Deficiency Records for Creekside Village Health and Rehabilitation Center
Updated as of April 01, 2022
This is not the most recent data for Creekside Village Health and Rehabilitation Center. For the most recent information, click here.
A list of the most recent deficiencies for Creekside Village Health and Rehabilitation Center. 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 appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-09 | 2022-01-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-02-03 | 2021-02-03 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-08-31 | 2020-09-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-08-31 | 2020-09-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2020-08-31 | 2020-09-30 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-08-31 | 2020-09-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-08-31 | 2020-09-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-04-16 | 2020-05-15 | N |
| 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 | 2020-01-14 | 2020-04-09 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-01-14 | 2020-04-09 | 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 | 2020-01-14 | 2020-04-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-01-14 | 2020-04-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-14 | 2020-04-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-14 | 2020-04-09 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2020-01-14 | 2020-04-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-14 | 2020-04-09 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-01-14 | 2020-02-12 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-12-19 | 2020-02-07 | N |
| Respond appropriately to all alleged violations. | Health | 2019-12-19 | 2020-01-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-19 | 2020-01-23 | 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 | 2019-12-19 | 2020-01-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-12-19 | 2020-01-23 | N |
| Provide activities to meet all resident's needs. | Health | 2019-12-19 | 2020-01-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-12-19 | 2020-01-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-19 | 2020-01-23 | N |
| 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 | 2019-12-19 | 2020-01-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-12-19 | 2020-01-23 | 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 | 2019-12-19 | 2020-01-23 | 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 | 2019-12-19 | 2020-01-23 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-12-19 | 2020-01-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-19 | 2020-01-23 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-12-19 | 2020-01-23 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-10-08 | 2019-11-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-08 | 2019-11-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-08 | 2019-11-01 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-10-08 | 2019-11-01 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-10-08 | 2019-11-01 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-03 | 2019-05-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-03 | 2019-05-16 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-18 | 2019-02-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-11-29 | 2019-02-04 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2018-12-18 | 2019-02-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-12-18 | 2019-02-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-12-18 | 2019-02-01 | N |
| Ensure new upholstered furniture and mattresses meet char length and heat release criteria. | Fire Safety | 2018-12-18 | 2019-02-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-12-18 | 2019-02-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-12-18 | 2019-01-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-12-18 | 2019-01-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-12-18 | 2019-01-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-12-18 | 2019-01-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-12-18 | 2019-01-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-11-29 | 2018-12-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-11-29 | 2018-12-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-12-18 | 2018-12-28 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2018-12-18 | 2018-12-28 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-03-09 | 2017-05-17 | N |
| Ensure that residents are safe from serious medication errors. | Health | 2017-03-09 | 2017-05-17 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-03-09 | 2017-05-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-03-27 | 2017-05-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2017-03-27 | 2017-05-01 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2017-03-27 | 2017-05-01 | 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 | 2017-03-27 | 2017-05-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2017-03-27 | 2017-05-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-03-27 | 2017-05-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-03-27 | 2017-05-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2017-03-27 | 2017-05-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-03-27 | 2017-05-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-03-27 | 2017-05-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-03-27 | 2017-05-01 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2017-03-27 | 2017-05-01 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2017-03-09 | 2017-04-11 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-03-09 | 2017-04-11 | N |
| Keep each resident free from physical restraints, unless needed for medical treatment. | Health | 2017-03-09 | 2017-04-11 | N |
| Provide housekeeping and maintenance services. | Health | 2017-03-09 | 2017-04-11 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-03-09 | 2017-04-11 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-03-09 | 2017-04-11 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-03-09 | 2017-04-11 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-03-09 | 2017-04-11 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-03-09 | 2017-04-11 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-03-09 | 2017-04-11 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2017-03-27 | 2017-04-11 | N |
