Spring Creek Rehabilitation & Nursing Care Center

Inspectors wroteBased on observation, record review, and interviews during a survey, the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice. This was evident for one (1) out of three (3) sample residents (Resident #1) reviewed for nutrition and hydration. Specifically, Resident #1 with history of poor oral intake had no documented oral intake from 03/14/2026 at 8:00 AM through 03/16/2026 at 1:00 PM was not assessed by Registered Nurse to prevent complication. Additionally, the medical doctor was not notified until 03/16/2026 at 3:44 PM after Registered Nurse Supervisor #2's assessment due to Resident #1 change in mental status and was rapidly declining.

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00351563), the facility did not permit a resident to return to the facility following hospitalization. This was evident for one (1) of six (6) residents (Resident #1). Specifically, on 09/10/2024 Resident #1 was transferred to the hospital for an evaluation of severe dysphagia. During an interview with Resident #1's Representative on 02/07/2025 at 11:50 AM, they stated that the facility refused to readmit Resident #1 to the facility. Additionally, the facility did not notify Resident #1, or their representative, and the Long-term Care Ombudsman in writing of the discharge, including notification of appeal rights. The hospital transferred Resident #1 to another facility.

Inspectors wroteBased on record review and interviews during the Recertification Survey conducted from 02/05/2025 to 02/12/2025, the facility did not ensure sufficient nursing staff were available to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, the facility reported short staffing on weekends confirmed by a review of the weekend staffing and the Payroll Based Journal Staffing Data Report.

Inspectors wroteBased on record review and interview during the Recertification Survey conducted from 02/05/2025 to 02/12/2025, the facility did not ensure that, to the extent practicable, the resident or resident representative participated in the development, review, and revision of the comprehensive care plan. This was evident in 1 (Resident #36) of 4 residents reviewed for Care Planning. Specifically, Resident #36's representative has been unable to attend care plan meetings. The facility failed to ensure that the care plan meeting invitations were mailed and received by Resident #36's representative.

Inspectors wroteBased on interview and record review conducted during the Recertification survey from 02/05/2025 through 02/12/2025, the facility did not ensure that a resident has a right to make choices about aspects of their life in the facility that are significant to the resident. This was evident for 1 (Resident #7) of 1 resident reviewed for Choices. Specifically, Resident #7 was not consistently showered twice a week or according to their preference.

Inspectors wroteBased on observation, record review and interview during the Recertification Survey conducted from 02/05/2025 to 02/12/2025, the facility did not ensure individual resident financial records were made available to resident and resident representatives through quarterly statements. Specifically, quarterly statements were not provided in writing to residents and/or resident representatives within 30 days after the end of the quarter. This was evident in 1 (Resident #142) of 2 residents reviewed for Personal Funds out of 39 total sampled residents.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 02/05/2025 to 02/12/2025, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice. This was evident in 1 (Resident #101) of 35 total sampled residents. Specifically, during 2 observations conducted on 02/05/2025, medications were observed unattended in Resident #101's bedside. Licensed Practical Nurse #4 failed to ensure Resident #101 had taken the medications before leaving the room and documenting in the Medication Administration Record.

Inspectors wroteBased on observation, record review, and interview during the Recertification Survey conducted from 02/05/2025 to 02/12/2025, the facility did not ensure that infection control practices were maintained. This was evident in 11 (Residents # 1, # 8, #26, #31, #39, #44, #54, #82, #102, #145 and #157) of 24 total sampled residents during the Dining Task. Specifically, Certified Nursing Assistant #7 failed to clean their hands in between residents while assisting multiple residents with hand hygiene before meal service.

Inspectors wroteBased on record review and interview during the Recertification and Complaint Survey (NY00331525) conducted from 02/05/2025 to 02/12/2025, the facility did not ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegations were made, to the State Survey Agency. This was evident in 1 (Resident #97) of 2 residents out of 39 total sampled residents reviewed for Abuse. Specifically, on 01/12/2024 at approximately 8:08 AM, Resident #97 alleged that a staff slapped them in the face. The facility reported the abuse allegation to the New York State Department of Health on 01/12/2024 at 7:03 PM.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey from 1/19/23 to 1/26/23, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards of food service safety. This was evident during the Kitchen observation. Specifically, expired cottage cheese and tofu were stored in the Kitchen refrigerator.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 1/19/23 to 1/26/23, the facility did not ensure infection control practices and procedures were maintained. This was evident for 1 of 5 resident floors (2nd Floor) and 1 (Resident #86) of 37 total sampled residents. Specifically, 1.) unmasked facility clergy was observed providing religious services to residents, and 2.) Resident #86 was placed on indefinite contact isolation in their room for colonized Candida Auris (CA) in the urine.

Inspectors wroteBased on observation, interviews, and record reviews conducted during a recertification survey from 1/19/23 to 1/26/23, the facility did not ensure that each resident was provided with the necessary care and services to attain or maintain the highest practicable mental and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. This was evident for 1 (Resident #86) of 37 sampled residents. Specifically, Resident #86 was placed on indefinite contact isolation in their room for colonized Candida Auris (CA) in the urine. As a result, the resident was not allowed to attend activities outside of the room since 12/24/21.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 1/19/23 to 1/26/23, the facility did not ensure medications and biologicals were stored in accordance with professional standards of practice. This was evident for 1 of 5 units (2A/B Unit). Specifically, two bags of expired intravenous fluid (IVF) were stored in the 2A/B Unit medication room.

Inspectors wroteBased on observation, record review and interviews conducted during the Recertification Survey initiated on 1/19/23 and completed on 1/26/23, the facility did not implement policies and procedures to ensure that all staff were fully vaccinated for COVID-19. This was evident for 2 of 5 Certified Nursing Assistants (CNA) reviewed for Infection Control (CNA #4, #5). Specifically, CNA #4 and CNA #5 did not have adequate clinical rationale for not being vaccinated against COVID-19.

Inspectors wroteBased on interviews and record review conducted during the recertification survey, the facility did not ensure that a copy of the Notice of Transfer was sent to a representative of the Office of the State Long-Term Care Ombudsman within a timely manner when a resident was discharged from the facility to the hospital. This was evident for 1 of 2 residents reviewed for Hospitalization in a sample size of 38 residents. (Resident #96)

Inspectors wroteBased on observations, record reviews and staff interview conducted during the Recertification survey, the facility did not ensure that a person-centered care plans with measurable goals, time frames and interventions were developed to address resident's concerns. Specifically, there was no documented evidence that a Comprehensive Care Plan (CCP) was developed, implemented and included measurable goals, objectives and interventions to address a resident with contracture. This was evident for 1 of 3 residents reviewed for Limited Range of Motion (ROM) out of a sample of 38 residents investigated. (Resident #56)

Inspectors wroteBased on observations, record review and staff interviews conducted during the recertification survey, the facility did not ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, a resident with a contracture of 45 degrees to right hand had no assistive device in place. This was evident for 1 of 3 residents reviewed for Limited Range of Motion (ROM) out of a sample of 38 residents investigated. (Resident #56).