Spring Creek Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, patternF600Apr 13, 2022

  Based on interview and record review, it was determined for 18 of 51 sample residents, that the facility did not ensure that residents were free from abuse and neglect. Specifically, two residents with severe cognitive impairment were engaged in sexual relationships of which the staff were aware, with no assessments to determine if this was consensual, appropriate or safe. Additionally, multiple residents were engaged in verbal and physical abuse altercations with other residents, and interventions were inconsistent or non-existent with regard to how facility staff addressed resident behaviors (prevention, re-direction, allowing privacy, and the administration of psychoactive medications). […]

• Immediate jeopardy, patternF609Apr 13, 2022

  Based on record review and interview it was determined for 14 of 51 sample residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency. Specifically, entity reports of multiple abuse allegations were not submitted to the State Survey in a timely manner. These findings were determined to have occurred at an Immediate Jeopardy Level. […]

• Immediate jeopardy, patternF610Apr 13, 2022

  Based on interview and record review it was determined that in response to allegations of abuse, neglect, exploitation, or mistreatment the facility failed to have evidence that all alleged violations were thoroughly investigated for 14 of 51 sample residents. Specifically, based on a review of Entity Reports, filed with the State Survey Agency (SSA), between 8/22/21 and 3/31/22, the facility has submitted multiple initial Entity Reports with no subsequent final investigation report. Multiple instances of resident to resident physical, verbal and sexual abuse occurred with an insufficient investigation. This was determined to have occurred at an Immediate Jeopardy level. […]

• Immediate jeopardy, patternF684Apr 13, 2022

  Based on observation, interview, and record review, it was determined for 9 of 51 sample residents, that the facility did not ensure that all residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, residents had pressure ulcers that were not treated as ordered and one resident's that was not examined by a physician, and residents who underwent change of condition that were not treated timely. These findings were determined to have resulted in Immediate Jeopardy for residents 22, 41, and 61; and Harm for residents 29 and 40. […]

• Immediate jeopardy, patternF689Apr 13, 2022

  Based on observation, interview and record review it was determined, for 10 out of 51 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident with a history of suicidal ideation (SI) and major depressive disorder eloped from the facility and was gone for 24 hours before staff notified administration and the local police department, a resident with suicidal ideation and homicidal ideation (HI) was found with multiple weapons in his possession, and a resident was found in the unsecured laundry area near cleaning chemicals and the unlocked broiler room. […]