Creekside Transitional Care and Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview it was determined the facility failed to ensure infection control practices were implemented for a Pure Wick (female external catheter system). This was true for 1 of 1 resident (Resident #75) who used a Pure Wick. This failure created the potential for infection when Resident #75's Pure Wick tubing and canister was not maintained in sanitary conditions. Findings include: Resident #75 was admitted to the facility on [DATE], with multiple diagnoses including need for assistance with personal care and pressure ulcer to left buttocks. On 6/9/25 at 2:24 PM, Resident #75 was observed sitting in her wheelchair with her Pure Wick sitting on her nightstand. The canister was observed to be full with foul smelling, dark, cloudy urine and clear tubing connected to it. The tubing with visible urine inside it was observed to be resting on the nightstand. On 6/9/25 at 2:58 PM, LPN #2 confirmed the room smelled like urine and stated the Pure Wick canister and tubing…

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, policy review and staff interview, it was determined the facility failed to use appropriate personal protective equipment (PPE) while working in food preparation areas. The facility failed to ensure chemical level testing supplies were available to test the quaternary (sometimes called quat - a group of chemicals used for sanitization) in the sanitation compartment of a three-compartment sink. The facility failed to ensure clean pans were air dried prior to storage. These failures increased the risk of food borne illness for the 118 residents that consumed food prepared by the facility. Findings include: 1. The facility policy titled, Sanitary Standards- Dietary Personnel, dated 12/2023, documented the dietary personnel will wear hair restraints, such as hair nets, hats, and/or beard net coverings at all times while in food preparation areas. On 6/24/24 at 8:30 AM, [NAME] #2 was observed to have a beard and mustache and did not have a covering over their facial hair while working in a food preparation area. On 6/24/24 at 8:34 AM, Dietary Aide #1 was observed to…

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,policy review, and staff interview, it was determined the facility failed to ensure garbage was contained and disposed of properly. This failure put all residents, staff, and guests in danger of illness or harm due to the increased the risk for pests and rodents to be present on the property. Findings include: A facility policy titled Garbage and Rubbish Disposal, dated 10/2023, documented garbage will be stored to be inaccessible to vermin and the dumpsters outside must be kept closed and free of litter around the dumpster area. On 6/24/24 at 8:37 AM, two dumpsters were observed outside the facility. Dumpsters #1 and #2 had two lids each, both lids on both dumpsters were open and exposed the garbage within. The lid on the right side of dumpster #2 had bags of garbage preventing the lid from closing. [NAME] #2 was observed placing flattened cardboard into the right side of dumpster #2 then began to walk toward the facility; at this time, [NAME] #1 directed [NAME] #2 to close the dumpster and reminded them the dumpster lids must always be closed. On 6/24/24 at…

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 record review, policy review, and staff interview, it was determined the facility failed to ensure a bed hold notice was provided to residents and/or their representatives upon transfer to the hospital. This was true for 2 of 5 residents (#81 and #99) reviewed for hospital transfers. This deficient practice created the potential for harm if residents and/or their representatives were not informed of the residents' rights to return to their former bed/room at the facility within a specified time. Findings include: The facility's Admission/Discharge/Transfer policy and procedure, revised 10/2023, documented the resident or their representatives shall be informed in writing, of their right to exercise the bed hold provision in the event of a transfer from the facility to a general acute care hospital or for a therapeutic leave. 1. Resident #81 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including dementia, diabetes, and metabolic encephalopathy (disorders where…

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, record review, and resident and staff interview, it was determined the facility failed to honor residents' choices to have a pitcher of water on the bedside table in the resident's room. This was true for 1 of 1 resident (Resident #86) reviewed for choices. This failure created the potential for psychological harm when resident preferences were not honored. Findings include: The facility's Resident Rights policy and procedure, revised 12/2023, documented You have the right to self-determination through support of your choice, including the right to make choices about aspects of your life in the facility that significant to you. Resident #86 was admitted to the facility on [DATE], with multiple diagnoses including end stage renal disease and congestive heart failure (weakness of the heart leading to a buildup of fluid in the body). An annual MDS assessment, dated 6/6/24, documented Resident #86 was cognitively intact. A physician's order, dated 2/21/24, documented Resident #86 was to have…

