Spring Creek Nursing and Rehabilitation Center LLC

In the surveyor’s words

From the most serious findings on record at Spring Creek Nursing and Rehabilitation Center LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 24, 2024

  Based on medical record review, review of facility incident investigations with witness statements, review of staff education, staff interviews, review of a resident handbook, review of a facility Self-Reported Incident (SRI), and review of facility smoking policies, the facility failed to ensure Resident #75 who had a known history of smoking with oxygen on, was assessed as an independent smoker, exhibited safe smoking practices and did not smoke while wearing oxygen. This resulted in Immediate Jeopardy and serious life-threatening harm, injuries and/or death when Resident #75 lit a cigarette while wearing oxygen therapy via nasal cannula, in the designated smoking area. Resident #75's oxygen ignited and set Resident #75 on fire with the oxygen. […]

• No harm, potential for more than minimal, widespreadF835Sep 24, 2024

  Based on review of the facility's billing statements, review of email communication, vendor interviews, and staff interviews, the facility failed to operate the facility in a manner to ensure facility bills were being paid in a timely manner. This had the potential to affect all 73 residents in a facility with a census of 73. Findings include: 1. Review of the facility's electric invoice dated 07/29/24 revealed an amount of $438,869.15 was due by 09/19/24 with a disconnection notice provided which states the facility's electric service payment is past due and the electric service could be disconnected unless payment of $409,334.97 is made by 08/19/24. […]

• No harm, potential for more than minimal, widespreadF563Nov 1, 2021

  Based on observations, record review, review of the Resident Council meeting minutes, family and staff interview and review of the facility policy, the facility failed to allow one (#8) resident to have visitors at the time of the resident and visitor's choosing. This deficient practice had the potential to affect 59 of 59 residents who reside in the facility. Findings include: Review of Resident #8's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was rarely or never understood. […]

• No harm, potential for more than minimal, widespreadF880Nov 1, 2021

  Based on record reviews, observations, staff interviews, review of the facility policy, review of the Legionella guide, and review of the map and census, the facility failed to maintain standards of infection control practices during a clean dressing change for one (#14) resident. The facility failed to ensure resident care equipment was clean and stored in an appropriate manner for one (#32) resident to prevent potential infections. The facility also failed to implement the Legionella guide to ensure the water supply was adequate. In addition, the facility failed to ensure staff and visitors wore proper personal protective equipment (PPE) during a COVID-19 outbreak in the facility, including the staff swabbing for COVID-19 tests of unvaccinated staff. […]

• No harm, potential for more than minimal, patternF656May 7, 2026

  Based on medical record review, staff interview, and facility policy review the facility failed to ensure resident care plans were properly completed to include all identified care areas. This affected six (#03, #11, #13, #21, #25, and # 32) of six residents reviewed for care plan accuracy and had the ability to affect all residents. The facility census was 71.Findings include: 1. Review of Resident #03's medical record revealed an admission date of 06/15/26. Diagnoses included respiratory failure, congestive heart failure, and diabetes mellitus. Review of Resident #03's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's medications included insulin, antianxiety, antidepressant, anticoagulant, diuretic, opioid, hypoglycemic, and an anticonvulsant. […]