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Deficiency Records for Three Creeks Post Acute
View the most recent health deficiencies and inspection results for Three Creeks Post Acute. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Three Creeks Post Acute. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2026-03-03 | 2026-05-01 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2026-02-26 | 2026-03-20 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2025-11-10 | 2026-02-09 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-12-23 | 2026-01-28 | Y |
| 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 | 2025-12-22 | 2026-01-28 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2025-12-22 | 2026-01-28 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-12-22 | 2026-01-28 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2025-12-23 | 2026-01-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2025-11-10 | 2025-12-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2025-01-10 | 2025-02-14 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-11-17 | 2024-12-23 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2024-11-17 | 2024-12-23 | 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 | 2024-11-17 | 2024-12-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-11-17 | 2024-12-23 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-11-17 | 2024-12-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-11-17 | 2024-12-23 | 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 | 2024-11-17 | 2024-12-23 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-11-17 | 2024-12-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-11-17 | 2024-12-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-11-17 | 2024-12-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-11-17 | 2024-12-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-11-17 | 2024-12-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-11-17 | 2024-12-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-11-17 | 2024-12-16 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2024-11-17 | 2024-12-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-24 | 2024-06-19 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-05-24 | 2024-06-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-05-24 | 2024-06-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-24 | 2024-06-19 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-05-01 | 2024-06-19 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-05-01 | 2024-06-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-05 | 2023-12-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-05 | 2023-12-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-09 | 2023-12-07 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-10-02 | 2023-10-17 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-19 | 2023-09-20 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-08-19 | 2023-09-20 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-08-19 | 2023-09-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-19 | 2023-09-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-19 | 2023-09-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-19 | 2023-09-20 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-08-19 | 2023-09-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-08-19 | 2023-09-20 | N |
| Meet the requirements of an integrated health system. | Fire Safety | 2023-08-19 | 2023-09-20 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-08-19 | 2023-09-20 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-08-19 | 2023-09-20 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-08-19 | 2023-09-20 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-08-19 | 2023-09-20 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-08-19 | 2023-09-20 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-19 | 2023-09-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-19 | 2023-09-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-19 | 2023-09-13 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-07-24 | 2023-08-16 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-07-24 | 2023-08-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-10 | 2021-10-19 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-09-10 | 2021-10-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-09-10 | 2021-10-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-10 | 2021-10-19 | 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 | 2021-09-10 | 2021-10-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-10 | 2021-10-19 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-09-10 | 2021-10-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-10 | 2021-10-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-10 | 2021-10-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-10 | 2021-10-19 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-09-10 | 2021-10-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-09-10 | 2021-09-24 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-09-10 | 2021-09-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-09-10 | 2021-09-07 | N |