Creekview Skilled Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to administer and/or clarify doctor's order for Furosemide (commonly known as Lasix, which is used to remove excess fluids in the body) medication when one of 17 sampled residents (Resident 2) had pitting edema (swelling due to fluid buildup, where pressing the swollen area leaves an indentation or a pit) in both legs for 17 days. Resident 2 had a primary diagnosis of heart failure (a chronic condition in which heart does not pump blood effectively). This failure placed Resident 2 at risk for further increased edema, increased discomfort, skin breakdown, complications related to heart failure such as fluid accumulation in the lungs, shortness of breath, upto and including death. Findings: During a record review of Resident 2's admission Record (a record with resident's basic information) printed on 2/27/25, the record indicated Resident 2 was admitted to the facility on [DATE]. During a record review of Resident 2's Minimum Data Set (MDS, an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure kitchen staff were competent in job duties related to: 1. using the three compartment sink; 2. testing the sanitizer liquid in the red sanitization bucket; and 3. cleaning the juice machine. These failures have the potential for improper cleaning and sanitization which could lead to increased risk for food-borne illness for 45 residents who received food from the kitchen out of a facility census of 51. Findings: 1. During a concurrent observation and interview on 04/11/23, at 09:37 a.m., with Utility Worker (UW) and the Food and Nutrition Services Director (FNSD) in the kitchen dishwashing area, FNSD stated the 3-compartment sink is a back-up for washing dishes if the dish machine did not work. She stated UW was a dishwasher and would be responsible for cleaning dishes in the 3-compartment sink if needed. UW stood in front of the 3-compartment sink and spoke to how she would clean dishes and utensils in the sink. On the wall, above the 3-compartment sink, was a sign with directions on sink use. UW…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food safely when: 1. Meat was not thawed according to storage guideline dates; 2. kitchen staff did not follow appropriate hand hygiene and glove use procedures when going between and handling dirty dishes and clean dishes; 3. Three out of 5 storage bins for bulk dry goods had crumbling plastic liners; 4. Four out of 12 pairs of tongs and 1 ladle had cracked handles; 5. 2 of 2 Ice machines in the kitchen and nourishment room had rough, discolored surfaces on ceiling of the ice bin where ice was stored; and 6. Food in resident's refrigerator was undated for one out of 2 residents (Resident 14) and food was kept more than 3 days for one out of 2 residents (Resident 351). These failures has the potential of placing the 45 residents who received food from the kitchen at risk for foodborne illnesses out of a census of 51. Findings: 1. During a concurrent observation and interview on 04/10/23, at 09:54 a.m., with Sous Chef (SC) and Food and Nutrition Services Director (FNSD),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review, the facility failed to ensure infection control practices were implemented when the following was noted for eight of eight residents: 1. An unlabeled bedpan and basin were observed in the shared bathroom of Residents 14 and 34. A yellow basin labeled for Resident 34 was on the floor in the Resident's shared bathroom. 2. Resident 34's feeding pump had tannish-brown residue in the tubing channel and flaky, light brown residue on the base of the pole. 3. Resident 17's wheelchair had torn armrests and dried, flaky reddish-brown matter and white staining on the seat and in the metal frame. 4. The facility did not have appropriate isolation precaution signage for four of four sampled residents (2, 21, 100 and 349). 5. Certified Nurse Assistant 1 (CNA 1) and Certified Nurse Assistant 2 (CNA 2) did not perform hand hygiene and or change gloves during peri-care for Resident 8. These failures placed the facility's residents at risk for healthcare-associated infections.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to store and label medication in accordance with standards of practice by failing to date three open bottles of medications (sodium chloride, milk of magnesia and bismuth subsalicylate), and one open container of blood sugar test strip for two of three medication carts inspected. This failure had the potential to result in medications and test strip used to not be effective. Findings: During a concurrent observation and interview of medication cart 3 on 4/11/23, at 10:40 a.m., with LVN 2, LVN 2 pulled from medication cart drawer one bottle of sodium chloride (salt - an essential compound a body uses to function) and one container of blood sugar test strip (the strip work with glucose meters to read blood sugar levels) had no open date. LVN 2 stated, the standard practice was to date the bottles right away. During an interview on 4/12/23, at 1:45 p.m., with the Director of Nursing (DON), DON stated, medication bottles including blood sugar test strip should be labeled immediately with open date because…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure dignity and maintain privacy for one of three sampled residents (Resident 14), when Resident 14's uncovered care instructions were posted above the bed visible to anyone entering the room. This failure resulted in a lack of dignity and privacy for Resident 14. Findings During a review of facility's admission Record for Resident 14, dated 4/12/23, Resident 14 was readmitted 11/22. During a review of Resident 14's Minimum Data Set (MDS - an assessment tool used to guide care) assessment dated [DATE], Section C showed a Brief Interview for Mental Status (BIMS - an assessment tool used to evaluate mental status) score of 2 out of 15, indicating severely impaired mental status. During an observation on 4/10/23, at 10:47 a.m., in Resident 14's room, care instructions labeled Strict Aspiration Precautions were posted on the wall above the head of Resident 14's bed. The instructions were not covered and stated, Diet Texture: thin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to reconcile controlled substances (a drug subject to special handling, storage, and