Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Spring Creek Nursing And Rehabilitation Center Llc during CMS and state inspections, most recent first.
Incomplete care plans were identified for multiple residents when records and staff interviews showed missing care areas tied to meds, hospice, wounds, and activities. Residents had diagnoses including CHF, dementia, depression, CKD, COPD, paraplegia, and pressure ulcers, with orders for insulin, anticoagulants, psychotropics, hospice services, and a high-protein diet, yet the care plans did not reflect these needs or related monitoring/interventions.
Failure to Provide Resident-Requested Community Outings: A resident stated she wanted to leave the facility more often, but outings were not offered because the van was broken. Another resident said she wanted to shop for personal items, but staff said transportation could not be provided without a van. The AD reported there was no activities bus available, she could not drive it due to vision issues, and the only transport aide was usually busy with appointments. The activities calendar showed no outside activities, while the Resident Handbook described community outings as a common activity.
An LPN observed multiple opened, in-use meds in medication carts without open dates, including acetaminophen, ibuprofen, laxatives, vitamins, sodium bicarbonate, aspirin, and loratadine. A discontinued chlorhexidine solution for a resident also remained in the cart. The LPNs confirmed the meds were not dated when opened, and the facility policy required drugs and biologicals to be stored in a safe, secure, and orderly manner.
Cold Meal Service and Delayed Tray Delivery: During breakfast, the DM checked Denver scrambled eggs at 180 degrees F before service, but after delayed tray delivery through the hallway and room service process, the eggs were 120 degrees F when rechecked, below the 135 degrees F minimum holding temp. The DM stated she was unaware of concerns and said nursing staff delays after trays left dietary were outside her control. Two residents reported cold meals in their rooms, and one resident said she skipped breakfast because cold eggs and pancakes tasted terrible.
Failure to Provide Fresh Water Daily: Residents were not offered fresh water daily, and fresh water was not present in resident rooms during observations. A resident reported having the same water in the room for three days, and a CNA stated staff did not pass fresh ice water and residents had to ask for it. Resident council minutes showed residents wanted water passed to rooms during the day, while the facility policy required aides to provide and encourage fluids on a daily and routine basis.
Soiled breakfast trays were placed on the same cart as clean lunch trays during meal service on a hallway, and staff continued distributing lunch trays from that cart. CNAs confirmed the trays were mixed together because the breakfast trays had not been picked up and said this was a common practice when trays were missed after breakfast.
Failure to Perform Hand Hygiene During Meal Tray Distribution: Nursing staff and CNAs were observed passing meal trays and assisting residents while wearing the same gloves between residents and without washing hands or using hand sanitizer at key points. Staff touched multiple surfaces, including door handles, tray tables, wheelchairs, refrigerators, TV remotes, and call lights, while handling food trays and assisting with meals. Facility policy stated hand hygiene is the primary means of preventing infection and required hand hygiene before and after resident contact, after glove removal, and before and after handling food.
Resident room temperature was not maintained at a comfortable level. A resident with paraplegia, acute transverse myelitis, and stage 3 and 4 pressure ulcers reported her room was cold and was observed in bed wearing a bathrobe and covered with three blankets while the wall register produced no heat. Maintenance staff measured the room at 57.7 degrees F, below the facility’s stated 71 to 81 degree target and below the 65 degree threshold in the facility policy.
The facility failed to timely submit discharge MDS assessments for two former residents. One resident had diagnoses including substance abuse disorder, TIA, and hip replacement, and another had acute respiratory failure, pneumonia, COPD, sepsis, and CHF. In both cases, the discharge return not anticipated MDS was export ready but was not submitted to CMS within the required timeframe, and the MDS coordinator acknowledged the delay.
The facility failed to ensure ongoing communication between hospice and facility staff for a resident receiving hospice services. The resident had liver failure, autoimmune hepatitis, COPD, and biliary cirrhosis, and the chart contained no hospice communication notes. Staff reported there was no hospice communication binder, only a flyer in the chart, and the DON stated everything was completed online. Hospice visit notes were later received via fax.
Failure to timely schedule vision services for a resident with severe cognitive impairment and traumatic brain injury-related deficits. The resident had documented eye conditions including dry eyes, constant exotropia, and myopic astigmatism, and was supposed to have a comprehensive eye exam, but the facility had not arranged for the vision provider to come to the facility since the prior year. The Administrator confirmed the resident had not been seen as scheduled, and the facility policy assigned appointment scheduling to the scheduler.
Failure to provide an ordered high protein diet was identified for a resident with multiple pressure ulcers, paraplegia, and intact cognition. Wound care notes and the RD review directed protein intake to support wound healing, but the resident was served a regular diet with thin liquids, reported no extra high protein foods, and meal observations showed regular meals high in carbohydrates with minimal protein; the DON confirmed the ordered high protein meals were not provided.
A resident with intact cognition and diagnoses including multiple myeloma, bone cancer, anemia, thrombocytopenia, and severe protein calorie malnutrition had a portable space heater operating in her room. Surveyors observed the heater on a window ledge and still in use later the same day, and an LPN confirmed it was being used because the room was cold and the resident was receiving chemotherapy. Facility policy prohibited portable space heaters in resident sleeping rooms and other resident-accessible areas.
