Creekside Post-Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents received the necessary care and services for one of three residents (1) when the wound doctor's order for Resident 1's venous ulcer (open sores that occur when the veins in the legs do not push blood back up to the heart as well as they should) on his right lower lateral leg was not carried out to the treatment administration record (TAR). This failure had the potential for Resident 1's wound did not receive the treatment, became deteriorated, and delayed wound healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices when certified nursing assistant B (CNA B) walked out of Resident 2's room and in the hallway without sanitizing her hands. This failure had the potential to spread infection in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure they had communicated throughout the facility for one of three sampled residents (Resident 1)'s code status and documented in the medical record Resident 1's wishes and preference immediately, so that staff would know what action to take or not take when an emergency arises when: 1. The case manager (CM) did not communicate to staff immediately regarding the changes in Resident 1's code status of DNR Do Not Resuscitate (DNR, is a medical order to instruct providers not to do cardiopulmonary resuscitation (CPR, is an emergency lifesaving procedure performed when the heart stops beating) order in her electronic medical record (EMR)when Resident 1's daughter submitted to the facility a copy of the POLST signed by Resident 1 and her attending physician while she was in the acute hospital dated [DATE]. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care and services in accordance with professional standards of practice for one of three sampled residents (Resident 1) when: 1. The licensed nurse failed to notify the physician when Resident 1 experienced a change in condition. 2. The licensed nurse failed to transfer the wound care order from the hospital discharge instructions to the Skilled Nursing Facility (SNF) orders, resulting in no wound dressing change for Resident 1 for two days. These failures resulted in Resident 1 being sent to the hospital for further evaluation and treatment.

Inspectors wroteBased on record review, interview, and review of the Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurate for 1 (Resident #125) of 24 sampled residents. Specifically, the facility failed to ensure Resident #125's discharge MDS accurately reflected the resident's discharge status.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure Level I Preadmission Screening and Resident Reviews (PASRRs) were submitted when required and failed to complete them accurately for 2 (Resident #41 and Resident #70) of 3 residents reviewed for PASRR requirements. Specifically, the facility failed to ensure Resident #41's Level I PASRR screening reflected the presence of a serious diagnosed mental disorder and failed to submit a Level I PASRR screening after Resident #70 remained in the facility longer than 30 days.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide supervision to prevent a fall for 1 (Resident #68) of 2 residents reviewed for falls and failed to ensure the environment remained free of accident hazards for 1 (Resident #45) of 1 resident reviewed for accident hazards.

Inspectors wroteBased on interview and record review, the facility failed to timely complete and submit a Discharge Minimum Data Set (MDS, a clinical assessment tool) data to the Centers for Medicare & Medicaid Services (CMS, oversees federal healthcare programs) for three of three residents (1, 2, and 3). This failure resulted in non-compliance with CMS regulatory requirements.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (1) received the necessary care and services when Resident 1's wounds did not have the weekly wound assessments completed consistently as required. This failure resulted in undetermined wound status and could negatively affect the progress of wound healing for Resident 1.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to provide a safe, functional, and comfortable environment for the residents and staff when the facility's floor had multiple holes. This failure placed the residents, staff and visitors at risk for accident and/or injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure the safety for one of two residents (Resident 1) when: 1. The Certified Nursing Assistant A (CNA A) did not position Resident 1 properly in wheelchair before doing another task, 2. CNA A did not notify the Licensed Nurse (LN) immediately to assess Resident 1 for possible injury after the fall prior to transferring back Resident 1 to wheelchair and 3. The facility failed to document the correct information on how the fall incident happened for Resident 1 on 8/5/24. These failures put Resident 1's safety at risk.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy and procedure related to staff screening procedures for hiring direct access employee (means any individual who has access to a resident or patient of a long term care (LTC) facility) when the criminal background check (used to check for any convictions or claims of crime, including abuse) was not done prior to re-employment for Certified Nursing Assistant A (CNA A). This failure had the potential to put the residents' safety at risk.

