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 October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Spring Creek Healthcare Center during CMS and state inspections, most recent first.
Two residents receiving insulin did not have ordered blood glucose checks completed, including missed checks when one resident was sleeping and a documented shortage of test strips. One resident with type 2 DM had multiple missed BG checks and no documentation that the provider was contacted when BG exceeded the ordered threshold, while another resident with type 2 DM, CHF, chronic respiratory failure, and obesity also had missed q4h BG checks and no provider notification documented for BG readings over 400 mg/dL.
Sewage flooded the second-floor hallway, resident rooms, and bathrooms, with wastewater also leaking into a first-floor office. Video and interviews showed staff laying towels and sheets across the corridor to soak up the sewage while confused residents and wheelchair users moved through the contaminated water, and one resident reported sewage backing up from toilets and shower drains with urine and feces in the water.
Failure to maintain the sewer line and sanitary environment resulted in raw sewage backing up through toilets and shower drains into resident rooms and hallways, with wastewater also leaking into an office area. Residents reported repeated clogs, the building water supply was shut off for hours, and staff confirmed corroded piping, flushed wipes, and that no medical or clinical assessments were completed after residents were exposed to sewage and fumes.
A resident with type 2 DM, CHF, chronic respiratory failure, and obesity did not receive a prescribed daily Tradjenta 5 mg dose as ordered. The MAR documented the medication was out of stock on one occasion and not in stock on another, while the DON stated the pharmacy had received the prescription and the medication should have been available for administration; staff also described standard processes for reordering and obtaining medications when supply is low or unavailable.
Failure to supervise a resident at risk for elopement: A resident with hemiplegia, altered mental status, and schizophrenia was assessed as unsafe to leave unsupervised due to exit-seeking behavior, poor compliance with safety instructions, and lack of awareness of safety concerns. Staff later found the resident outside the facility after a CNA saw her on the sidewalk, and records show she eloped, was located hours later, returned refusing assessment, and was sent for an emergency involuntary psych commitment.
A resident with DM2 and multiple chronic conditions had an order for daily insulin glargine, but an RN documented that the dose was not given because the medication was unavailable. An LPN stated staff should reorder meds when five doses remain and, if out, notify the provider and pharmacy and use the emergency medication supply system; an RN and the DON confirmed backup insulin was available in a lockbox, and the DON noted there was no documentation explaining the omission.
Several residents did not have comprehensive, updated care plans reflecting their current needs, including one who required two-person assist for ADLs after a fall, another with repeated public disrobing behaviors not addressed in the care plan, a resident lacking an activities assessment and care plan despite documented interests, and a resident with multiple falls whose care plan was not revised with new interventions. Staff interviews revealed inconsistent communication and documentation of care needs, and required assessments and updates were not completed.
Three residents experienced preventable accidents due to lapses in supervision and failure to implement or communicate appropriate safety interventions. Two residents fell during repositioning or care due to unclear or insufficient staffing instructions, and another resident set his hair on fire after obtaining a lighter from another resident, despite being on a supervised smoking schedule. Staff interviews and documentation revealed inconsistent communication and incomplete care planning regarding safety needs.
Multiple failures in infection prevention and control were observed, including staff touching medications with bare or gloved hands, lack of Enhanced Barrier Precautions (EBP) signage and PPE for residents with indwelling devices, and absence of contact precautions for a resident with a MRSA-infected wound. Staff were unaware of required precautions, did not consistently use appropriate PPE, and disposed of used PPE improperly, all contrary to facility policy.
A resident receiving NG tube feeding for nutrition did not have the formula bag labeled with the required nurse initials or rate of infusion, and the water flush was also unlabeled. The RN administering the feed included only partial information on the label, which did not meet facility policy or professional standards for enteral feeding documentation.
Two residents did not receive appropriate care to prevent UTIs and manage incontinence, including a lack of follow-up on a urinalysis for one resident and improper positioning of a urinary catheter bag above the bladder for another. Staff interviews and observations confirmed lapses in both documentation and catheter care practices.
A resident with multiple medical conditions receiving enteral nutrition via NG tube was given water flushes in excess of the physician's order during medication administration. The RN administered a total of 140 ml of water flushes, exceeding the prescribed 20-30 ml before and after medications, and did not check tube placement as required. The resident experienced discomfort and respiratory symptoms during the process, and the DON confirmed that the nurse should have followed the physician's specific flush order.
