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Deficiency Records for Spring Creek Nursing and Rehabilitation Center LLC

A list of the most recent deficiencies for Spring Creek Nursing and Rehabilitation Center LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

A list of the most recent deficiencies for Spring Creek Nursing and Rehabilitation Center LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Have proper power supply for life support equipment. Fire Safety 2024-02-16 2024-06-03 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2024-02-15 2024-04-03 N
Reasonably accommodate the needs and preferences of each resident. Health 2024-02-15 2024-04-03 N
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Health 2024-02-15 2024-04-03 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2024-02-15 2024-04-03 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2024-02-15 2024-04-03 N
Ensure that residents are free from significant medication errors. Health 2024-02-15 2024-04-03 N
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Health 2024-02-15 2024-04-03 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2024-02-15 2024-04-03 N
Address subsistence needs for staff and patients. Fire Safety 2024-02-16 2024-04-03 N
Establish procedures for tracking staff and patients during an emergency. Fire Safety 2024-02-16 2024-04-03 N
Create arrangements with other facilities to receive patients. Fire Safety 2024-02-16 2024-04-03 N
Provide family notifications of emergency plan. Fire Safety 2024-02-16 2024-04-03 N
Use approved construction type or materials. Fire Safety 2024-02-16 2024-04-03 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2024-02-16 2024-04-03 N
Have an enclosure around a vertical opening shaft. Fire Safety 2024-02-16 2024-04-03 N
Provide properly protected cooking facilities. Fire Safety 2024-02-16 2024-04-03 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-02-16 2024-04-03 N
Install corridor and hallway doors that block smoke. Fire Safety 2024-02-16 2024-04-03 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2024-02-16 2024-04-03 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2024-02-16 2024-04-03 N
Provide a written emergency evacuation plan. Fire Safety 2024-02-16 2024-04-03 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2024-02-16 2024-04-03 N
Ensure that gas containers are correctly designed and tested, and in locations that are labeled. Fire Safety 2024-02-16 2024-04-03 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2024-02-16 2024-04-03 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2024-02-16 2024-04-03 N
Ensure proper usage of power strips and extension cords. Fire Safety 2024-02-16 2024-04-03 N
Have proper medical gas storage and administration areas. Fire Safety 2024-02-16 2024-04-03 N
Ensure that the resident and his/her doctor meet face-to-face at all required visits. Health 2023-11-30 2023-12-18 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-04-26 2023-04-27 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-03-01 2023-03-10 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2023-03-01 2023-03-10 Y
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. Health 2021-11-01 2021-12-01 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2021-11-01 2021-12-01 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2021-11-01 2021-12-01 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-11-01 2021-12-01 N
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Health 2021-11-01 2021-12-01 N
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Health 2021-11-01 2021-12-01 N
Provide and implement an infection prevention and control program. Health 2021-11-01 2021-12-01 N
Keep all essential equipment working safely. Health 2021-11-01 2021-12-01 N
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2021-11-01 2021-12-01 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2021-10-26 2021-12-01 N
Install corridor and hallway doors that block smoke. Fire Safety 2021-10-26 2021-12-01 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2021-10-26 2021-12-01 N
Have simulated fire drills held at unexpected times. Fire Safety 2021-10-26 2021-12-01 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2021-10-26 2021-12-01 N
Have power receptacles that are properly grounded. Fire Safety 2021-10-26 2021-12-01 N
Ensure proper usage of power strips and extension cords. Fire Safety 2021-10-26 2021-12-01 N
Provide safe, appropriate pain management for a resident who requires such services. Health 2019-04-18 2019-07-01 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2019-04-18 2019-07-01 N
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Health 2019-04-18 2019-07-01 N
Provide and implement an infection prevention and control program. Health 2019-04-18 2019-07-01 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2019-04-16 2019-07-01 N
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Fire Safety 2019-04-16 2019-07-01 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2019-04-16 2019-07-01 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2019-04-16 2019-07-01 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2019-04-16 2019-07-01 N
Ensure medical gas and vacuum systems have documented maintenance programs. Fire Safety 2019-04-16 2019-07-01 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2019-04-16 2019-07-01 N

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