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 record review and staff interview, it was determined the facility failed to ensure residents' MDS assessments had correct assessment information. This was true for 1 of 1 resident (Resident #116) whose record was reviewed. This failure created the potential for residents to not have their care needs met due to inaccurate assessments. Findings include: The RAI Manual, dated 10/23 indicated .It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT (Interdisciplinary Team) completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. Resident #116 was admitted to the facility on [DATE], with multiple diagnoses including stroke. A quarterly MDS assessment, dated 11/6/23,…

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, resident interview, family interview, Resident Group interview, test tray evaluation, and staff interview, it was determined the facility failed to ensure palatable food was served. This affected 3 of 5 residents (#25, #31, and #50) who were reviewed for dietary concerns. This failed practice created the potential to negatively affect residents' nutritional status and psychosocial well-being. Findings include: Residents and family were interviewed regarding the food. Examples include: * On 2/25/19 at 10:03 AM, Resident #31 said the food did not always taste good, the hot items were cold, the cold items were not cold, and the vegetables were mushy. * On 2/25/19 at 11:34 AM, Resident #50's daughter said she was a very picky eater and frequently complained about the food. * On 2/26/19 at 10:02 AM, during the Resident Group Interview, Resident #25 said the food did not taste good sometimes and could be cold, like the oatmeal served that morning. * On 2/28/19 at 10:28 AM, when asked about the facility's food, Resident #50 made an unpleasant face, said the food was…

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 record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents' medical records were accurately documented and documented in a timely manner after care and/or services were provided. This was true for 4 of 19 residents (#24, #31, #49 and #76) whose records were reviewed. This deficient practice created the potential for harm should inappropriate care and/or treatment be provided based on inaccurate information. Findings include: The facility's Health Information policy, dated 2016, documented: * Clinical health records are maintained in accordance with regulations and professional practice standards to provide complete and accurate information on each resident for continuity of care. * Avoid assuming the responsibilities of the other health care professionals in the facility. * The purpose of the clinical record is to document the course of the resident's plan of care and to provide a medium of communication among health care professionals…

