Spring Creek Healthcare Center

Based on observation, interview, and document review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe consistent manner. This deficient practice was evidenced by the following: On 04/09/2025 from 9:59 AM until 10:37 AM the surveyor, who was accompanied by the Director of the Kitchen (DOK), observed the following in the kitchen: 1. In the first refrigerator, there was baked ziti in a metal container covered with clear plastic wrap. It was dated 3/8/25. The DOK said the baked ziti was probably misdated, however she will throw it away. 2. In the first refrigerator there was a loaf of rye bread dated 3/13/25 and a loaf of raisin bread dated 3/24/25. The DOK said the bread is good for 30 days in the refrigerator. On 04/10/2025 at 12:11 PM, the Licensed Nursing Home Administrator clarified that bread is good for 5 to 7 days in the refrigerator and the 2 loaves of bread were discarded. On 04/10/2025 at 11:29 AM, the surveyor, accompanied by the Licensed Practical Nurse (LPN#1), observed the following in the second-floor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and pertinent facility documentation, it was determined that the facility did not maintain the dignity of a resident specifically, by transporting the resident backward in a geriatric chair (specialized, high-backed reclining chair designed to provide comfort, support, and mobility for individuals with limited mobility) down the hallway. This deficiency was identified in 1 of the 36 residents (Resident # 2) reviewed. This deficient practice was evidenced by the following: On 01/13/2025 at 10:15 AM, the surveyor observed Certified Nurse Aide #1, pulling the resident in a geriatric chair backward down the third-floor hallway. During an interview with the surveyor on 04/14/2025 at 11:22 AM, the Licensed Practical Nurse/Unit Manager #1 said that residents should not be pushed backward in their geriatric chairs as it is a dignity concern. During an interview with the surveyor on 04/15/2025 at 10:04 AM, the Director of Nursing said that residents should not be pushed backward in a geriatric chair it is a dignity issue. A review of a facility policy dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain a clean, safe and sanitary environment for 2 of 3 units, the second floor and the third floor. This deficient practice was evidenced by the following: During initial tour on 04/09/2025 at 10:56 AM surveyor #1 observed the wall behind bed 1 in room [ROOM NUMBER], which had two strips of black sticky tape with what appeared to be white foam on them that looked to have been used to anchor an object to the wall. During a room visit on 04/10/2025 in room [ROOM NUMBER], bed 2, surveyor #1 observed broken trim with sharp edges along the center of the wall behind the resident's bed. The resident was unsure of how long the trim had been broken. During an interview on 04/14/2025 at 11:56 AM with surveyor #1, the Maintenance Director (MD) said that rounds on the resident's room were done daily to see if anything was in need of repair. The MD said that he would talk to the residents to see if…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, it was determined that the facility failed to develop and implement a care plan that meets the medical needs identified on the comprehensive assessment care for 1 of 24 residents reviewed for comprehensive care plans, Resident #36. This deficient practice was evidenced by the following: A review of Resident # 36's admissions record revealed that, Resident #36 was admitted with but not limited to Chronic Obstructive Pulmonary Disease (an ongoing lung condition caused by damage to the lungs), and Major Depressive Disorder. There was no order for Atrial Fibrillation (rapid heart rhythm) until brought to the facilities attention by the surveyor. A review of Resident #36's Electronical Medical Record revealed a physician's order with a state date of 08/05/2024 Apixaban (an anticoagulant used to lower the risk of a stroke) 5 milligrams twice a day for Arterial fibrillation. There were no orders to monitor for any signs of bleeding. A review of the current Care Plan (CP) for Resident #36 did not include documentation of a CP focus area or interventions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide respiratory care consistent with professional standards of practice by not storing a nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) mask properly and failed to document the use of oxygen in Electronic Medical Record (EMR) for 1 of 2 residents (Resident #67) reviewed for Respiratory Care. The deficient practice was evidenced by the following: During the initial tour on 04/09/2025 at 10:09AM, Resident #67 was observed sitting in the wheelchair with oxygen in use via a nasal cannula (tubing that delivers oxygen through the nose). The surveyor also observed a nebulizer mask laying open to air on the resident's bed. On 04/10/2025 at 11:29 AM the surveyor observed Resident # 67 in the wheelchair with oxygen in use via nasal cannula. The surveyor also observed a nebulizer mask laying open to air on the resident's bed with a plastic bag next to it. Resident # 67 said he/she uses oxygen everyday when…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY COMPLAINT # NJ168251 Based on interviews, medical record review, and review of other pertinent facility documentation on 10/17/23 and 10/18/23, it was determined that the facility failed to follow their policies and procedures for a facility-initiated discharge. A resident (Resident #3) was involved in an altercation with another resident and was sent to the hospital for a behavioral evaluation. When the resident was discharged from the hospital, the facility would not permit the resident to return to the facility. The deficient practice was identified for Resident #3, 1 of 6 residents reviewed and was evidenced by the following: According to the admission Record, Resident #3 was admitted to the facility on [DATE] with diagnoses which included but were not limited to: Chronic Obstructive Pulmonary Disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe), Cardiomegaly (an enlarged heart), Peripheral Vascular disease (a circulatory condition in which narrowed blood vessels…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and review of facility documentation, it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses, b.) properly wash hands and c.