Spring Creek Rehab: Resident Not Eating for Days - NY
The resident was transferred to the hospital on March 16.
The Director of Nursing said the discovery came not from any alert system or staff report, but from going back through the certified nursing assistants' documentation herself, after the fact. What she found was a three-day gap. Starting at 4:00 PM on March 13, the resident had eaten zero percent of their meals. That continued until 1:00 PM on March 16, when the resident's condition had already visibly changed.
She also found something else. Some staff hadn't been documenting fluid consumption either.
The unit manager, Registered Nurse Supervisor #2, said they reviewed the 24-hour report on March 16 and saw nothing unusual about the resident. No flags. No documentation of refusals. No mention of the resident not eating. The supervisor said they were responsible for checking the completeness of their staff's documentation but, when pressed, acknowledged they were unable to actually see the percentage of oral intake the resident had consumed. The system they were using to check on their staff's work couldn't show them the most basic number: how much the resident had eaten.
The doctor who had been treating the resident said he last examined the patient on March 13 and documented that the resident was eating well. He received no call on March 15. He was explicit about what a call would have triggered: intravenous fluids for hydration, blood work. He found out about the change in condition on March 16, examined the resident, and made the decision to transfer them to the hospital. He told inspectors the sudden decline was not a direct result of the missed meals but attributed it to other underlying conditions.
The resident's health care proxy and an adult sibling had been closely involved in the resident's care. The unit supervisor knew the family well, knew the resident's history with appetite and refusals, and had addressed those issues in a care plan meeting on February 25, less than three weeks before the three-day gap began.
The Director of Nursing told inspectors she followed up with the hospital after the transfer. The hospital confirmed the resident had been admitted. They did not provide a diagnosis.
After the fact, the Director of Nursing said she taught unit managers how to run reports that would show eating and fluid consumption data, so it wouldn't happen again. The unit managers, she said, were responsible for running those reports to ensure the completeness of care. They had not been doing it in a way that let them see whether a resident had stopped eating entirely.
The inspection, conducted in response to a complaint, was completed April 30, 2026. The violation was cited at a level of minimal harm or potential for actual harm, affecting a small number of residents.
The resident's sibling had been involved enough that the unit supervisor mentioned them by name when describing how engaged the family was. Whether that family knew, during those three days in March, that the person they were advocating for had eaten nothing, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Spring Creek Rehabilitation & Nursing Care Center from 2026-04-30 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 6, 2026 · Our methodology
Spring Creek Rehabilitation & Nursing Care Center in Brooklyn, NY was cited for violations during a health inspection on April 30, 2026.
The resident was transferred to the hospital on March 16.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.