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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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-09-24 | 2024-09-25 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-09-24 | 2024-09-25 | Y |
| 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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