Deficiency Records for Creekside Rehabilitation and Behavioral Health

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Updated as of March 01, 2024

A list of the most recent deficiencies for Creekside Rehabilitation and Behavioral Health. 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 be treated with respect and dignity and to retain and use personal possessions. Health 2023-11-17 2024-01-05 N
The resident has the right to receive notices in a format and a language he or she understands. Health 2023-11-17 2024-01-05 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2023-11-17 2024-01-05 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 2023-11-17 2024-01-05 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-11-17 2024-01-05 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-11-17 2024-01-05 N
Provide enough food/fluids to maintain a resident's health. Health 2023-11-17 2024-01-05 N
Provide safe, appropriate pain management for a resident who requires such services. Health 2023-11-17 2024-01-05 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2023-11-17 2024-01-05 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 2023-11-17 2024-01-05 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 2023-11-17 2024-01-05 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2023-11-17 2024-01-05 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-11-17 2024-01-05 N
Hire a qualified full-time social worker in a facility with more than 120 beds. Health 2023-11-17 2024-01-05 N
Provide and implement an infection prevention and control program. Health 2023-11-17 2024-01-05 N
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Health 2023-11-17 2024-01-05 N
Keep all essential equipment working safely. Health 2023-11-17 2024-01-05 N
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2023-11-17 2024-01-05 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-11-17 2024-01-05 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-11-17 2024-01-05 Y
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Health 2023-11-17 2024-01-05 Y
Use approved construction type or materials. Fire Safety 2023-11-28 2023-12-12 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2023-11-28 2023-12-12 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 2023-11-28 2023-12-12 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2023-11-28 2023-12-12 N
Properly provide smoke detection systems in areas open to corridors. Fire Safety 2023-11-28 2023-12-12 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-11-28 2023-12-12 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2023-11-28 2023-12-12 N
Install corridor and hallway doors that block smoke. Fire Safety 2023-11-28 2023-12-12 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-11-28 2023-12-12 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-11-28 2023-12-12 N
Meet requirements for the use of electrical equipment. Fire Safety 2023-11-28 2023-12-12 N
Ensure proper usage of power strips and extension cords. Fire Safety 2023-11-28 2023-12-12 N
Have proper medical gas storage and administration areas. Fire Safety 2023-11-28 2023-12-12 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2023-07-14 2023-07-27 Y
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2023-07-14 2023-07-27 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2023-07-14 2023-07-27 Y
Provide and implement an infection prevention and control program. Health 2023-02-02 2023-03-09 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2023-02-02 2023-03-09 N
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2022-02-07 2022-04-05 N
Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. Health 2022-02-07 2022-04-05 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 2022-02-07 2022-04-05 N
Observe each nurse aide's job performance and give regular training. Health 2022-02-07 2022-04-05 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 2022-02-07 2022-04-05 N
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 2022-02-07 2022-04-05 N
Have a plan that describes the process for conducting QAPI and QAA activities. Health 2022-02-07 2022-04-05 N
Provide and implement an infection prevention and control program. Health 2022-02-07 2022-04-05 N
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2022-02-07 2022-04-05 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2022-02-07 2022-04-05 Y
Conduct risk assessment and an All-Hazards approach. Fire Safety 2022-02-08 2022-02-22 N
Establish roles under a Waiver declared by secretary. Fire Safety 2022-02-08 2022-02-22 N
Provide primary/alternate means for communication. Fire Safety 2022-02-08 2022-02-22 N
Establish staff and initial training requirements. Fire Safety 2022-02-08 2022-02-22 N
Implement emergency and standby power systems. Fire Safety 2022-02-08 2022-02-22 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2022-02-08 2022-02-22 N
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. Fire Safety 2022-02-08 2022-02-22 N
Properly provide smoke detection systems in areas open to corridors. Fire Safety 2022-02-08 2022-02-22 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-02-08 2022-02-22 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2022-02-08 2022-02-22 N
Install corridor and hallway doors that block smoke. Fire Safety 2022-02-08 2022-02-22 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2022-02-08 2022-02-22 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2022-02-08 2022-02-22 N
Meet requirements for the use of electrical equipment. Fire Safety 2022-02-08 2022-02-22 N
Ensure proper usage of power strips and extension cords. Fire Safety 2022-02-08 2022-02-22 N
Provide and implement an infection prevention and control program. Health 2021-09-15 2021-10-20 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2021-05-11 2021-05-25 Y
Use approved construction type or materials. Fire Safety 2019-10-16 2019-11-14 N
Have properly installed hallway dispensers for alcohol-based hand rub. Fire Safety 2019-10-16 2019-11-14 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2019-10-16 2019-11-14 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2019-10-16 2019-11-14 N
Install corridor and hallway doors that block smoke. Fire Safety 2019-10-16 2019-11-14 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2019-10-16 2019-11-14 N
Have proper medical gas storage and administration areas. Fire Safety 2019-10-16 2019-11-14 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 2019-09-27 2019-11-05 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2019-09-27 2019-11-05 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 2019-09-27 2019-11-05 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2019-09-27 2019-11-05 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2019-09-27 2019-11-05 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 2019-09-27 2019-11-05 N
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 2019-09-27 2019-11-05 N