Failure to timely identify and intervene for significant weight loss. A resident with dysphasia, severe protein-calorie malnutrition, hypokalemia, vitamin D deficiency, and cognitive impairment lost 13.9 pounds, or 7.4%, over a short period. Nutrition recommended a mighty shake and appetite stimulant, and the APRN-NP-C signed off, but the appetite stimulant was not implemented and the record showed confusion about the resident's nutrition orders, including Magic Cup and Boost. The DON and APRN-NP-C verified the resident did not receive the ordered appetite stimulant.
A resident with ESRD, cognitive impairment, and dependence for ADLs repeatedly refused or stopped dialysis early because of nausea, vomiting, and cramping, but staff did not document assessments or notify the NP or nephrologist. Records showed multiple missed and shortened dialysis sessions, no nurse notes for the refusals, and no PRN Zofran given despite an order for nausea and vomiting.
Provider order for an appetite stimulant was not carried out for a resident with dysphagia, severe protein-calorie malnutrition, and cognitive impairment who had significant weight loss. A nutrition recommendation for a mighty shake and appetite stimulant was signed by the APRN-NP-C, but the order was not implemented and Boost was used instead; the APRN-NP-C later stated she did not necessarily want the appetite stimulant, and the DON verified there was no order for Magic Cup and that the resident did not receive the appetite stimulant.
Failure to Provide Dental Services: A resident with severe cognitive impairment, periodontal disease, and dependence for ADLs had inflamed and bleeding gums, with dental notes showing repeated inability to complete exams because the resident was not cooperative. The resident’s chart included orders for oral treatment and dental follow-up for tooth extraction, but no dental appointment was scheduled and the transportation aide had not been notified of any extraction visit.
A resident with mild cognitive impairment and multiple chronic conditions discovered unauthorized charges on a debit card and reported the card missing after reviewing a bank statement. A police report documented several unauthorized transactions totaling over $500. Law enforcement investigation identified a CNA as the perpetrator linked to at least one of the charges, and the facility’s self-report substantiated misappropriation of the resident’s property in violation of its abuse and misappropriation policy.
Three residents with significant physical limitations and intact cognition did not consistently receive scheduled showers as required, with missing or incomplete documentation and reports from both residents and staff confirming missed care. Facility policy required documentation of showers or refusals, but this was not followed, resulting in a failure to support resident choice and self-determination.
Multiple residents experienced non-functioning or inaccessible call light systems in their bathrooms, bedrooms, and shower rooms. Some residents were unable to summon assistance when needed, with one resident left unattended in the bathroom for over an hour. Facility staff confirmed that call lights were not working due to battery and wiring issues, and some shower areas lacked accessible call lights altogether.
Multiple residents were found without access to hand soap, paper towels, or functioning bathroom sinks, with staff confirming that supply shortages and maintenance issues led to the lack of basic hygiene provisions. Residents had to rely on staff to bring supplies from outside the room or use personal towels, and in one case, a resident purchased their own soap due to the facility's failure to provide it.
A resident with type I DM and an insulin pump did not have a care plan developed to address diabetes management or insulin pump care. Staff provided snacks during episodes of low blood sugar, but there was no documentation or monitoring orders, and both nursing staff and the DON confirmed the lack of a care plan.
Surveyors found that the facility did not maintain clean and safe shower rooms, with observations including brown substances on shower equipment, missing tiles, dirty washcloths, and standing water. These issues were confirmed by LPNs and were not in line with the facility's policy for providing a safe and homelike environment.
A resident with multiple health issues experienced a significant change in condition, leading to a transfer to the hospital. The facility failed to notify the resident's representative of this change, as confirmed by staff interviews and a review of the medical record. This action was contrary to the facility's policy requiring timely notification of changes in a resident's status.
A resident with a history of smoking while using oxygen was assessed as an independent smoker, leading to a fatal incident when they lit a cigarette while wearing oxygen therapy. Despite being educated on the risks, the resident's oxygen ignited, causing severe burns and death. The facility's smoking policy required supervision for smokers using oxygen, but the resident was allowed to smoke unsupervised, resulting in Immediate Jeopardy and serious harm.
The facility failed to manage its financial obligations, resulting in overdue payments to essential service providers, including the electric service provider, medical equipment supplier, and fire protection service company. This deficiency had the potential to affect all 73 residents, including eight who were ventilator-dependent. The administrator acknowledged that payments were paused to allocate funds for facility repairs, leading to the financial shortfall.
