interview, observation, and record review, the facility did not develop and implement a comprehensive person-centered care plan for 10 of 51 sample residents, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Specifically care plans were not developed or implemented with regard to pain, wound care, nutrition, social work, catheters, and mental health needs. Resident identifiers: 14, 17, 29, 31, 32, 41, 46, 53, 57, and 61.

Inspectors wroteBased on interview and record review, the facility did not develop and implement an effective discharge planning process for 5 of 51 sample residents that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. Resident identifiers: 6, 21, 35, 38, and 51.

Inspectors wroteBased on interview and record review, it was determined, for 3 of 51 sample residents, that the facility did not ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene. Specifically, residents were not provided showers according to their schedules. Resident identifiers: 16, 29, and 41. Findings Include: 1. Resident 29 was initially admitted to the facility on [DATE] and again on 1/24/22 with diagnoses which included type 2 diabetes mellitus, chronic obstructive pulmonary disease, cerebral infarction, acute myocardial infarction, unspecified dementia, anxiety disorder, and low back pain. On 4/6/22 at 11:15 AM an interview with resident 29 was conducted. Resident 29 stated that he does not remember the last time he had a shower or bed bath. [...]

Inspectors wroteBased on observation, interview and record review it was determined, for 4 of 51 sampled residents, that the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, residents had medications scheduled for administration that were unavailable from the pharmacy. Resident identifiers: 17, 43, 112, and 212.

Inspectors wroteBased on observation, interview, and record review it was determined the facility did not store medications in a proper manner. Specifically, for 4 out of 51 sampled residents, medications were left in residents rooms without nurse verification that resident had taken medications, and medications were improperly labeled. Resident identifiers: 16, 43, 51, and 53.

Inspectors wroteBased on observations and interviews it was determined that, for 11 of 51 sampled residents, that the facility did not provide food prepared by methods that conserve nutritive value, flavor, and appearance; food and drink that was not palatable, attractive, and at a safe and appetizing temperature. Specifically, multiple residents complained about the palatability of food, appearance of the food, and the temperature of the food. Resident identifiers: 4, 7, 11, 15, 16, 18, 31, 33, 43, 51, and 111.

Inspectors wroteBased on interview and record review, the facility did not ensure that medical records were complete and accurate for 10 of 51 sample residents. Specifically, physicians orders were not correctly added to residents' electronic medical records, outside provider records were not correctly added to residents' electronic medical records, private health information was not secured, and medications were not documented accurately. Resident identifiers: 1, 8, 17, 18, 40, 41, 46, 49, 112, and 212.

Inspectors wroteBased on interview and record review it was determined that the facility did not test residents and facility staff based on the identification of any individual identified as diagnosed with COVID-19 in the facility. Specifically, staff members who were not fully vaccinated were not tested as required.

Inspectors wroteBased on interview and record review it was determined, for 5 out of 5 staff members sampled, that the facility did not ensure that that each staff member was provided education regarding the benefits and risks and potential side effects associated with the vaccine before offering the COVID-19 vaccine. Specifically, the facility did not maintain documentation that staff were provided education regarding the benefits and potential risks associated with the COVID-19 vaccine and that staff were offered the COVID-19 vaccine unless medically contraindicated or the staff member had already been immunized. Staff Identifier: Staff 1, Staff 2, Staff 3, Staff 4, and Staff 5.

Inspectors wroteBased on observation, interview and record review it was determined the facility did not follow policy and procedures for residents with COVID-19 vaccination exemptions. Specifically, staff with COVID-19 vaccination exemptions were not wearing personal protective equipment according to the facility's policy and procedures.

Inspectors wroteBased on observation, interview, and record review it was determined the facility did not provide an means for contacting nursing staff that was reliable and easily to use. Specifically, for 1 out of 51 sampled residents, multiple call lights were not working, and an emergency call light in a bathroom was not accessible. Resident identifier: 43.

Inspectors wroteBased on observation and interview it was determined that the facility did not provide a safe, functional, sanitary, and comfortable environment for residents. Specifically, the emergency water tanks had not been maintained or disinfected since August 2020.

Inspectors wroteBased on observation, interview, and record review it was determined the facility did not accommodate the residents needs or preferences. Specifically, for 2 out of 51 sample residents, residents were not provided the correct size briefs or provide for communication barriers for non-English speaking residents. Resident identifiers: 16 and 28.

Inspectors wroteBased on observation and interview it was determined, for 2 of 51 sample residents, that the facility did not ensure that the resident had the right to and the facility promoted and facilitated the resident self-determination through support of the resident choice. Specifically, a resident was not able to access the facility gym due to the elevator's continued disrepair and the facility did not assist a resident with arranging transportation to the Department of Motor Vehicles (DMV) to obtain a drivers license. Resident identifiers: 11 and 38.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to formulate an advance directive for 1 of 51 sampled residents. Specifically, a resident did not have an advance directive available for facility staff to access. Resident identifier: 41.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to inform a Medicaid-eligible resident in writing periodically during the resident's stay, of services available in the facility, and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate. Specifically, the Notice of Medicare Non-Coverage (NOMNC) form, which documents notification from the facility to the resident could not be found for 1 of 51 sampled residents. Resident identifier: 21.

