Deficiency Records for Whites Creek Wellness and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Whites Creek Wellness and Rehabilitation 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-13 | 2023-09-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-09-13 | 2023-09-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-14 | 2023-05-12 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-12-01 | 2022-12-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-01 | 2022-12-29 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-12-01 | 2022-12-29 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-26 | 2022-05-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-26 | 2022-05-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-14 | 2021-09-02 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-07-14 | 2021-09-02 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2021-07-14 | 2021-09-02 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-03-20 | 2019-04-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-03-20 | 2019-04-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-03-20 | 2019-04-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-20 | 2019-04-27 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-03-21 | 2019-04-27 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-03-21 | 2019-04-27 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-03-21 | 2019-04-27 | 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 | 2019-03-21 | 2019-04-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-03-21 | 2019-04-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-21 | 2019-04-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-03-21 | 2019-04-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-03-21 | 2019-04-27 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-03-21 | 2019-04-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-03-21 | 2019-04-27 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-03-21 | 2019-04-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-03-21 | 2019-04-27 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-03-02 | 2018-03-20 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-03-02 | 2018-03-20 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2018-03-02 | 2018-03-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-03-02 | 2018-03-20 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-03-02 | 2018-03-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-03-02 | 2018-03-20 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2018-03-02 | 2018-03-20 | 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 | 2018-03-02 | 2018-03-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-03-02 | 2018-03-20 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2018-03-02 | 2018-03-20 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-03-02 | 2018-03-20 | 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 | 2018-03-02 | 2018-03-20 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2018-03-02 | 2018-03-20 | 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 | 2018-03-02 | 2018-03-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-03-02 | 2018-03-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-03-02 | 2018-03-20 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-01-29 | 2018-02-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-01-29 | 2018-02-28 | 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 | 2018-01-29 | 2018-02-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-01-29 | 2018-02-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-01-29 | 2018-02-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-01-29 | 2018-02-28 | N |
