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Deficiency Records for Creekside Village
A list of the most recent deficiencies for Creekside Village. 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. 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 activities to meet all resident's needs. | Health | 2025-01-13 | 2025-02-13 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-01-13 | 2025-02-13 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2025-01-13 | 2025-02-13 | N |
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2025-01-13 | 2025-02-13 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2025-01-13 | 2025-02-13 | N |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2025-01-13 | 2025-02-13 | N |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-07-02 | 2024-07-02 | Y |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-02-09 | 2024-03-10 | 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 | 2024-02-09 | 2024-03-10 | N |
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-02-09 | 2024-03-10 | N |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-02-09 | 2024-03-10 | 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 | 2024-02-09 | 2024-03-10 | N |
Provide and implement an infection prevention and control program. | Health | 2024-02-09 | 2024-03-10 | N |
Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-10-06 | 2023-10-27 | Y |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-06 | 2023-10-27 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-18 | 2023-09-09 | Y |
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-08-18 | 2023-09-09 | Y |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-01-05 | 2023-02-21 | N |
Have properly located and lighted "Exit" signs. | Fire Safety | 2023-01-05 | 2023-02-21 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-05 | 2023-02-21 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-05 | 2023-02-21 | N |
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-12-02 | 2023-01-05 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-02 | 2023-01-05 | 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 | 2022-12-02 | 2023-01-05 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-02 | 2023-01-05 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-02 | 2023-01-05 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-02 | 2023-01-05 | N |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-12-02 | 2023-01-05 | 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 | 2022-12-02 | 2023-01-05 | N |
Provide and implement an infection prevention and control program. | Health | 2022-12-02 | 2023-01-05 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-26 | 2022-07-15 | Y |
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-03-25 | 2022-04-25 | Y |
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