Springcreek Rehabilitation and Nursing Center

In the surveyor’s words

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

• Actual harm, isolatedF689Mar 27, 2026

  This citation pertains to intake 2803162 Based on observation, interview and record review the facility failed to prevent an avoidable fall as well as conduct a thorough root-cause analysis investigation into falls for five residents (R3, R17, R71, R98, and R106), of six residents reviewed for falls resulting in transfer to hospital and major injuries including fractures and subdural hematoma. Findings include: R3 Review of the medical record reflected R3 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included unsteadiness on feet, lack of coordination, vascular dementia, and displaced subtrochanteric fracture of right femur. […]

• Actual harm, isolatedF689Oct 11, 2023

  This Citation Has Two Deficient Practice Statements A and B. DPS A. Based on observation, interview and record review the facility failed to investigate and identify root causes for falls and implement interventions as identified on incident and accident reports and physician orders, thus failing to prevent a series of falls for one resident (#52) of three residents reviewed for falls, resulting in a fall with a left hip fracture that required surgical repair. Findings include: Resident #52 According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] Resident # 52 (R52) was a [AGE] year old female admitted to the facility with a diagnoses of dementia, R52 scored 03 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). […]

• Actual harm, isolatedF686Nov 9, 2021

  This citation pertains to intake MI 621. Based on observation, interview and record review, the facility failed to prevent and provide pressure ulcer care and services in one of two residents reviewed for pressure ulcers (Resident #103), resulting in delay in physician involvement in the care plan, potential for delayed wound healing, infection, and pain. Findings include: Resident #103 (R103) During an observation and interview on 11/08/21 at 10:00 AM, R103 was observed lying in bed with pillows on her right side. R103 reported to the surveyor she was in pain. R103's Minimum Data Set (MDS) 3.0 assessment dated [DATE] introduced the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, score of 4 (00-07 Severe Impairment). […]

• No harm, potential for more than minimal, widespreadF865Mar 27, 2026

  Based on interview and record review, the facility failed to develop and maintain a Quality Assistance and Process Improvement (QAPI) program which identified and prioritized quality deficiencies, systematically analyzed the underlying causes of systemic quality deficiencies, and implemented effective corrective action or performance improvement activities to remedy those deficiencies. This deficient practice has the potential to affect the safety and quality of life of all 93 residents at the facility.Findings Included: On 03/27/2026 at 01:01 p.m. an interview was conducted with Nursing Home Administrator (NHA) A regarding concerns identified during the current Recertification Survey. […]

• No harm, potential for more than minimal, widespreadF812Oct 11, 2023

  Based on observation, interview, and record review, the facility failed to: (1) effectively date mark all potentially hazardous ready-to-eat food products, (2) effectively don hair and beard restraints, (3) effectively clean and maintain food service equipment, and (4) monitor food for safe temperatures prior to serving and maintain temperature logs effecting 74 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and resident foodborne illness. Findings include: During a kitchen observation on 10/11/23 at 8:35 AM, vegetable soup was observed in a refrigerator in a 4-liter container dated 10/09/23. […]