Spring Creek Healthcare Center

This section preserves official CMS inspection text matched to this facility from the current provider page source.

Inspection Report:
2025-02-03
This report is the official CMS Statement of Deficiencies (Form 2567) filed after the most recent health inspection.
Each
12
is a federal standard the facility failed to meet.
Read the full inspection report
Survey: 2025-02-03 | Tag F0622 | Resident Rights Deficiencies | Severity: D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
---
Survey: 2025-02-03 | Tag F0656 | Resident Assessment and Care Planning Deficiencies | Severity: E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
---
Survey: 2025-02-03 | Tag F0658 | Resident Assessment and Care Planning Deficiencies | Severity: D
Ensure services provided by the nursing facility meet professional standards of quality.
---
Survey: 2025-02-03 | Tag F0689 | Quality of Life and Care Deficiencies | Severity: E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
---
Survey: 2025-02-03 | Tag F0690 | Quality of Life and Care Deficiencies | Severity: D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
---
Survey: 2025-02-03 | Tag F0693 | Quality of Life and Care Deficiencies | Severity: D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
---
Survey: 2025-02-03 | Tag F0694 | Quality of Life and Care Deficiencies | Severity: D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
---
Survey: 2025-02-03 | Tag F0755 | Pharmacy Service Deficiencies | Severity: D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
---
Survey: 2025-02-03 | Tag F0756 | Pharmacy Service Deficiencies | Severity: D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
---
Survey: 2025-02-03 | Tag F0758 | Pharmacy Service Deficiencies | Severity: E
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
---
Survey: 2025-02-03 | Tag F0761 | Pharmacy Service Deficiencies | Severity: D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
---
Survey: 2025-02-03 | Tag F0880 | Infection Control Deficiencies | Severity: E
Provide and implement an infection prevention and control program.
---
Survey: 2024-01-11 | Tag F0550 | Resident Rights Deficiencies | Severity: E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
---
Survey: 2024-01-11 | Tag F0692 | Quality of Life and Care Deficiencies | Severity: D
Provide enough food/fluids to maintain a resident's health.
---
Survey: 2024-01-11 | Tag F0761 | Pharmacy Service Deficiencies | Severity: D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
---
Survey: 2024-01-11 | Tag F0779 | Administration Deficiencies | Severity: D
Keep signed and dated reports of x-rays and other diagnostic services in the residents record.
---
Survey: 2024-01-11 | Tag F0801 | Nutrition and Dietary Deficiencies | Severity: E
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
---
Survey: 2024-01-11 | Tag F0804 | Nutrition and Dietary Deficiencies | Severity: E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
---
Survey: 2024-01-11 | Tag F0805 | Nutrition and Dietary Deficiencies | Severity: D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
---
Survey: 2024-01-11 | Tag F0806 | Nutrition and Dietary Deficiencies | Severity: D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
---
Survey: 2024-01-11 | Tag F0811 | Nutrition and Dietary Deficiencies | Severity: D
Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
---
Survey: 2024-01-11 | Tag F0812 | Nutrition and Dietary Deficiencies | Severity: E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
---
Survey: 2024-01-11 | Tag F0842 | Resident Assessment and Care Planning Deficiencies | Severity: E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
---
Survey: 2024-01-11 | Tag F0880 | Infection Control Deficiencies | Severity: F
Provide and implement an infection prevention and control program.
---
Survey: 2024-01-11 | Tag F0881 | Infection Control Deficiencies | Severity: E
Implement a program that monitors antibiotic use.
---
Survey: 2024-01-11 | Tag F0684 | Quality of Life and Care Deficiencies | Severity: G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
---
Survey: 2024-01-11 | Tag F0689 | Quality of Life and Care Deficiencies | Severity: D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
---
Survey: 2023-03-13 | Tag F0600 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
---
Survey: 2022-04-13 | Tag F0550 | Resident Rights Deficiencies | Severity: E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
---
Survey: 2022-04-13 | Tag F0558 | Resident Rights Deficiencies | Severity: D
Reasonably accommodate the needs and preferences of each resident.
---
Survey: 2022-04-13 | Tag F0561 | Resident Rights Deficiencies | Severity: D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
---
Survey: 2022-04-13 | Tag F0565 | Resident Rights Deficiencies | Severity: E
Honor the resident's right to organize and participate in resident/family groups in the facility.
