A list of the most recent deficiencies for Creekside Village. 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? |
|---|---|---|---|---|
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-02-09 | 2024-03-10 | 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 | 2024-02-09 | 2024-03-10 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-02-09 | 2024-03-10 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-02-09 | 2024-03-10 | 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 | 2024-02-09 | 2024-03-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-09 | 2024-03-10 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-10-06 | 2023-10-27 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-06 | 2023-10-27 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-18 | 2023-09-09 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-08-18 | 2023-09-09 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-01-05 | 2023-02-21 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-01-05 | 2023-02-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-05 | 2023-02-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-05 | 2023-02-21 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-12-02 | 2023-01-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-02 | 2023-01-05 | 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 | 2022-12-02 | 2023-01-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-02 | 2023-01-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-02 | 2023-01-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-02 | 2023-01-05 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-12-02 | 2023-01-05 | 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 | 2022-12-02 | 2023-01-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-02 | 2023-01-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-26 | 2022-07-15 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-03-25 | 2022-04-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-14 | 2022-01-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-07 | 2021-07-07 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-16 | 2019-10-24 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2019-09-16 | 2019-10-24 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-09-16 | 2019-10-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-16 | 2019-10-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-16 | 2019-10-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-16 | 2019-10-24 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-16 | 2019-10-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-16 | 2019-10-24 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-07-26 | 2019-08-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-26 | 2019-08-25 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-07-26 | 2019-08-25 | N |
