SPA CREEK CENTER

Nursing Home Inspector

35 MILKSHAKE LANE
ANNAPOLIS, MD 21403
Anne Arundel County
Phone: 410-269-5100
Provider Number: 215258
Last Inspection: 07/13/2017

About the Nursing Home

Number of Beds: 134
Number of Residents: 106
Beds Available: 28
Percent Occupancy: 79%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

18

Facility
26

County
29

MD
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

18

2017
30

2016
9

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

7/13/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Try to resolve each resident's complaints quickly. Isolated : Minimal 3 8/27/2017
 
Failed To: Review or revise the resident's care plan after any major change in physical or mental health. Isolated : Minimal 3 8/27/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Isolated : Minimal 3 8/27/2017
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 8/27/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 8/27/2017
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 8/27/2017
 

8/11/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Pattern : Minimal 4 9/21/2016
 
Failed To: Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. Isolated : Minimal 3 9/21/2016
 
Failed To: Reasonably accommodate the needs and preferences of each resident. Isolated : Minimal 3 9/21/2016
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 9/21/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 9/21/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 9/21/2016
 
Failed To: Dispose of garbage and refuse properly. Pattern : Potential 3 9/21/2016
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 9/21/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 9/21/2016
 

5/21/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Post nurse staffing information/data on a daily basis. Pattern : Potential 3 7/2/2015
 
Failed To: Hire sufficient dietary support personnel. Isolated : Minimal 3 7/2/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Isolated : Minimal 3 7/2/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

8/5/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Pattern : Potential 3 8/20/2015
 

1/20/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 3/6/2015
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 3/6/2015
 
Failed To: Ensure that residents are safe from serious medication errors. Isolated : Minimal 3 3/6/2015
 

12/18/2014 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide housekeeping and maintenance services. Pattern : Potential 3 1/15/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MD State Avg
Number of Residents 106 106.47 107.44
Registered Nurses 1.24 0.90 0.94
Licensed Practical / Vocational Nurses 1.20 0.98 0.87
Certified Nursing Assistants 1.98 2.13 2.35
Total Staff Hours 4.41 4.00 4.16

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% MD State Avg%
of high risk long-stay residents with pressure ulcers 3 5 7
of long-stay residents assessed and appropriately given the pneumococcal vaccine 95 92 94
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 99 94 95
of long-stay residents experiencing one or more falls with major injury 3 2 2
of long-stay residents who have depressive symptoms 0 2 3
of long-stay residents who lose too much weight 8 6 6
of long-stay residents who received an antianxiety or hypnotic medication 6 14 18
of long-stay residents who received an antipsychotic medication 16 13 12
of long-stay residents who self-report moderate to severe pain 5 3 4
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 34 23 21
of long-stay residents whose need for help with daily activities has increased 31 16 17
of long-stay residents with a catheter inserted and left in their bladder 3 1 1
of long-stay residents with a urinary tract infection 8 4 3
of low risk long-stay residents who lose control of their bowels or bladder 51 56 58
of short-stay residents assessed and appropriately given the pneumococcal vaccine 92 85 83
of short-stay residents who had an outpatient emergency department visit 7 9 10
of short-stay residents who made improvements in function 71 64 67
of short-stay residents who newly received an antipsychotic medication 1 1 1
of short-stay residents who self-report moderate to severe pain 29 10 12
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 90 87 82
of short-stay residents who were rehospitalized after a nursing home admission 16 20 20
of short-stay residents who were successfully discharged to the community 74 58 55
of short-stay residents with pressure ulcers that are new or worsened 1 0 1