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 record review, policy review, resident interview, and staff interview, it was determined the facility failed to ensure a resident received showers as he desired and as care planned. This was true for 1 of 19 residents (Resident #24) reviewed for choices. This deficient practice had the potential for harm should a resident experience a decreased sense of well-being, lack of self-worth, and frustration when his desire to receive a shower was not accommodated. Findings include: The facility's Resident Care policy, revised 5/2007, documented showers and/or baths were provided to promote cleanliness, stimulate circulation, and assist in relaxation. The facility's policy for Monitoring of Resident Care, revised 5/2007, documented each resident would be provided with the necessary care and services to allow them to reach or maintain their highest practicable physical, mental, and psychosocial well-being, according to the comprehensive care plan. Residents would receive services with reasonable accommodation 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 staff interview, policy review, and record review, it was determined the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) was complete and accurate for 1 of 5 residents (Resident #24) whose PASRRs were reviewed. This failure created the potential for harm if residents required, but did not receive, specialized services for mental health while residing in the facility. Findings include: The facility's policy for PASRR, revised 10/2007, documented the following: * Each resident was appropriately screened using the PASRR as specified by the state. * Based on the assessment, the facility would ensure a proper referral was made to the appropriate state agency for specialized services for residents with mental illness/mental retardation. * Social Services would contact the appropriate state agency for a referral of specialized care and services the resident may need. Resident #24 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease 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 record review, policy review, and staff interview, it was determined the facility failed to develop and implement comprehensive resident-centered care plans that included a resident's code status. This was true for 1 of 19 residents (Resident #76) whose care plans were reviewed. This failure created the potential for residents to receive inappropriate or inadequate care and for their resuscitation code status to not be honored. Findings include: The facility's Comprehensive Care Planning policy, dated 8/2017, documented a comprehensive care plan would be developed to meet a resident's medical, nursing, mental, and psychosocial needs. Resident #76 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease. Resident #76's record documented she had a DPOA. Her POST, dated and signed by the DPOA on 11/15/18, documented her code status was a Full Code. Resident #76's physician orders, dated 11/15/18, documented her code status was a Full Code. Resident #76's care plan 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Resident #14 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease. Resident #14's quarterly MDS assessment, dated 1/2/19, documented she was cognitively intact and required oxygen therapy. Resident #14's care plan documented she had oxygen related to congestive heart failure, initiated on 12/5/18. The care plan also documented Resident #14 received oxygen continuously at 2 LPM by nasal cannula, initiated on 12/5/18 and revised on 12/13/18. Resident #14's physician orders, dated 10/25/18, documented oxygen was ordered at 3 LPM continuously. On 2/26/19 at 9:55 AM and on 2/26/19 at 10:38 AM, Resident #14 was in the community TV area with oxygen on at 2 LPM. On 2/27/19 at 10:35 AM, CNA #1 said Resident #14's oxygen was on at 2 LPM and it should have been at 3 LPM. On 2/27/19 at 10:42 AM, LPN #1 said Resident #14's oxygen should be on at 3 LPM, and she was responsible for adjusting the oxygen. On 2/27/19 at 11:22 AM, the DON said the nurse was responsible…

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, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure bathing and/or grooming and urinary care needs were provided consistent with residents' needs. This was true for 2 of 4 residents (#14 and #31) who were reviewed for ADL care. This failure created the potential for residents to experience skin breakdown and a negative effect to their psychosocial well-being when care was not provided as needed. Findings include: 1. The facility's Resident Care policy, dated 5/2007, directed staff to assist residents with bathing to promote cleanliness and to provide residents with the necessary care to maintain the highest practicable physical well-being. Resident #31 was admitted to the facility on [DATE], with multiple diagnoses including muscle weakness and difficulty in walking. Resident #31's quarterly MDS assessments, dated 10/4/18 and 1/2/19, documented she required extensive assistance of one-person with bathing and personal hygiene.…

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, record review, policy review, family member interview, and staff interview, it was determined the facility failed to ensure there was an ongoing activity program to meet individual and social needs for residents. This was true for 2 of 3 residents (#27 and #76) reviewed for activities. This failure created the potential for harm if residents experienced boredom and lacked meaningful engagement throughout the day. Findings include: The facility's Activity policy, dated 7/2007, documented the Activity Director was to consult with nursing staff to develop suitable activity plans, be informed of residents' changes, and for nursing to use the resident's care plan, and encourage them to participate in appropriate activities. 1. Resident #27 was admitted to the facility on [DATE], with multiple diagnoses including anxiety, major depression, dementia, and stroke affecting the left side. Resident #27's annual MDS assessment, dated 6/15/18, documented she was severely cognitively impaired, required…

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, record review, policy review, and staff interview, it was determined the facility failed to ensure neurological assessments were performed after a fall with trauma to the resident's head. This was true for 1 of 7 residents (Resident #56) reviewed for falls. These failures created the potential for harm should residents experience undetected changes in neurological status due to lack of appropriate assessment. Findings include: The facility's policy for Neurological Evaluation, dated 5/2007, documented the following: * All incidents that involved trauma to the head would have a comprehensive neurological assessment for a minimum of 72 hours. * The neurological evaluation would be performed by a licensed nurse. * Any resident who experienced an injury involving their head or an unobserved fall would have neurological assessments and vital signs taken at least every 8 hours for 24 hours, or per specific facility policy, or physician's order. * Comprehensive neurological assessments would be…

