A list of the most recent deficiencies for Accordius Health at Creekside Care. 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? |
|---|---|---|---|---|
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-09-12 | 2023-10-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-12 | 2023-10-13 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-08-10 | 2023-09-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-10 | 2023-09-07 | 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 | 2023-08-10 | 2023-09-07 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-08-10 | 2023-09-07 | 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 | 2022-04-08 | 2022-04-11 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-08 | 2022-04-11 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-04-08 | 2022-04-11 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-02-04 | 2022-04-11 | 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 | 2022-02-04 | 2022-04-11 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-02-04 | 2022-04-11 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-04 | 2022-04-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-04 | 2022-04-08 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-02-04 | 2022-04-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-02-04 | 2022-04-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-02-04 | 2022-04-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-04 | 2022-04-08 | 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 | 2022-02-04 | 2022-04-08 | 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 | 2022-02-04 | 2022-04-08 | 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 | 2022-02-04 | 2022-04-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-04 | 2022-04-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-04 | 2022-04-08 | N |
| Keep all essential equipment working safely. | Health | 2022-02-04 | 2022-04-08 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-02-04 | 2022-04-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-02-04 | 2022-04-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-04 | 2022-04-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-04 | 2022-04-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-04 | 2022-04-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-04 | 2022-04-08 | Y |
| Post nurse staffing information every day. | Health | 2022-02-04 | 2022-03-08 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-05-13 | 2021-05-31 | Y |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-09-18 | 2019-10-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-09-18 | 2019-10-18 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-08-22 | 2019-09-09 | 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 | 2019-08-22 | 2019-09-09 | N |
| Dispose of garbage and refuse properly. | Health | 2019-08-22 | 2019-09-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-22 | 2019-09-09 | N |