A resident with a PICC line did not have physician orders for IV fluids, flushes, or dressing changes, and there was no documentation supporting the continued use of the line. The PICC line was not being flushed daily, and staff were unaware of its required maintenance, resulting in a lack of adherence to professional standards for parenteral fluid administration.
A resident with complex medical needs did not receive multiple prescribed medications, including chemotherapy, antipsychotics, an SSRI, an antibiotic, an anticoagulant, and a protein supplement, due to repeated delays in pharmacy delivery and lack of availability. Nursing and administrative staff described a process of faxing and calling the pharmacy for refills, but documentation showed ongoing gaps in medication administration.
A resident with multiple complex conditions was prescribed Risperidone and Sertraline for dementia, which the pharmacist identified as not having labeled indications. Although the pharmacist documented this irregularity and discussed it with psychiatric providers, there was no documentation from the MD in the medical record indicating review or action taken. Interviews with the DON and ADON revealed unclear processes for ensuring MD review and documentation of pharmacy recommendations.
Surveyors found that four opened insulin injector pens for two residents with diabetes were not labeled with open dates in a medication cart. Both the RN and DON confirmed that insulin should be dated when opened, but the pens were only labeled with resident names and were available for use without the required open date labeling.
Missed Blood Glucose Monitoring for Residents Receiving Insulin
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary drugs by not completing ordered blood glucose monitoring for two residents receiving insulin. One resident with type 2 diabetes mellitus had a physician order for insulin lispro before meals and at bedtime, with blood glucose checks to guide treatment, but the July 2026 MAR documented 25 instances where the resident was sleeping and the blood glucose was not drawn. The MAR also documented that no glucose test strips were in the building on July 28, 2026, and it did not show blood glucose checks at 4:00 PM on July 2, 4, 5, 11, 17, and 18, 2026. The resident stated that the facility had run out of glucose test strips, so staff could not test blood sugar or administer insulin that day. A second resident with type 2 diabetes mellitus and other diagnoses including chronic diastolic heart failure, chronic respiratory failure, and obesity had a physician order for blood sugar checks every 4 hours, with instructions to contact the provider if blood sugar exceeded 400 mg/dL. The May 2026 MAR showed missed blood glucose checks at 12:00 AM on May 13, 12:00 PM on May 15, and 12:00 AM and 4:00 AM on May 16. The MAR and progress notes also did not show that the physician was contacted when blood glucose levels exceeded 400 mg/dL on May 13 at 8:00 PM and May 14 at 4:00 PM. Staff interviews confirmed that sleeping residents were expected to be awakened for ordered blood glucose testing and that the facility should not run out of strips or insulin.
Sewage Flood Exposed Residents to Contaminated Water
Penalty
Summary
The facility failed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections when a sewage flood occurred on the second floor. Video reviewed by the surveyor showed standing sewage water covering portions of the second-floor hallway, wet bath towels and bedsheets laid across the corridor to soak up wastewater, water flooding both sides of the hallway, and sewage leaking through the first-floor ceiling into an administrative office. During interviews, staff stated the flooding affected resident rooms, bathrooms, and the hallway, and that some confused residents were seen walking through the contaminated sewage water in the hallway and their rooms wearing only socks. One resident stated that sewage water containing urine and feces backed up through toilets and shower drains, ran down the second-floor hallway and into resident rooms on both sides of the corridor, and that residents in wheelchairs or wearing socks traversed the contaminated water to go outside because of the odor. Another resident stated that sewage flooded out of the bathrooms into resident rooms and the main hallway, and that staff placed sheets and towels across the hallway floor to soak up the water while the resident had to drive a wheelchair directly through the flooded sewage water to go outside. The Maintenance Director stated residents were instructed to stay in their rooms, but some chose not to due to the smell, and observed residents wheeling their wheelchairs through the sewage water and then touching their faces.
Failure to Maintain Sewer Line and Sanitary Conditions
Penalty
Summary
The facility failed to provide housekeeping and maintenance services necessary for a safe, functional, sanitary, and comfortable environment when the main sewer plumbing line backed up and raw sewage containing urine and feces entered resident rooms and corridors. Surveyors observed that the flooding extended through the second-floor hallway, with wet bath towels and bedsheets used to soak up wastewater, and that the sewage also leaked through the first-floor ceiling into an administrative office. Stained ceiling tiles were later observed in a resident room, and a resident reported that a prior clogged toilet had caused the damage about six months earlier. Residents 2, 6, and 7 reported that sewage water backed up through toilets and shower drains, flooding the hallway and their rooms, and that the building water supply was shut off for several hours after the incident. Resident 6 also reported another clog the following week. Maintenance staff stated the main sewer drain backed up because of corroded cast-iron piping and flushed wipes, and confirmed that sewage entered resident rooms and that residents in wheelchairs traveled through the contaminated water. The Administrator confirmed the sewer line backed up due to pipe separation and flushed wipes, that staff tried to divert traffic and kept unaffected residents in their rooms, and that no medical or clinical assessments were conducted on residents after exposure to the sewage and fumes.
