Spring Creek Nursing and Rehabilitation Center LLC

Inspectors wroteBased on medical record review, staff interview, and facility policy review the facility failed to ensure resident care plans were properly completed to include all identified care areas. This affected six (#03, #11, #13, #21, #25, and # 32) of six residents reviewed for care plan accuracy and had the ability to affect all residents. The facility census was 71.

Inspectors wroteBased on interview, review of the facility activities calendar, review of Resident Council minutes, and review of the Resident Handbook, the facility failed to ensure activities outside the facility, per resident preferences. This had the potential to affect residents able to travel outside the facility. The facility census was 71.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to store medications in a safe manner. This affected one resident (#27) and had the ability to affect all residents. The facility census was 71.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure food was served at a safe, appetizing temperature, and acceptable palatability. This had the potential to affect all residents receiving meal service on hallway one hundred except one resident who the facility identified was to receive nothing by mouth (NPO). The facility census was 71.

Inspectors wroteBased on observation, interview, review of the Resident Council Minutes, and review of the facility policy, the facility failed to ensure residents were offered fresh water daily. This affected all residents except four (#27, #37, #43, #56) residents identified as receiving nothing by mouth (NPO). The facility census was 71.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to maintain sanitary conditions during meal service for one of two meal observations conducted. This had the potential to affect all residents receiving meal service on hallway one hundred hallway except one resident who the facility identified as receiving nothing by mouth (NPO). The facility census was 71.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to follow appropriate hand hygiene and infection control practices during meal tray distribution for one of two meal service observations conducted. This had the potential to affect all residents receiving meal service on hallway one hundred except one resident who the facility identified as not receiving anything by mouth (NPO). The facility census was 71.

Inspectors wroteBased on observation, medical record review, resident interview, staff interview, and policy review the facility failed to ensure resident rooms were at comfortable temperatures. This affected one (#25) of two residents interviewed for environmental temperature concerns. The facility census was 71.

Inspectors wroteBased on record review, staff interview, and review of the Center for Medicaid and Medicare Services (CMS) manual revealed the facility failed to submit discharge assessments in a time manner. This affected two former residents (#09, #53) reviewed for Minimum Data Set (MDS) report submission. The facility census was 71.

Inspectors wroteBased on medical record review, staff interview, and review of hospice reports, the facility failed to ensure hospice and facility staff had ongoing communication. This affected one (#11) of one resident reviewed for hospice services. The facility identified two Residents (#11, #43) who received hospice service. The facility census was 71.

Inspectors wroteBased on medical record review, interview, and review of the facility policy, the facility failed to ensure residents who had vision concerns were seen timely by the ophthalmologist. This affected one (#37) resident reviewed for ancillary services. The facility census was 71.

Inspectors wroteBased on observation, record review, resident interview, staff interview, and policy review revealed the facility failed to ensure a resident with pressure ulcers was provided a high protein diet as prescribed by a physician. This affected one (#25) of two residents reviewed for wounds. The facility census was 71.

Inspectors wroteBased on observation, staff interview, resident interview, and policy review, the facility failed to ensure safety by allowing a space heater in a resident's room. This affected one (#70) of one resident reviewed for resident safety. The facility census was 71.

Inspectors wroteBased on record review, staff interview, and review of facility policy, the facility failed to timely identify, assess, and intervene for significant weight loss. This affected one (#5) resident of one resident reviewed for weight loss. The facility census was 71.

Inspectors wroteBased on observation, medical record review, interview, and review of the facility policy the facility failed to ensure a resident on dialysis who frequently refused due to nausea and vomiting was monitored, and that the physician was notified. This affected one (#64) resident reviewed for dialysis. The facility census was 71.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure provider orders were carried out as prescribed. This affected one (#5) of one resident reviewed for the implementation of provider orders. The facility census was 71.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure dental services were provided for one (#37) resident reviewed for dental services. The facility census was 71.

Inspectors wroteBased on medical record review, resident interview, staff interview, police officer interview, review of Self-Report Incident (SRI) #269318, review of the facility investigation, and review of the facility policy, the facility failed to protect a resident from misappropriation. This affected one resident (#2) of three reviewed for misappropriation. The facility census was 71.

