Creekside at the Springs

Inspectors wroteBased on observation, record review, and interview, it was determined that the facility failed to ensure a call light was kept within a resident's reach to allow the resident to summon assistance, and to provide prompt assistance to address a resident ' s pain and discomfort once requested for one (Resident # 62) of one sampled resident dependent on staff for assistance.

Inspectors wroteBased on record review and interview, the facility failed to ensure necessary care and services were provided including the monitoring of lab orders to ensure results were obtained in a timely manner, the physician was notified of results and treatment provided accordingly which resulted in hospitalization and subsequent death for 1 (Resident #70), as evidenced by: failure to monitor for return lab results; failure to appropriately assess and diagnose the symptoms of a urinary tract infection; failure to provide adequate treatment and services to reduce symptoms including confusion, disorientation, delusions, weakness, poor gait/imbalance, irregular heart rhythm and nausea which resulted in hospitalization and subsequent diagnosis of Sepsis for 1 (Resident #70) of 1 sampled resident with UA (urinalysis) culture orders. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure kitchen employees washed their hands and changed gloves between clean and dirty tasks; utilized food items were used prior to their expiration date to prevent food borne illness; the kitchen was clean and free of excess trash, grease, grime, and dust.

Inspectors wroteSurveyor: [NAME] Based on observation and interview, the facility failed to provide a sanitary, uncluttered, odor free, and homelike physical environment to enhance quality of life for the residents in Rooms #102, #108, #109, #111 and #115 and 1 (Resident #417) of 1 sampled resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a pressure relieving device to 1 (Resident #29) of 1 sampled resident who did not have a pressure relieving device in the wheelchair.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired medications were removed from the medication carts and medication rooms on 2 (Rose Hall and [NAME] Hall) halls.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure meals were served at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents with a physician's order for a pureed, or a mechanical soft diet, received food of the correct consistency to prevent choking.

Inspectors wroteBased on observation and interview, the facility failed to ensure after eating lunch, 1 (Resident #24) of 1 sampled resident's face was cleaned and clothing changed before going into the sitting area to promote dignity and respect.

Inspectors wroteBased on observation and interview the facility failed to ensure the Dietary Manager (DM) had the necessary education and qualifications to meet the Centers for Medicare and Medicaid Services (CMS) minimum requirements to ensure nutritional needs and food safety needs were met for the 74 residents who resided in the facility and received trays from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a sufficient number of competent staff were employed to carry out the functions safely and effectively for 1 of 1 kitchen in the facility which fed 74 residents according to the Diet List provided by the Administrator on 11/7/22.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meals were not prepared and held on the steam table losing nutritive value, flavor, and appearance; meals were held and served at acceptable temperatures, hot foods were maintained at or above a temperature of 135 degrees Fahrenheit (F.), and cold foods were maintained at or below 41 degrees (F.) while awaiting service to prevent potential food borne illness and to improve palatability and encourage good nutritional intake during 1 of 1 meal observed for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 74 residents who received a tray from the kitchen, as documented on a list provided by the Administrator on 11/7/22.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods stored in the kitchen freezer, refrigerators, and dry storage area were labeled and dated when received and/or opened; foods in unit refrigerators were labeled and dated; clean dishes were properly stored; 2 of 2 ice machines were maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages; hot foods were maintained at or above a temperature of 135 degrees Fahrenheit (F), and cold foods were maintained at or below 41 degrees F. while awaiting service to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 74 residents who received meal trays and beverages from the kitchen, as documented on a list provided by the Administrator on 11/7/22.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meals were prepared and served according to the planned written recipes and menu to meet the nutritional needs of 5 residents who required pureed diets per the Diet List provided by the Administrator on 11/7/22 for 1 of 1 meal observed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pureed food items were blended to a smooth and pudding-like texture to promote good nutritional intake and prevent potential choking for residents who required pureed diets during 1 of 1 meal observed. The failed practice had the potential to affect 5 residents who required pureed diets, according to a Diet List provided by the Administrator on 11/7/22.

Inspectors wroteBased on interview and record review, the facility failed to ensure pneumococcal immunizations were administered to eligible residents and immunization records were tracked and documented completely for 4 (Resident #5, R #10, R #63, and R #133) of 5 (Resident #5, R #10, R #59, R #63, and R #133) sample selected residents who had signed consents for the pneumococcal vaccine to help protect against pneumococcal bacteria which can cause serious infections and was potentially fatal.