Spring Creek Post-Acute Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Spring Creek Post-Acute Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 10, 2025

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 26 sampled residents (Resident (R)529). Immediate Jeopardy (IJ) was identified on 05/09/2025 and was determined to exist on 04/18/2025 in the area of S483.25(d) Accidents Hazards, F689. On 05/09/2025, the Administrator was provided a copy of the CMS Immediate Jeopardy (IJ) Template and notified that the failure to ensure residents were provided supervision and protected from elopement is likely to cause serious injury, impairment, or death and constituted IJ at 42 CFR 483.25 F689. […]

• Immediate jeopardy, isolatedF656Oct 27, 2023

  Based on interview, record review and a review of the facility's policy, it was determined the facility failed to implement the resident's Person-Centered Comprehensive Care Plan for one (1) of three (3) sampled residents (Resident #5), who required a specific diet. On [DATE], the Speech Language Pathologist evaluated Resident #5 and determined the resident had a change in his/her condition that led to the resident's therapeutic diet being downgraded to a Dysphagia Level 1, which meant the resident's diet consisted of regular thin liquids, as the resident had difficulty chewing and swallowing his/her foods. The resident's care plan was revised on the same day, to reflect the change in the resident's diet. […]

• Immediate jeopardy, isolatedF803Oct 27, 2023

  Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure a resident with Dysphagia (difficulty swallowing food or liquid) and at risk for choking, received food that was appropriate for the residents assessed diet for one (1) of three (3) sampled residents (Resident #5) who were at risk for aspiration and/or choking. On [DATE], the Speech Language Pathologist evaluated Resident #5 and determined the resident had a change in his/her condition that led to the resident's therapeutic diet being downgraded to a Dysphagia Level 1, which meant the resident's diet consisted of regular thin liquids as the resident had difficulty chewing and swallowing his/her foods. […]

• Actual harm, isolatedF656Mar 8, 2024

  Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to implement the comprehensive person-centered care plan for one (1) of twenty-eight (28) sampled residents (Resident #61). Resident #61's Comprehensive Care Plan, revised 01/05/2024, revealed an intervention to utilize the mechanical lift with two (2) staff members for transfers. However, on 02/01/2024, Certified Nursing Assistant (CNA) #7 and CNA #14, transferred Resident #61 from the bed to the wheelchair without using a mechanical lift (device used to transfer residents who require support for mobility beyond the manual support provided by caregivers alone). […]

• Actual harm, isolatedF689Mar 8, 2024

  Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for two (2) of twenty-eight (28) sampled residents (Resident #61 and Resident #74). 1. On 02/01/2024, Certified Nursing Assistant (CNA) #7 and CNA #14, transferred Resident #61 from the bed to the wheelchair without using a Hoyer mechanical lift (device used to transfer residents who require support for mobility beyond the manual support provided by caregivers alone). […]