Spring Creek Post-Acute: Fall Prevention Failure - KY
That is what federal inspectors found when they investigated a complaint at Spring Creek Post-Acute Rehabilitation Center in Murray, Kentucky. The inspection, completed May 29, 2026, focused on a single resident, identified in records as Resident 134, and what happened to him on April 26 of that year.
Resident 134 had been admitted to Spring Creek on December 26, 2025, with pneumonia, altered mental status, and a documented need for help with personal care. By March, a formal cognitive assessment placed him at a score of eight out of 15, a range the assessment tool classifies as moderately impaired. His care plan, drawn up within days of his admission, spelled out what staff were supposed to do: supervise him while he used the bedside commode.
On April 26, Certified Nursing Assistant 14 helped him onto the commode. Then his roommate asked for a blanket. CNA 14 turned her back, handed the roommate the blanket, and Resident 134 fell off the commode. He was assessed and returned to bed. Progress notes documented a rib contusion.
Four days later, on April 30, the resident's daughter requested he be discharged to the hospital for further evaluation.
When inspectors interviewed CNA 14 on May 29, she was direct about what happened and what it would have taken to prevent it. She said the incident would not have occurred if she had not turned her back on the resident. She also said it would not have occurred if another staff member had been present to help her.
That second point, about staffing, did not appear to factor into the facility's official explanation of events.
The Director of Nursing told inspectors the facility's protocol and procedures had been followed. She said the fall assessment was completed and the incident was investigated. She said the facility identified the root cause as an accident. As a corrective measure, CNA 14 was required to complete additional training on care plans, fall risks, and accidents.
The Administrator said her expectation was for all direct care staff to know and follow residents' care plans.
What the inspection record does not show is any facility acknowledgment that a cognitively impaired resident, one whose own care plan flagged the specific risk of unsupervised commode use, was left without supervision while a staff member attended to a competing demand in the same room. CNA 14 named the problem herself: one aide, two residents, and nowhere near enough hands.
The facility's Fall Prevention Program policy, which inspectors reviewed, required that each resident be assessed for fall risk and that care and services be provided in accordance with that individualized risk level. The facility's Incidents and Accidents policy required staff to report, investigate, and review any accidents or incidents. By the DON's account, those boxes were checked.
But the care plan intervention requiring supervision on the bedside commode existed precisely because someone, at some point, recognized that Resident 134 could not safely be left alone in that position. The intervention was documented. It was not followed. A man with moderately impaired cognition sat on a commode without anyone watching him, fell, and left the facility four days later at his daughter's request.
Inspectors cited the deficiency at a level of minimal harm or potential for actual harm, the lowest tier of the federal harm scale. A rib contusion, at that tier, is the outcome.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Spring Creek Post-acute Rehabilitation Center from 2026-05-29 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 19, 2026 · Our methodology
Spring Creek Post-Acute Rehabilitation Center in Murray, KY was cited for violations during a health inspection on May 29, 2026.
That is what federal inspectors found when they investigated a complaint at Spring Creek Post-Acute Rehabilitation Center in Murray, Kentucky.
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.