---
Survey: 2022-04-13 | Tag F0567 | Resident Rights Deficiencies | Severity: E
Honor the resident's right to manage his or her financial affairs.
---
Survey: 2022-04-13 | Tag F0568 | Resident Rights Deficiencies | Severity: E
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
---
Survey: 2022-04-13 | Tag F0578 | Resident Rights Deficiencies | Severity: D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
---
Survey: 2022-04-13 | Tag F0580 | Resident Rights Deficiencies | Severity: G
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
---
Survey: 2022-04-13 | Tag F0582 | Resident Rights Deficiencies | Severity: D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
---
Survey: 2022-04-13 | Tag F0584 | Resident Rights Deficiencies | Severity: E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
---
Survey: 2022-04-13 | Tag F0585 | Resident Rights Deficiencies | Severity: E
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
---
Survey: 2022-04-13 | Tag F0600 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: K
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
---
Survey: 2022-04-13 | Tag F0606 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: E
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
---
Survey: 2022-04-13 | Tag F0608 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: E
Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting.
---
Survey: 2022-04-13 | Tag F0609 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: K
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
---
Survey: 2022-04-13 | Tag F0610 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: K
Respond appropriately to all alleged violations.
---
Survey: 2022-04-13 | Tag F0622 | Resident Rights Deficiencies | Severity: D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
---
Survey: 2022-04-13 | Tag F0644 | Resident Assessment and Care Planning Deficiencies | Severity: G
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
---
Survey: 2022-04-13 | Tag F0645 | Resident Assessment and Care Planning Deficiencies | Severity: D
PASARR screening for Mental disorders or Intellectual Disabilities
---
Survey: 2022-04-13 | Tag F0655 | Resident Assessment and Care Planning Deficiencies | Severity: E
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
---
Survey: 2022-04-13 | Tag F0656 | Resident Assessment and Care Planning Deficiencies | Severity: E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
---
Survey: 2022-04-13 | Tag F0660 | Resident Assessment and Care Planning Deficiencies | Severity: E
Plan the resident's discharge to meet the resident's goals and needs.
---
Survey: 2022-04-13 | Tag F0677 | Quality of Life and Care Deficiencies | Severity: E
Provide care and assistance to perform activities of daily living for any resident who is unable.
---
Survey: 2022-04-13 | Tag F0684 | Quality of Life and Care Deficiencies | Severity: K
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
---
Survey: 2022-04-13 | Tag F0685 | Quality of Life and Care Deficiencies | Severity: D
Assist a resident in gaining access to vision and hearing services.
---
Survey: 2022-04-13 | Tag F0686 | Quality of Life and Care Deficiencies | Severity: J
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
---
Survey: 2022-04-13 | Tag F0688 | Quality of Life and Care Deficiencies | Severity: G
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
---
Survey: 2022-04-13 | Tag F0689 | Quality of Life and Care Deficiencies | Severity: K
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
---
Survey: 2022-04-13 | Tag F0690 | Quality of Life and Care Deficiencies | Severity: D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
---
Survey: 2022-04-13 | Tag F0692 | Quality of Life and Care Deficiencies | Severity: H
Provide enough food/fluids to maintain a resident's health.
---
Survey: 2022-04-13 | Tag F0695 | Quality of Life and Care Deficiencies | Severity: D
Provide safe and appropriate respiratory care for a resident when needed.
---
Survey: 2022-04-13 | Tag F0697 | Quality of Life and Care Deficiencies | Severity: H
Provide safe, appropriate pain management for a resident who requires such services.
---
Survey: 2022-04-13 | Tag F0698 | Quality of Life and Care Deficiencies | Severity: D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
---
Survey: 2022-04-13 | Tag F0710 | Nursing and Physician Services Deficiencies | Severity: G
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
---
Survey: 2022-04-13 | Tag F0725 | Nursing and Physician Services Deficiencies | Severity: H
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
---
Survey: 2022-04-13 | Tag F0726 | Nursing and Physician Services Deficiencies | Severity: H
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
---
Survey: 2022-04-13 | Tag F0727 | Nursing and Physician Services Deficiencies | Severity: F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
---
Survey: 2022-04-13 | Tag F0732 | Nursing and Physician Services Deficiencies | Severity: D
Post nurse staffing information every day.