Incomplete Care Plans for Multiple Residents
Penalty
Summary
The facility failed to ensure resident care plans were properly completed to include all identified care areas for six of six residents reviewed. The facility policy titled Resident Care Plan required a comprehensive care plan for each resident with measurable objectives and timetables to meet identified medical, nursing, mental, and psychosocial needs. Review of the records and interviews with the MDS Coordinator confirmed that the care plans for the reviewed residents were incomplete and did not include several documented care needs. Resident #03 had diagnoses including respiratory failure, CHF, and diabetes mellitus, and the record showed orders for insulin Lispro, Spironolactone for edema, Bumex for edema, and Eliquis for anticoagulant therapy. The most recent care plan did not address diuretic use, insulin, or anticoagulant therapy. Resident #21 had diagnoses including dementia, depression, anxiety, and atherosclerotic heart disease, with orders for Buspirone, Sertraline, and Xarelto, but the care plan did not include monitoring for antianxiety, antidepressant, or anticoagulant medications. Resident #13 had depression, dementia with psychotic disturbance, severe cognitive impairment, and orders for Buspirone, Cymbalta, Depakote, and Seroquel, yet the care plan lacked monitoring for antipsychotic, antianxiety, and antidepressant medications. Resident #11 began hospice services upon admission, but the care plan contained no information regarding hospice care. Resident #25 had acute transverse myelitis, paraplegia, and stage three and four pressure ulcers, and wound notes indicated a high protein diet to promote wound healing, but the care plan did not include that intervention. Resident #32 had CHF, lymphedema, CKD, COPD, and fibromyalgia, was cognitively intact and wheelchair mobile, and stated a desire to participate in outdoor activities and outings, but the care plan had no information regarding activities or activity preferences.
Failure to Provide Resident-Requested Community Outings
Penalty
Summary
The facility failed to ensure activities outside the facility were provided according to resident preferences. During interviews, Resident #32 stated she wanted to get out of the facility more often and reported that because the facility van was broken, residents were not allowed to go on outings. Resident #32 said the last outing she attended was in August 2025. Resident #48 also stated the facility did not have activities outside of the facility and said she preferred to shop for personal items, but the facility stated it could not provide transportation because it did not have a van available for resident outings. The Activities Director stated the facility did not currently have an activities bus and said she was not allowed to drive it because of bad vision. She further stated that the only person who could transport residents to outside activities was the transportation aide, who was busy with appointments during the week and rarely worked weekends. Review of the May 2026 activities calendar showed no activities outside of the facility, although the facility had set days when Activities Aides would go shopping for residents. The Resident Handbook stated that a variety of activities are provided daily and that common activities included community outings. Resident Council minutes showed residents were reminded that shopping would occur at the beginning of each month and that staff would not go to the store daily; later minutes documented residents requesting a bus for outings and staff stating they were only doing small trips and trying to work with the transport van on days with no appointments.
Medications Left Undated and Discontinued Drug Kept in Cart
Penalty
Summary
The facility failed to store medications in a safe manner. During observation of the 100 hall medication cart with an LPN, an open, undated bottle of Chlorhexidine Gluconate mouth/throat solution remained in the cart for Resident #27 even though the order had been discontinued. The same cart also contained open and undated bottles of acetaminophen 325 mg, acetaminophen 500 mg, Ibuprofen 200 mg, Senna Plus, fiber laxative, stool softener, Geri Kot, Vitamin D3 125 mcg, Vitamin D3 1250 mcg, Bisacodyl suppositories, and Mucus Relief DM. The LPN verified that medication bottles are to be dated when opened and confirmed the listed medications were not dated and that the discontinued medication remained in the cart. A separate observation of the [NAME] medication cart with another LPN found opened and in-use medications that also lacked open dates, including sodium bicarbonate 325 mg, aspirin 81 mg, and Loratadine 10 mg. The LPN verified that these multiple-use medications are to be dated when opened and confirmed they were not dated. Review of the facility policy titled Storage of Medications undated stated that the facility shall store all drugs and biologicals in a safe, secure, and orderly manner.
Cold Meal Service and Delayed Tray Delivery
Penalty
Summary
Food was not served at a safe, appetizing temperature and acceptable palatability during breakfast meal service on hallway one hundred. At 7:30 A.M., the Dietary Manager checked the food temperatures before service and found the Denver scrambled eggs were 180 degrees Fahrenheit. The surveyor requested a test tray at 7:48 A.M., hallway trays left the kitchen at 7:50 A.M., and the first tray arrived in the one hundred hallway dining room at 7:52 A.M. The first tray was passed at 8:00 A.M., the remaining room trays were pushed to the hallway at 8:15 A.M., the first hallway tray was delivered at 8:17 A.M., and the last tray was passed and the test tray removed at 8:33 A.M. When the Dietary Manager checked the food after the delay, the Denver eggs were 120 degrees Fahrenheit, below the stated minimum holding temperature of 135 degrees Fahrenheit. The Dietary Manager verified that eggs should be served at a minimum holding temperature of 135 degrees Fahrenheit and stated she was unaware of any concerns related to food temperature because she did not have control of nursing staff delays in delivering meals after they left the dietary department. Two residents reported that meals served in their rooms were cold, and one resident stated she never ate breakfast because eggs and pancakes taste terrible cold. The facility policy stated hot foods must be held and served at least 135 degrees Fahrenheit and transported to maintain that temperature.
Failure to Provide Fresh Water Daily
Penalty
Summary
The facility failed to ensure residents were offered fresh water daily. Observation on 05/04/26 at 9:00 A.M. on the [NAME] hallway revealed residents did not have fresh water in their rooms, and observation on 05/05/26 at 2:00 P.M. revealed staff had not offered residents fresh water throughout the day. During interview, Resident #7 stated the facility did not pass fresh water or offer fresh water daily and reported having the same water in the room for three days. A CNA stated staff does not pass fresh ice water and that residents must ask for water, and the CNA was unable to explain how cognitively impaired residents or residents unable to ask receive fresh water. Review of Resident Council Minutes from 04/27/26 showed residents wanted water passed to rooms during the day, and the facility policy stated nurses' aides will provide and encourage intake of bedside, snack, and meal fluids on a daily and routine basis as part of daily care.