Inspectors wroteBased on medical record review, resident and staff interview, review of resident shower sheets and shower schedules, and facility policy review, the facility failed to ensure residents who were dependent on staff for bathing received showers on their scheduled days per their preference. This affected three (#17, #25, and #67) of four residents reviewed for showers. The facility census was 68.

Inspectors wroteBased on observation, resident and staff interviews, and review of the facility policy, the facility failed to ensure the resident's call devices were functioning in their bathroom and/or bedrooms and failed to ensure the residents had accessibility and/or functionality of call devices in the shower rooms. This affected three (#22, #23, and #24) of five residents reviewed for call lights and had the potential to affect the residents who utilize the showers on first and third floor. The facility census was 74.1. Observation and interview on 08/14/25 at 8:45 A.M. revealed Resident #22's bathroom call light did not work. Resident #22 stated he would just wait for staff to come back after he was toileted. He could not recall if he used his call light or not. Interview on 08/14/25 at 11:10 A.M. with Plant Operation Director (POD) #102 confirmed Resident #22's bathroom call light did not work. [...]

Inspectors wroteBased on observation, resident and staff interviews, record review, and review of the facility policy, the facility failed to ensure the residents had a homelike environment. This affected three (#22, #23,and #24) of four residents reviewed for homelike environment. The facility census was 72.1. Review of the medical record for Resident #22 revealed a re-admission on [DATE]. Diagnoses included chronic obstructive pulmonary disease and seizures. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had severe cognitive impairment. Observation and interview on 08/14/25 at 8:45 A.M. of Resident #22's bathroom revealed a sink with a built in soap dispenser holder without a soap container in the holder. There was not any soap or paper towels available. Interview on 08/14/25 at 8:45 A.M. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to develop a care plan based on Resident #23's medical needs. This affected one (#23) of one resident reviewed for care plans. The facility census was 72. Review of the medical record for Resident #23 revealed an admission on [DATE]. Diagnoses included type I diabetes mellitus (DM). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact. Review of Resident #23's physician orders dated 06/05/25 revealed an order for insulin aspart injection solution 100 units (u) per milliliter (ml). Inject 100 units subcutaneously as needed for type I DM, administered through insulin pump. [...]

Inspectors wroteBased on observation, interview, and policy review, the facility failed to maintain a clean environment in the shower rooms. This had the potential to affect all residents residing One South and One [NAME] (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, and #74). The facility census was 73.

Inspectors wroteBased on medical record review, staff interview, and facility policy, the facility failed to notify a resident representative of a change of condition. This affected one (Resident #41) of three residents reviewed for notification of change. The facility census was 69.

Inspectors wroteBased on medical record review, review of facility incident investigations with witness statements, review of staff education, staff interviews, review of a resident handbook, review of a facility Self-Reported Incident (SRI), and review of facility smoking policies, the facility failed to ensure Resident #75 who had a known history of smoking with oxygen on, was assessed as an independent smoker, exhibited safe smoking practices and did not smoke while wearing oxygen. This resulted in Immediate Jeopardy and serious life-threatening harm, injuries and/or death when Resident #75 lit a cigarette while wearing oxygen therapy via nasal cannula, in the designated smoking area. Resident #75's oxygen ignited and set Resident #75 on fire with the oxygen. Resident #75 sustained singed facial hair, and the skin around his mouth, nose, and bilateral cheeks was charred black. [...]

Inspectors wroteBased on review of the facility's billing statements, review of email communication, vendor interviews, and staff interviews, the facility failed to operate the facility in a manner to ensure facility bills were being paid in a timely manner. This had the potential to affect all 73 residents in a facility with a census of 73.

Inspectors wroteBased on observation, resident interview, staff interview, medical record review, the facility failed to ensure the electronic medical record (EMR) accurately reflected physician orders and treatments provided to residents. This affected four (#49, #71, #74, and #77) of 20 residents reviewed for an accurate medical record. The facility census was 75.

Inspectors wroteBased on observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure resident dignity was maintained. This affected one (#24) of one residents reviewed for dignity. The facility census was 75.

