8 Reports
Inspection Report — Nov 29, 2024
Complaint Investigation
Date: Nov 29, 2024
Visit Reason
Complaint inspection conducted to investigate reported issues at Spring Creek Inn Memory Care Community.
Complaint Details
The complaint involved inadequate personal care services including delayed treatment for a urinary tract infection and failure to notify the correct provider, which led to worsening health and death of a resident.
Findings
One deficiency was cited involving personal care services where delayed treatment and inadequate provider notification contributed to a resident's decline and subsequent death.
Deficiencies (1)
37.106.2843-2 Personal care services: delayed reapplication of compression boots and antibiotic treatment occurred, and the resident did not have a UTI antibiotic order due to wrong provider notification, contributing to the resident's decline and death.
Inspection Report — Apr 14, 2023
Original Licensing
Date: Apr 14, 2023
Visit Reason
The inspection was conducted as a provisional status inspection for licensing purposes.
Findings
Two deficiencies were found: the disaster plan's last updated off-site evacuation agreement was outdated, and the facility did not maintain temperature logs for fridges and freezers.
Deficiencies (2)
37.106.322-3 Minimum standards for all health care facilities: the disaster plan's last updated written agreement for an off-site evacuation point was from 10/28/21 and is outdated.
37.106.2860-9 Food service: the facility has not maintained temperature logs for any of the fridges and freezers.
Inspection Report — Oct 26, 2022
Complaint Investigation
Date: Oct 26, 2022
Visit Reason
The complaint inspection was conducted due to concerns about resident care and facility conditions.
Complaint Details
The complaint inspection cited deficiencies related to poor facility cleanliness, inadequate staffing response, insufficient personal care, improper oxygen use, and housekeeping training issues.
Findings
The inspection found multiple deficiencies including unclean resident rooms, lack of response to call systems, poor personal care and hygiene of residents, improper oxygen use, unmade beds, and inadequate housekeeping training.
Deficiencies (8)
37.106.320-2 Minimum standards for all health care facilities: resident rooms were not regularly vacuumed, beds were unmade, and bathrooms were dirty.
37.106.2816-6 Assisted living facility staffing: no response to activated call system in residents' shared room within 10 minutes.
37.106.2843-1 Personal care services: many residents had greasy hair, stained clothing, and were observed walking without shoes or socks; scheduled showers were not provided due to staffing issues; persistent urine and bowel movement odors were present in common areas.
37.106.2853-2 Oxygen use: a resident's portable oxygen tank was set to zero despite orders for continuous use at 2 liters per minute.
37.106.2853-3 Oxygen use: staff was unable to turn on a resident's portable oxygen without surveyor assistance due to a stripped oxygen key.
37.106.2853-4 Oxygen use: residents on as-needed oxygen only had concentrators; backup portable tanks were not located.
37.106.2861-4 Laundry: beds in resident rooms were unmade with sheets stripped and blankets thrown on the floor.
37.106.2862-1 Housekeeping: housekeeping staff were not trained in proper infection control procedures when handling clean and soiled linen.
Report Facts
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Inspection Report — Jul 2, 2019
Complaint Investigation
Date: Jul 2, 2019
Visit Reason
The survey was conducted following a complaint inspection to evaluate the facility's compliance with regulations.
Complaint Details
The complaint inspection cited issues with incident report documentation, staffing levels, resident room security, and facility furnishings.
Findings
The facility showed deficiencies in administrator oversight of incident reports, inadequate staffing to meet resident needs, unsecured resident room access, and insufficient furnishings such as privacy screens for semi-private rooms.
Deficiencies (4)
37.106.2814-12 Administrator: incident reports lacked documentation of corrective actions to prevent falls and recent reports were not reviewed by the administrator.
37.106.2816-6 Assisted living facility staffing: staffing was insufficient as evidenced by delayed responses to call lights and communication indicating only one staff member was on the floor during lunch.
37.106.2835-2 Resident units: resident room doors were locked without assessment or documentation of residents' ability to use keys, causing residents to be locked out and requiring staff assistance.
37.106.2836-1 Furnishings: the facility had only two privacy screens available for 26 semi-private rooms, which is inadequate.
Report Facts
incident_reports_reviewed: 52
incident_reports_recent: 15
falls_june_2019: 50
falls_may_2019: 61
falls_april_2019: 26
falls_march_2019: 45
residents_with_incontinency: 39
total_residents_reviewed: 62
semi_private_rooms: 26
privacy_screens_available: 2
Inspection Report — Feb 17, 2017
Complaint Investigation
Date: Feb 17, 2017
Visit Reason
The complaint inspection was conducted following concerns about inappropriate sexual interactions between residents and the facility's handling of discharge procedures.
Complaint Details
The complaint involved concerns about sexual interactions between residents and the facility's response, including discharge procedures and respect for residents' rights.
Findings
The facility failed to provide adequate justification for the discharge of Resident #1 and did not respect the privacy and decision-making rights of residents involved in sexual interactions. Documentation and family communications showed misunderstandings and inadequate responses to the incidents.
Deficiencies (2)
37.106.2824-1 Involuntary discharge criteria: the facility issued a 30-day discharge notice to Resident #1 without adequate reason, despite limited incidents and no evidence of repeated interference with other residents' rights or safety.
37.106.2843-2 Personal care services: the facility failed to grant privacy and decision-making rights to Resident #1 and Resident #3 regarding their personal relationships, despite no indication of injury or health problems.
Report Facts
date: Feb 17, 2017
date: Feb 27, 2017
date: Jan 13, 2017
integer: 30
Inspection Report — Oct 18, 2016
Renewal
Date: Oct 18, 2016
Visit Reason
The survey was conducted as a renewal inspection of the facility.
Findings
Two deficiencies were found related to staffing and health care plans. The staffing documents referenced incorrect state regulations, and some health care plans were not dated or timely completed.
Deficiencies (2)
37.106.2816-3 Assisted living facility staffing: the facility's staffing documents referenced Washington State regulations instead of Montana regulations.
37.106.2895-1 Health care plan: category C: several residents' health care plans were not dated, making it unclear if they were completed within 21 days of admission.
Inspection Report — Oct 23, 2014
Complaint Investigation
Date: Oct 23, 2014
Visit Reason
The survey was conducted following a complaint investigation regarding incidents involving two residents.
Complaint Details
The complaint investigation focused on incidents involving inappropriate contact between two residents and the facility's handling of incident reports and documentation.
Findings
Two deficiencies were found related to incident reporting and resident file documentation. The facility failed to document administrator review of incident reports and lacked proper notification and family contact documentation regarding inappropriate contact between two residents.
Deficiencies (2)
37.106.2814-12 Administrator: the incident reports regarding two residents were not documented as reviewed by the facility administrator.
37.106.2829-2 Resident file: documentation lacked provider notification and response, as well as family contact regarding inappropriate contact between two residents.
Inspection Report — Oct 23, 2014
Renewal
Date: Oct 23, 2014
Visit Reason
The survey was conducted as a renewal inspection of the assisted living facility.
Findings
Two deficiencies were found related to resident health care plans and medication records. Health care plans were not documented as reviewed quarterly, and medication administration records lacked reasons for scheduled medication use.
Deficiencies (2)
50-5-226-3 Placement in assisted living facilities: there is no documentation indicating that the health care plans for any residents are reviewed quarterly.
37.106.2849-2 Medications, records and documentation: medication administration records do not include the reason for use for scheduled medications.
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