Inspectors wroteBased on interview and record review, the facility failed to ensure the safety of one of three residents (Resident 1) when the facility did not investigate thoroughly the root causes of the incidents of skin tears during transfers from bed to wheelchair and transfer to wheelchair after using the bathroom. This failure led to four recurrent incidents that resulted to lower legs skin tears for Resident 1. Resident 1 had skin tear incidents on 2/24/24, 4/2/24, 5/17/24, and 6/10/24.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services for one of three residents (Resident 1) when: 1. Resident 1's physician was not notified regarding her multiple refusal in participating in the Restorative Nursing Assistant program (RNA, a program that helps residents to gain an improved quality of life by increasing their level of strength and mobility) in a timely manner. 2. Resident 1's frequent refusal of RNA programs was not care planned. These failures had the potential to result in resident's decline in range of motion and mobility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from unwanted touching of her perineal area when one staff (receptionist E) found Resident 2 was inside Resident 1's room with his hands seen to be inside Resident 1's diaper between her legs, and when the facility did not complete Resident 2 whereabout monitoring to help prevent this incident of sexual allegation to happen. Failure to protect Resident 1's rights to be free from sexual abuse could result in psychological harm to her.

Inspectors wroteBased on interview and record review, the facility failed to obtain routine medications for two of three residents (1 and 2) when Resident 1's and Resident 2's routine medications were not available for administration. This failure resulted in Resident 1's and Resident 2's needs were not met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received the treatment and care in accordance with professional standards of practice related to pain management for one of three sampled residents (Resident 1) when the licensed nurses did not follow the doctor's order to administer PRN (as needed) pain medication as ordered. The Acetaminophen (pain medication0 500 mg 2 tablets was ordered for mild pain but it was adminsitered when Resdient 1 complained of moderate and severe pain. This failure resulted in Resident 1's pain remained uncontrolled affecting his quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when staff did not wear appropriate Personal Protective Equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) as required when working with transmission-based precaution (TBP, the second tier of basic infection control and are to be used in addition to Standard Precautions ) residents who were COVID-19-positive (an infectious disease caused by the SARS-CoV-2 virus). This failure had the potential to result in cross-contamination and spread of infections among residents, staff and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident's medical records were complete and readily available for review by an official authorized by law for one of three sampled residents (Resident 1) when the physician's initial admission Note and physician's Progress Notes were not found in Resident 1's medical record during the surveyor's two facility visits. This failure had the potential to cause a delay in the determination of the quality of care rendered to Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure needs were accommodated for five residents (72, 13, 3, 36, and 66) when the call light devices were not within reach. This failure had the potential for a delayed response and not meeting the resident needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the food and nutrition services, when: 1. There were 12 cracked edge meal trays placed in the food cart. 2. There was ice build-up on the ceiling of the walk-in freezer. 3. There were pieces of undated sandwich bread kept in plastic found in the dry storage area. 4. The cleaning solution in the red bucket was not adequate. These failures had the potential to result in food-borne illness among residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices when: 1. For Resident 66, facility staff did not label and date the resident's nebulizer (drug delivery device used to administer medication in the form of a mist inhaled into the lungs) tubing; 2. Facility staff did not clean and disinfect the resident's shower room promptly; and 3. For Resident 16, facility staff did not put the indwelling urinary catheter drainage bag below the level of the bladder (the organ that stores urine). These failures have the potential to compromise the health and well-being of the residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respect and dignity was maintained for four residents (Residents 25, 80, 240 and 241) when staff provided feeding assistance while standing. This failure had the potential to affect the emotional and psychosocial well-being of the residents.

Inspectors wroteBased on interview and record review, the facility failed to maintain a copy of an advance directive (a legal document that designates a decision-maker and has written instruction that indicates the medical decisions desired when the individual is not able to make choices) in the resident's medical record for one of 19 residents (Resident 30). This failure had the potential to delay care in accordance with the resident's wishes.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool) for one of 19 sampled residents (Resident 70). Failure to accurately assess the resident had the potential to compromise the facility's ability to provide resident-centered care planning and interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet services according to professional standards of quality, for four of eight sampled residents, when: 1. There was no monitoring for volume intake in Resident 4's gastrostomy (GT, opening into the stomach) tube. 2. There was no monitoring for urine volume output to Residents 48 and 52, which had the potential to result in dehydration. 3. Resident 61 had no thromboembolic deterrant hose (TED, compression stockings to reduce the risk of developing blood clot) applied to her right lower leg since the time it was ordered, which had the potential to result to complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care in accordance with the professional standards of practice for 2 of 19 sampled residents (Residents 8 and 16) when: 1. For Resident 8, nursing staff did not apply the ace bandage as ordered by the physician; and 2. For Resident 16, no current physician's order for the indwelling urinary catheter (a soft, plastic or rubber tube that is inserted into the bladder to drain the urine). These failures had the potential to compromise the residents' health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medications for one of three residents reviewed, when Resident 39's use of divalproex sodium (medication used to treat seizure disorder, manic episodes of bipolar disorder and helps prevent migraine headaches) had lack of monitoring of adverse (harmful) effects. This failure had the potential to result in increased risk of serious complications of drug therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored appropriately when: 1. One expired medication was not properly discarded and was stored in the medication cart and, 2. Medications were stored under improper temperature. These deficient practices had the potential for unsafe and ineffective use of medications.

