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Deficiency Records for Spring Creek Healthcare Center
A list of the most recent deficiencies for Spring Creek Healthcare Center. 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 Healthcare Center. 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? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2024-01-09 | 2024-03-04 | N |
| Meet other general requirements. | Fire Safety | 2024-01-09 | 2024-03-04 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-01-09 | 2024-03-04 | 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 | 2024-01-09 | 2024-03-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-09 | 2024-03-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-01-09 | 2024-03-04 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-01-09 | 2024-03-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-09 | 2024-03-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-01-09 | 2024-03-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-09 | 2024-03-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-01-09 | 2024-03-04 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-01-09 | 2024-03-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-01-09 | 2024-03-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-11 | 2024-02-12 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-11 | 2024-02-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-11 | 2024-02-12 | 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 | 2024-01-11 | 2024-02-12 | N |
| Keep signed and dated reports of x-rays and other diagnostic services in the residents record. | Health | 2024-01-11 | 2024-02-12 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-01-11 | 2024-02-12 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-01-11 | 2024-02-12 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-01-11 | 2024-02-12 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-01-11 | 2024-02-12 | N |
| Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised. | Health | 2024-01-11 | 2024-02-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-11 | 2024-02-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-11 | 2024-02-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-11 | 2024-02-12 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-01-11 | 2024-02-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-11 | 2024-02-12 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-13 | 2023-04-04 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-04-13 | 2022-06-23 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-13 | 2022-06-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-13 | 2022-06-23 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-04-13 | 2022-06-23 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-04-13 | 2022-06-23 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-04-13 | 2022-06-23 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-04-13 | 2022-06-23 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2022-04-13 | 2022-06-23 | Y |
| 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 | 2022-04-13 | 2022-06-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-04-13 | 2022-06-23 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-04-13 | 2022-06-23 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-04-13 | 2022-06-23 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-04-13 | 2022-06-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-13 | 2022-06-23 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2022-04-13 | 2022-06-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-13 | 2022-06-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-04-13 | 2022-06-23 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-04-13 | 2022-06-23 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-04-13 | 2022-06-23 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-04-13 | 2022-06-23 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-04-13 | 2022-06-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-13 | 2022-06-23 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-04-13 | 2022-06-23 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-13 | 2022-06-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-13 | 2022-06-23 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-04-13 | 2022-06-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-13 | 2022-06-23 | Y |
| 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 | 2022-04-13 | 2022-06-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-13 | 2022-06-23 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-04-13 | 2022-06-23 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-13 | 2022-06-23 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-13 | 2022-06-23 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-04-13 | 2022-06-23 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-04-13 | 2022-06-23 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-04-13 | 2022-06-23 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-04-13 | 2022-06-23 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-04-13 | 2022-06-23 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-04-13 | 2022-06-23 | Y |
| Post nurse staffing information every day. | Health | 2022-04-13 | 2022-06-23 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-04-13 | 2022-06-23 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2022-04-13 | 2022-06-23 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-04-13 | 2022-06-23 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-04-13 | 2022-06-23 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-13 | 2022-06-23 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-04-13 | 2022-06-23 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-13 | 2022-06-23 | Y |
| 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 | 2022-04-13 | 2022-06-23 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-04-13 | 2022-06-23 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-04-13 | 2022-06-23 | Y |
| Keep complete, dated laboratory records in the resident's record. | Health | 2022-04-13 | 2022-06-23 | Y |
| Keep signed and dated reports of x-rays and other diagnostic services in the residents record. | Health | 2022-04-13 | 2022-06-23 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-04-13 | 2022-06-23 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-04-13 | 2022-06-23 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-04-13 | 2022-06-23 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2022-04-13 | 2022-06-23 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-04-13 | 2022-06-23 | Y |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2022-04-13 | 2022-06-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-13 | 2022-06-23 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-04-13 | 2022-06-23 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-04-13 | 2022-06-23 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-04-13 | 2022-06-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-13 | 2022-06-23 | Y |
| Implement a program that monitors antibiotic use. | Health | 2022-04-13 | 2022-06-23 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-04-13 | 2022-06-23 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-04-13 | 2022-06-23 | Y |
| Keep all essential equipment working safely. | Health | 2022-04-13 | 2022-06-23 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-04-13 | 2022-06-23 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-04-13 | 2022-06-23 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-04-13 | 2022-06-23 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-04-13 | 2022-06-23 | Y |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2022-04-13 | 2022-06-23 | Y |
| Establish emergency prep training and testing. | Fire Safety | 2022-03-28 | 2022-05-28 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-03-28 | 2022-05-28 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-03-28 | 2022-05-28 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-03-28 | 2022-05-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-03-28 | 2022-04-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-28 | 2022-04-09 | 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 | 2022-03-28 | 2022-04-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-03-28 | 2022-04-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-28 | 2022-04-05 | 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 | 2022-03-28 | 2022-04-01 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-03-28 | 2022-03-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-03-28 | 2022-03-29 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-06-02 | 2021-07-31 | 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 | 2021-06-02 | 2021-07-31 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-06-02 | 2021-07-31 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-06-02 | 2021-07-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-02 | 2021-07-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-06-02 | 2021-07-31 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-06-03 | 2021-07-16 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-06-03 | 2021-07-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-03 | 2021-07-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-03 | 2021-07-16 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-06-03 | 2021-07-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-06-03 | 2021-07-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-03 | 2021-07-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-03 | 2021-07-16 | N |
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