Spring Creek Rehabilitation and Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689May 14, 2026

  Based on clinical record review, observations, facility document review, resident and staff interviews, and facility policy review, it was determined that the facility displayed past non-compliance by failing to implement interventions, supervision, and effective safety measures to prevent elopement of a resident identified as being at risk for elopement and exhibiting exit seeking behaviors (Resident 334). This failure resulted in an immediate jeopardy situation for Resident 334 as evidenced by an elopement from the facility to the airport. Findings include: Review of facility policy, titled Emergency Procedure - Missing Resident, revised March 21, 2025, read, in part; 1. […]

• Actual harm, isolatedF689Apr 9, 2026

  Based on clinical record reviews, review of facility investigation, and resident and staff interviews, it was determined that the facility displayed past non-compliance in its failure to provide adequate assistance devices during a transfer, which resulted in harm as evidenced by a dislocated shoulder requiring surgical repair for one of five residents reviewed (Resident 1).Findings include: Review of Resident 1's clinical record revealed diagnoses that included cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) with hemiplegia (paralysis of one side of body) to left non-dominant side, muscle weakness, and need for assistance with personal care. […]

• Actual harm, isolatedF684Jul 7, 2025

  Based on a review of clinical records, hospital records, facility documents, and staff interviews, it was determined the facility failed to monitor residents and provide care and services during elevated temperatures in resident care areas, resulting in actual harm as evidenced by hyperthermia and respiratory distress for one of eight residents reviewed (Resident 1). Findings include: Hyperthermia is defined as a medical condition characterized by an abnormally high body temperature. Respiratory distress is defined as a condition where a person has difficulty breathing, characterized by increased effort or difficulty taking in enough oxygen. […]

• Actual harm, isolatedF689Oct 15, 2024

  Based on clinical record review, review of facility investigation, observations and staff interviews, it was determined that the facility displayed past non-compliance in its failure to provide adequate supervision to prevent elopement, which resulted in harm, as evidenced by a fall and knee abrasion for one of four resident's reviewed (Resident 1). Findings include: Review of Resident 1's clinical record revealed diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things) and generalized muscle weakness. Review of select facility report detailing an elopement that occurred on October 6, 2024, stated, Resident 1 walked to the front door and asked the receptionist to let him out of the door. […]

• Actual harm, isolatedF684Feb 1, 2021

  Based on interviews, record review, and policy review, the facility failed to follow physician orders to administer medications, failed to have medications available, and failed to notify hospice resulting in unnecessary labored and rapid breathing (struggling and unable to breathe easily, breathing rate above normal 12-16 breaths per minute), restlessness (unable to relax), and no pain management for one of eight residents reviewed (Resident 7). Findings include: A review of the facility provider pharmacy policy titled, Emergency Pharmacy Services and Emergency Kits, last revised August 2020, states the following; The pharmacy supplies emergency or STAT medications according to the pharmacy provider agreement. […]