Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Nursing And Rehabilitation Center Llc during CMS and state inspections, most recent first.
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.
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.
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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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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 | ★★★★★ | 4 | 0 |
| Countryside Manor Nursing And Rehabilitation Llc | 7 mi | ★★★★★ | 14 | 1 |
| Valley View Health Campus | 7.3 mi | ★★★★★ | 3 | 0 |
| Bethesda Care Center | 8 mi | ★★★★★ | 17 | 0 |
| Elmwood Assisted Living & Skilled Nursing Of Fremo | 8 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.