Deficiency Records for Creekside Health and Rehabilitation Center
Updated as of May 01, 2024
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Deficiency Records for Creekside Health and Rehabilitation Center
A list of the most recent deficiencies for Creekside Health and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Creekside 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-05 | 2023-12-29 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-12-05 | 2023-12-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-05 | 2023-12-29 | 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 | 2023-12-05 | 2023-12-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-05 | 2023-12-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-05 | 2023-12-29 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-12-05 | 2023-12-29 | 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 | 2023-12-05 | 2023-12-29 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2023-12-15 | 2023-12-22 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-03-14 | 2023-04-05 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-09-19 | 2022-09-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-19 | 2022-09-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-09-19 | 2022-09-28 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-08-09 | 2022-09-07 | 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 | 2022-08-09 | 2022-09-07 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-09 | 2022-09-07 | N |
| Respond appropriately to all alleged violations. | Health | 2022-08-09 | 2022-09-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-08-09 | 2022-09-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-08-09 | 2022-09-07 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-08-09 | 2022-09-07 | 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 | 2022-08-09 | 2022-09-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-09 | 2022-09-07 | N |
| Provide activities to meet all resident's needs. | Health | 2022-08-09 | 2022-09-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-09 | 2022-09-07 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-08-09 | 2022-09-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-09 | 2022-09-07 | 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 | 2022-08-09 | 2022-09-07 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-09 | 2022-09-07 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-08-09 | 2022-09-07 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-08-09 | 2022-09-07 | N |
| Keep complete, dated laboratory records in the resident's record. | Health | 2022-08-09 | 2022-09-07 | N |
| Provide or obtain dental services for each resident. | Health | 2022-08-09 | 2022-09-07 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-08-09 | 2022-09-07 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2022-08-09 | 2022-09-07 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-29 | 2022-07-14 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-29 | 2022-07-14 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-06-29 | 2022-07-14 | Y |
| Provide appropriate foot care. | Health | 2022-05-10 | 2022-05-25 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-05-10 | 2022-05-25 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-05-10 | 2022-05-25 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-27 | 2022-05-12 | Y |
| 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 | 2022-04-27 | 2022-05-12 | Y |
| 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 | 2022-01-13 | 2022-01-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-11 | 2022-01-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-11 | 2022-01-28 | 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 | 2022-01-11 | 2022-01-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-06 | 2021-12-28 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-12-06 | 2021-12-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-05 | 2021-10-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-05 | 2021-10-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-03 | 2021-09-21 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-15 | 2021-07-28 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-07-15 | 2021-07-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-15 | 2021-07-28 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-15 | 2021-07-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-16 | 2021-07-28 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-05-19 | 2021-07-28 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-05-19 | 2021-07-28 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-05-19 | 2021-07-28 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-05-19 | 2021-07-28 | 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 | 2021-05-19 | 2021-07-28 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2021-05-19 | 2021-07-28 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-05-19 | 2021-07-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-19 | 2021-07-28 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-05-19 | 2021-07-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-05-19 | 2021-07-28 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-05-19 | 2021-07-28 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-05-19 | 2021-07-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-19 | 2021-07-28 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-05-19 | 2021-07-28 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-05-19 | 2021-07-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-19 | 2021-07-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-19 | 2021-07-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-19 | 2021-07-28 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-05-19 | 2021-07-28 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-05-19 | 2021-07-28 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-06-08 | 2021-06-18 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-06-08 | 2021-06-18 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-06-08 | 2021-06-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-06-08 | 2021-06-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-08 | 2021-06-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-06-08 | 2021-06-18 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-06-08 | 2021-06-18 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2021-06-08 | 2021-06-18 | N |
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