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, record review, policy review, and staff interview, it was determined the facility failed to ensure residents received appropriate care to prevent skin breakdown. This was true for 1 of 5 residents (Resident #76) reviewed for skin breakdown. This failure created the potential for harm if residents developed pressure ulcers. Findings include: The facility's Care and Treatment policy, dated 5/2007, documented a resident who enters the facility without pressure sores does not develop them and to implement appropriate resident care. Resident #76 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease, pain in both knees, and repeated falls. Resident #76's admission and quarterly MDS assessment, dated 11/22/18 and 12/19/18 respectively, documented she did not have pressure ulcers and required extensive assistance of one-person for bed mobility. Resident #76's physician orders, dated 11/15/18, documented to Bridge heels while in bed. Resident #76's care plan…

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, staff interview, record review, and policy review, it was determined the facility failed to ensure residents received treatment and services to prevent decrease in Range of Motion (ROM). This was true for 1 of 3 residents (Resident #27) reviewed for treatment and services related to ROM. This failure created the potential for harm when a therapy carrot (an orthotic device used to gently open the hand) was not implemented as ordered to prevent deterioration of existing contractures of the hand. Findings include: The facility's Restorative Care Program policy, undated, documented staff were to apply devices and splints according to therapy direction. Resident #27 was admitted to the facility on [DATE], with multiple diagnoses including stroke affecting the left side. Resident #27's quarterly MDS assessments, dated 11/14/18 and 2/14/19, documented she had an impairment to her upper extremity, required one-to-two staff with physical assistance for all ADLs, and was severely cognitively…

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, record review, policy review, resident interview, and staff interview, it was determined the facility failed to ensure fall prevention interventions were implemented as ordered following a fall. This was true for 1 of 7 residents (Resident #56) reviewed for falls. This failure had the potential for harm if residents sustained injuries from falling. Findings include: The facility's policy Fall Prevention, dated 5/2007, documented the following: * The facility would implement measures to decrease the incidence of additional falls and minimize the potential for injury. * If a resident experienced a fall, the care plan would be created or the existing care plan would be updated. Resident #56 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's disease, dementia, and repeated falls. Resident #56 received hospice services. A Fall Risk Evaluation, dated 1/16/19 at 5:35 PM, documented Resident #56 was at medium risk for falling. Resident #56's admission MDS…

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, record review, policy review, and staff interview, it was determined the facility failed to ensure residents received oxygen therapy per physician orders. This was true for 2 of 4 residents (#14 and #15) reviewed for oxygen therapy. This failure created the potential for harm if residents' respiratory needs were not met. Findings include: The facility's oxygen administration policy, revised 5/2007, documented staff were to administer oxygen therapy as ordered by the physician, reassess oxygen flowmeter for appropriate flow and document all appropriate information in the medical record. 1. Resident #15 was admitted to the facility on [DATE], with multiple diagnoses including chronic respiratory failure with hypoxia (low oxygen supply in body tissue). A physician order, dated 11/14/18, documented Resident #15 was to receive oxygen therapy continuously via nasal cannula at 2 LPM and staff were to monitor Resident #15 for signs and symptoms of respiratory distress. A quarterly MDS 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interview, policy review, and record review, it was determined the facility failed to ensure adequate communication was provided to a dialysis center. This was true for 1 of 1 resident (Resident #49) reviewed for dialysis. The failure created the potential for harm when the facility failed to communicate the resident's current care, access site, and vital signs to the dialysis center. Findings include: The facility's Dialysis policy, revised 5/2007, documented staff were to assess a resident's blood pressure (in the non-shunt arm) prior to being transported to the dialysis center. Resident #49 was admitted to the facility on [DATE], with multiple diagnoses including end stage renal disease. Resident #49's annual MDS assessment, dated 11/28/18, documented he was cognitively intact and received dialysis. Resident #49's care plan, dated 11/28/18, documented he received hemodialysis related to end stage renal disease and he had an arteriovenous (AV) fistula/graft (a surgically created…

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.