Creekside Transitional Care and Rehabilitation

Inspectors wroteBased on observation, and staff interview, it was determined the facility failed to ensure food was stored in a safe and sanitary manner. This deficient practice had the potential to affect the 129 residents who consumed food prepared by the facility. This placed residents at risk for adverse health outcomes, including food-borne illnesses.

Inspectors wrote3. Resident #183 was admitted to the facility on [DATE], with multiple diagnoses including urinary tract infection, constipation and depression. On 6/10/25 at 9:34 AM, the computer screen on top of the 500 Hall medication cart was observed to be open with Resident #183's medical information visible. On 6/10/25 at 9:47 AM, LPN #3 stated she did not realize she left the computer open. LPN #3 stated she should have made sure to log off from the computer before leaving her medication cart. Based on observation, record review, and resident and staff interview, it was determined the facility failed to ensure residents' privacy was maintained, treatment information was protected, and residents received mail and packages unopened. This was true for 3 of 24 residents (#29, #35, and #183) reviewed for privacy and confidentiality. [...]

Inspectors wroteBased on observation, record review, and resident and staff interviews, it was determined the facility failed to ensure residents were provided with a safe, clean, and homelike environment. This was true for 2 of 2 residents (#37 and #82) whose shared room was observed for a homelike environment. This deficient practice created the potential for diminished quality of life and psychosocial distress for Resident #82 when his roommate, Resident #37's, living space was not kept clean.

Inspectors wrote2. Resident #104 was admitted to the facility on [DATE], with multiple diagnoses including Wernicke's encephalopathy (a neurological disorder caused by a thiamine vitamin deficiency) and cognitive communication deficit. Resident #104's medical record documented on 3/14/24, he was diagnosed with delusional disorder and alcohol-induced dementia. Resident #104's Annual MDS Assessment, dated 7/18/24, documented the following: -In Section A, under A1500, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? This question was answered no. -In Section I, under I5950, Resident #104 had an active diagnosis of a psychotic disorder other than schizophrenia. [...]

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) was accurately completed when new mental health diagnoses were identified for 1 of 2 residents (Resident #104), whose records were reviewed for PASRR screenings. This failure created the potential for harm if the resident required, but did not receive, specialized services for mental health while residing in the facility.

Inspectors wroteBased on observation, record review, and interviews, it was determined the facility failed to ensure resident's medications were administered according to professional standards of practice. This was true for 1 of 3 residents (Resident #184) whose insulin administrations were observed. This failed practice created the potential for Resident #184 to receive an incorrect dose of insulin and experienced hypoglycemia.

Inspectors wroteBased on observation and staff interview it was determined the facility failed to ensure residents were provided with assistance to meet their needs. This was true for 1 of 24 residents (Resident #92) who were reviewed for activities of daily living. This failed practice created the potential for embarrassment and psychosocial harm when Resident #92's toenails were not maintained.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 1 of 15 residents (Resident #18) reviewed for bowel and bladder care. This failed practice created the potential for Resident #18 to experience discomfort when his medications were not administered according to the physician's order.

Inspectors wroteBased on observation, record review, and interview, it was determined the facility failed to ensure the CPAP water chamber was kept clean. This was true for 1 of 1 resident (Resident #119) reviewed for respiratory care. This deficient practice created the potential for respiratory infection due to growth of bacteria in respiratory equipment.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to assess, monitor, and identify potential triggers for 1 of 1 resident (Resident #53) reviewed for trauma-informed care. This failure created the potential for further trauma and psychosocial harm when the residents Post-Traumatic Stress Disorder (PTSD- a mental health condition that is triggered by a terrifying event) triggers were not assessed.

Inspectors wroteBased 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.

Inspectors wroteBased on reviews of incident reports, medical records, hospital records, and staff interviews, it was determined the facility failed to ensure residents' safety during mechanical lift transfers. This was true for two of two residents (#1 and #2) reviewed for accidents. This failure harmed Resident #1 when she sustained a facial contusion and fractures to her lumbar vertebrae and left leg.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wrote3. 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.