Missed Antidiabetic Medication Doses
Penalty
Summary
The facility failed to ensure that Resident 4 received a prescribed antidiabetic medication in accordance with the physician’s order, the comprehensive person-centered care plan, and the resident’s choices. Resident 4 was admitted with diagnoses including type 2 diabetes mellitus, chronic diastolic heart failure, chronic respiratory failure, and obesity. A physician order initiated on 2/2/26 directed staff to administer Tradjenta 5 mg by mouth once daily. The medical record documented that on 5/9/26 the medication could not be administered because it was out of stock and had been reordered, and on 5/11/26 it again could not be administered because it was not in stock. During interviews, an LPN stated residents should not run out of medications and that medications are reordered through the eMAR when five pills remain; if a medication is completely out of stock, staff must notify the provider and pharmacy immediately. An RN stated that if a medication is in the emergency medication supply system, staff retrieve it from there, and if not, staff write it down, obtain it from the pharmacy, and contact the pharmacy. The DON stated Tradjenta was not in the emergency medication supply system and had to be ordered directly from the pharmacy, and that the pharmacy received Resident 4’s prescription on 5/9/26, meaning the medication was in stock at the facility and should have been administered on 5/9/26 and 5/11/26. The DON stated it was unknown why staff did not administer the medication on 5/9/26 after it was received, or why the dose was given on 5/10/26 but omitted again on 5/11/26.
Failure to Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to ensure that a resident assessed as unsafe to leave the facility unsupervised was supervised to prevent elopement. Resident 1 was admitted with diagnoses including hemiplegia, altered mental status, and schizophrenia. A Community Risk Assessment dated 9/11/2025 documented that the resident did not know the facility address or phone number, was unaware of basic traffic laws, and lacked awareness of surroundings and safety concerns. An Elopement Risk Assessment identified the resident as at-risk due to exit-seeking behaviors, poor compliance with safety instructions, and non-cooperation with safety plans. A nursing note documented that a CNA saw Resident 1 operating her wheelchair on the sidewalk at about 6:40 AM, and staff then searched for the resident and notified the DON, Administrator, and police. A facility investigation documented that Staff 1 responded to an outside kitchen alarm and found Resident 1 at the door; the resident stated she had signed papers to leave and went outside, after which Staff 1 sought help from other staff. Another nursing note documented that the resident later returned by van, refused assessment, and was sent to the hospital for an emergency involuntary psychiatric commitment. A certification for emergency commitment documented that the resident eloped around 6:50 AM and was located around 3:40 PM, and she returned with altered mental status, hallucinations, dehydration, and refusal of all care.
Missed Insulin Dose Due to Medication Unavailability
Penalty
Summary
A resident with type 2 diabetes mellitus, chronic diastolic heart failure, chronic respiratory failure, and obesity had a physician order for Insulin Glargine Solostar 300 units/mL, 50 units subcutaneously once daily. On 3/20/26 at 11:19 AM, an RN documented that the insulin was not administered because the medication was unavailable. During interviews on 7/30/26, an LPN stated that medications should be reordered through the eMAR when five doses remain and that if a medication is completely out, staff must immediately notify the provider and pharmacy and use the emergency medication supply system. An RN confirmed that backup insulin was available in a lockbox in the third-floor refrigerator and that staff should not run out of insulin. The DON also confirmed the backup insulin location and the pharmacy restocking alert system, and stated there was no documentation in the progress notes or TAR explaining the omission; because she was not employed at the facility at the time, the exact reason for the unavailable medication and omitted dose remained unknown.
