Creekside Village

Inspectors wroteBased on record review and interview, the facility failed to ensure that the resident representative was promptly notified of a significant change in the resident's condition for 1 of 7 Residents (Resident #1) reviewed for notification. Specifically, the facility did not notify Resident #1's RP following an unwitnessed fall that occurred on 3/19/2026. This failure has the potential to delay the representative's involvement in the resident's care and decision making.

Inspectors wroteBased on observation, interview and record review the facility failed to provide personal privacy when providing personal care for 1 (Resident #1) of 5 residents observed for personal care. -CNA A failed to provide privacy for Resident #1during incontinent care This failure placed residents at risk for their loss of dignity, respect, and psychological distress.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide resident with care and services for 1 (Resident #1) of 5 residents reviewed for activities of daily living care, in that: CNA B failed to check Resident #1 for incontinence and provided incontinent care every 2-3 hours. CNA A failed to thoroughly clean Resident #1 during incontinent care when resident pants were soiled and brief was heavily soiled in urine. This failure placed resident at risk for not being provided the care and services needed.

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain, and infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 1 of 5 (Resident #1) reviewed for infection control. -CNA A did not practice hand washing/hand hygiene prior, during, and after providing incontinent care for Resident #1 -CNA A did not transport soiled linen in plastic bag. -CNA A removed disposable wipes from Resident #1's room and placed them back on cart in the hallway. These failures placed residents at risk for infections and cross contamination.

Inspectors wroteBased on interview and record review the facility failed to ensure within 14 days after a facility completed a resident assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System for 1 of 15 residents (Resident #34) reviewed for MDS transmission. The facility failed to transmit a completed Quarterly MDS assessment for Resident #34 within 14 days of completion. This failure could place residents at-risk of not having their assessment/s completed timely, which could result in denial of services and or denial of payment for services.

Inspectors wroteBased on interview, and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 1 of 5 resident (Resident #257) reviewed for resident rights, in that: The facility failed to obtain a signed consent for antipsychotic medication, Buspirone HCI 10MG, Klonopin 0.5 MG, Olanzapine 5 MG and Veriafaxine HCI ER 75 MG that was administered to Resident #257. The failure could affect residents who received psychoactive medications without informed consents and placed them at risk of receiving treatments without informed consent.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident assessments were completed,, electronically transmitted, encoded accurately and , MDS data entered to the CMS System within 7 to14 days after the death for 1 of 16 residents (CR #56) reviewed for encoding and transmitting resident assessments: - The facility failed to encode and transmit MDS data after the a Death in Facility for CR #56 within the required timeframe This failure could place discharged residents at risk of not having their assessments transmitted/exported timely.

Inspectors wroteBased on Record review and interview, the facility failed to develop and implement a Baseline Care Plan for resident 1 of 1 (CR #56) reviewed for baseline care plans. The facility failed to initiate a Baseline Care plan within 48 hours of admission for CR # 56 admitted for respite care on 03/12/24. This failure could place the resident at risk of not receiving person-centered care that is needed for communicating with staff to ensure the resident's needs are met.

Inspectors wroteBased on observation, record review, and interview, the facility failed to follow written policies on permitting residents to return to the facility after they were hospitalized or placed on therapeutic leave for 1(CR #1) of 11 residents reviewed for admission, transfer, and discharge. The facility failed to readmit CR #1 after he was hospitalized . This failure could place residents at risk of being discharged and not allowed to return to the facility causing a disruption in their care and services and potential decline in health.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that [NAME] professional standards of quality care for 1 (Resident #120) of 5 Residents reviewed for care plans. -The facility failed to develop a 48-hour baseline care plan for smoking, with goals, interventions, treatments, and psychosocial needs addressed in a resident specific care plan for Resident #120. This deficient practice could affect the residents not having their individual, medical, functional, and psychosocial needs identified, appropriately addressed, and could cause physical or psychosocial decline in health.

Inspectors wroteBased on record review and interview the facility failed to revise and update a Comprehensive care plan for 1 (Resident #8), of 24 residents reviewed for comprehensive care plans in that: Resident #8 readmitted to the facility with an active diagnosis of Urinary Tract Infection (UTI) and the care plan did not address her diagnosis of infection. Resident #8's care plan did not address her antibiotic medication. These failures could place residents at risk for receiving decreased quality of care and or not receiving the appropriate required care and services to meet their individual needs. The Findings Include: [...]