Soiled Breakfast Trays Placed on Cart with Clean Lunch Trays
Penalty
Summary
The facility failed to maintain sanitary conditions during lunch meal service on hallway 100 when staff placed used breakfast trays containing soiled dishes and food debris onto the same food cart holding fresh lunch trays that were actively being distributed to residents. Staff continued passing lunch trays from the cart after the soiled breakfast trays were placed on it. CNA #425 confirmed that the used breakfast trays were returned to the same cart with clean lunch meal trays because the staff missed picking up the breakfast trays after breakfast. CNA #405 also confirmed that used breakfast trays were placed in the same cart with clean lunch meal trays and stated this was a common practice if the trays were not picked up after breakfast.
Failure to Perform Hand Hygiene During Meal Tray Distribution
Penalty
Summary
The facility failed to follow appropriate hand hygiene and infection control practices during meal tray distribution on hallway one hundred, affecting residents receiving meal service except one resident identified as NPO. During the lunch meal service observation, nursing staff were seen passing meal trays in the dining room without washing their hands before delivery and while wearing the same pair of gloves between residents. Staff removed tray lids, cut up foods, and placed clothing protectors around residents' necks while continuing to wear the same gloves, and they were also observed touching food cart door handles, refrigerator doors, cabinetry doors, residents' wheelchairs, and the backs of dining room chairs without changing gloves or performing hand hygiene. During hallway tray passage, CNAs were observed knocking on resident doors, touching door knobs, moving over bed tray tables, entering closets and personal refrigerators, removing tray lids, cutting up foods, touching TV remotes, and turning off call lights while wearing the same gloves and without using hand sanitizer or washing hands when entering or exiting rooms. Two CNAs later confirmed they did not wash their hands between passing hall trays. On a later observation, CNAs used hand disinfectant before glove use and changed gloves between residents after using hand sanitizer, but still did not wash their hands at any time during tray passage. The facility's infection control and hand hygiene policies stated hand hygiene is the primary means of preventing the spread of infection and directed staff to perform hand hygiene before and after resident contact, after contact with objects in the resident's vicinity, after removing gloves, and before and after handling food or assisting with meals.
Resident Room Temperature Below Facility Standard
Penalty
Summary
The facility failed to ensure resident rooms were maintained at comfortable temperatures. Resident #25, who was admitted with acute transverse myelitis in demyelinating disease of the central nervous system, paraplegia, and stage three and four pressure ulcers, had an intact cognition on the quarterly MDS and was dependent on staff for all activities of daily living except eating. During interview, the resident stated her room was cold and she wanted the heat increased. At the time of the interview, she was observed lying in bed in a bathrobe and covered with three blankets, and the room wall register was not producing any heat. Observation of the room with Maintenance Assistants #503 and #505 showed the room temperature was 57.7 degrees Fahrenheit. Maintenance Assistant #503 verified the temperature and stated he could not explain why and that the Maintenance Director would need to assist for more information. The facility policy titled Excessive Temperature Guidelines stated every reasonable attempt would be made to maintain temperatures between 71 and 81 degrees Fahrenheit and required notification if temperatures fell below 65 degrees Fahrenheit in resident areas that could not be moved.
Late Submission of Discharge MDS Assessments
Penalty
Summary
The facility failed to submit discharge Minimum Data Set (MDS) assessments to the State within 7 days of the assessment event for two former residents. Former Resident #09 was admitted on 10/21/25 and discharged on 12/23/25 with diagnoses including substance abuse disorder, transient ischemic attack, and hip replacement; the quarterly MDS was completed and exported on 12/12/25, and the discharge return not anticipated MDS was export ready but was not submitted to CMS. Former Resident #53 was admitted on 10/31/25 and discharged on 12/15/25 with diagnoses including acute respiratory failure, pneumonia, COPD, sepsis, and CHF; the entry MDS and Medicare 5-day assessment were completed and submitted, but the discharge return not anticipated assessment was export ready on the discharge date and had not been submitted by the facility. The MDS Coordinator stated she failed to submit both discharge MDSs in a timely manner, and the CMS RAI Manual requires discharge records to be completed within 7 days of the event date.
Lack of Ongoing Hospice Communication
Penalty
Summary
The facility failed to ensure ongoing communication between hospice and facility staff for one resident receiving hospice services. Resident #11 was admitted with diagnoses including liver failure, autoimmune hepatitis, COPD, and biliary cirrhosis, and the quarterly MDS indicated intact cognition and hospice services for cirrhosis of the liver. Review of the medical record found no communication notes to or from hospice for this resident. Staff interviews confirmed the lack of a communication binder for the hospice group. The RN Supervisor and LPN stated the chart contained only a simple hospice flyer and no hospice communication records, and the LPN denied knowledge of any binder. The DON stated there was no communication book and that everything was completed online, while the RN Supervisor later stated she and the LPN had spoken with the SSD about the missing binder and were told one could be requested from hospice. Review of hospice patient information reports showed the facility received visit notes via fax on 05/07/26.