Failure to Develop and Update Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for several residents, as required by regulation. For one resident with multiple complex diagnoses including hemiplegia, morbid obesity, and schizoaffective disorder, the care plan and Kardex did not reflect the need for two-person assistance with activities of daily living (ADLs), specifically during incontinence care. This omission persisted despite a witnessed fall during a brief change, which resulted in injury and required paramedic assistance. Staff interviews revealed inconsistent understanding and communication of the resident's care needs, and the care plan was not updated to include the necessary interventions following the incident. Another resident with severe intellectual disabilities and behavioral health diagnoses exhibited repeated episodes of disrobing in public areas. Despite frequent observations of this behavior and staff acknowledgment that it was a recurring issue, there was no care plan or documented interventions addressing this specific behavior. The resident's care plans focused on other behavioral and mental health concerns but failed to include strategies or monitoring for public disrobing, and staff responses were limited to redirection without formalized guidance. A third resident, with a history of traumatic brain injury and psychiatric conditions, expressed boredom and lack of engagement in activities. The resident's records indicated interests in art and music, but there was no care plan focus area for activities, and the required assessment had not been completed. Additionally, another resident with a history of falls did not have new interventions added to the care plan after multiple fall incidents, despite documentation of the events and staff recognition of the resident's high fall risk. In each case, the facility did not ensure that care plans were updated to reflect the residents' current needs and risks as identified through assessment and incident review.
Failure to Prevent Accidents and Ensure Resident Safety
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and that residents received adequate supervision and assistance devices to prevent accidents. For one resident with multiple diagnoses including morbid obesity, hemiplegia, and blindness in one eye, a fall occurred during incontinence care when only one CNA was present, despite documentation and staff interviews indicating that two staff were needed for such care. The resident's care plan and Kardex did not clearly specify the required level of assistance, and staff were inconsistent in their understanding and implementation of the necessary precautions. The incident resulted in the resident falling from the bed and sustaining bruises, with emergency personnel required to assist in returning the resident to bed. Another resident with cerebral infarction, status epilepticus, and lack of coordination experienced a fall during a bed change when the aide rolled the resident and he continued to roll off the bed, hitting a cabinet and sustaining a red area on his cheek. The care plan for this resident did not include new interventions after the fall, and staff interviews revealed that the Kardex was not updated with current safety or fall interventions. Staff relied on frequent checks and lowering the bed as fall prevention measures, but there was a lack of clear, updated documentation and communication regarding individualized fall prevention strategies. A third resident with dementia and nicotine dependence was able to obtain a lighter from another resident and set his hair on fire, despite being on a supervised smoking schedule and not being deemed independent with smoking. Facility policy required all smoking paraphernalia to be kept secured and only accessible during supervised smoking times, but the event occurred when the resident was unsupervised in his room. Staff interviews and documentation confirmed that the lighter was supposed to be secured, and the resident was not to have access to it, yet the incident still occurred, indicating a lapse in supervision and enforcement of safety protocols.
Failure to Implement Effective Infection Control and Precaution Protocols
Penalty
Summary
The facility failed to establish and implement an effective infection prevention and control program, as evidenced by multiple observed deficiencies in infection control practices. A nurse was observed preparing and administering medications using bare hands and gloved hands to touch pills, including picking up a tablet that had fallen onto the medication cart and administering it to a resident. The medication cart was not sanitized during the medication administration process, contrary to facility expectations. The DON confirmed that staff are not permitted to touch medications with bare hands and that any medication that becomes dirty must be discarded. Several residents with indwelling medical devices, such as PICC lines, urinary catheters, and feeding tubes, did not have Enhanced Barrier Precautions (EBP) signage posted on their doors, nor was personal protective equipment (PPE) such as gloves, gowns, and masks readily available inside or outside their rooms. Staff were unaware of the need for EBP for these residents, and in some cases, were not aware of the presence of indwelling devices. Observations revealed that staff did not consistently don appropriate PPE when providing care to residents with these devices, and EBP protocols were not followed as outlined in facility policy. A resident with a chronic wound infected with MRSA did not have contact precautions signage posted, and the PPE cart outside the room was inadequately stocked, lacking gloves and gowns. Staff and contracted wound care providers were observed entering the room without proper PPE, and used PPE was disposed of in a shared bathroom garbage rather than in a designated receptacle inside the resident's room. Additionally, improper technique was observed in the sanitization of a PICC line port prior to use. These failures were confirmed through interviews with nursing staff, the infection preventionist, and review of facility policies, which require clear signage, proper PPE availability, and adherence to EBP and contact precautions for residents with indwelling devices or infections.
