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Creekside Center For Rehabilitation And Nursing

Inspection Results

Nursing Homes Maryland Hagerstown Creekside Center For Rehabilitation And Nursing

Creekside Center For Rehabilitation And Nursing has been cited for a total of 153 deficiencies since we began saving each survey. We believe it is worthwhile to show how things are and were. Some improve and some get worse. Rather than a snapshot, we take s longer view than most. A longer view, we believe, paints a better and more worthwhile picture. We start from them most recent and go back as you scroll down.

Tip: Surveys happen throughout the year and you may want to check with the location or here to see if more recent data is available for Creekside Center For Rehabilitation And Nursing.

Since we bagan longer term (multi year tracking, numbers will naturally be higher than 3 (or so surverys).
There are 238 nursing homes in Maryland with a total of 18,830 deficiencies resulting in an average of 79.12 deficiencies per nursing home.

The following table describes how deficiencies are scored. An easy way to remember the severity of a deficiency's scope is that the further along in the alphabet (A through L) the scope value is, the more severe the deficiency is.
Additionally, A through F means no actual harm has happened.

Table describing the severity and scope of deficiencies

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Deficiency Cited, Scope, survery date, stems from a complaint, and Date of Correction
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
N
Standard:
N
Survey Date:
2020-07-23
Corrected:
2020-08-25
Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Honor the resident's right to organize and participate in resident/family groups in the facility.
Category:
Resident Rights Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Protect each resident from the wrongful use of the resident's belongings or money.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Respond appropriately to all alleged violations.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
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.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-11-19
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
J
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Provide enough food/fluids to maintain a resident's health.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category:
Nursing and Physician Services Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-11-19
Post nurse staffing information every day.
Category:
Nursing and Physician Services Deficiencies
Scope:
C
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-11-19
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-11-19
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.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Ensure medication error rates are not 5 percent or greater.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-11-19
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-11-19
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category:
Administration Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Honor the resident's right to organize and participate in resident/family groups in the facility.
Category:
Resident Rights Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Protect each resident from the wrongful use of the resident's belongings or money.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Respond appropriately to all alleged violations.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
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.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-11-19
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
J
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Provide enough food/fluids to maintain a resident's health.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category:
Nursing and Physician Services Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-11-19
Post nurse staffing information every day.
Category:
Nursing and Physician Services Deficiencies
Scope:
C
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-11-19
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-11-19
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.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Ensure medication error rates are not 5 percent or greater.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-11-19
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-11-19
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category:
Administration Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2019-07-25
Corrected:
2019-09-25
Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Category:
Resident Rights Deficiencies
Scope:
C
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
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.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Ensure each resident receives an accurate assessment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Honor each resident's preferences, choices, values and beliefs.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Category:
Nursing and Physician Services Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Category:
Nursing and Physician Services Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Observe each nurse aide's job performance and give regular training.
Category:
Nursing and Physician Services Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
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.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Ensure medication error rates are not 5 percent or greater.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
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.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Provide timely, quality laboratory services/tests to meet the needs of residents.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Provide routine and 24-hour emergency dental care for each resident.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Have a plan that describes the process for conducting QAPI and QAA activities.
Category:
Administration Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Category:
Resident Rights Deficiencies
Scope:
C
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
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.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Ensure each resident receives an accurate assessment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Honor each resident's preferences, choices, values and beliefs.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Category:
Nursing and Physician Services Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Category:
Nursing and Physician Services Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Observe each nurse aide's job performance and give regular training.
Category:
Nursing and Physician Services Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
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.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Ensure medication error rates are not 5 percent or greater.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
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.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Provide timely, quality laboratory services/tests to meet the needs of residents.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Provide routine and 24-hour emergency dental care for each resident.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Have a plan that describes the process for conducting QAPI and QAA activities.
Category:
Administration Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2018-02-05
Corrected:
2018-03-28
Let residents voice a complaint or grievance without being treated differently or badly.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Allow residents to easily view the results of the nursing home's most recent inspection.
Category:
Resident Rights Deficiencies
Scope:
C
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-27
Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Provide housekeeping and maintenance services.
Category:
Environmental Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Conduct initial and periodic assessments of each resident's functional capacity.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Review or revise the resident's care plan after any major change in physical or mental health.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Ensure each resident receives an accurate assessment by a qualified health professional.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Allow residents the right to participate in the planning or revision of care and treatment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Provide care by qualified persons according to each resident's written plan of care.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
Category:
Environmental Deficiencies
Scope:
G
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Ensure that residents are safe from serious medication errors.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Have enough nurses to care for every resident in a way that maximizes the resident's well being.
Category:
Nursing and Physician Services Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Store, cook, and serve food in a safe and clean way.
Category:
Nutrition and Dietary Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Have a program that investigates, controls and keeps infection from spreading.
Category:
Environmental Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Category:
Environmental Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
Category:
Administration Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Let residents voice a complaint or grievance without being treated differently or badly.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Allow residents to easily view the results of the nursing home's most recent inspection.
Category:
Resident Rights Deficiencies
Scope:
C
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-27
Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Provide housekeeping and maintenance services.
Category:
Environmental Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Conduct initial and periodic assessments of each resident's functional capacity.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Review or revise the resident's care plan after any major change in physical or mental health.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Ensure each resident receives an accurate assessment by a qualified health professional.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Allow residents the right to participate in the planning or revision of care and treatment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Provide care by qualified persons according to each resident's written plan of care.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
Category:
Environmental Deficiencies
Scope:
G
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Ensure that residents are safe from serious medication errors.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Have enough nurses to care for every resident in a way that maximizes the resident's well being.
Category:
Nursing and Physician Services Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Store, cook, and serve food in a safe and clean way.
Category:
Nutrition and Dietary Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Have a program that investigates, controls and keeps infection from spreading.
Category:
Environmental Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Category:
Environmental Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
Category:
Administration Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-11-01
Corrected:
2017-01-12

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Creekside Center For Rehabilitation And Nursing

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