Failure to Timely Schedule Vision Services
Penalty
Summary
The facility failed to ensure a resident with vision concerns was seen timely by the ophthalmologist. Resident #37 was admitted with diagnoses including traumatic subarachnoid hemorrhage with loss of consciousness, periodontal diseases, persistent vegetative state, and encephalopathy. The annual MDS showed severe cognitive impairment and dependence on staff for ADLs, and the care plan included wearing glasses during the day for ADL self-care performance deficit related to traumatic brain injury. Ancillary vision service provider notes showed the resident was seen on 01/28/25, with findings of dry eyes in both eyes, constant exotropia of the left eye, and myopic astigmatism in both eyes; the resident used prescription eyeglasses for distance viewing as needed, and a comprehensive exam was recalled for 01/28/26. However, the facility had not scheduled the vision provider to come to the facility since August 2025. The ancillary vision service provider customer care representative stated it was the facility’s responsibility to schedule the provider, and the Administrator confirmed the resident was supposed to be seen on 01/28/26 but had not been seen since 01/28/25. The facility policy on scheduling appointments stated the scheduler would receive the request from the unit and check whether the appointment needed to be scheduled.
Failure to Provide Ordered High Protein Diet for Resident With Pressure Ulcers
Penalty
Summary
Failure to provide a resident with pressure ulcers a high protein diet as prescribed by a physician was identified for Resident #25, who was admitted on 06/07/24 with diagnoses including acute transverse myelitis in demyelinating disease of the central nervous system, paraplegia, and stage three and four pressure ulcers. The quarterly MDS documented intact cognition and three stage four pressure ulcers and one stage two pressure ulcer. The care plan addressed pressure ulcers to the right buttock, left posterior thigh, and coccyx, with interventions including ordered treatments, education on skin breakdown, and good nutrition and frequent repositioning. Outside wound care progress notes dated 02/13/26, 03/13/26, and 04/15/26 stated the resident was to receive a high protein diet to promote wound healing, and the Dietician Quarterly Nutrition Review dated 03/12/26 directed staff to encourage protein foods at meals. However, the meal ticket dated 05/06/26 showed a regular diet with thin liquids, the resident stated on 05/06/26 that no extra high protein foods were served, and meal observations on 05/06/26 and 05/27/26 showed regular meals high in carbohydrates with minimal high protein foods. The DON verified on 05/07/26 that the resident had not been provided a high protein meal as ordered by wound care and recommended by the dietician.
Portable Space Heater Allowed in Resident Room
Penalty
Summary
The facility failed to ensure an area was free from accident hazards and adequately supervised when it allowed a portable space heater to be used in Resident #70's room. Resident #70 was admitted with diagnoses including multiple myeloma, malignant neoplasm of bone, anemia, thrombocytopenia, and severe protein calorie malnutrition, and her quarterly MDS indicated intact cognition. On 05/05/26, surveyors observed a space heater sitting on the window ledge in the resident's room and operating, blowing hot air. A later observation the same day showed the heater still in use while the resident was sitting in bed with a visitor at bedside. The resident stated the heater was working and needed to keep her room warm, and an LPN confirmed the resident had a portable heater because her room was cold and she needed to be comfortable due to receiving chemotherapy. The facility policy stated portable space heaters are not allowed in resident sleeping rooms, hallways, resident activity areas, or any area accessible to residents.
Failure to Timely Address Significant Weight Loss
Penalty
Summary
The facility failed to timely identify, assess, and intervene for significant weight loss for one resident. The resident was admitted with diagnoses including dysphasia, severe protein-calorie malnutrition, hypokalemia, and vitamin D deficiency, and the quarterly MDS documented cognitive impairment. The clinical record showed weights of 187.9 pounds on 02/08/26, 177.9 pounds on 03/06/26, and 174.0 pounds on 04/26/26, reflecting a 13.9-pound loss or 7.40 percent. A nutrition recommendation dated 03/12/26 called for a mighty shake and an appetite stimulant to be added because of significant weight loss in the prior 30 days, and the APRN-NP-C signed agreement on 03/16/26. The record showed the recommended appetite stimulant was not implemented between 03/12/26 and 04/22/26, and instead an order for Boost was initiated. During interview, the APRN-NP-C stated she did not necessarily want to start an appetite stimulant because the resident was already on Magic Cup and Boost, and said staff were providing more assistance with meals based on a later weight gain. The DON and APRN-NP-C verified there was not an order in the medical record for Magic Cup, and the DON further verified the resident did not receive an appetite stimulant despite the APRN-NP-C's orders. An LPN later located an order for Magic Cup twice daily, entered at 1:59 P.M. on 05/05/26. Facility policy stated residents with unintended significant weight loss should receive immediate nutrition interventions and that the goal is to identify causes and intervene to stabilize weight.