Failure to Properly Label Enteral Feeding Formula Bag
Penalty
Summary
A deficiency was identified when a resident receiving enteral nutrition via a nasogastric (NG) tube did not have the formula bag properly labeled according to professional standards and facility policy. The resident, who had chronic obstructive pulmonary disease, congestive heart failure, and pneumonia, was observed to have a tube feed administered by an RN. The label on the formula bag included the resident's name, formula type, room number, and date, but did not include the nurse's initials or the rate of infusion. Additionally, the water flush was not labeled. The resident's care plan required adherence to physician orders for tube feeding and monitoring for aspiration, and the physician had ordered a specific enteral feed and water flush regimen. Facility policy required that the enteral feeding label include the nurse's initials, date and time the formula was hung, and verification against the order, as well as the rate of administration. National nursing procedures also specify that the label should include patient identifiers, formula name, date and time of preparation, administration route, rate, duration, initials of the preparer, and other key details. The Director of Nursing confirmed that the label should include the date, time, and nurse's initials, and was uncertain if the rate and formula type were required per policy. The observed failure to fully label the formula bag and water flush did not meet these professional standards.
Deficient Catheter Care and Inadequate UTI Prevention
Penalty
Summary
Two residents were identified as not receiving appropriate care related to bladder incontinence and urinary catheter management. One resident, with a history of vascular dementia, muscle weakness, and recurrent urinary tract infections (UTIs), was always incontinent of bowel and bladder and required extensive assistance with toileting. Despite a care plan to monitor for signs and symptoms of infection and to report abnormal laboratory values, there was a lack of documented follow-up after a urinalysis (UA) was ordered and collected. The medical record did not contain the UA results, and there was a delay in identifying and treating a UTI, as evidenced by the eventual initiation of antibiotic therapy following a positive culture for pathogens. Another resident, admitted with acute kidney failure, hypertension, sepsis, and urinary retention, was observed with a urinary catheter collection bag positioned above the level of the bladder on multiple occasions. The urine in the catheter tubing was noted to be dark amber with sediment. Staff interviews confirmed that the catheter bag should be positioned below the bladder to allow for proper drainage and to prevent backflow, but observations showed the bag placed on a wheelchair seat or attached to the head of the bed, both above the bladder level. Staff acknowledged that improper positioning could lead to complications, including infection. The facility's staff described procedures for lab order processing, specimen collection, and catheter care, but inconsistencies in documentation and practice were evident. There was a lack of timely follow-up on lab results and improper catheter bag positioning, both of which contributed to the failure to provide appropriate care to prevent UTIs and restore continence to the extent possible for the affected residents.
Excessive Water Flushes Administered via NG Tube
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease, congestive heart failure, and pneumonia, who was receiving nutrition via a nasogastric (NG) tube, was administered water flushes that exceeded the physician's ordered amount. The physician's order specified 20 to 30 milliliters (ml) of water before and after medication administration. However, during a medication pass, the registered nurse (RN) administered a total of 140 ml of water flushes and 140 ml of medication mixed with water, surpassing the ordered parameters. The RN did not check NG tube placement by aspirating for color and volume prior to administering the medication, as stated in her interview. During the medication administration, the resident was observed lying flat in bed, complained of heartburn, and experienced difficulty breathing and shortness of breath, requesting the head of the bed be lowered. The Director of Nursing (DON) confirmed that the water flush amount should be determined strictly by the physician's order and that exceeding the ordered flush volume was not within the nurse's discretion. The DON also stated that administering more than the ordered amount could increase the risk of aspiration, and that nurses should monitor for signs and symptoms of aspiration.
Failure to Ensure Safe and Appropriate PICC Line Management
Penalty
Summary
A deficiency occurred when a resident with a peripherally inserted central catheter (PICC) line did not have physician orders for intravenous (IV) fluids, flushes, or dressing changes, nor was there documentation indicating the continued need for the PICC line. The resident, who had diagnoses including enterocolitis due to clostridium difficile, hereditary and idiopathic neuropathy, respiratory failure, and congestive heart failure, was observed with a locked PICC line that had not been used for medication administration since the completion of IV antibiotics and fluids. The dressing on the PICC line was dated nearly two weeks prior to the observation, and the resident reported that the line was not being flushed daily. Record review confirmed the absence of current physician orders for PICC line maintenance, including flushes and dressing changes, and no comprehensive care plan addressing the PICC line was found. Interviews with nursing staff revealed a lack of awareness regarding the need for ongoing PICC line care, with one medication technician unaware of the line's presence and no orders for flushes visible in the medical record. Nursing management acknowledged that orders for flushes and dressing changes should have been in place and that the necessity of the PICC line should have been reassessed with the physician after the last IV medication was administered.
