Spring Creek

In the surveyor’s words

From the most serious findings on record at Spring Creek, in the surveyor’s own words.

• Immediate jeopardy, isolatedF808May 23, 2023

  Based on interview and record review the facility failed to provide a resident with a pureed diet as ordered by the physician. This failure resulted in R1 being found unresponsive while eating, requiring the Heimlich maneuver and CPR (Cardio-Pulmonary Resuscitation). R1 required admission to the local hospital intensive care unit and expired at the hospital on [DATE]. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when V6 (LPN-Licensed Practical Nurse) discontinued R1's pureed consistency diet. V1 (Administrator), V2 (DON-Director of Nursing), and V19 (Regional Nurse Consultant) were notified of the Immediate Jeopardy on [DATE] at 2:48 PM. […]

• Actual harm, isolatedF692Dec 12, 2025

  Based on observation, interview, and record review, the facility failed to implement nutritional interventions for a resident (R10) with a known significant weight loss. This failure resulted in R10 experiencing additional significant weight loss of 10.3% in one month. The facility also failed to serve residents double portions as ordered.This applies to 3 out of 4 (R10, R27, and R106) residents reviewed for nutrition in a sample of 27.The findings include:1. R10's nutritional care plan initiated on 11/03/2025 said he was at risk for compromised nutritional status. The care plan's goal was for R10 not to experience any further weight loss. […]

• Actual harm, isolatedF689Mar 20, 2025

  Based on observations, interviews and record reviews the facility failed to implement safety interventions and provide supervision to prevent a resident from injury when drinking hot liquids. This failure resulted in R1 sustaining 1st and 2nd degree burns to her chest. This applies to 1 of 3 residents (R1) reviewed for dependent assistance with feeding in a sample of 4. The findings include: R1's electronic health record showed that on 3/9/25, R1 was sent to the local community hospital for evaluation and treatment to burns on her chest. R1 has diagnoses including quadriplegia (loss of motor and sensory function in all four limbs), C5 - C7 complete. […]

• Actual harm, isolatedF689Sep 10, 2024

  Based on interview and record review, the facility failed to provide supervision to a cognitively impaired resident, while outdoors, to prevent prolonged sun exposure that resulted in burns to the skin. This applies to 1 of 3 (R1) residents reviewed for improper nursing care. This failure resulted in R1 obtaining full thickness burns to the upper back and posterior neck due to prolonged sun exposure. The findings include: R1 was identified by the facility with a skin condition incident report dated July 28, 2024, and identified on the facility wound report as a resident with full thickness skin injury. R1's New Skin Condition report, dated July 28, 2024, written by V9 (RN) showed R1 was noted with blisters left shoulder to mid back. […]

• Actual harm, isolatedF658May 23, 2023

  Based on interview and record review, the facility failed to meet professional standards of nursing when a nurse changed a resident's diet order from a pureed consistency diet to a regular consistency diet without obtaining a physician's order and without following the facility's policy. This failure resulted in R1 being found unresponsive while eating, requiring the Heimlich maneuver and CPR (Cardio-Pulmonary Resuscitation). R1 required admission to the local hospital intensive care unit and expired at the hospital on [DATE]. This applies to 1 of 3 residents (R1) reviewed for improper nursing in the sample of 3. The findings include: The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. […]