Creekside Health and Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to correctly document a resident's anti-psychiatric medication use on the annual Minimum Data Set assessment for 1 of 4 residents reviewed for use of accuracy of assessments. (Resident D)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' dignity was maintained and respected by not using cell phones while assisting with eating (Resident ZZ), and staff turning off the call lights and not returning to the residents' room to provide the services that had been requested (Residents' C, D, E, F, G, H, J, K, L, M, N, P, Q, R, S, T, and V) for 18 of 109 residents reviewed for dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to timely address a resident's skin condition; to ensure a resident's fall interventions were implemented; to obtain a resident's heart rate and medication hold perimeters were followed; address a resident's ear wax buildup; to ensure weights were obtained and the provider was notified of out of parameter weights for 5 of 10 residents reviewed for Quality of Care. (Residents BB, 86, 3, E, and V)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff donned Personal Protective Equipment(PPE) prior to entering a room of a resident in contact isolation precautions and prior to performing tracheostomy care for a resident in enhanced barrier precautions, to ensure hand hygiene was performed after doffing (removing) gloves, and to ensure a resident's catheter bag was correctly positioned for 1 resident randomly observed for contact isolation, 1 of 1 resident reviewed for tracheostomy and 2 of 2 residents reviewed for urinary catheter care (Resident 22, Resident 1,and Resident 80).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was provided with heel protective boots, as ordered, and ensure timely follow-up with podiatry services for 1 of 3 residents reviewed for foot care. (Resident V)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident's palm protector, per his functional maintenance program, for 1 of 1 resident reviewed for limited range of motion. (Resident V)

Inspectors wroteBased on interview and record review, the facility failed to timely implement provision of a resident's nutritional supplements for 1 of 1 resident reviewed for nutrition. (Resident 25)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was treated with dignity and respect for 1 of 4 residents reviewed for dignity. (Resident B)

Inspectors wroteBased on interview and record review, the facility failed to timely notify a resident's representative of a medication change for 1 of 3 residents reviewed for changes of condition. (Resident C)

Inspectors wroteBased on interview and record review, the facility failed to document the reason for transferring a resident to a local hospital and ensured communication to the receiving health facility for 1 of 3 residents reviewed for discharge rights. (Resident B)

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 3 residents reviewed for pressure ulcers had a baseline care plan developed and implemented within 48 hours of admission. (Resident D)

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 3 residents reviewed for pressure ulcers had a comprehensive care plan developed and implemented. (Resident D)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident with adequate assistance of two staff members for bed mobility during perineal care resulting in a fall from bed, and ensure a transfer from the wheelchair to the toilet was performed in accordance with the plan of care for 2 of 4 residents reviewed for accidents and 1 of 5 residents reviewed for Activities of Daily Living (ADLs). This deficient practice resulted in Resident 60 falling and sustaining a fracture of the left upper arm. (Resident 1, Resident 60, and Resident B)

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were treated with dignity and respect for 5 of 6 residents reviewed for dignity. (Residents' 13, 24, 37, 43, and 95)

Inspectors wroteBased on interview and record review, the facility failed to ensure care plan meetings were conducted quarterly for 2 of 2 residents reviewed for care plan meetings (Resident 63 and Resident 95).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide routine oral care and appropriate incontinence care timely to 1 of 5 residents reviewed for Activities of Daily Living (ADL) care (Resident B).

Inspectors wroteBased on interview and record review, the facility failed to ensure pre and post assessments were conducted for a resident receiving dialysis for 1 of 1 resident reviewed for dialysis. (Resident 43)

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' respect and dignity was maintained by staff not being respectful and ensuring a resident was able to exercise her right to vote for 1 of 23 residents reviewed for activities and 26 of 104 residents reviewed for dignity. (Residents' B, C, D, E, F, G, H, J, K, L, M, N, P, Q, R, S, T, V, W, X, Y, Z, BB, CC, DD, EE, and FF)

Inspectors wroteBased on interview and record review, the facility failed to follow up with resolutions to grievances reported in resident council for 3 of 3 resident council minutes reviewed. (Residents' B, C, D, E, F, G, J, K, L, M, N, P, Q, R, S, T, V, W, X, Y, Z, BB, and CC)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident had a care plan to address his seizure diagnosis for 1 of 5 residents reviewed for unnecessary. (Resident 74)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's care plan included non-pharmacological interventions for pain management and ensure care plan meetings were completed quarterly and when a resident had a significant change for 3 of 24 residents' care plans reviewed. (Residents' 30, 57 and G)

Inspectors wroteBased on observation, interview, and record review, the facility failed to: administer a resident's morning medications timely for 1 of 3 residents reviewed for ADLs (Activities of Daily Living) (Resident EE); adequately document a resident's behaviors per the facility's behavior documentation policy for 1 of 5 residents reviewed for unnecessary medications (Resident EE); ensure a resident's pain was managed per the facility's pain management policy; coordinate care for a resident on hospice services (Resident 57) for 1 of 1 residents reviewed for hospice; and perform neurochecks following a resident's unwitnessed fall with head injury (Resident 57) for 1 of 3 residents reviewed for accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to timely implement a resident's fall intervention; update a resident's care plan with identified safety interventions to prevent accidents; and appropriately implement a safety intervention to prevent accidents for 2 of 3 residents reviewed for accidents. (Residents 74 and L)

Inspectors wroteBased on interview and record review, the facility failed to check assess a dialysis fistula as ordered by the physician and to complete post dialysis assessments timely for 1 of 1 resident reviewed for dialysis (Resident 36).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications stored in the facility's medication carts were not expired and/or had current orders for their use and vacu-tainers used for blood collection were not expired for 2 of 4 medication rooms and 4 of 8 medication carts reviewed.