---
Survey: 2022-04-13 | Tag F0740 | Quality of Life and Care Deficiencies | Severity: J
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
---
Survey: 2022-04-13 | Tag F0741 | Quality of Life and Care Deficiencies | Severity: H
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
---
Survey: 2022-04-13 | Tag F0742 | Quality of Life and Care Deficiencies | Severity: G
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
---
Survey: 2022-04-13 | Tag F0745 | Quality of Life and Care Deficiencies | Severity: H
Provide medically-related social services to help each resident achieve the highest possible quality of life.
---
Survey: 2022-04-13 | Tag F0755 | Pharmacy Service Deficiencies | Severity: E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
---
Survey: 2022-04-13 | Tag F0757 | Pharmacy Service Deficiencies | Severity: D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
---
Survey: 2022-04-13 | Tag F0760 | Pharmacy Service Deficiencies | Severity: D
Ensure that residents are free from significant medication errors.
---
Survey: 2022-04-13 | Tag F0761 | Pharmacy Service Deficiencies | Severity: E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
---
Survey: 2022-04-13 | Tag F0770 | Administration Deficiencies | Severity: G
Provide timely, quality laboratory services/tests to meet the needs of residents.
---
Survey: 2022-04-13 | Tag F0773 | Administration Deficiencies | Severity: D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
---
Survey: 2022-04-13 | Tag F0775 | Administration Deficiencies | Severity: D
Keep complete, dated laboratory records in the resident's record.
---
Survey: 2022-04-13 | Tag F0779 | Administration Deficiencies | Severity: D
Keep signed and dated reports of x-rays and other diagnostic services in the residents record.
---
Survey: 2022-04-13 | Tag F0804 | Nutrition and Dietary Deficiencies | Severity: E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
---
Survey: 2022-04-13 | Tag F0825 | Quality of Life and Care Deficiencies | Severity: D
Provide or get specialized rehabilitative services as required for a resident.
---
Survey: 2022-04-13 | Tag F0835 | Administration Deficiencies | Severity: H
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
---
Survey: 2022-04-13 | Tag F0837 | Administration Deficiencies | Severity: H
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
---
Survey: 2022-04-13 | Tag F0838 | Administration Deficiencies | Severity: F
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
---
Survey: 2022-04-13 | Tag F0841 | Nursing and Physician Services Deficiencies | Severity: H
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
---
Survey: 2022-04-13 | Tag F0842 | Resident Assessment and Care Planning Deficiencies | Severity: E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
---
Survey: 2022-04-13 | Tag F0865 | Administration Deficiencies | Severity: H
Have a plan that describes the process for conducting QAPI and QAA activities.
---
Survey: 2022-04-13 | Tag F0867 | Administration Deficiencies | Severity: H
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
---
Survey: 2022-04-13 | Tag F0868 | Administration Deficiencies | Severity: H
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
---
Survey: 2022-04-13 | Tag F0880 | Infection Control Deficiencies | Severity: F
Provide and implement an infection prevention and control program.
---
Survey: 2022-04-13 | Tag F0881 | Infection Control Deficiencies | Severity: D
Implement a program that monitors antibiotic use.
---
Survey: 2022-04-13 | Tag F0882 | Infection Control Deficiencies | Severity: F
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
---
Survey: 2022-04-13 | Tag F0886 | Infection Control Deficiencies | Severity: E
Perform COVID19 testing on residents and staff.
---
Survey: 2022-04-13 | Tag F0887 | Infection Control Deficiencies | Severity: E
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
---
Survey: 2022-04-13 | Tag F0888 | Infection Control Deficiencies | Severity: E
Ensure staff are vaccinated for COVID-19
---
Survey: 2022-04-13 | Tag F0908 | Environmental Deficiencies | Severity: F
Keep all essential equipment working safely.
---
Survey: 2022-04-13 | Tag F0919 | Environmental Deficiencies | Severity: E
Make sure that a working call system is available in each resident's bathroom and bathing area.
---
Survey: 2022-04-13 | Tag F0921 | Environmental Deficiencies | Severity: E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
---
Survey: 2022-04-13 | Tag F0943 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: F
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
---
Survey: 2022-04-13 | Tag F0947 | Nursing and Physician Services Deficiencies | Severity: F
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Source: U.S. Centers for Medicare & Medicaid Services. Data reflects the most recent available inspection.