Spring Creek Rehabilitation & Nursing Care Center received 33 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 21, 2019. Those citations number one more than the statewide average of 32. The Brooklyn nursing home’s citations resulted from a total of four inspections by state surveyors. The deficiencies they describe include the following:
1. The nursing home did not implement proper measures to treat, heal, and prevent pressure ulcers and bedsores. Section 483.25(c) of the Federal Code stipulates that nursing home facilities must ensure that residents who enter without pressure sores do not develop them unless their condition renders such unavoidable; and that residents with existing pressure sores receive proper treatment and services. A September 2018 citation found that Spring Creek Rehabilitation and Nursing Care Center failed to comply with this requirement in connection to one resident observed by a state inspector. That resident was specifically observed on numerous instances not wearing the protective heel device ordered by his physician and documented in his comprehensive care plan. The citation notes that the resident had a stage 3 pressure ulcer on his right heel, and as such was required to wear a pressure-relieving device or devices as appropriate. However, the resident was observed on multiple instances without the necessary devices, and the inspector states that “there were no skin checks or dressing changes occurring” at the instances in question. In an interview, a Certified Nursing Assistant said that “sometimes she forgets” to apply the resident’s protective devices and returns later to apply them.
2. The nursing home did not employ adequate measures to prevent and control infection. Under Section 483.80 of the Federal Code, nursing home facilities must “establish and maintain an infection prevention and control program” that creates a “safe, sanitary and comfortable environment.” A September 2018 citation states that the nursing home did not ensure such an environment, specifically by failing to clean or properly maintain “multiple areas in the laundry room.” An inspector observed that the room in question was not “in good repair or condition,” specifically noting that the walls contained chipped paint, that a drain behind a washing machine was dirty, that the drain was “littered with paper,” and that there was a presence of “brown colored” and stagnant water. The inspector also observed a clogged water drain, dust and water built up on the floor beside a washing machine, a sink with a dirty handle, and brown streaks on a washing machine and dryer. In an interview, the facility’s Director of Nursing stated that “she did not know why the laundry room was in such a condition.”