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination. This deficient practice was evidenced by the following: On 03/27/2023 at 9:40 AM, the surveyor toured the kitchen, in the presence of the Regional Food Service Director (RFSD) and the Food Service Director (FSD) and observed the following: The surveyor observed an unlabeled box filled with seven logs of frozen ground beef in the freezer. Upon interviewing the dietary aide (DA), the DA stated the older meat was placed in the same box on top of the newer meat and informed the surveyor that they could tell the difference because the older meat had a darker discoloration. The surveyor asked how they could identify the date that the older or newer meat came in to which neither the DA, RFSD, nor the FSD could…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, it was determined that the facility failed to provide daily delivery of mail, to include Saturdays. This deficient practice was identified for 7 of 7 residents interviewed during the resident council group meeting (Resident #21, #30, #43, #72, #73, #91 and #100), and was evidenced by the following: On 04/03/23 at 10:30 AM, the surveyor attended a resident council group meeting with Residents #21, #30, #43, #72, #73, #91 and #100. The surveyor interviewed the residents regarding mail delivery and all the residents in attendance told the surveyor that mail was only delivered on Mondays and Fridays, with no other days during the week. On 04/04/23 at 11:45 AM, the surveyor interviewed the Activities Director (AD) regarding mail delivery. The AD told the surveyor that the process for the mail was that it gets delivered to the facility, the front desk goes through the mail and hands it over to the business office. From the business office, the mail then goes to the Social Worker (SW) who will go through the mail and the mail then gets placed in a box for the activities…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of medical records and other facility documentation, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS) for 1 of 26 residents reviewed, Resident #54. This deficient practice was evidenced by the following: The surveyor reviewed the admission Record for Resident #54 which reflected that the resident was admitted with diagnoses that included depression and hypertension (high blood pressure). The surveyor reviewed the smoking safety evaluation dated 6/30/22, which indicated that Resident #54 currently smokes. The surveyor reviewed Resident #54's Annual MDS dated [DATE]. The section for current tobacco use was coded as zero (0), indicating that Resident #54 does not currently use tobacco. When interviewed on 4/3/23 at 12:38 PM, the MDS Coordinator stated that Resident #54's Annual MDS dated [DATE] should have been coded as Resident #54 currently using tobacco. When interviewed on 4/4/23 at 11:30 AM, the Director of Nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review it was determined the facility failed to maintain professional standards of clinical practice for 1 of 28 residents reviewed (Resident # 206) by failing to document the transfer of a resident to the hospital following a fall. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The nurse practice act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure expired controlled substance (narcotic) medications were detected, removed, and disposed from the emergency (back-up) supply identified for 1 of 1 back up box. This deficient practice was evidenced by the following: On 4/3/23 at 10:30 AM, the surveyor and the Assistant Director of Nursing (ADON) entered the room that contained the narcotic back up medications which was stored in a locked box in a locked room on the second floor. At 10:34 AM, the surveyor with the ADON began the inspection of the narcotic medications in the back up box. At 10:36 AM, in the presence of the ADON, the surveyor observed five patches of Fentanyl 50 microgram/hour (mcg/hr.; a medication used to relieve the symptom of pain) which reflected a manufacturer expiration date of 8/2022. At that time, the ADON confirmed she observed five Fentanyl 50 mcg/hr. which reflected a manufacturer expiration date of 8/2022. At 10:52 AM, in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication observation performed on 3/31/23, the surveyors observed two (2) nurses administer medication to five (5) residents. There were 28 opportunities, and two (2) errors were observed, which calculated to a medication administration error rate of 7.14%. This deficient practice was identified for 2 of 5 residents (Unsampled Resident #1, and Unsampled Resident #2) that were administered medications by 1 of 2 nurses. The deficient practice was evidenced by the following: On 3/31/23 at 8:21 AM, during the medication administration observation, the surveyor observed breakfast meal trays being collected from resident rooms, indicating breakfast had been served and consumed. The Licensed Practical Nurse (LPN) informed the surveyor at this time that Unsampled Resident #1 had already eaten breakfast. The surveyor observed the LPN as she prepared 11 medications for Unsampled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.