Failure to Monitor and Report Repeated Dialysis Refusals Due to Nausea and Vomiting
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis care for a resident with end stage renal disease, encephalopathy, hypo-osmolality, and hyponatremia who was dependent on staff for activities of daily living and had cognitive impairment. The resident’s care plan included monitoring and documenting signs and symptoms of renal insufficiency, and the physician had ordered Zofran 4 mg every six hours as needed for nausea and vomiting, but the MAR showed no PRN Zofran was given in May. During interview, the resident stated she had refused dialysis because of nausea and vomiting. Review of the records showed no nurse progress notes documenting the resident’s nausea or dialysis refusals, and no assessments were documented when she missed dialysis or returned early from treatment. In April, the resident missed seven dialysis days due to nausea and/or vomiting, and in May missed one day; the dialysis communication sheets also showed ten treatments were stopped early because she felt nauseous, vomited, or had leg cramps. Staff interviews confirmed the NP was not notified when the resident refused dialysis and the nephrologist was not updated about the repeated nausea, vomiting, and cramping during treatment. The renal dialysis coordination agreement stated the facility would monitor for altered thought process, nausea, vomiting, agitation, and changes in behavior.
Provider order for appetite stimulant was not implemented
Penalty
Summary
The facility failed to ensure provider orders were carried out as prescribed for one resident reviewed for implementation of provider orders. The resident was admitted with diagnoses including dysphasia, severe protein-calorie malnutrition, hypokalemia, and vitamin D deficiency, and the quarterly MDS indicated cognitive impairment. The clinical record showed a monthly weight of 187.9 pounds on 02/08/26, 177.9 pounds on 03/06/26, and 174.0 pounds on 04/26/26, reflecting a 13.9-pound loss or 7.40% weight loss. An Individual Nutrition Recommendations/Response form dated 03/12/26 documented a recommendation for a mighty shake and appetite stimulant to be added because of significant weight loss in the last 30 days, and the APRN-NP-C signed agreement on 03/16/26. However, the record showed the appetite stimulant recommendation was not implemented between 03/12/26 and 04/22/26, and instead an order for Boost was initiated. During interview, the APRN-NP-C stated she did not necessarily want to start an appetite stimulant because the resident was already on Magic Cup and Boost, and the DON verified there was no order in the record for Magic Cup and that the resident did not receive an appetite stimulant despite the signed order.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide dental services for one resident who had traumatic subarachnoid hemorrhage with loss of consciousness, periodontal disease, persistent vegetative state, and encephalopathy. The resident’s annual MDS showed severe cognitive impairment, dependence on staff for ADLs, and inflamed or bleeding gums. The care plan included staff performing oral care, and dental health service notes documented that the resident was not cooperative during dental exams on multiple occasions. Nurse progress notes documented inflamed and bleeding gums, and the physician ordered Peridex for bleeding gums, follow-up with dental for tooth extraction, and doxycycline for gum infection. Dental services reported the resident’s last dental cleaning was over two years earlier because the resident was not cooperative during other visits, and that no further appointment had been scheduled. The NP stated the resident needed outside dental extraction due to rotting teeth and would require sedation, while the transportation aide confirmed she had not been notified of any extraction appointment and that no dentist appointment was scheduled.
Failure to Protect Resident From Misappropriation of Debit Card by Staff
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when a staff member wrongfully used the resident’s debit card without consent. The resident, who had mild cognitive impairment and multiple medical conditions including MS, type 2 diabetes, COPD, heart failure, CKD stage three, A-fib, hypertension, and peripheral vascular disease, discovered unauthorized charges after reviewing a bank statement. The resident reported that she could not find her debit card, had already contacted the bank to cancel the card, and was expecting paperwork from the bank. A bank statement showed multiple charges over several days, totaling $514.31, which the resident stated she did not make. A police report was filed for a stolen credit card with unauthorized use, and subsequent investigation identified a CNA as the perpetrator linked to at least one of the charges. The resident reported to surveyors that a staff member had stolen and used her card without permission and that law enforcement had informed her the perpetrator had been identified and would be prosecuted. The facility’s own SRI documented that misappropriation was substantiated and that the CNA was connected to at least one unauthorized transaction, while the facility’s abuse and misappropriation policy defined misappropriation as the deliberate misplacement or wrongful use of a resident’s belongings or money without consent.
Failure to Provide Scheduled Showers and Document Care for Dependent Residents
Penalty
Summary
The facility failed to ensure that residents who were dependent on staff for bathing received showers on their scheduled days according to their preferences. Medical record reviews, resident and staff interviews, and documentation audits revealed that three residents with intact cognition and significant physical limitations did not consistently receive scheduled showers. For example, one resident with multiple sclerosis, COPD, and atrial fibrillation, who required maximal assistance and mechanical lift transfers, had no shower documentation for two consecutive months and confirmed missed showers. Another resident with a right lower leg fracture and bipolar disorder, requiring moderate assistance, did not receive a scheduled shower, with no documentation or record of refusal, and also reported missed showers. A third resident, with a left femur fracture and polyneuropathy, dependent on a wheelchair and requiring substantial assistance, did not receive a scheduled shower, and documentation was incomplete. This resident stated that she had not received a shower for over a week and described waiting for staff assistance that never occurred. Staff interviews confirmed inconsistencies in documentation and communication regarding shower schedules, with some confusion between day and night shift responsibilities. The Director of Nursing verified the absence of required documentation for the affected residents on the specified dates. Facility policy required staff to document when showers were performed or refused, including the reason for refusal, but this was not consistently followed. The lack of documentation and missed showers for residents dependent on staff for bathing constituted a failure to honor resident choice and self-determination, as well as a failure to follow established care plans and facility procedures.
