A list of the most recent deficiencies for Triple Creek Retirement Community. 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? |
|---|---|---|---|---|
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-08-18 | 2022-09-25 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-08-18 | 2022-09-25 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-08-18 | 2022-09-25 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-08-18 | 2022-09-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-18 | 2022-09-25 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-08-18 | 2022-09-25 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-08-18 | 2022-09-25 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-08-18 | 2022-09-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-18 | 2022-09-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-08-18 | 2022-09-12 | 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 | 2022-08-18 | 2022-09-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-28 | 2022-07-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-28 | 2022-07-19 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-07-06 | 2021-07-27 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-06 | 2021-07-27 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-03 | 2019-08-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-03 | 2019-08-15 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2019-07-03 | 2019-08-15 | 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 | 2019-07-03 | 2019-08-15 | N |
| Provide or obtain dental services for each resident. | Health | 2019-07-03 | 2019-08-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-03 | 2019-08-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-07-02 | 2019-08-15 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-07-02 | 2019-08-15 | N |
| Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled. | Fire Safety | 2019-07-02 | 2019-08-15 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-06-07 | 2018-07-13 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-06-07 | 2018-07-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-06-07 | 2018-07-13 | 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 | 2018-06-07 | 2018-07-13 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-06-07 | 2018-07-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-06-07 | 2018-07-13 | 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 | 2018-06-07 | 2018-07-13 | 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 | 2018-06-07 | 2018-07-13 | N |
| Install proper backup exit lighting. | Fire Safety | 2018-06-04 | 2018-07-13 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-06-04 | 2018-07-13 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2018-06-04 | 2018-07-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-06-04 | 2018-07-13 | N |