Inspectors wroteBased on observation, medical record review, resident interview, and staff interview, the facility failed to ensure timely response to activated call lights and failed to ensure call lights were within reach of residents who were capable of using the call light and were dependent for care. This affected two (#1 and #4) of three residents reviewed for call lights. The facility census was 75.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure advanced directives were consistent throughout the medical record. This affected one (#49) of 24 residents reviewed for advanced directives. The facility census was 75.

Inspectors wroteBased on observation, resident and staff interview, medical record review, and review of a facility policy, the facility failed to ensure only physician ordered tracheostomy supplies were readily available to staff for respiratory needs, and failed to ensure supplemental oxygen tubing was changed as ordered. This affected three (#71, #74, and #76) of four residents reviewed for respiratory care. The facility census was 75.

Inspectors wroteBased on medical record review, staff interview, pharmacy staff interview, and review of a pharmacy agreement document, the facility failed to ensure irregularities were identified during monthly drug regimen reviews and those irregularities were reported to the facility. This affected one (#20) of six residents reviewed for pharmacy monthly drug regimen reviews. The facility census was 75.

Inspectors wroteBased on observation, staff interview, medical record review, review of pharmacy packing slips, review of a pharmacy provider agreement, and review of a facility policy, the facility failed to ensure medications were available and administered as ordered by the physician resulting in significant medication errors. This affected one (#77) of two residents observed during medication administration and two (#76 and #331) of five residents reviewed for medications. The facility census was 75.

Inspectors wroteBased on observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure medications were stored in a safe and secure manner. This affected two (#8 and #53) of four residents reviewed for medication storage. The facility census was 75.

Inspectors wroteBased on record review and interview, the facility failed to ensure the physician visited residents every 60 days. This affected one (Resident #87) of three residents reviewed for physician services. The facility census was 79.

Inspectors wroteBased on observations, record review, review of the Resident Council meeting minutes, family and staff interview and review of the facility policy, the facility failed to allow one (#8) resident to have visitors at the time of the resident and visitor's choosing. This deficient practice had the potential to affect 59 of 59 residents who reside in the facility.

Inspectors wroteBased on record reviews, observations, staff interviews, review of the facility policy, review of the Legionella guide, and review of the map and census, the facility failed to maintain standards of infection control practices during a clean dressing change for one (#14) resident. The facility failed to ensure resident care equipment was clean and stored in an appropriate manner for one (#32) resident to prevent potential infections. The facility also failed to implement the Legionella guide to ensure the water supply was adequate. In addition, the facility failed to ensure staff and visitors wore proper personal protective equipment (PPE) during a COVID-19 outbreak in the facility, including the staff swabbing for COVID-19 tests of unvaccinated staff. This deficient practice had the potential to affect 59 of 59 residents who reside in the facility.

Inspectors wroteBased on observations, staff interview and review of the facility policy, the facility failed to maintain resident rooms and the resident smoking area in a sanitary and comfortable manner. This affected eight (#12, #20, #32, #36, #38, #50, #53, and #54) of 59 residents who reside in the facility. The total facility census was 59.

Inspectors wroteBased on record review, staff and resident interviews, review of the facility policy and review of the facility Self-Reported Incidents (SRI's), the facility failed to report an allegation of verbal abuse involving one resident to the State Agency. This affected one (#47) of one resident reviewed for abuse. The total facility census was 59.

Inspectors wroteBased on record review, observations, and staff interview, the facility failed to properly position one resident during a meal to ensure she was able to feed herself appropriately. This affected one (#46) of one resident observed for meals. The total facility census was 59.

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to ensure compression stockings were applied as ordered for one resident. This affected one (#46) of two residents reviewed for assistive devices. The total facility census was 59.

Inspectors wroteBased on record review, observation, and staff interviews, the facility failed to implement interventions that included a palm protector for one resident to ensure his hand contractures did not worsen. This affected one (#19) of one resident observed for contractures. The total facility census was 59.

Inspectors wroteBased on observations, staff interview and review of the facility policy, the facility failed to ensure the medication was stored properly and in locked compartments. This affected one (#257) of one residents medication that was not secured. The total facility census was 59.

Inspectors wroteBased on observations, staff interview and review of the facility policy, the facility failed to maintain one residents bed in safe manner. This affected one (#257) of one residents bed observed during the environmental tour. The total facility census was 59.