Spring Creek Post-Acute Rehabilitation Center

Inspectors wroteBased on interview, record review, review of facility job description and employment records, and review of State Agency (SA) records, the facility failed to employ a qualified full-time social worker (SW) in a facility with greater than 120 beds. During the time that the facility failed to have a qualified SW, one resident (Resident (R) 1) was issued a defective discharge notice for which there was also inadequate rationale. The failure to ensure the employment of a qualified SW had the potential to affect all residents in this facility which, per SA records, was currently certified for 226 beds.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility attempted to discharge on e (Resident (R)1)) of 10 sampled residents reviewed for transfer/discharge without adequate evidence, the stated reason for the discharge was accurate. The facility issued a discharge notice using the rationale that R1's condition had improved and the resident no longer needed its service after the state agency responsible for Medicaid , known as the Kentucky Level of Care System (KLOCS ), denied R1's Level of Care evaluation.

Inspectors wroteBased on interview, record review, review of the facility's policy, and review of a Final Order issued by an Administrative Law Judge, the facility failed to provide a discharge notice which met federal requirements for one Resident (R) 1) of 10 sampled residents reviewed for transfer/discharge. The facility failed to ensure that all required information on the discharge notice was accurate, to facilitate a request for an appeal of the discharge decision.

Inspectors wroteBased on interviews, record review, and review of facility job descriptions, the facility failed to provide medically related social services, such as assisting residents with legal and/or financial matters for one (Resident (R)1)) of 10 sampled residents reviewed for transfer/discharge. The facility failed to assist the resident by providing needed information so the state agency responsible for Medicaid could make a determination as to the resident's continuing eligibility for services/payor source. The facility subsequently issued R1 a discharge notice after Medicaid denied eligibility based on the facility's failure to provide the requested information per Kentucky Administrative Regulations ([NAME]) 1:022, Section 10.

Inspectors wroteBased on observation, interview, closed record review, and review of the facility's policy, the facility failed to ensure residents were adequately assisted to prevent accidents for 1 of 4 residents sampled for falls, out of the total sample of 26 residents, (Resident (R)134).

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 26 sampled residents (Resident (R)529). Immediate Jeopardy (IJ) was identified on 05/09/2025 and was determined to exist on 04/18/2025 in the area of §483.25(d) Accidents Hazards, F689. On 05/09/2025, the Administrator was provided a copy of the CMS Immediate Jeopardy (IJ) Template and notified that the failure to ensure residents were provided supervision and protected from elopement is likely to cause serious injury, impairment, or death and constituted IJ at 42 CFR 483.25 F689. The IJ at F689 also constituted Substandard Quality of Care (SQC) at 42 CFR 483.25, Quality of Care. [...]

Inspectors wroteBased on observation, interview, and review of facility policy, it was determined the facility failed to ensure food was distributed and served in accordance with professional standards for food service safety for 4 of 26 sampled residents (Resident (R)111, R106, R32, and R122).

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to review and update the facilitys assessment which had the potential to affect 131 residents.

Inspectors wroteBased on observations, interviews, and review of facility policy, it was determined the facility failed to maintain a safe, clean, comfortable and homelike environment for twenty-six (26) sampled residents.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to establish and 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 for 6 of 26 sampled residents, (Resident (R)32, R65, R106, R111, R122, and R229)

Inspectors wroteBased on observation, interview, medical record review and facility policy review, the facility failed to ensure residents had a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility related to residents with eating difficulties for four (4) of 26 sampled residents (Resident (R) 32, 106, R122, , R111) and one (1) unsampled resident (R2).

Inspectors wroteBased on interview, record review, review of the facility's Director of Nursing (DON) and Administrator's Job Descriptions, and policy review, the facility failed to ensure it was 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 related to the facility's Administrator and/or DON failed to notify the state regulatory office on the elopement on 04/18/2025 of R529.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to implement the comprehensive person-centered care plan for one (1) of twenty-eight (28) sampled residents (Resident #61). Resident #61's Comprehensive Care Plan, revised 01/05/2024, revealed an intervention to utilize the mechanical lift with two (2) staff members for transfers. However, on 02/01/2024, Certified Nursing Assistant (CNA) #7 and CNA #14, transferred Resident #61 from the bed to the wheelchair without using a mechanical lift (device used to transfer residents who require support for mobility beyond the manual support provided by caregivers alone). [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for two (2) of twenty-eight (28) sampled residents (Resident #61 and Resident #74). 1. On 02/01/2024, Certified Nursing Assistant (CNA) #7 and CNA #14, transferred Resident #61 from the bed to the wheelchair without using a Hoyer mechanical lift (device used to transfer residents who require support for mobility beyond the manual support provided by caregivers alone). Resident #61 sustained a laceration to the left lateral calf and required transfer to the hospital emergency room (ER) for placement of three (3) skin clips (medical metallic device used to close open wounds). [...]

Inspectors wroteBased on interview, record review and review of facility policy, it was determined the facility failed to ensure the Minimum Data Set (MDS) Assessments accurately reflected the resident's status for three (3) of twenty-eight (28) sampled residents (Residents #21, #112 and #141). Resident #21's admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 12/08/2023, was coded under Section N as the resident receiving an anticoagulant; however, the resident did not receive an anticoagulant during the seven (7) day look back period. Additionally, review of Resident #112's MDS Assessment with an ARD date of 03/12/2023, was coded under Section N as the resident receiving an anticoagulant; however, the resident did not receive an anticoagulant during the seven (7) day look back period. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure the Comprehensive Care Plan (CCP) was reviewed and revised by the interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs for two (2) of twenty-eight (28) sampled residents (Resident #48 for and Resident #74). On 01/10/2024, staff transferred Resident #74 from the bed to the chair using a Hoyer lift (mechanical body lift). After the transfer, it was observed by staff the Hoyer lift pad was poor-fitting in size, resulting in skin-shear injury to the resident's left gluteal fold. After the incident, the resident's lift pad was changed to the green Hoyer lift pad with the blue stripe manufactured by Liko. However, the resident's CCP was not revised to reflect the change in lift pads. [...]

