Deficiency Records for Creekside Center For Rehabilitation and Nursing
Updated as of April 01, 2024
A list of the most recent deficiencies for Creekside Center For Rehabilitation and Nursing. 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? |
|---|---|---|---|---|
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-07-25 | 2019-11-19 | 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 | 2019-07-25 | 2019-11-19 | N |
| Post nurse staffing information every day. | Health | 2019-07-25 | 2019-11-19 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-07-25 | 2019-11-19 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-07-25 | 2019-11-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-07-25 | 2019-11-19 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-07-25 | 2019-09-25 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-07-25 | 2019-09-25 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-07-25 | 2019-09-25 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-07-25 | 2019-09-25 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2019-07-25 | 2019-09-25 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-07-25 | 2019-09-25 | N |
| Respond appropriately to all alleged violations. | Health | 2019-07-25 | 2019-09-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-07-25 | 2019-09-25 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-07-25 | 2019-09-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-07-25 | 2019-09-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-25 | 2019-09-25 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-07-25 | 2019-09-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-25 | 2019-09-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-07-25 | 2019-09-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-25 | 2019-09-25 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-07-25 | 2019-09-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-07-25 | 2019-09-25 | 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 | 2019-07-25 | 2019-09-25 | 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 | 2019-07-25 | 2019-09-25 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-07-25 | 2019-09-25 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-07-25 | 2019-09-25 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-07-25 | 2019-09-25 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2018-02-14 | 2018-04-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-02-14 | 2018-04-11 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-02-05 | 2018-03-28 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2018-02-05 | 2018-03-28 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-02-05 | 2018-03-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-02-05 | 2018-03-28 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-02-05 | 2018-03-28 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-02-05 | 2018-03-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-02-05 | 2018-03-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-02-05 | 2018-03-28 | 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 | 2018-02-05 | 2018-03-28 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2018-02-05 | 2018-03-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-02-05 | 2018-03-28 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2018-02-05 | 2018-03-28 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2018-02-05 | 2018-03-28 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2018-02-05 | 2018-03-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-02-05 | 2018-03-28 | 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 | 2018-02-05 | 2018-03-28 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-02-05 | 2018-03-28 | 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 | 2018-02-05 | 2018-03-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-02-05 | 2018-03-28 | 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 | 2018-02-05 | 2018-03-28 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2018-02-05 | 2018-03-28 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2018-02-05 | 2018-03-28 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-02-05 | 2018-03-28 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2018-02-05 | 2018-03-28 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2016-11-01 | 2017-01-27 | N |
| Let residents voice a complaint or grievance without being treated differently or badly. | Health | 2016-11-01 | 2017-01-12 | N |
| Allow residents to easily view the results of the nursing home's most recent inspection. | Health | 2016-11-01 | 2017-01-12 | 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 | 2016-11-01 | 2017-01-12 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2016-11-01 | 2017-01-12 | N |
| Provide housekeeping and maintenance services. | Health | 2016-11-01 | 2017-01-12 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2016-11-01 | 2017-01-12 | N |
| Review or revise the resident's care plan after any major change in physical or mental health. | Health | 2016-11-01 | 2017-01-12 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2016-11-01 | 2017-01-12 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-11-01 | 2017-01-12 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2016-11-01 | 2017-01-12 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2016-11-01 | 2017-01-12 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2016-11-01 | 2017-01-12 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-11-01 | 2017-01-12 | 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 | 2016-11-01 | 2017-01-12 | N |
| Ensure that residents are safe from serious medication errors. | Health | 2016-11-01 | 2017-01-12 | N |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2016-11-01 | 2017-01-12 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-11-01 | 2017-01-12 | 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 | 2016-11-01 | 2017-01-12 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-11-01 | 2017-01-12 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-11-01 | 2017-01-12 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2016-11-01 | 2017-01-12 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-11-01 | 2017-01-12 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2016-11-01 | 2017-01-12 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2016-10-28 | 2016-12-15 | N |
| Weekly inspections and monthly testing of generators. | Fire Safety | 2016-10-28 | 2016-12-15 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2016-10-28 | 2016-12-15 | N |
