Deficiency Records for Creekside Post-Acute
Updated as of June 01, 2021
This is not the most recent data for Creekside Post-Acute. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2021-03-04 | 2021-03-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-11-09 | 2020-12-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-11-16 | 2020-12-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-11-04 | 2020-11-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-10-26 | 2020-11-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-10-21 | 2020-11-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-05 | 2019-12-04 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-07-18 | 2019-08-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-07-18 | 2019-08-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-18 | 2019-08-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-18 | 2019-08-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-06-06 | 2019-07-01 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2019-06-06 | 2019-07-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-06 | 2019-07-01 | 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 | 2019-06-06 | 2019-07-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-06-06 | 2019-07-01 | 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 | 2019-06-06 | 2019-07-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-06-06 | 2019-07-01 | 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 | 2019-06-06 | 2019-07-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-06 | 2019-07-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-06 | 2019-07-01 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-06-06 | 2019-07-01 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-05-28 | 2019-06-26 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-01-30 | 2019-02-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-06 | 2018-11-30 | 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 | 2018-11-06 | 2018-11-30 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-11-02 | 2018-11-30 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-06-27 | 2018-07-17 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-06-27 | 2018-07-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-06-27 | 2018-07-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-06-27 | 2018-07-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-06-27 | 2018-07-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-06-27 | 2018-07-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-06-27 | 2018-07-17 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-06-27 | 2018-07-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-06-27 | 2018-07-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-06-27 | 2018-07-17 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-05-11 | 2018-06-08 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2018-05-11 | 2018-06-08 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-05-11 | 2018-06-08 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-05-11 | 2018-06-08 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-05-11 | 2018-06-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-05-11 | 2018-06-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-11 | 2018-06-08 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-05-11 | 2018-06-08 | N |
| Let residents voice a complaint or grievance without being treated differently or badly. | Health | 2017-04-21 | 2017-05-19 | N |
| Provide residents with private access to a telephone. | Health | 2017-04-21 | 2017-05-19 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-04-21 | 2017-05-19 | N |
| Provide activities to meet the interests and needs of each resident. | Health | 2017-04-21 | 2017-05-19 | N |
| Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. | Health | 2017-04-21 | 2017-05-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-04-21 | 2017-05-19 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-04-21 | 2017-05-19 | N |
| Ensure that residents are safe from serious medication errors. | Health | 2017-04-21 | 2017-05-19 | N |
| Provide food in a way that meets a resident's needs. | Health | 2017-04-21 | 2017-05-19 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-04-21 | 2017-05-19 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-04-21 | 2017-05-19 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2017-04-21 | 2017-05-19 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-04-21 | 2017-05-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-04-27 | 2017-05-16 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2017-04-27 | 2017-05-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-04-27 | 2017-05-16 | N |
