A list of the most recent deficiencies for Creekside at The Springs. 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 a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-05 | 2023-07-03 | Y |
| 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 | 2023-06-05 | 2023-07-03 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-05 | 2023-07-03 | Y |
| 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 | 2022-11-10 | 2022-11-30 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-11-10 | 2022-11-30 | 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 | 2022-11-10 | 2022-11-30 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-11-10 | 2022-11-30 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-11-10 | 2022-11-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-10 | 2022-11-30 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-11-10 | 2022-11-30 | 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 | 2022-11-07 | 2022-11-30 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-11-07 | 2022-11-30 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-16 | 2022-04-15 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-10-21 | 2021-11-20 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-10-21 | 2021-11-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-10-21 | 2021-11-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-21 | 2021-11-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-21 | 2021-11-20 | 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 | 2021-10-21 | 2021-11-20 | 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 | 2021-10-21 | 2021-11-20 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-10-21 | 2021-11-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-21 | 2021-11-20 | 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 | 2021-10-21 | 2021-11-20 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-10-21 | 2021-11-20 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-10-21 | 2021-11-20 | Y |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-10-18 | 2021-11-16 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-10-18 | 2021-11-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-02 | 2021-05-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-07-28 | 2020-09-30 | N |
| Install proper backup exit lighting. | Fire Safety | 2020-07-21 | 2020-08-28 | 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 | 2020-07-21 | 2020-08-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-07-21 | 2020-08-28 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-07-28 | 2020-08-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-07-28 | 2020-08-21 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-07-28 | 2020-08-21 | 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 | 2020-07-28 | 2020-08-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-07-28 | 2020-08-21 | N |
| Ensure that residents are free from significant medication errors. | Health | 2020-07-28 | 2020-08-21 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2020-07-28 | 2020-08-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-07-28 | 2020-08-21 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2020-07-28 | 2020-08-21 | N |
