Deficiency Records for Creekside Village Health and Rehabilitation Center
Updated as of October 01, 2016
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? |
|---|---|---|---|---|
| Proper stairway enclosures and vertical shafts. | Fire Safety | 2016-01-28 | 2016-03-08 | N |
| Exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2016-01-28 | 2016-03-08 | N |
| Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2016-01-28 | 2016-03-08 | N |
| Exits that are accessible at all times. | Fire Safety | 2016-01-28 | 2016-03-08 | N |
| Emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2016-01-28 | 2016-03-08 | N |
| An approved automatic sprinkler system connected to the fire alarm system. | Fire Safety | 2016-01-28 | 2016-03-08 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2016-01-28 | 2016-03-08 | N |
| Posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2016-01-28 | 2016-03-08 | N |
| Properly protected cooking facilities. | Fire Safety | 2016-01-28 | 2016-03-08 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2016-01-28 | 2016-03-08 | N |
| Proper stairway enclosures and vertical shafts. | Fire Safety | 2016-01-28 | 2016-03-08 | N |
| Exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2016-01-28 | 2016-03-08 | N |
| Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2016-01-28 | 2016-03-08 | N |
| Exits that are accessible at all times. | Fire Safety | 2016-01-28 | 2016-03-08 | N |
| Emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2016-01-28 | 2016-03-08 | N |
| An approved automatic sprinkler system connected to the fire alarm system. | Fire Safety | 2016-01-28 | 2016-03-08 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2016-01-28 | 2016-03-08 | N |
| Posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2016-01-28 | 2016-03-08 | N |
| Properly protected cooking facilities. | Fire Safety | 2016-01-28 | 2016-03-08 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2016-01-28 | 2016-03-08 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-01-11 | 2016-02-18 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-01-11 | 2016-02-18 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-01-11 | 2016-02-18 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-01-11 | 2016-02-18 | N |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2016-01-11 | 2016-02-16 | N |
| Listen to the resident groups and act on their complaints and suggestions that affect resident care and life. | Health | 2016-01-11 | 2016-02-16 | N |
| Give notice to the resident before a room or roommate change. | Health | 2016-01-11 | 2016-02-16 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2016-01-11 | 2016-02-16 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-01-11 | 2016-02-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2016-01-11 | 2016-02-16 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-01-11 | 2016-02-16 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2016-01-11 | 2016-02-16 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-01-11 | 2016-02-16 | Y |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2016-01-11 | 2016-02-16 | Y |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2016-01-11 | 2016-02-16 | Y |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2016-01-11 | 2016-02-16 | N |
| Listen to the resident groups and act on their complaints and suggestions that affect resident care and life. | Health | 2016-01-11 | 2016-02-16 | N |
| Give notice to the resident before a room or roommate change. | Health | 2016-01-11 | 2016-02-16 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2016-01-11 | 2016-02-16 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-01-11 | 2016-02-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2016-01-11 | 2016-02-16 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-01-11 | 2016-02-16 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2016-01-11 | 2016-02-16 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-01-11 | 2016-02-16 | Y |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2016-01-11 | 2016-02-16 | Y |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2016-01-11 | 2016-02-16 | Y |
| Proper stairway enclosures and vertical shafts. | Fire Safety | 2014-12-17 | 2015-01-09 | N |
| Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2014-12-17 | 2015-01-09 | N |
| Exits that are accessible at all times. | Fire Safety | 2014-12-17 | 2015-01-09 | N |
| Proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2014-12-17 | 2015-01-09 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2014-12-17 | 2015-01-09 | N |
| Proper stairway enclosures and vertical shafts. | Fire Safety | 2014-12-17 | 2015-01-09 | N |
| Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2014-12-17 | 2015-01-09 | N |
| Exits that are accessible at all times. | Fire Safety | 2014-12-17 | 2015-01-09 | N |
| Proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2014-12-17 | 2015-01-09 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2014-12-17 | 2015-01-09 | N |
| Try to resolve each resident's complaints quickly. | Health | 2014-11-17 | 2014-12-22 | N |
| Provide residents with private access to a telephone. | Health | 2014-11-17 | 2014-12-22 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2014-11-17 | 2014-12-22 | N |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2014-11-17 | 2014-12-22 | N |
| Provide activities to meet the interests and needs of each resident. | Health | 2014-11-17 | 2014-12-22 | N |
| Provide housekeeping and maintenance services. | Health | 2014-11-17 | 2014-12-22 | N |
| Review or revise the resident's care plan after any major change in physical or mental health. | Health | 2014-11-17 | 2014-12-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2014-11-17 | 2014-12-22 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2014-11-17 | 2014-12-22 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2014-11-17 | 2014-12-22 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2014-11-17 | 2014-12-22 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2014-11-17 | 2014-12-22 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2014-11-17 | 2014-12-22 | N |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2014-11-17 | 2014-12-22 | N |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2014-11-17 | 2014-12-22 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2014-11-17 | 2014-12-22 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2014-11-17 | 2014-12-22 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2014-11-17 | 2014-12-22 | N |
