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Deficiency Records for Creekside Center For Rehabilitation and Nursing
A list of the most recent deficiencies for Creekside Center For Rehabilitation and Nursing. 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 Center For Rehabilitation and Nursing. 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? |
|---|---|---|---|---|
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-08-05 | 2024-11-22 | 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 | 2024-08-05 | 2024-11-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-08-05 | 2024-11-22 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-08-05 | 2024-11-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-05 | 2024-11-22 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2024-08-05 | 2024-11-22 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-08-05 | 2024-11-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-08-05 | 2024-11-22 | 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 | 2024-08-05 | 2024-11-22 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-08-05 | 2024-11-22 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-08-05 | 2024-11-22 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-08-05 | 2024-11-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-05 | 2024-11-22 | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2024-08-05 | 2024-11-22 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-08-05 | 2024-11-22 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2024-08-05 | 2024-11-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-05 | 2024-11-22 | Y |
| 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 | 2024-08-05 | 2024-11-22 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-08-22 | 2024-11-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-08-22 | 2024-11-04 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-08-22 | 2024-11-04 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-08-22 | 2024-10-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-22 | 2024-10-09 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-08-22 | 2024-10-09 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-08-22 | 2024-10-09 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-08-05 | 2024-10-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-08-05 | 2024-10-08 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-08-05 | 2024-10-08 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2024-08-05 | 2024-10-08 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-08-05 | 2024-10-08 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-08-05 | 2024-10-08 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-08-05 | 2024-10-08 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2024-08-05 | 2024-10-08 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-08-05 | 2024-10-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-08-05 | 2024-10-08 | N |
| Assess the resident when there is a significant change in condition | Health | 2024-08-05 | 2024-10-08 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-08-05 | 2024-10-08 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-08-05 | 2024-10-08 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2024-08-05 | 2024-10-08 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-08-05 | 2024-10-08 | N |
| Post nurse staffing information every day. | Health | 2024-08-05 | 2024-10-08 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-08-05 | 2024-10-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-08-05 | 2024-10-08 | 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 | 2024-08-05 | 2024-10-08 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-08-05 | 2024-10-08 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-08-05 | 2024-10-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-08-05 | 2024-10-08 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-08-05 | 2024-10-08 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-08-05 | 2024-10-08 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2024-08-05 | 2024-10-08 | N |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2024-08-05 | 2024-10-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-08-05 | 2024-10-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-08-05 | 2024-10-08 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-08-05 | 2024-10-08 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-08-05 | 2024-10-08 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-08-05 | 2024-10-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-08-05 | 2024-10-07 | 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 | 2019-07-25 | 2019-11-19 | 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 | 2019-07-25 | 2019-11-19 | N |
| Post nurse staffing information every day. | Health | 2019-07-25 | 2019-11-19 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-07-25 | 2019-11-19 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-07-25 | 2019-11-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-07-25 | 2019-11-19 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-07-25 | 2019-09-25 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-07-25 | 2019-09-25 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-07-25 | 2019-09-25 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-07-25 | 2019-09-25 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2019-07-25 | 2019-09-25 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-07-25 | 2019-09-25 | N |
| Respond appropriately to all alleged violations. | Health | 2019-07-25 | 2019-09-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-07-25 | 2019-09-25 | 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 | 2019-07-25 | 2019-09-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-07-25 | 2019-09-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-25 | 2019-09-25 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-07-25 | 2019-09-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-25 | 2019-09-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-07-25 | 2019-09-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-25 | 2019-09-25 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-07-25 | 2019-09-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-07-25 | 2019-09-25 | 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 | 2019-07-25 | 2019-09-25 | 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 | 2019-07-25 | 2019-09-25 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-07-25 | 2019-09-25 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-07-25 | 2019-09-25 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-07-25 | 2019-09-25 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2018-02-14 | 2018-04-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-02-14 | 2018-04-11 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-02-05 | 2018-03-28 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2018-02-05 | 2018-03-28 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-02-05 | 2018-03-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-02-05 | 2018-03-28 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-02-05 | 2018-03-28 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-02-05 | 2018-03-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-02-05 | 2018-03-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-02-05 | 2018-03-28 | 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 | 2018-02-05 | 2018-03-28 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2018-02-05 | 2018-03-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-02-05 | 2018-03-28 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2018-02-05 | 2018-03-28 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2018-02-05 | 2018-03-28 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2018-02-05 | 2018-03-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-02-05 | 2018-03-28 | 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 | 2018-02-05 | 2018-03-28 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-02-05 | 2018-03-28 | 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 | 2018-02-05 | 2018-03-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-02-05 | 2018-03-28 | 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 | 2018-02-05 | 2018-03-28 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2018-02-05 | 2018-03-28 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2018-02-05 | 2018-03-28 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-02-05 | 2018-03-28 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2018-02-05 | 2018-03-28 | N |
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