Failure to Provide Timely Routine and Emergency Medications
Penalty
Summary
The facility failed to provide routine and emergency medications to a resident with multiple complex medical conditions, including malignant neoplasm of the right breast, severe dementia, delusional disorders, urinary tract infections, repeated falls, dysphagia, and unsteadiness. The resident was prescribed several critical medications, such as hormone-based chemotherapy (anastrozole), antipsychotics (aripiprazole, risperidone), a selective serotonin reuptake inhibitor (sertraline), an antibiotic (cephalexin), an anticoagulant (Eliquis), and a liquid protein supplement (Pro Stat). Documentation in the resident's medical record repeatedly noted that these medications were pending delivery or not available for administration over an extended period. Nursing staff and leadership interviews revealed that the process for obtaining medications involved faxing refill requests to the pharmacy when there were about seven days of medication left, followed by a phone call if the medications were not received. Staff reported that the pharmacy typically delivered medications within a day or two of the request, but there were instances where medication refills were missed. The emergency medication system was described as being stocked with basic medications, including pain medications and antibiotics, but not all required medications were available through this system. The liquid protein supplement was ordered separately through a medical supply store, with central supply staff responsible for ordering and stocking. Despite these procedures, the resident experienced multiple documented instances where prescribed medications were not available for administration due to pending delivery or lack of stock. The facility's processes for medication ordering, follow-up, and emergency supply did not ensure that the resident consistently received all prescribed medications as ordered.
Failure to Ensure Physician Review and Documentation of Pharmacy-Identified Drug Regimen Irregularities
Penalty
Summary
The facility failed to ensure that the pharmacist's identified irregularities in a resident's drug regimen were properly reported and acted upon by the attending physician, Medical Director (MD), and Director of Nursing (DON). Specifically, for one resident with multiple complex diagnoses including malignant neoplasm of the breast, severe dementia, delusional disorders, and repeated falls, the pharmacist noted that the resident was prescribed Risperidone and Sertraline for dementia, which are not labeled indications for these medications. The pharmacist documented the irregularity and discussed it with psychiatric providers, concluding that the benefits of treatment outweighed the risks and that no recommendations were needed at that time. However, there was no documentation in the resident's medical record from the MD indicating that the identified irregularity had been reviewed or what action, if any, had been taken to address it. Interviews with the DON and ADON revealed that pharmacist recommendations were typically sent via email and that the process for ensuring MD review and documentation was unclear. The pharmacist confirmed that she conducted monthly reviews and had identified the lack of appropriate diagnosis for the prescribed medications, but the required follow-up and documentation by the MD was not present in the resident's record.
Insulin Pens Not Labeled with Open Dates
Penalty
Summary
Surveyors observed that the facility failed to ensure that drugs and biologicals, specifically insulin injector pens, were labeled in accordance with accepted professional principles. During an inspection of a medication cart on the third floor East hallway, four opened insulin injector pens were found without open dates, making it unclear when they had been started. The Registered Nurse present confirmed that insulin should be dated when removed from refrigeration and acknowledged that the pens were not labeled with open dates, although they were labeled with resident names. The Director of Nursing also confirmed that staff are expected to date insulin upon opening and that insulin is considered good for 28 days after opening. This deficiency was identified for two residents who had been admitted with diagnoses including type 2 diabetes mellitus, diabetic neuropathy, and long-term use of insulin. The specific insulin pens involved included Basaglar KwikPen Solution, Humalog Solution, Insulin Glargineyfgn Solution, and Insulin Lispro-aabc Injection Solution. All four pens were available for use in the medication cart without the required open date labeling.
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.
Illustrative
What surveyors actually found near you
We read the 181 citations issued within 25 miles in the last 12 months — including the 1 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.
Illustrative
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.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Salt Lake City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Highland Care Center | 0.6 mi | ★★★★★ | 1 | 0 |
| Monument Healthcare Cottonwood Creek | 1.1 mi | ★★★★★ | 0 | 0 |
| Holladay Healthcare Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Monument Healthcare Millcreek | 1.1 mi | ★★★★★ | 10 | 0 |
| Monument Healthcare Murray Creek | 2.1 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Spring Creek Healthcare Center.
100% money-back within 48 hours.
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.