Deficiency Records for Inners Creek Skilled Nursing and Rehabilitation Ce
Updated as of March 01, 2024
A list of the most recent deficiencies for Inners Creek Skilled Nursing and Rehabilitation Ce. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-30 | 2024-01-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-30 | 2024-01-17 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-11-30 | 2024-01-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-11-30 | 2024-01-17 | 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 | 2023-11-30 | 2024-01-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-30 | 2024-01-17 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-11-30 | 2024-01-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-30 | 2024-01-17 | 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 | 2023-11-30 | 2024-01-17 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-30 | 2024-01-17 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2023-11-30 | 2024-01-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-30 | 2024-01-17 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-11-30 | 2024-01-17 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-11-30 | 2024-01-17 | N |
| Post nurse staffing information every day. | Health | 2023-11-30 | 2024-01-17 | 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 | 2023-11-30 | 2024-01-17 | 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 | 2023-11-30 | 2024-01-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-30 | 2024-01-17 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-11-30 | 2024-01-17 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-11-30 | 2024-01-17 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-11-30 | 2024-01-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-14 | 2023-12-05 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-11-14 | 2023-12-05 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-11-14 | 2023-12-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-14 | 2023-12-05 | N |
| Meet other general requirements. | Fire Safety | 2022-12-22 | 2023-02-20 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-12-22 | 2023-02-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-12-22 | 2023-02-20 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-12-22 | 2023-02-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-12-22 | 2023-02-20 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-12-22 | 2023-02-20 | N |
| Meet other general requirements. | Fire Safety | 2022-12-22 | 2023-02-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-08 | 2022-12-26 | 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 | 2022-12-08 | 2022-12-26 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-26 | 2022-07-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-26 | 2022-07-26 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-12-27 | 2022-01-28 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-12-27 | 2022-01-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-27 | 2022-01-28 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-16 | 2022-01-20 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-12-16 | 2022-01-20 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-12-16 | 2022-01-20 | 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 | 2021-12-16 | 2022-01-20 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-12-16 | 2022-01-20 | 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 | 2021-12-16 | 2022-01-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-16 | 2022-01-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-16 | 2022-01-20 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-12-16 | 2022-01-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-12-16 | 2022-01-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-12-16 | 2022-01-20 | N |
| Provide or obtain dental services for each resident. | Health | 2021-12-16 | 2022-01-20 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-12-16 | 2022-01-20 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-12-16 | 2022-01-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-16 | 2022-01-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-16 | 2022-01-20 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-12-16 | 2022-01-20 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-05 | 2021-12-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-05-18 | 2021-06-22 | N |
