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Deficiency Records for South Creek Post Acute
A list of the most recent deficiencies for South Creek Post Acute. 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 South Creek Post Acute. 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-23 | 2024-06-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-05-23 | 2024-06-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-05-23 | 2024-06-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-05-23 | 2024-06-25 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-05-24 | 2024-06-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-24 | 2024-06-17 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-05-24 | 2024-06-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-24 | 2024-06-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-05-24 | 2024-06-17 | N |
| Respond appropriately to all alleged violations. | Health | 2024-05-02 | 2024-05-13 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-30 | 2023-07-31 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-06-30 | 2023-07-31 | 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 | 2023-06-30 | 2023-07-31 | 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 | 2023-06-30 | 2023-07-31 | 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 | 2023-06-30 | 2023-07-31 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-06-30 | 2023-07-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-30 | 2023-07-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-30 | 2023-07-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-30 | 2023-07-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-06-30 | 2023-07-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-30 | 2023-07-31 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-06-30 | 2023-07-31 | 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 | 2023-06-30 | 2023-07-31 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-06-30 | 2023-07-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-30 | 2023-07-31 | 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 | 2023-07-05 | 2023-07-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-05 | 2023-07-31 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-07-05 | 2023-07-31 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-01-26 | 2023-02-24 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-01-26 | 2023-02-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-26 | 2023-02-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-04 | 2022-12-05 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-11-04 | 2022-12-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-04 | 2022-12-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-11-04 | 2022-12-05 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-04 | 2022-12-05 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-11-04 | 2022-12-05 | Y |
| 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 | 2022-06-09 | 2022-07-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-06-09 | 2022-07-14 | 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 | 2022-06-09 | 2022-07-14 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-06-09 | 2022-07-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-06-09 | 2022-07-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-09 | 2022-07-14 | N |
| Provide activities to meet all resident's needs. | Health | 2022-06-09 | 2022-07-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-09 | 2022-07-14 | N |
| Post nurse staffing information every day. | Health | 2022-06-09 | 2022-07-14 | 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 | 2022-06-09 | 2022-07-14 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-06-09 | 2022-07-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-09 | 2022-07-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-09 | 2022-07-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-06-07 | 2022-07-11 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-06-07 | 2022-07-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-07 | 2022-07-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-07 | 2022-07-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-06-07 | 2022-07-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-07 | 2022-07-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-06-07 | 2022-07-11 | N |
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