Non-Functioning and Inaccessible Call Light Systems in Resident Bathrooms and Shower Areas
Penalty
Summary
The facility failed to ensure that resident call devices were functioning and accessible in bathrooms, bedrooms, and shower rooms. Observations and interviews revealed that multiple residents had non-functioning call lights in their bathrooms and bedrooms. One resident's bathroom call light did not work, and the resident reported waiting for staff to return after toileting, unable to recall if he used the call light. Another resident's bathroom call light was found in the pulled position but not functioning; she reported being left on the toilet for over an hour and having to call out for help. The Plant Operation Director confirmed that these call lights were not working and explained that the bathroom call systems operated on batteries, which could die without warning, and that wiring issues sometimes caused the batteries to fail quickly. Further observations showed that another resident's bedside and bathroom call lights were not working. In addition, two call lights in a shower room did not function when tested, and a third-floor bathroom lacked a call light in the shower area, with existing call lights either not accessible or not working. The facility's policy required staff to ensure call lights were plugged in and functioning at all times and to promptly report defective call lights to the nurse supervisor. These deficiencies affected several residents and had the potential to impact others who used the showers on the first and third floors.
Failure to Provide Hygiene Supplies and Maintain Resident Bathrooms
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for multiple residents, as evidenced by the lack of basic hygiene supplies and maintenance issues in resident bathrooms. For one resident with severe cognitive impairment, the bathroom lacked soap and paper towels, requiring staff to retrieve supplies from outside the room and use towels for drying hands. Another cognitively intact resident reported a non-functional soap dispenser and the absence of paper towels, leading her to purchase her own soap. She also could not access the sink near the entrance due to being in a wheelchair. A third resident, also cognitively intact, had a non-working sink marked 'out of order' and a leaking bathroom sink overflowing onto the floor, with no hand soap or paper towels available. In each case, staff interviews confirmed the absence of necessary hygiene supplies and acknowledged that supply shortages sometimes occurred due to missed deliveries. Facility staff, including housekeeping and plant operations, confirmed the deficiencies during interviews, noting that soap and paper towels should be available in every resident bathroom. The facility's policy requires housekeeping to maintain a clean, safe, and healthy environment, including providing personal hygiene items. Despite this, the affected residents did not have access to essential hygiene supplies or functioning bathroom fixtures, directly impacting their ability to maintain personal hygiene and comfort.
Failure to Develop Care Plan for Diabetes Management and Insulin Pump
Penalty
Summary
The facility failed to develop a care plan addressing the medical needs of a resident with type I diabetes mellitus (DM), including the use of insulin and management of an insulin pump. Medical record review showed that although the resident had physician orders for insulin administration via pump, there was no corresponding care plan for diabetes management or insulin pump care. Interviews with the resident and staff revealed that the resident experienced episodes of low blood sugar, for which staff provided snacks, but there was no documentation of these events or orders for monitoring. Both the registered nurse and the director of nursing confirmed the absence of a care plan for the resident's type I DM and insulin pump management.
Failure to Maintain Clean and Safe Shower Room Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and safe environment in the shower rooms on two units, affecting all residents residing in those areas. Specific findings included a brown substance on the back of a shower chair seat, brown residue underneath a shower bed on the drip cloth, and a peg-tube cap found under the shower bed mattress. Additional observations revealed a brown sticky substance on the floor in the shower area, a missing tile on the shower wall, brown/black substance on the ceiling above the foot washer, brown substance on the wall of the foot washer, three dirty washcloths left in the tub, and standing water near the drain of the tub. These conditions were verified by interviews with LPNs who confirmed the presence of the substances and environmental issues. A review of the facility's policy titled 'Quality of Life-Homelike Environment' indicated that residents are to be provided with a safe, clean, comfortable, and homelike environment. The observed deficiencies in cleanliness and maintenance of the shower rooms were not in accordance with this policy. The issues were identified during the investigation of two complaint numbers and had the potential to affect all residents on the specified units, with a facility census of 73.
Failure to Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of a change in condition, which is a requirement according to their policy. This deficiency affected one resident who was admitted with multiple diagnoses, including acute and chronic respiratory failure, heart failure, and chronic kidney disease. The resident, who was cognitively intact, experienced shortness of breath and a heavy chest, with oxygen saturation levels dropping into the 70s and 80s. Despite increasing oxygen levels, the resident requested to be sent to the emergency room, and emergency medical services were called. The medical record review revealed that there was no documentation indicating that the resident's representative was notified of the change in condition or the transfer to the hospital. Interviews with the facility's Administrator and a Registered Nurse confirmed that the notification was not made. The facility's policy, dated November 2023, requires that the responsible party or family member be notified in a timely manner of any changes in a resident's status and the treatment plan. This deficiency was investigated under Complaint Number OH00160699.