Inspectors wroteBased on interview and record review it was determined, for 1 out of 51 sample residents, that the facility did not ensure that the transfer was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider and included: contact information of the practitioner responsible for the care of the resident; resident representative; advance directive information; all special instructions for ongoing care; comprehensive care plan; and any other documentation to ensure a safe and effective transition of care. Specifically, a resident was transferred to the hospital and no documentation could be found in the resident's medical record that information was communicated to the receiving provider for the transition of care. Resident identifier 40.

Inspectors wroteBased on record review and interview it was determined, for 2 out of 51 sample residents, that the facility did not ensure that the Preadmission Screening for individuals with a mental disorder was performed by a person or entity other than the State mental health authority, prior to admission; and that because of the physical and mental condition of the individual, the individual required the level of services provided by the nursing facility; and whether the individual required specialized services. Specifically, two residents admitted with a mental health disorder did not have a Preadmission Screening Resident Review (PASRR) Level II recommended or completed. Resident identifiers: 14 and 111.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that 2 out of 51 sample residents received the appropriate treatment and assistive devices to maintain vision. Specifically, one resident was missing glasses and another resident's glasses had been broken by a Certified Nursing Assistant (CNA) without being repaired or replaced. Resident identifiers: 18 and 51.

Inspectors wroteBased on interview, observation and record review, the facility did not ensure for 1 of 51 sample residents, that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Resident identifier: 16.

Inspectors wroteBased on observation, and interview it was determined the facility did not ensure oxygen delivery systems were in good working condition. Specifically, for 1 out of 51 sampled residents, resident did not have water in humidifier, and the oxygen concentrator was too close to the walls to work as designed. Resident identifier: 16.

Inspectors wroteBased on interview and record review it was determined for 1 of 51 sample residents that the facility did not ensure that residents who required dialysis receive such services, consistent with professional standards of practice. Specifically, a resident receiving dialysis did not always receive the needed dialysis, there was no contract with the dialysis company, and communication did not always occur between dialysis staff and the facility . Resident identifier 41.

Inspectors wroteBased on observation and interview, it was determined that the facility did not have the nurse staffing information posted. The facility must post the following information on a daily basis: Facility name, the current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurses, Licensed practical nurses, Certified Nurse aides, and resident census. The facility must post the nurse staffing data daily at the beginning of each shift and maintain the posted daily nurse staffing data for a minimum of 18 months. Additionally, the information must be displayed in a prominent place readily accessible to residents and visitors. Specifically, the wrong nurse staffing posted at the facility was posted for the wrong date or not at all.

Inspectors wroteBased on interview and record review it was determined for 1 of 51 sample residents, that each resident was not free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; excessive duration; without adequate monitoring; without adequate indication for its use; or in the presence of adverse consequences which indicated the dose should have been reduced or discontinued. Specifically, on resident received a blood pressure medication when their blood pressure was low, and a resident received medication without required monitoring. Resident identifier: 38.

Inspectors wroteBased on interview and record review, the facility did not ensure that 2 of 51 sample residents were free of significant medication errors. Specifically, residents were not provided inhalers, antibiotics or insulin as ordered. Resident identifiers: 31 and 112.

Inspectors wroteBased on interview and record review and it was determined that, for 2 of 51 sample residents, that the facility did not provide or obtain laboratory services when ordered by the physician. Specifically, prothrombin time (PT)/international normalized ratio (INR) blood draws and a basic metabolic panel (BMP) were not completed as ordered by the physician. Resident identifiers: 2 and 61.

Inspectors wroteBased on interview and record review it was determined, for 1 of 51 sample residents, that the facility did not file in the resident's clinical record laboratory reports that were dated and contained the name and address of the testing laboratory. Resident identifier 17.

Inspectors wroteBased on interview and medical record review it was determined, for 1 of 51 sample resident, that the facility did not file in the resident's clinical record, a signed and dated report of radiological services. Specifically, one resident who had a fall from a Hoyer lift did not have the Computerized Tomography (CT) and X-ray reports from the hospital in the medical record. Resident identifier: 18.

Inspectors wroteBased on interview and record review, the facility did not provide the required specialized rehabilitation services as ordered by a physician. Specifically, a physician-ordered speech therapy evaluation was not completed. Resident identifier: 30.

Inspectors wroteBased on interview and record review it was determined that the facility did not establish an infection prevention and control program (IPCP) that included an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. Specifically, a resident was receiving a prophylactic antibiotic without justification, not all antibiotics were administered when ordered, and infection control tracking and trending was not completed. Resident identifier: 30. Findings Include: 1. Infection control documentation was requested. The antibiotic documentation revealed that antibiotic stewardship was completed in January, 2022. No Infection Control Surveillance Logs were available for the months of February, March or April, 2022. No antibiotic reviews were completed by the pharmacy in 2022. There was no acting Director of Nursing (DON) in the building. [...]