Creekside Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of one resident (Resident 4) reviewed for pressure ulcers (a localized injury to the skin and/or underlying tissue resulting from pressure on the skin) received care for skin breakdown as specified in the resident's care plan (an individualized plan for the medical care of a resident) and physician's orders when there was no documented evidence to indicate Resident 4 received physician ordered wound care treatment for multiple days in May, June, and July 2025.This failure had the potential for Resident 4 to experience worsening pressure ulcer wounds and delayed wound healing.A review of Resident 4's admission Record (contains medical and demographic information), indicated Resident 4 was initially admitted on [DATE], with diagnoses which included cerebral palsy (a neurological disorder that affects movement, posture, and muscle tone), multiple sclerosis (a condition that affects your brain and spinal cord [central nervous system]), and…

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 one of two residents (Resident 43) reviewed for environment/accidents was free from accident hazards when Resident 43 fell from bed while receiving care from a Certified Nursing Assistant (CNA) on April 22, 2025.This failure may have contributed to Resident 43 to experience uncontrolled pain in the resident's coccyx area (often referred to as the tailbone, a small bone at the base of the spine) which resulted in the resident needing treatment and evaluation at a hospital.A review of Resident 43's admission Record (contains medical and demographic information), indicated Resident 43 was initially admitted on [DATE], with diagnoses which included osteomyelitis of vertebra (infection of the spine), dependence on respirator [ventilator] (ventilator- a machine which helps a person to breathe) status (refers to a patience reliance on a mechanical ventilator to breathe due to impaired lung function).During a review of Resident 43'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure their manual resuscitation (process of assisting or taking over a patient's breathing using a handheld device) policy was implemented for one of three residents (Resident 4) reviewed for respiratory care, when Resident 4 did not have an Artificial Manual Breathing Unit bag (AMBU bag - a hand-held medical device used to provide respiratory support to patients who are not breathing or are having difficulty breathing. Also known as a bag-valve-mask (BVM) or a manual resuscitator) at the bedside.This failure had the potential for Resident 4 to receive delayed emergency resuscitative measures during an emergency as a result of not having the required medical equipment immediately available.A review of Resident 4's admission Record (contains medical and demographic information) indicated Resident 4 was initially admitted on [DATE], with diagnoses which included acute respiratory failure with hypoxia (a condition where the lungs cannot…

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 interview and record review, the facility failed to ensure the documentation in the Electronic Health Record (EHR) was accurate for one of four residents (Resident 4) reviewed for advance directives (a legal document that outlines a person's healthcare wishes in the event that they become unable to make medical decisions for themselves due to illness, injury, or incapacity) when Resident 4's code status (refers to a patient's preferences regarding cardiopulmonary resuscitation [CPR] and other life-sustaining measures in the event of cardiac or respiratory arrest) contradictorily indicated Resident 4 was both Do Not Resuscitate (DNR - a medical order that instructs healthcare providers not to perform CPR if a patient's heart stops or breathing ceases) and Full-Code (indicates a patient's wish to receive all possible medical interventions, including CPR in the event the heart stops or breathing ceases).This failure had the potential for Resident 4 to receive end of life care not in accordance with their…

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 facility staff follow the Infection Control Policies and Procedure 's standards for Transmission-Based Precautions (actions implemented in addition to standard precautions that are based upon the means of transmission in order to prevent or control infections) when a staff member was observed entering a Contact Precaution (measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment) room without wearing the required Personal Protective Equipment (PPE- protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-transmission.). This failure had the potential to place all residents, visitors, and staff at risk of being exposed to a contagious disease (illness caused by the spread of germs) that could compromise their health.Findings: During a review of…

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 appropriate treatment and management of a gastrostomy tube (G-tube- tube inserted through the abdomen into the stomach that delivers nutrition, hydration, and medications) was implemented in accordance with the facility's policy and procedure for three of six residents (Residents 18, 19, and 6) reviewed for g-tube when a Licensed Vocational Nurse (LVN 2) did not check Residents 18, 19, and 6's G-tube placement (listening to gurgling sound when flushing air through the g-tube to confirm for correct position) before administering medications. These failures had the potential to place Residents 18, 19, and 6 at increased risk of aspiration (when food or liquids enter the lungs). Findings: 1. During a review of Resident 18's admission Record (contains demographic and medical information), it indicated Resident 18 was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure with hypoxia (condition…

