Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Spring Creek Post-acute Rehabilitation Center during CMS and state inspections, most recent first.
A resident with altered mental status and moderately impaired cognition fell from a bedside commode after a CNA turned her back to help the roommate with a blanket, despite the care plan requiring supervision while on the commode. The resident sustained a rib contusion, and the CNA stated the fall could have been prevented if she had not turned away or if another staff member had been present.
A resident assessed as high risk for elopement was able to leave the facility through a storage room door with a broken lock and no alarm, reaching an exterior loading dock. Staff present in the area did not notice the resident's exit, and the incident was not immediately recognized or reported as an elopement. The facility failed to provide adequate supervision and maintain a safe environment, resulting in the resident being unsupervised outside.
An LPN was observed handling unwrapped food items and straws with bare hands while serving meals to several residents, contrary to facility policy requiring the use of gloves. Both the DON and Administrator confirmed that staff are expected to avoid direct contact with food and straws.
The facility did not review or update its facility-wide assessment as required, with the last documented review occurring nearly two years prior. The Administrator acknowledged the lapse and was in the process of updating the assessment, but it remained incomplete, potentially affecting all residents.
The facility did not ensure a safe, clean, and comfortable environment for residents, as evidenced by dirty and stained floors, soiled medical equipment, and inconsistent cleaning practices. Staff interviews revealed confusion over cleaning responsibilities, infrequent deep cleaning, and inadequate resources, while a state guardian and staff described the facility as unsanitary and poorly maintained.
Multiple lapses in infection prevention and control were identified, including failure to clean medical equipment, improper use of PPE during contact isolation, and direct handling of food items without gloves. Staff interviews revealed confusion about cleaning responsibilities and inconsistent verification of staff training on infection control procedures. These deficiencies affected several residents, including one with an open wound and chronic ulcer on contact precautions.
Several residents with eating difficulties were observed being draped with bath towels instead of proper clothing protectors or napkins during meals. Staff interviews revealed inconsistent practices, with some CNAs defaulting to towels due to lack of knowledge about clothing protector availability, and the DON acknowledging an insufficient supply. Residents expressed a preference for napkins or proper protectors, and the Administrator confirmed that towels were not appropriate and resident choice should be respected.
A resident exited the facility through multiple doors and accessed the loading dock, where she operated a lift and was elevated above the ground. The DON and Administrator did not report this elopement to the state agency as required by policy, due to miscommunication and misunderstanding of the incident details and reporting requirements.
Failure to Supervise Resident on Bedside Commode
Penalty
Summary
The facility failed to ensure a resident was adequately assisted to prevent an accident when the resident fell from a bedside commode. The resident was admitted with diagnoses including pneumonia, altered mental status, and need for assistance with personal care, and the Quarterly MDS showed a BIMS score of 8, indicating moderately impaired cognition. The resident's care plan included an intervention that the resident must be supervised while on the bedside commode. According to the fall report, a CNA assisted the resident to the bedside commode, then became distracted by the roommate asking for a blanket and turned her back while the resident was sitting on the commode. The resident fell off the bedside commode and was assessed and returned to bed. Progress notes documented that the resident sustained a rib contusion after the fall. During interviews, the CNA stated the fall would have been prevented if she had not turned her back on the resident and if another staff member had been present to assist her.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Environmental Hazards
Penalty
Summary
A deficiency occurred when a resident with a history of mild cognitive impairment and alcohol abuse eloped from the facility. The resident had previously been assessed as low risk for elopement upon admission, but subsequent assessments identified her as high risk, and interventions such as a wander guard and daily checks were implemented. Despite these measures, the resident was able to leave her room, pass through two sets of double doors, enter a staff break room, and exit through a storage room door that led to a loading dock. The door she used to exit had a broken lock and was not equipped with an alarm for the wander guard, allowing her to access the dock undetected. Staff interviews and video footage revealed that a housekeeper present in the break room did not notice the resident entering or exiting, as she was distracted by her phone. The resident was found outside on the loading dock by another staff member, who alerted maintenance. The maintenance team and a CNA assisted the resident back inside, and she was assessed for injuries, with none found. The incident was not immediately recognized as an elopement by facility leadership, and there was a lack of communication regarding the broken door lock prior to the event. Maintenance staff reported that no work orders had been submitted for the faulty lock, and the door was not discussed in morning meetings following the incident. The facility's policies required that residents at risk for elopement receive adequate supervision and that the environment remain as free from accident hazards as possible. However, the resident was able to leave the building through an unsecured and unmonitored exit, and staff failed to provide the necessary supervision to prevent the elopement. The incident was not promptly reported or fully investigated at the time, and the care plan was not updated with additional interventions after the resident's risk status changed. These failures resulted in the resident being exposed to significant risk while unsupervised outside the facility.
