A list of the most recent deficiencies for Creekside 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? |
|---|---|---|---|---|
| Ensure that residents are free from significant medication errors. | Health | 2023-08-31 | 2023-09-08 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-09 | 2022-08-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-22 | 2022-07-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-25 | 2022-06-21 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2022-03-22 | 2022-06-02 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-03-22 | 2022-06-02 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-03-22 | 2022-06-02 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-03-22 | 2022-06-02 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-03-22 | 2022-06-02 | N |
| Use approved construction type or materials. | Fire Safety | 2022-03-22 | 2022-06-02 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-03-22 | 2022-06-02 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-03-22 | 2022-06-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-22 | 2022-06-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-22 | 2022-06-02 | N |
| Have enough space near smoke barriers to protect residents. | Fire Safety | 2022-03-22 | 2022-06-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-22 | 2022-06-02 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-03-22 | 2022-06-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-22 | 2022-06-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-03-22 | 2022-06-02 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-04-25 | 2022-05-17 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-03-17 | 2022-05-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-03-17 | 2022-05-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-17 | 2022-05-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-17 | 2022-05-10 | 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 | 2022-03-17 | 2022-05-10 | 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 | 2022-03-17 | 2022-05-10 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-03-17 | 2022-05-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-17 | 2022-05-10 | N |
| Dispose of garbage and refuse properly. | Health | 2022-03-17 | 2022-05-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-17 | 2022-05-10 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-03-17 | 2022-05-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-02 | 2022-02-16 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-12-22 | 2022-01-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-22 | 2022-01-10 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-09-28 | 2021-10-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-12 | 2021-09-22 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-03-30 | 2021-04-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-03-09 | 2021-03-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-09 | 2021-03-22 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-09-03 | 2019-09-26 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-09-03 | 2019-09-26 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-09-03 | 2019-09-26 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2019-09-03 | 2019-09-26 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-09-03 | 2019-09-26 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-09-03 | 2019-09-26 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-09-03 | 2019-09-26 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-09-03 | 2019-09-26 | N |
| Establish methods for sharing information. | Fire Safety | 2019-09-03 | 2019-09-26 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-09-03 | 2019-09-26 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-09-03 | 2019-09-26 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-03 | 2019-09-26 | 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 | 2019-09-03 | 2019-09-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-03 | 2019-09-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-03 | 2019-09-26 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-09-03 | 2019-09-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-03 | 2019-09-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-03 | 2019-09-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-03 | 2019-09-26 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-08-12 | 2019-09-18 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-08-12 | 2019-09-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-12 | 2019-09-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-08-12 | 2019-09-18 | N |
| Provide activities to meet all resident's needs. | Health | 2019-08-12 | 2019-09-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-12 | 2019-09-18 | 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 | 2019-08-12 | 2019-09-18 | 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 | 2019-08-12 | 2019-09-18 | 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 | 2019-08-12 | 2019-09-18 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2019-08-12 | 2019-09-18 | 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 | 2019-08-12 | 2019-09-18 | 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 | 2019-08-12 | 2019-09-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-12 | 2019-09-18 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-08-12 | 2019-09-18 | N |
| Dispose of garbage and refuse properly. | Health | 2019-08-12 | 2019-09-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-08-12 | 2019-09-18 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-08-12 | 2019-09-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-12 | 2019-09-18 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-08-12 | 2019-09-18 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-10-17 | 2018-11-29 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-10-17 | 2018-11-29 | N |
| Develop a communication plan. | Fire Safety | 2018-10-17 | 2018-11-29 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-10-17 | 2018-11-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-10-17 | 2018-11-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-17 | 2018-11-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-10-17 | 2018-11-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-10-17 | 2018-11-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-07-13 | 2018-08-08 | 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 | 2018-07-13 | 2018-08-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-07-13 | 2018-08-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-07-13 | 2018-08-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-07-13 | 2018-08-08 | 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 | 2018-07-13 | 2018-08-08 | N |
| 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 | 2018-07-13 | 2018-08-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-13 | 2018-08-08 | N |