disposal because of its potential for abuse or addiction) for one of 51 residents (Resident 37). This failure had the potential for the loss or diversion of controlled substances. Findings: During a concurrent observation and record review on 4/11/23, at 11:17 a.m., with RN 1, Resident 37's Controlled Drug Record (CDR) for morphine sulfate (a controlled medication used for moderate to severe pain) 0.25 ml (milliliters - a unit of measurement), dated 4/4/23, was reviewed. The CDR indicated as follows: 4/4/23; PM; 0.25ml; 16 ml remaining. An observation of morphine bottle container showed, 14 ml remaining. During a subsequent interview with RN 1, RN 1 stated the amount remaining in the morphine bottle did not match the CDR. RN 1 further added, she did not do narcotic count with the going off duty nurse. During an interview on 4/12/23, at 1:27 p.m., with the Director Of Nursing (DON), DON confirmed Resident 37's morphine bottle did…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure menu was followed when one of 51 residents (Resident 4) was given pureed broccoli instead of minced and moist broccoli. This failure has the potential for one of 51 residents to not get the type of food texture as indicated on the planned menu which could compromise the resident's intake of food and nutritional status. Findings: A review of the cook spreadsheet menu titled Daily Spreadsheet dated for 4/11/23, and used for lunch, the spreadsheet indicated a minced and moist diet receives minced and moist (food cut into very small pieces, less than 1/8 inch pieces; minimal chewing is required) seasoned broccoli florets. A review of Resident 4's diet card, dated 04/12/23, indicated [ .]3) Minced and most or mashed chilled steamed vegetables [ .]. During a concurrent observation and interview on 04/11/23, at 11:46 a.m., at tray line, Dietary Aide (DA 1) was looked at tray tickets and called out diets to [NAME] 1. [NAME] 1 then placed hot food on resident plates according to the diet DA 1 called out. [NAME]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to implement its COVID-19 [Coronavirus disease] Vaccination policy and procedures to ensure two of two sampled Residents (46 and 249) were fully vaccinated for Coronavirus Disease-19 (an acute respiratory illness with fever, cough, and capable of progressing up to and including death). This failure resulted in Residents 46 and 249 to be unaware of the risks and benefits associated with the COVID-19 vaccine. Findings During a review of the Resident 46's admission Record printed on 04/13/23, the record showed Resident 46 was admitted to the facility 03/23. During a review of the Resident 249's admission Record printed on 04/13/23, the record showed Resident 249 was admitted to the facility 02/23. During an interview and record review on 04/12/23, at 09:56 a.m., the Director Nursing (DON) was asked to provide a list of unvaccinated residents. DON stated Resident 46, Resident 249 were unvaccinated, and they did not have a pending and/ or granted exemptions for COVID-19 vaccination. The DON stated facility expected all resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to prepare and serve food under sanitary conditions when: 1. Two male dietary staff did not cover their beards while working in the kitchen; and 2. Two ice machines (one in the kitchen and one in the front Nursing Station) had brownish/black substances in the ice bins. This failure resulted in all 54 residents of the facility receiving food prepared under conditions not meeting professional standards and had the potential to cause food-borne illnesses. Findings: 1. During a dietary observation with the Director of Dietary Services (DDS) and concurrent interviews with Kitchen Utility Staff 1 (KU 1) and [NAME] 3 on 11/13/19 at 11:20 a.m., KU 1 was in the kitchen with his hairnet on but his overgrown beard was uncovered. KU 1 indicated the DDS did not tell him to wear a beard guard, and stated, I don't cook, but I work inside the kitchen. I know I should cover my beard or just shave it. [NAME] 3 was observed walking around in the kitchen with his beard uncovered. [NAME] 3 indicated this was the first time he had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, for one of 14 sampled residents (Resident 43) the facility failed to provide appropriate treatment and services to a resident with an indwelling catheter (a tube inserted into the body that drains the urine into an external bag) when facility staff failed to monitor the resident's intake (the measurement of fluids taken into the body) and the output (the measurement of fluids expelled from the body). This failure had the potential to negatively impact Resident 43's existing urinary conditions. FINDINGS: A review of Patient 43's admission Record indicated Resident 43 was admitted with multiple diagnoses, including Benign Prostatic Hyperplasia (an enlarged prostate gland that can cause urinary symptoms such as blocking the flow of urine out of the bladder) with lower urinary tract symptoms, a urinary tract infection, retention of urine (the inability to completely empty the bladder of urine), and a flaccid neuropathic bladder (impairment of the bladder function due to nerve damage). A review of Patient 43's Minimum Data Set (MDS, an assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 144) received appropriate medical care when oxygen was administered to Resident 144 without a physician's order. This failure placed Resident 144 at risk for a delay in identifying or treating any adverse effects from oxygen therapy. Findings: A review of Resident 144's admission Record indicated Resident 144 was admitted to the facility for hospice care with multiple diagnoses, including acute respiratory failure with hypoxia (a low oxygen level), acute respiratory distress, and lung cancer that had spread to the bone. During an observation and concurrent interview with Resident 144 on 11/12/19 at 11:50 a.m., Resident 144 was wearing a nasal cannula (tubing that fits in the nares) and receiving oxygen at 4 liters per minute. Resident 144 stated he had been receiving oxygen since he was admitted to the facility at the beginning of the month. A review of the Order Summary Report in Resident 144's medical record indicated there was no physician's order for oxygen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.