Removal Plan
- The Unit Manager completed a head-to-toe skin assessment and pain evaluation of R529 with no injuries or pain noted.
- The wander guard to her left ankle was noted to be in place.
- R529's Physician and family/responsible party were notified of the event.
- The Maintenance Director inspected the storage door and found the lock to be broken.
- The door was repaired by placing a keypad lock on it.
Failure to Follow Food Handling Protocols During Meal Service
Penalty
Summary
Facility staff failed to follow professional standards for food service safety during meal distribution and service for four residents. Observation during a dinner meal revealed that an LPN handled unwrapped food items, specifically buns, with bare hands while cutting sandwiches in half, and also touched straws with bare hands when placing them in residents' drinks. The facility's policy explicitly states that staff should avoid handling unwrapped food items with bare hands. During interviews, the LPN acknowledged not wearing gloves and stated she had not considered the need due to familiarity with the residents. Both the Director of Nursing and the Administrator confirmed that staff are expected to wear gloves and avoid direct contact with food and straws, in accordance with facility policy.
Failure to Update Facility-Wide Assessment
Penalty
Summary
The facility failed to review and update its facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The facility's policy required that the assessment be conducted, documented, and reviewed at least annually, with the Administrator responsible for ensuring its completion. The last documented assessment was dated June 2023, with a review date in July 2023, and indicated a capacity for 226 residents, while the actual census averaged 115 residents at that time. Despite policy stating monthly reviews, there was no evidence of updates or reviews since 2023. Interviews revealed that the Director of Nursing had no involvement with the facility assessment, confirming it was solely the Administrator's responsibility. The current Administrator, who began in March 2025, acknowledged that the assessment had not been updated since 2023 and stated she was in the process of updating it, pending feedback from residents and their representatives. As a result, the facility failed to maintain an up-to-date assessment, potentially affecting all 131 residents.
Failure to Maintain Clean and Homelike Environment for Residents
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for twenty-six sampled residents, as evidenced by multiple observations and interviews. Facility policies required routine cleaning and disinfection of high-touch surfaces and resident-care equipment, as well as adherence to preventative maintenance schedules. However, observations revealed that floors throughout the main corridors were heavily stained with wax buildup and grime, and some resident rooms had a yellowish film on the floors. The bottom of one resident's infusion pole was found coated in a dried brown substance. A grievance form documented concerns about overall cleanliness and stained floors, which the facility attributed to non-fecal stains, but acknowledged the need for deep cleaning. Interviews with staff and a state guardian highlighted ongoing issues with cleanliness and maintenance. The state guardian described the facility as dirty and unsanitary, noting chipped paint, brown smears on walls and privacy curtains, and dirty floors. He reported that while some cleaning and repairs had been attempted, the improvements were insufficient. Staff interviews revealed confusion and inconsistency regarding responsibility for cleaning medical equipment, with LPNs and CNAs providing differing accounts of their roles. Housekeeping staff and the floor technician reported that deep cleaning was infrequent, floors had not been stripped and waxed in a long time, and that there was a lack of enforcement and oversight from management. Further, the former Environmental Services Director stated that inadequate staffing and limited resources hindered the ability to maintain cleanliness, despite requests for additional support. The current Director of Environmental Services, new to the position, was still in the process of revising policies and implementing documentation for cleaning duties. The DON and Administrator expressed differing views on who should be responsible for cleaning medical equipment, with the Administrator stating that CNAs should not handle medical equipment and that nurses should address any visible dirt. The Administrator also noted that staff had been instructed to stop waxing floors over dirt, as this practice contributed to the facility's unclean appearance.
