A list of the most recent deficiencies for Creekview Health and Rehabilitation. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-14 | 2023-03-01 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-06-28 | 2022-07-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-06-28 | 2022-07-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-28 | 2022-07-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-28 | 2022-07-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-28 | 2022-07-25 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-28 | 2022-07-25 | 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 | 2022-06-28 | 2022-07-25 | 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 | 2022-06-28 | 2022-07-25 | 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 | 2022-06-28 | 2022-07-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-28 | 2022-07-25 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-06-26 | 2022-07-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-06-26 | 2022-07-25 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-06-26 | 2022-07-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-06-26 | 2022-07-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-26 | 2022-07-25 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-06-26 | 2022-07-25 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-06-26 | 2022-07-25 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-24 | 2021-07-12 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2019-10-21 | 2019-12-06 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-10-22 | 2019-12-03 | 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 | 2019-10-22 | 2019-12-03 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-10-22 | 2019-12-03 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2019-10-22 | 2019-12-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-22 | 2019-12-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-22 | 2019-12-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-22 | 2019-12-03 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-10-21 | 2019-11-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-21 | 2019-11-14 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-10-21 | 2019-11-07 | 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 | 2019-10-21 | 2019-11-07 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2019-10-21 | 2019-11-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-10-21 | 2019-11-06 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-10-01 | 2018-11-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-01 | 2018-11-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-10-01 | 2018-11-15 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-10-01 | 2018-11-15 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-10-03 | 2018-11-01 | 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 | 2018-10-03 | 2018-11-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-10-03 | 2018-11-01 | N |
| Respond appropriately to all alleged violations. | Health | 2018-10-03 | 2018-11-01 | 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 | 2018-10-03 | 2018-11-01 | 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 | 2018-10-03 | 2018-11-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-03 | 2018-11-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-10-03 | 2018-11-01 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2018-10-03 | 2018-11-01 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-10-01 | 2018-11-01 | N |