| Try to resolve each resident's complaints quickly. | Health | 2014-11-17 | 2014-12-22 | N |
| Provide residents with private access to a telephone. | Health | 2014-11-17 | 2014-12-22 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2014-11-17 | 2014-12-22 | N |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2014-11-17 | 2014-12-22 | N |
| Provide activities to meet the interests and needs of each resident. | Health | 2014-11-17 | 2014-12-22 | N |
| Provide housekeeping and maintenance services. | Health | 2014-11-17 | 2014-12-22 | N |
| Review or revise the resident's care plan after any major change in physical or mental health. | Health | 2014-11-17 | 2014-12-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2014-11-17 | 2014-12-22 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2014-11-17 | 2014-12-22 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2014-11-17 | 2014-12-22 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2014-11-17 | 2014-12-22 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2014-11-17 | 2014-12-22 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2014-11-17 | 2014-12-22 | N |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2014-11-17 | 2014-12-22 | N |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2014-11-17 | 2014-12-22 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2014-11-17 | 2014-12-22 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2014-11-17 | 2014-12-22 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2014-11-17 | 2014-12-22 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2014-07-16 | 2014-08-19 | Y |
| Try to resolve each resident's complaints quickly. | Health | 2014-07-16 | 2014-08-19 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2014-07-16 | 2014-08-19 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2014-07-16 | 2014-08-19 | Y |
| Give residents a notice of rights, rules, services and charges. | Health | 2014-07-16 | 2014-08-19 | Y |
| Try to resolve each resident's complaints quickly. | Health | 2014-07-16 | 2014-08-19 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2014-07-16 | 2014-08-19 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2014-07-16 | 2014-08-19 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2014-05-09 | 2014-06-11 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2014-05-09 | 2014-06-11 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2014-05-09 | 2014-06-11 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2014-05-09 | 2014-06-11 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2014-03-24 | 2014-04-21 | Y |
| Ensure residents maintain acceptable nutritional status. | Health | 2014-03-24 | 2014-04-21 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2014-03-24 | 2014-04-21 | Y |
| Ensure residents maintain acceptable nutritional status. | Health | 2014-03-24 | 2014-04-21 | Y |
| Smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2014-01-08 | 2014-02-12 | N |
| Exits that are accessible at all times. | Fire Safety | 2014-01-08 | 2014-02-12 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2014-01-08 | 2014-02-12 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2014-01-08 | 2014-02-12 | N |
| Smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2014-01-08 | 2014-02-12 | N |
| Exits that are accessible at all times. | Fire Safety | 2014-01-08 | 2014-02-12 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2014-01-08 | 2014-02-12 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2014-01-08 | 2014-02-12 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2013-12-10 | 2014-01-10 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2013-12-10 | 2014-01-10 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2013-12-10 | 2014-01-10 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2013-12-10 | 2014-01-10 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2013-12-10 | 2014-01-10 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2013-12-10 | 2014-01-10 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2013-12-10 | 2014-01-10 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2013-12-10 | 2014-01-10 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2013-12-10 | 2014-01-10 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2013-12-10 | 2014-01-10 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2013-12-10 | 2014-01-10 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2013-12-10 | 2014-01-10 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2013-12-10 | 2014-01-10 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2013-12-10 | 2014-01-10 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2016-08-18 | Not Fixed | Y |
| Provide housekeeping and maintenance services. | Health | 2016-08-18 | Not Fixed | Y |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2016-08-18 | Not Fixed | Y |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2016-08-18 | Not Fixed | Y |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2016-08-18 | Not Fixed | Y |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2016-08-18 | Not Fixed | Y |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2016-08-18 | Not Fixed | Y |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-08-18 | Not Fixed | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-08-18 | Not Fixed | Y |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2016-08-18 | Not Fixed | Y |
| Provide housekeeping and maintenance services. | Health | 2016-08-18 | Not Fixed | Y |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2016-08-18 | Not Fixed | Y |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2016-08-18 | Not Fixed | Y |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2016-08-18 | Not Fixed | Y |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2016-08-18 | Not Fixed | Y |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2016-08-18 | Not Fixed | Y |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-08-18 | Not Fixed | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-08-18 | Not Fixed | Y |
