Deficiency Records for Creekside Transitional Care and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Creekside Transitional Care and Rehabilitation. 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 | 2021-10-06 | 2022-01-02 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-10-06 | 2021-11-23 | N |
| Report COVID19 data to residents and families. | Health | 2021-10-06 | 2021-11-23 | 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 | 2021-10-06 | 2021-11-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-13 | 2021-06-25 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-05-13 | 2021-06-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-13 | 2021-06-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-13 | 2021-06-07 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-03-01 | 2019-04-05 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-03-01 | 2019-04-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-01 | 2019-04-05 | 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 | 2019-03-01 | 2019-04-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-03-01 | 2019-04-05 | N |
| Provide activities to meet all resident's needs. | Health | 2019-03-01 | 2019-04-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-03-01 | 2019-04-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-03-01 | 2019-04-05 | 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 | 2019-03-01 | 2019-04-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-01 | 2019-04-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-03-01 | 2019-04-05 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-03-01 | 2019-04-05 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-03-01 | 2019-04-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-03-01 | 2019-04-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-10-09 | 2018-12-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-10-09 | 2018-11-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-09 | 2018-11-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-10-09 | 2018-11-03 | N |
| Keep each resident free from physical restraints, unless needed for medical treatment. | Health | 2017-06-16 | 2017-09-13 | N |
| Try to resolve each resident's complaints quickly. | Health | 2017-06-16 | 2017-08-10 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-06-16 | 2017-08-10 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-06-16 | 2017-08-10 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-06-16 | 2017-08-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-06-16 | 2017-08-10 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-06-16 | 2017-08-10 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-06-16 | 2017-08-10 | N |
| Ensure that residents are safe from serious medication errors. | Health | 2017-06-16 | 2017-08-10 | N |
| 1) Provide 3 meals at regular times; 2) serve breakfast within 14 hours of dinner; and 3) offer a snack at bedtime each day. | Health | 2017-06-16 | 2017-08-10 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-06-16 | 2017-08-10 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-06-16 | 2017-08-10 | N |
| Train all employees on what to do in an emergency, and carry out unannounced staff drills. | Health | 2017-06-16 | 2017-08-10 | N |
| Approved construction type or materials. | Fire Safety | 2016-08-10 | 2016-09-22 | N |
| Corridor and hallway doors that block smoke. | Fire Safety | 2016-08-10 | 2016-09-22 | N |
| Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2016-08-10 | 2016-09-22 | N |
| Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2016-08-10 | 2016-09-22 | N |
| Heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2016-08-10 | 2016-09-22 | N |
| Properly protected cooking facilities. | Fire Safety | 2016-08-10 | 2016-09-22 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2016-08-10 | 2016-09-22 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2016-04-29 | 2016-06-17 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2016-04-29 | 2016-06-17 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2016-04-29 | 2016-06-17 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2016-04-29 | 2016-06-17 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-04-29 | 2016-06-17 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-04-29 | 2016-06-17 | N |
| Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents. | Health | 2016-04-29 | 2016-06-17 | N |
| Train all employees on what to do in an emergency, and carry out unannounced staff drills. | Health | 2016-04-29 | 2016-06-17 | N |
| Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2015-07-17 | 2015-08-13 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2015-07-17 | 2015-08-06 | N |
| Smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2015-07-17 | 2015-08-04 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2015-07-17 | 2015-07-22 | N |
| Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2015-07-17 | 2015-07-20 | N |
