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Deficiency Records for Creekside Village Rehabilitation and Nursing LLC
A list of the most recent deficiencies for Creekside Village Rehabilitation and Nursing LLC. 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 Village Rehabilitation and Nursing LLC. 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? |
|---|---|---|---|---|
| Honor the resident's right to choose his or her attending physician. | Health | 2024-07-17 | 2024-08-12 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-01 | 2024-08-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-01 | 2024-08-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-05-01 | 2024-05-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-05-01 | 2024-05-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-05-01 | 2024-05-28 | 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 | 2024-05-01 | 2024-05-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-04-02 | 2024-04-26 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-04-02 | 2024-04-26 | N |
| Provide or obtain dental services for each resident. | Health | 2024-04-02 | 2024-04-26 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-04-02 | 2024-04-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-02 | 2024-04-26 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-04-02 | 2024-04-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-02 | 2024-04-26 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-12-19 | 2024-01-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-19 | 2023-12-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-26 | 2023-10-25 | Y |
| 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 | 2023-03-15 | 2023-04-21 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-15 | 2023-04-21 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-04-27 | 2022-05-30 | Y |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-04-27 | 2022-05-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-09 | 2022-04-11 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-09 | 2022-04-10 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-09 | 2022-04-07 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-09 | 2022-04-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-09 | 2022-04-07 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-09 | 2022-04-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-09 | 2022-04-07 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-03-09 | 2022-04-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-09 | 2022-01-01 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2020-01-14 | 2020-04-09 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-01-14 | 2020-04-09 | 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 | 2020-01-14 | 2020-04-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-01-14 | 2020-04-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-14 | 2020-04-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-14 | 2020-04-09 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2020-01-14 | 2020-04-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-14 | 2020-04-09 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-01-14 | 2020-02-12 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-12-19 | 2020-02-07 | N |
| Respond appropriately to all alleged violations. | Health | 2019-12-19 | 2020-01-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-19 | 2020-01-23 | 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 | 2019-12-19 | 2020-01-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-12-19 | 2020-01-23 | N |
| Provide activities to meet all resident's needs. | Health | 2019-12-19 | 2020-01-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-12-19 | 2020-01-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-19 | 2020-01-23 | N |
| 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 | 2019-12-19 | 2020-01-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-12-19 | 2020-01-23 | 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 | 2019-12-19 | 2020-01-23 | 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 | 2019-12-19 | 2020-01-23 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-12-19 | 2020-01-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-19 | 2020-01-23 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-12-19 | 2020-01-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-18 | 2019-02-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-11-29 | 2019-02-04 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2018-12-18 | 2019-02-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-12-18 | 2019-02-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-12-18 | 2019-02-01 | N |
| Ensure new upholstered furniture and mattresses meet char length and heat release criteria. | Fire Safety | 2018-12-18 | 2019-02-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-12-18 | 2019-02-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-12-18 | 2019-01-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-12-18 | 2019-01-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-12-18 | 2019-01-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-12-18 | 2019-01-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-12-18 | 2019-01-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-11-29 | 2018-12-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-11-29 | 2018-12-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-12-18 | 2018-12-28 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2018-12-18 | 2018-12-28 | N |
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