A list of the most recent deficiencies for The Broadmoor at Creekside Park. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-02 | 2023-10-03 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-10-02 | 2023-10-03 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-02 | 2023-10-03 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-10-02 | 2023-10-03 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-02 | 2023-10-03 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-10-02 | 2023-10-03 | Y |
| 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 | 2023-10-02 | 2023-10-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-02 | 2023-10-03 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-29 | 2023-10-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-29 | 2023-10-03 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2023-06-21 | 2023-07-20 | Y |
| 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 | 2023-06-21 | 2023-07-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-24 | 2023-06-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-23 | 2022-08-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-05 | 2022-08-06 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-08-05 | 2022-08-06 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-08-05 | 2022-08-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-05 | 2022-08-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-05 | 2022-08-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-05 | 2022-08-06 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-08-05 | 2022-08-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-04 | 2022-08-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-04 | 2022-08-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-16 | 2022-08-01 | Y |
| 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 | 2022-06-16 | 2022-08-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-16 | 2022-08-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-16 | 2022-07-13 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-06-16 | 2022-06-17 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2022-06-16 | 2022-06-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-16 | 2022-06-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-16 | 2022-06-17 | Y |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-06-16 | 2022-06-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-03 | 2021-12-01 | Y |
| Post nurse staffing information every day. | Health | 2021-11-03 | 2021-12-01 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-11-03 | 2021-12-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-03 | 2021-12-01 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-09-10 | 2021-10-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-05 | 2021-10-04 | Y |
| 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 | 2021-05-07 | 2021-06-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-07 | 2021-06-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-07 | 2021-06-28 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-06 | 2021-05-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-05-06 | 2021-05-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-05-06 | 2021-05-20 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-05-07 | 2021-05-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-07 | 2021-05-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-05-06 | 2021-05-14 | N |
