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Deficiency Records for Creekside Rehabilitation and Behavioral Health
A list of the most recent deficiencies for Creekside Rehabilitation and Behavioral Health. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Creekside Rehabilitation and Behavioral Health. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-03-20 | 2024-07-15 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-03-29 | 2024-04-24 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-11-17 | 2024-01-05 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2023-11-17 | 2024-01-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-17 | 2024-01-05 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-11-17 | 2024-01-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-17 | 2024-01-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-17 | 2024-01-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-11-17 | 2024-01-05 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-11-17 | 2024-01-05 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-11-17 | 2024-01-05 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-11-17 | 2024-01-05 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-11-17 | 2024-01-05 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-11-17 | 2024-01-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-17 | 2024-01-05 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2023-11-17 | 2024-01-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-17 | 2024-01-05 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-11-17 | 2024-01-05 | N |
| Keep all essential equipment working safely. | Health | 2023-11-17 | 2024-01-05 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-11-17 | 2024-01-05 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-17 | 2024-01-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-17 | 2024-01-05 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-11-17 | 2024-01-05 | Y |
| Use approved construction type or materials. | Fire Safety | 2023-11-28 | 2023-12-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-28 | 2023-12-12 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-11-28 | 2023-12-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-28 | 2023-12-12 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-11-28 | 2023-12-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-28 | 2023-12-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-11-28 | 2023-12-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-28 | 2023-12-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-28 | 2023-12-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-28 | 2023-12-12 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-11-28 | 2023-12-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-28 | 2023-12-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-28 | 2023-12-12 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-07-14 | 2023-07-27 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-07-14 | 2023-07-27 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-14 | 2023-07-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-02 | 2023-03-09 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-02-02 | 2023-03-09 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-02-07 | 2022-04-05 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-02-07 | 2022-04-05 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-02-07 | 2022-04-05 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-02-07 | 2022-04-05 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-02-07 | 2022-04-05 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-02-07 | 2022-04-05 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-02-07 | 2022-04-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-07 | 2022-04-05 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-02-07 | 2022-04-05 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-07 | 2022-04-05 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-02-08 | 2022-02-22 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-02-08 | 2022-02-22 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-02-08 | 2022-02-22 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-02-08 | 2022-02-22 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-02-08 | 2022-02-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-02-08 | 2022-02-22 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2022-02-08 | 2022-02-22 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-02-08 | 2022-02-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-08 | 2022-02-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-02-08 | 2022-02-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-08 | 2022-02-22 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-02-08 | 2022-02-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-08 | 2022-02-22 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-02-08 | 2022-02-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-08 | 2022-02-22 | N |
| Use approved construction type or materials. | Fire Safety | 2019-10-16 | 2019-11-14 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2019-10-16 | 2019-11-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-16 | 2019-11-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-10-16 | 2019-11-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-16 | 2019-11-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-10-16 | 2019-11-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-10-16 | 2019-11-14 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-09-27 | 2019-11-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-09-27 | 2019-11-05 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-09-27 | 2019-11-05 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-09-27 | 2019-11-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-27 | 2019-11-05 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-09-27 | 2019-11-05 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-09-27 | 2019-11-05 | N |
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