Inspectors wroteBased on interview, record review and a review of the facility's policy, it was determined the facility failed to implement the resident's Person-Centered Comprehensive Care Plan for one (1) of three (3) sampled residents (Resident #5), who required a specific diet. On 10/10/2023, the Speech Language Pathologist evaluated Resident #5 and determined the resident had a change in his/her condition that led to the resident's therapeutic diet being downgraded to a Dysphagia Level 1, which meant the resident's diet consisted of regular thin liquids, as the resident had difficulty chewing and swallowing his/her foods. The resident's care plan was revised on the same day, to reflect the change in the resident's diet. Staff failed to implement the resident's care plan. [...]

Inspectors wroteBased on interview, record review, and review of facility policy, it was determined the facility failed to ensure a resident with Dysphagia (difficulty swallowing food or liquid) and at risk for choking, received food that was appropriate for the residents assessed diet for one (1) of three (3) sampled residents (Resident #5) who were at risk for aspiration and/or choking. On 10/10/2023, the Speech Language Pathologist evaluated Resident #5 and determined the resident had a change in his/her condition that led to the resident's therapeutic diet being downgraded to a Dysphagia Level 1, which meant the resident's diet consisted of regular thin liquids as the resident had difficulty chewing and swallowing his/her foods. On 10/13/2023; however, at approximately 12:50 AM, Certified Nursing Assistant (CNA) # 6 gave Resident #5 a piece of her cheeseburger, causing the resident to choke. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to maintain a system that accepted accounting principles and proper bookkeeping techniques, in order to maintain the ongoing balance for each resident's personal funds entrusted to the facility on the resident's behalf for two (2) of eighteen (18) sampled residents (Resident #6 and Resident #8). Additionally, the facility failed to refund the resident's representative upon the death or discharge of a resident (Resident #8).

Inspectors wroteBased on interviews, record review, and review of facility policy, it was determined the facility failed to ensure one (1) of eighteen (18) sampled residents' environment remained free from accident hazards (Resident #3). On 06/11/2023, Resident #3 reported to Certified Nursing Assistant (CNA) #14 that CNA #16 had grabbed his/her upper inner left arm while repositioning him/her in bed, resulting in two (2) bruises on the resident's left upper arm.

Inspectors wroteBased on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored, in accordance with professional standards for food service safety. Kitchen observations on 02/05/19, revealed food stored in the walk-in refrigerator and walk-in freezer was not sealed after opening; the top cook's oven had a large build up of dry black crusted material and brown moist material; seventeen (17) cartons of whole milk stored in the milk cooler were not labeled with dates or use by dates; and, a large container of crushed graham crackers with a used by date of 01/16/19 was still stored in the pantry. Review of the Census and Condition, dated 02/05/19, revealed one hundred twenty-five (125) of one hundred twenty-seven (127) residents received their food from the kitchen.

Inspectors wroteBased on observation, interview, record review and facility policy review, it was determined the facility failed to treat each resident with respect, dignity and care for each resident in a manner and an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality for one (1) of thirty-three (33) sampled residents (Resident #109) and one (1) unsampled resident (Resident #59). Observations on 02/06/19 and 02/07/19 revealed staff failed to ensure Resident #109 and #59's clothing fit properly, allowing the residents' bare shoulders to be exposed while out in the hallway.

Inspectors wroteBased on observation, interview, record review and review of facility policy, it was determined the facility failed to implement the comprehensive person-centered care plan for two (2) of thirty-three (33) sampled residents (Residents #7 and #105). The facility failed to implement the care plan for Resident #7 related to two (2) staff to assist with transfers on 12/01/18. One staff transferred the resident from the bed to the wheel chair and it became necessary to lower the resident to the floor. The resident sustained no injury. Resident #105 was care planned to wear a heel lift boot on right foot and to float heels when in bed; however, observations revealed the resident's heels were not floated and no heel lift boot was on the resident's right foot.

Inspectors wroteBased on interview, record review and review of facility policy, it was determined the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one (1) of thirty-three (33) sampled residents (Residents #7). Resident #7 had two (2) falls on 12/01/18, at 11:45 AM and 6:30 PM. Both falls were avoidable and the direct results of staff not following the care plan and standards of practice for transfers. There was no injury as a result of the first fall, however, the second fall resulted in a fracture to the left fifth metacarpal.

Inspectors wroteBased on interview, record review and review of facility policy, it was determined the facility failed to In accordance with accepted professional standards and practices, maintain medical records on each resident that are complete and accurately documented for one (1) of thirty-three (33) sampled residents (Resident #118). Staff failed to accurately document Resident #118's history of falls on the residents Fall Risk Assessments dated 11/22/18, 12/13/18, and 01/11/19. The findings Include: Review of the facility policy titled, Documentation Guidelines for the Point Click Care/Point of Care System, last revised May 2017, revealed Licensed and Unlicensed staff will utilize the Point Click Care and Point of Care System for the majority of their documentation. Point Click Care and Point of Care will be performed at the Nurses station or just outside the patient's room. [...]