Inspectors wroteBased observation, interview and record review, the facility failed to ensure room [ROOM NUMBER] had at least 80 square feet per resident. A room less than 80 square feet per resident could potentially compromise the care and services the residents receive in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the food services area when: 1. Open air ceiling vent had dust particles and grease build-up. 2. Expired food items were found in the refrigerator. These failures had the potential to result in cross contamination and food borne illnesses in residents who were on oral diets.

Inspectors wroteBased on observation, interview and record review, the failed to consistently implement infection control practices when housekeeping staff did not wear personal protective equipment (PPE, specialized equipment or clothing used to protect self and patients from the spread of infection. PPE includes gloves, gowns, goggles, masks and face shields) while sorting and handling soiled linens/dirty laundry. This failure had the potential to result in transmission of infection in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain residents' dignity and self-worth for five of 32 residents (Residents 29, 5, 47, 67 and 103) when: 1. Certified nursing assistant (CNA) kept her personal belongings inside Resident 29's closet; and 2. CNAs did not provide feeding assistance to Residents 5, 4, 6, and 103 within eye level position. These failures may affect the resident's well-being and quality of life in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure residents rights were reviewed and discussed during monthly group meetings when 7 of 7 residents (Residents 21, 60, 75, 85, 100, 103, and 105) who attended the meeting stated their rights were not reviewed and discussed during the monthly meetings. This failure had the potential for the residents not to be able to fully exercise theirs rights that may affect the quality of life during their stay in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services in accordance with professional standards of practice for three of 24 sampled residents (Residents 39, 48 and 108) when: 1. For Resident 39, the facility failed to ensure a lab test was done as ordered; 2. for Resident 48, staff did not implement a wheelchair alarm (device that makes sound to alert staff when the resident attempts to transfer unassisted) as ordered; and 3. for Resident 108, the facility failed to ensure his side rails were padded. These failures had the potential to negatively affect the health and safety of the residents.

Inspectors wroteBased on interview and record review the facility failed to provide restorative nursing services (a program that helps residents maintain and promote maximum functional capacity) consistently per physician's order for 6 of 13 residents (Residents 20, 29, 64,73, 94, and 103) when: 1. For Residents 73 and 103, passive range of motion (PROM, exercises that require assistance, usually provided by a caregiver or a therapist) exercises were not done consistently by the restorative nursing assistant (RNA, is a type of nursing assistant trained to help nurses in restoring mobility to residents) three to five times per week as per physicians order, 2. For Residents 20, 29, and 94 ambulations (walk) were not done consistently by an RNA three to five times per week as per physician's order, and 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to timely receive medications from the provider pharmacy for two of six residents (Residents 30 and 24) when two routine medications were not available during the 5 p.m. medication passing. This failure had the potential to cause delay in treatment and compromised residents' medical health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of 10 residents (Residents 39 and 9) were free from unnecessary psychotropic medications (medications capable of affecting the mind, emotions and behavior) when: 1. For Resident 39, licensed nurses failed to accurately assess and monitor for psychotropic medication side effects; and 2. for Resident 9, licensed nurses failed to monitor specific behaviors for the use of sertraline hydrochloride (HCL) (medication used to treat depression and anxiety). These failures put the residents at risk for experiencing adverse medication side effects and receiving psychotropic medication without the appropriate indication.

Inspectors wroteBased on observation, interview, and record review, the facility had 11.54% medication error rate when three medication errors out of 26 opportunities were observed during medication passes for two of six residents (Residents 30 and 24). This failure had the potential to compromise residents' medical health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored appropriately when one of four medication carts and one of three medication rooms had expired and unlabeled prescription medications. The deficient practice had the potential to place residents at risk for receiving expired and/or wrong medications.

Inspectors wroteBased observation, interview and record review, the facility failed to ensure room [ROOM NUMBER] had at least 80 square feet per resident. A room less than 80 square feet per resident could potentially compromise the care and services the residents receive in the facility.