Failure to Maintain Effective Infection Prevention and Control Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by multiple lapses in environmental cleaning, use of personal protective equipment (PPE), and food handling practices. Observations revealed that an infusion pole used by a resident remained coated in a dried brown substance over several days, despite facility policies requiring routine cleaning and disinfection of medical equipment. Interviews with staff indicated confusion and inconsistency regarding responsibility for cleaning such equipment, with night shift CNAs, nursing staff, and Environmental Services each cited as responsible at different times. The Administrator was unaware that the IV pole required cleaning, indicating a lack of oversight and communication regarding infection control procedures. Further deficiencies were observed in the implementation of transmission-based precautions. A resident admitted with an open wound, colostomy, and chronic ulcer was placed on contact isolation due to a parasite, with physician orders and facility policy requiring staff to don full PPE before entering the room. However, a CNA entered the resident's room without PPE while delivering a meal tray, later admitting she was aware of the requirement but failed to comply due to time constraints. The DON, acting as the Infection Prevention Nurse, stated that agency staff were expected to be educated on precautions but did not verify completion of this training, and the Administrator was unable to articulate the potential negative outcomes of non-compliance. Additional infection control lapses were identified during meal service, where an LPN was observed handling unwrapped food items and straws with bare hands for several residents, contrary to facility policy. Both the LPN and DON acknowledged that gloves should have been worn and that direct contact with food and straws should be avoided. The Administrator confirmed the expectation for staff to use gloves and avoid contaminating food items, but these practices were not consistently followed, contributing to the overall deficiency in infection prevention and control.
Failure to Ensure Dignified Dining Practices for Residents with Eating Difficulties
Penalty
Summary
The facility failed to ensure residents' rights to a dignified existence, self-determination, and appropriate communication, specifically in relation to residents with eating difficulties. Observations revealed that several residents, including those with severe cognitive impairment, moderate cognitive impairment, and intact cognition, were draped with bath towels instead of clothing protectors or napkins during meals. A large black plastic container labeled 'Towels' was present in the dining area, and the use of towels as clothing protectors was observed during both lunch and dinner meals. Interviews with residents indicated a preference for napkins or proper clothing protectors, with some expressing dissatisfaction with the available options. Staff interviews revealed inconsistent practices, with some CNAs stating they offered towels by default, were unaware of the location of clothing protectors, or simply used napkins from meal trays. The DON was uncertain about the availability of clothing protectors and acknowledged there were not enough for all residents, while the Administrator stated that towels were not appropriate and residents should be asked about their preference. The facility's policy on promoting and maintaining resident dignity requires all staff to treat residents with respect and to provide care in a manner that maintains or enhances quality of life. However, the observed use of bath towels in place of proper clothing protectors or napkins, without consistent resident choice or adequate supply of appropriate items, did not align with this policy. The deficiency was identified for multiple residents with varying cognitive and physical needs, and staff interviews confirmed that the practice was based on habit, lack of resources, or assumptions about resident capability, rather than individualized resident preference or dignity.
Failure to Report Resident Elopement to State Agency
Penalty
Summary
The facility failed to ensure it was administered in a manner that enabled effective and efficient use of its resources to maintain the highest practicable well-being of each resident, specifically related to the failure of the Administrator and/or DON to notify the state regulatory office of an elopement incident. On 04/18/2025, a resident exited her room, traversed multiple doors, entered a staff area, and ultimately accessed the facility's loading dock, where she operated a lift and was elevated above the pavement. The facility's policies required reporting such incidents to the State Survey Agency, but this was not done. Interviews with the DON and Administrator revealed a lack of clarity and communication regarding the incident. The DON was not present at the time and, after being informed, recognized the event as an elopement but did not report it. The Administrator, also absent during the incident, initially did not consider the event an elopement and therefore did not report it, only acknowledging the requirement after regulatory review. Both the Administrator and DON's job descriptions included responsibilities for regulatory compliance and incident reporting, which were not fulfilled in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Towne Square Care Of Puryear | 10.2 mi | ★★★★★ | 6 | 0 |
| Lake Way Rehabilitation And Healthcare Center | 17 mi | ★★★★★ | 0 | 0 |
| Green Acres Healthcare | 20.1 mi | ★★★★★ | 25 | 0 |
| Henry County Health And Rehabilitation | 20.2 mi | ★★★★★ | 2 | 0 |
| Patriot Health And Rehabilitation Center | 20.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.