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 medications being received by the residents were explained prior to administration to three of eight residents (Residents 18, 19, and 6) reviewed for medication administration. These failures had the potential to result in Residents 18, 19, and 6 being denied their right to know what medication is being given and breaking one of the seven rights of medication administration. Findings: 1. During a review of Resident 18's admission Record (contains demographic and medical information), it indicated Resident 18 was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure with hypoxia (condition where there is not enough oxygen in the body), other seizures (sudden, uncontrolled burst of electrical activity in brain), and chronic obstructive pulmonary disease (chronic inflammatory lung disease that obstructs airflow). An observation of medication administration for Resident 18 by LVN 2 was June 4,…

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 storage of medications was secure for one of one medication room, when the medication refrigerator inside the medication room was found unlocked. This failure had the potential to increase the risk of unauthorized access, misuse, and/or harm to highly vulnerable population of 49 residents. Findings: During a concurrent observation and interview, on June 3, 2024, at 10:24 AM, with the Infection Preventionist (IP), the medication room was inspected. The medication refrigerator was unlocked. The IP acknowledged the finding and stated the refrigerator needs to be locked when not in use. During a concurrent interview and record review, on June 4, 2024, at 9:24 AM, with the Director of Nursing (DON), the DON reviewed and acknowledged the facility's undated policy and procedure (P&P), titled Policy and Procedure for Med Pass, and stated that based on the P&P for medication storage the medication refrigerator should also always be locked. During a review of the facility's undated policy and procedure (P&P),…

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 document the Restorative Nursing [nursing interventions that promote the residents' ability to adapt and adjust] Weekly Summary for one of six residents (Resident 6) reviewed for limited range of motion (ROM- full movement potential of a joint.). This failure had the potential to result in inaccurate progress or regression in range of motion exercises which could negatively impact the range of motion for Resident 6. Findings: During an observation on June 3, 2024, at 11:16 AM, in Resident 6's room, Resident 6 was laying down in bed with a stuffed plush carrot toy in his right hand and splint (strip of rigid material used for supporting a bone) on the left hand. During a review of Resident 6's admission Record (contains demographic and medical information, it indicated Resident 6 was admitted to the facility on [DATE], with diagnoses of anoxic brain damage (complete lack of oxygen to the brain causing death of brain cells), cerebral…

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 one of three residents (Resident 2) call light remained within reach and accessible for a distressed resident (Resident 2) while in bed. This failure resulted in Resident 2 ' s needs not being met in a timely manner and deprived this mentally compromised resident of assistance when needed. Findings: During a review of Resident 2's clinical record, the face sheet (contains demographic and medical information), indicated Resident 2 was initially admitted on [DATE], with diagnoses which included: Anxiety, Depressive disorder, schizoaffective disorder (mental illness that can affect your thoughts, mood, and behavior) and palliative care (relieving the symptoms of an incurable medical condition using comfort measures). During a concurrent observation and interview with Resident 2, on February 15, 2024, at 12:07 PM, Resident 2 is observed shaking, crying, and wearing a sweatshirt with sweatpants. Resident 2 states, I need to get…

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 interview and record review, the facility failed to ensure three medications were administered to the appropriate resident for one of three residents (Resident 1). This failure had the potential to affect Resident 1's respiratory function and overall health and safety. Finding: An abbreviated survey was conducted on August 4, 2023, at 11:20 AM to investigate a complaint related to quality of care. During a review of Resident 1's clinical record, the face sheet indicated Resident 1 was admitted on [DATE], with diagnoses, which included Myocardial Infarction (Heart attack), Cerebral Vascular Accident (an interruption in the flow of blood to cells in the brain). During review of the clinical record for Resident 1, the Incident Note dated July 30, 2023, at 2:08 pm by the Director of Nursing (DON) indicated, Notified by RN regarding administering another residents' medications (Hydromorphone 4mg (a powerful pain killer), Cymbalta 60mg (used for treatment of depression and anxiety), and baclofen 20mg (a…