Failure to Supervise Resident Smoking with Oxygen Leads to Fatal Incident
Penalty
Summary
The facility failed to ensure that a resident with a known history of smoking while using oxygen was properly assessed and supervised, leading to a tragic incident. The resident, who was cognitively intact and had a history of smoking with oxygen on, was assessed as an independent smoker. Despite being educated on the risks and acknowledging understanding, the resident lit a cigarette while wearing oxygen therapy via nasal cannula in the designated smoking area. This resulted in the oxygen igniting and setting the resident on fire, causing severe burns and ultimately leading to the resident's death from smoke inhalation and thermal burns. The incident occurred when a State tested Nurse Aide observed a flash of light from the smoking area and found the resident on fire. The aide disconnected the oxygen tubing and extinguished the fire, but the resident had already sustained significant injuries. Emergency services were called, and the resident was transported to a burn hospital, where they passed away approximately eight hours later. The facility had identified other residents who smoked and used oxygen, but the resident involved in the incident was not adequately supervised despite their known history and the facility's smoking policies. The facility's smoking policy prohibited oxygen use in smoking areas and required residents who smoke and use oxygen to be supervised. However, the resident's care plan allowed for unsupervised smoking, and the facility's assessments did not consistently reflect the need for supervision. The facility was aware of the resident's history of smoking with oxygen on but did not take sufficient action to prevent the incident, resulting in Immediate Jeopardy and serious life-threatening harm.
Removal Plan
- Facility staff witnessed Resident #75's oxygen ignite while smoking in the facility smoking area, extinguished the fire and called for emergency services.
- The Interdisciplinary Team (IDT) met and reviewed the facility smoking policy and discussed a possible smoking area closure, but no changes were made.
- An SRI was submitted to the Ohio Department of Health.
- The Administrator individually met with 15 alert and oriented residents who smoke, and provided education on the smoking policy and safety, including with oxygen.
- The Administrator met with families of residents in the smoking area to educate them on the smoking policy and safety.
- The DON and Nursing Facility Registered Nurse (NFRN) #7000 completed smoking assessments on all residents who smoke. Care plans were reviewed on all residents who smoke. The care plans for Residents #17, #26 and #75 were updated to be supervised smokers, and all Kardex's were updated.
- The facility smoking assessment form was revised to reflect residents who smoke and utilize oxygen will require supervision for smoking and retired the previous smoking assessment utilized by the facility.
- Nursing supervisors were notified and educated of the change to the smoking assessment form by the DON and nursing education on the new assessment was initiated.
- The occupational therapy (OT) department evaluated all smokers for dexterity and speech therapy (ST), in conjunction with nursing, evaluated all smokers for cognition. The results of these evaluations were reviewed by the DON and NFRN #7000 and no changes in care plans were needed.
- All residents were notified of the smoking area time changes via a letter from the Administrator.
- Facility staff were notified via the mass messaging application GreyMAR by the Administrator. This message stated, Effective immediately, the smoking area outside 1 South will be closed from 11p-6a to everyone.
- The smoking policy, safety of not smoking with oxygen, and updated smoke area times are discussed in the Resident Council Meeting by Director of Activities #31.
- The Administrator educated independent smokers on the closure of the smoking area from 11:00 P.M. to 6:00 A.M. for supervised smokers.
- The DON placed the facility's updated smoking safety education on Clipboard (a website education platform utilized by agency staff).
- The facility began audits to monitor smoking safety that will be conducted two times per shift, four times per week, for four weeks. After that time, the audits will continue one time per shift, four times per week, for four weeks. After that time, audits will continue one time per shift, three times per week, for four weeks. After that time, audits will continue monthly for three months.
- The facility finalized updating the facility smoking policy as well as updated the facility handbook to reflect smoking changes along with the updated policy.
- The activities department ensured all residents were provided with copies of the new handbook and received their signatures.
- The Administrator provided staff education on the updated smoking policy to staff via the GreyMAR messaging system.
- The DON placed the facilities updated smoking safety education on Clipboard (a website education platform utilized by agency staff).
Facility's Financial Mismanagement Leads to Overdue Payments
Penalty
Summary
The facility failed to manage its financial obligations effectively, resulting in overdue payments to essential service providers. The electric service provider issued disconnection notices due to unpaid bills, with significant amounts past due. Despite attempts to negotiate payment plans, the facility had not made payments in several months, risking service disconnection. This situation was confirmed by interviews with the facility's administrator and the electric provider's customer service agent. Additionally, the facility's medical equipment supplier and fire protection service company also reported overdue payments, with the facility entering into payment agreements to address these debts. The deficiency had the potential to affect all 73 residents, including eight who were ventilator-dependent and relied on electricity for life support. The administrator acknowledged that payments were paused to allocate funds for facility repairs and updates, leading to the financial shortfall. The report highlights the facility's inability to pay its bills on time, which could have serious implications for resident care and safety.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 285 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Green Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Majestic Care Of Clyde | 5 mi | ★★★★★ | 6 | 0 |
| Countryside Manor Nursing And Rehabilitation Llc | 7 mi | ★★★★★ | 26 | 1 |
| Valley View Health Campus | 7.3 mi | ★★★★★ | 0 | 0 |
| Bethesda Care Center | 8 mi | ★★★★★ | 18 | 0 |
| Elmwood Assisted Living & Skilled Nursing Of Fremo | 8 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 October 2026) and official state health department websites.