A list of the most recent deficiencies for Eagle Creek Nursing 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-01-04 | 2023-01-25 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-04 | 2023-01-25 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-08-25 | 2022-10-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-25 | 2022-10-13 | 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 | 2022-08-25 | 2022-10-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-25 | 2022-10-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-25 | 2022-10-13 | N |
| Keep all essential equipment working safely. | Health | 2022-08-25 | 2022-10-13 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-08-23 | 2022-10-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-23 | 2022-10-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-23 | 2022-10-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-23 | 2022-10-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-23 | 2022-10-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-23 | 2022-10-13 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-08-23 | 2022-10-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-23 | 2022-10-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-08-23 | 2022-10-13 | N |
| Post nurse staffing information every day. | Health | 2022-08-25 | 2022-09-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-05 | 2021-08-30 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-08-05 | 2021-08-05 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-10-24 | 2019-11-21 | 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 | 2019-10-24 | 2019-11-21 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-10-24 | 2019-11-21 | 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 | 2019-10-24 | 2019-11-21 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-10-24 | 2019-11-21 | 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 | 2019-10-24 | 2019-11-21 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-10-24 | 2019-11-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-24 | 2019-11-21 | 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 | 2019-10-24 | 2019-11-21 | 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 | 2019-10-24 | 2019-11-21 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-10-24 | 2019-11-21 | 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 | 2019-10-24 | 2019-11-21 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-10-24 | 2019-11-21 | N |
| Provide or obtain dental services for each resident. | Health | 2019-10-24 | 2019-11-21 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-24 | 2019-11-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-24 | 2019-11-21 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-10-24 | 2019-11-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-10-21 | 2019-11-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-21 | 2019-11-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-10-21 | 2019-11-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-09-07 | 2018-10-12 | 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 | 2018-09-07 | 2018-10-12 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2018-09-07 | 2018-10-12 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-09-07 | 2018-10-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-09-07 | 2018-10-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-07 | 2018-10-12 | 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 | 2018-09-07 | 2018-10-12 | 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 | 2018-09-07 | 2018-10-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-09-07 | 2018-10-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-07 | 2018-10-12 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-09-04 | 2018-10-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-09-04 | 2018-10-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-09-04 | 2018-10-12 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-09-04 | 2018-10-12 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2018-09-04 | 2018-10-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-09-04 | 2018-10-12 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-09-04 | 2018-10-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-09-04 | 2018-10-12 | N |