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, staff interview, and record review, the facility failed to prevent entry of outside contaminants into the bulk container of thickener (a starch added to liquids and foods to make it firmer). This failure had the potential to cause contamination of food prepared with thickener, and possible foodborne illness in 47 of 48 medically compromised residents who received food from the kitchen. Findings: During a concurrent observation and interview on March 14, 2022, at 8:26 AM, with the Dietetic Services Supervisor (DSS), in the kitchen, the bulk container of thickener had multiple dark crumbs mixed in with the white thickener. The DSS stated that the thickener should not be like that. During a review of the Food and Drug Administration (FDA) Federal Food Code 2017, 3-701.11 indicates A food that is unsafe, adulterated, or not honestly presented . shall be discarded or reconditioned according to an approved procedure. In addition, 3-201.11 indicates, it is also critical to monitor food products to ensure that, after harvesting and processing, they do not fall victim…

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 did not properly dispose of trash when the outside garbage bin for trash was overflowing, and the lid was not closed for one of one dumpster. This failure had the potential to attract vermin (pests or nuisance animals that spread diseases) in a facility that cares for 48 medically compromised residents. Findings: During a concurrent observation and interview on March 14, 2022, at 10:43 AM, with the Dietetic Services Supervisor (DSS), in the outdoor garbage storage area, the trash dumpster was overflowing with garbage, and the lids were not closed. The DSS stated that the trash should not be overflowing, and the lids should be closed. During a review of the facility's policy and procedure (P&P) titled, Sanitation: Garbage and Trash, dated 2018, indicated, Garbage and trash cans must be inspected daily that no debris is on the ground or surrounding area, and that the lids are closed.

Based on observation, interview, and record review, the facility failed to follow their daily menu for lunch on March 15, 2022, by substituting the penne pasta with mashed potatoes for three of three puree (food is blended until it is a thick, smooth, lump-free consistency) lunch trays. Puree mashed potatoes were also served according to the menu on March 14, 2022. This failure had the potential for residents to lose their appetite because they were served the same starch two times in a row, which could compromise the nutritional status of three of three residents (Residents 6, 11, and 28) who are medically compromised. Findings: During a concurrent observation and interview on March 15, 2022, at 1:10 PM, with the Dietetic Services Supervisor (DSS), in the hallway directly outside of the kitchen, the lunch test trays for the regular and puree diet were observed to have two different food items. The regular lunch tray had penne pasta and the puree tray had mashed potatoes. The DSS stated the cook should follow the menu and the spreadsheet for the regular and puree diet. During a…

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 the proper consistency of the spinach served on the puree (food is blended until it is a thick, smooth, lump-free consistency) lunch trays for three of three residents (Residents 6, 11, 28). This failure had the potential to cause difficulties in swallowing and possible aspiration (when something swallowed enters the airway or lungs) in these medically compromised residents. Findings: During a concurrent observation and interview on March 15, 2022, at 10:55 AM, with Kitchen Aide (KA), in the kitchen, the KA was observed preparing pureed meatballs for lunch. She stated the pureed should be the consistency of ice cream or mashed potatoes. During a concurrent observation and interview on March 15, 2022, at 1:10 PM, with the Dietetic Services Supervisor (DSS), in the hallway directly outside the kitchen, the spinach on the puree lunch test tray was watery in consistency and spread out on the plate. The DSS stated that it should not be like that, it should be thicker. During a review of a facility document…

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 established and maintained to provide a safe, sanitary, and comfortable environment to help prevent the possible development and transmission of a Coronavirus, COVID-19 (a highly contagious respiratory infection) when, three nursing staff were observed not following proper personal protective equipment, PPE (equipment and cloths for protection against infectious diseases) guidelines when entering rooms in yellow zone (Residents under isolation observation for suspected COVID-19). This failure had the potential to result in the spread of Coronavirus (COVID-19) infection to 48 medically compromised residents. Findings: During an observation on March 14, 2022, at 10:35 AM, in room102, an isolation room, a Licensed Vocational Nurse (LVN 2) was entering a room without wearing an N-95 respirator. During an observation on March 14, 2022, at 11:00 AM, in room [ROOM NUMBER], a resident in the yellow zone,…

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 an antibiotic stewardship program (an effort to measure and improve how antibiotics are prescribed by physicians and used by residents) when Resident 29 was prescribed antibiotics and there were no criteria used to ensure that they had been prescribed appropriately. This failure had a potential to ineffectively treat infections, protect patients from harm caused by unnecessary antibiotic use and combat antibiotic resistance, for one resident reviewed for antibiotics. Findings: During a review of Resident 29's medication orders, it was noted that he had been prescribed Keflex (a medication used for infections) 500 mg (mg-unit of measurement) twice a day. There was no evidence that he had been screened and met criteria for antibiotic use per the facility policy. During an interview on March 16, 2022, at 9:47 AM, with a Licensed Vocational Nurse (LVN 3), she stated the physician orders antibiotics, but I don't know what an antibiotic stewardship program is. During an interview on March 17, 2022, at 1:20 PM, with…

