A list of the most recent deficiencies for Creekside 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-01 | 2023-12-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-10 | 2023-11-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-10 | 2023-11-03 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-06-22 | 2023-08-03 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-22 | 2023-08-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-22 | 2023-08-03 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-06-22 | 2023-08-03 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-22 | 2023-08-03 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-06-22 | 2023-08-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-07 | 2023-07-18 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-04-18 | 2023-04-28 | 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 | 2023-04-18 | 2023-04-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-10 | 2023-03-05 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-06-02 | 2022-06-03 | Y |
| Use approved construction type or materials. | Fire Safety | 2021-05-28 | 2021-06-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-05-28 | 2021-06-17 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-05-28 | 2021-06-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-28 | 2021-06-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-05-28 | 2021-06-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-21 | 2021-06-11 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-05-21 | 2021-06-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-05-21 | 2021-06-11 | 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 | 2021-05-21 | 2021-06-11 | 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 | 2021-05-21 | 2021-06-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-21 | 2021-06-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-21 | 2021-06-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-21 | 2021-06-11 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-09-24 | 2019-10-07 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-09-24 | 2019-10-07 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-09-24 | 2019-10-07 | 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 | 2019-09-24 | 2019-10-07 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-09-24 | 2019-10-07 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-09-24 | 2019-10-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-24 | 2019-10-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-24 | 2019-10-07 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-09-24 | 2019-10-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-24 | 2019-10-07 | 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 | 2019-08-23 | 2019-09-17 | 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 | 2019-08-23 | 2019-09-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-23 | 2019-09-17 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-08-23 | 2019-09-17 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-10-18 | 2018-11-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-10-18 | 2018-11-06 | 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 | 2018-10-18 | 2018-11-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-10-18 | 2018-11-06 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2018-10-18 | 2018-11-06 | 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 | 2018-09-21 | 2018-10-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-21 | 2018-10-17 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2018-09-21 | 2018-10-17 | N |