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 respect the rights and dignity of one resident (Resident 15) reviewed for urinary catheter, when Resident 15's urinary catheter bag (a hollow, flexible tube that collects urine from the bladder and leads to a drainage bag) was not covered with a dignity bag and was visible to public view. This failure had the potential to compromise Resident 15's dignity and violate his right to privacy. Findings: During an observation in Resident 15's room, on March 15, 2022, at 9:05 AM, Resident 15 was lying in bed in a semi upright position. Resident 15's urinary catheter bag was hanging on the right side of the bed. It was not covered with a dignity bag and was visible to public view. During a follow up observation and concurrent interview with a Certified Nursing Assistant (CNA 1), on March 16, 2022, at 1:46 PM, in Resident 15's room, Resident 15's urinary catheter bag was hanging on the right side of the bed, uncovered and was visible to public…

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 accurately code the Minimum Data Set (MDS - resident care assessment tool) for two of 18 sampled residents (Residents 17 and 42). These failures had the potential to result in unmet care needs for Residents 17 and 42, which could adversely affect their safety and health. Findings: 1. During an observation on March 16, 2022, at 6:51 AM, at Resident 17's room, Resident 17 was lying in bed in an upright position, watching television. During a review of Resident 17's clinical record, the face sheet (contains demographic and medical information) indicated Resident 17 was initially admitted to the facility on [DATE], with diagnoses that included liver cirrhosis (late-stage liver disease in which healthy liver tissue is replaced with scar tissue and the liver is permanently damaged), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interferes with one's daily activities).…

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 implement the Registered Dietician's (RD) recommendations for one of four residents sampled (Resident 11) when she lost 5 pounds each month since her admission date of December 29, 2021. The RD recommended that nursing document how many milliliters (mL) of a nutritional supplement (Resource 2.0) the resident consumed and for Resident 11 to be seen by a Speech-Language Pathologist (SLP) for evaluation. This failure had the potential to cause further impaired nutrition and weight loss in Resident 11 who is medically compromised. Findings: During a review of Resident 11's admission Record, it indicated Resident 11 was admitted to the facility on [DATE] with diagnoses of dysphagia following cerebral infarction (difficulty swallowing after suffering an illness in which part of the brain loses its blood supply). During a review of Resident 11's Weights and Vitals Summary, dated March 16, 2022, indicated Resident 11 weighed: 155 pounds on…

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 interview, and record review, the facility failed to ensure narcotics (government controlled medication due to its addictive nature) used to relieve pain was signed on the resident's electronic medication administration record (E-MAR) as given for one of eighteen sampled resident (Resident 33). This failure had the potential for drug diversion, theft, and loss of the controlled medication that could affect the health and safety of Resident 33. Findings: During the review of Resident 33's Face Sheet, (which contains resident demographic and medical information) indicated, the resident was admitted on [DATE], with the diagnoses of Paraplegia (the loss of ability to move parts of the body), anxiety (mental health disorder, feelings of worrying), and muscle spasm. During a review of Resident 33's physician orders, dated, March 2022, indicated Hydrocodone/Acetaminophen 10/325 mg (narcotic pain medication), give one tablet by mouth every six hours as needed for severe pain. During a review of the facility'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 ensure that medication was secured to be administered per the facility policy, when Silvadene Cream® (a topical medication used commonly on wounds to prevent and treat infections) was left unattended on the bedside table of one out of 18 sampled residents (Resident 12). This had the potential to cause harm due to medication being accessible to staff and residents who lacked knowledge, training, and the necessary qualifications to administer medication. Findings: During an observation on March 14, 2022, at 9:10 AM, in the resident's room, it was noted that Silvadene cream® had been left unattended on the bedside table next to Resident 12. During an interview on March 14, 2022, at 9:12 AM, with Resident 12, he stated, That's [name of Registered Nurse] (RN1), she left the cream. she's too lazy to put it on me herself, so she leaves it there for the CNA (certified nursing assistant) to apply it. During an interview on March 14, 2022, at 9:18 AM, with a certified nursing assistant (CNA 1), she stated the…

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.