Creekview Skilled Nursing

Inspectors wroteBased on observation, interview and record review the facility failed to administer and/or clarify doctor's order for Furosemide (commonly known as Lasix, which is used to remove excess fluids in the body) medication when one of 17 sampled residents (Resident 2) had pitting edema (swelling due to fluid buildup, where pressing the swollen area leaves an indentation or a pit) in both legs for 17 days. Resident 2 had a primary diagnosis of heart failure (a chronic condition in which heart does not pump blood effectively). This failure placed Resident 2 at risk for further increased edema, increased discomfort, skin breakdown, complications related to heart failure such as fluid accumulation in the lungs, shortness of breath, upto and including death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staff were competent in job duties related to: 1. using the three compartment sink; 2. testing the sanitizer liquid in the red sanitization bucket; and 3. cleaning the juice machine. These failures have the potential for improper cleaning and sanitization which could lead to increased risk for food-borne illness for 45 residents who received food from the kitchen out of a facility census of 51.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food safely when: 1. Meat was not thawed according to storage guideline dates; 2. kitchen staff did not follow appropriate hand hygiene and glove use procedures when going between and handling dirty dishes and clean dishes; 3. Three out of 5 storage bins for bulk dry goods had crumbling plastic liners; 4. Four out of 12 pairs of tongs and 1 ladle had cracked handles; 5. 2 of 2 Ice machines in the kitchen and nourishment room had rough, discolored surfaces on ceiling of the ice bin where ice was stored; and 6. Food in resident's refrigerator was undated for one out of 2 residents (Resident 14) and food was kept more than 3 days for one out of 2 residents (Resident 351). [...]

Inspectors wroteBased on observation interview and record review, the facility failed to ensure infection control practices were implemented when the following was noted for eight of eight residents: 1. An unlabeled bedpan and basin were observed in the shared bathroom of Residents 14 and 34. A yellow basin labeled for Resident 34 was on the floor in the Resident's shared bathroom. 2. Resident 34's feeding pump had tannish-brown residue in the tubing channel and flaky, light brown residue on the base of the pole. 3. Resident 17's wheelchair had torn armrests and dried, flaky reddish-brown matter and white staining on the seat and in the metal frame. 4. The facility did not have appropriate isolation precaution signage for four of four sampled residents (2, 21, 100 and 349). 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and label medication in accordance with standards of practice by failing to date three open bottles of medications (sodium chloride, milk of magnesia and bismuth subsalicylate), and one open container of blood sugar test strip for two of three medication carts inspected. This failure had the potential to result in medications and test strip used to not be effective.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dignity and maintain privacy for one of three sampled residents (Resident 14), when Resident 14's uncovered care instructions were posted above the bed visible to anyone entering the room. This failure resulted in a lack of dignity and privacy for Resident 14. Findings During a review of facility's admission Record for Resident 14, dated 4/12/23, Resident 14 was readmitted 11/22. During a review of Resident 14's Minimum Data Set (MDS - an assessment tool used to guide care) assessment dated [DATE], Section C showed a Brief Interview for Mental Status (BIMS - an assessment tool used to evaluate mental status) score of 2 out of 15, indicating severely impaired mental status. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to reconcile controlled substances (a drug subject to special handling, storage, and disposal because of its potential for abuse or addiction) for one of 51 residents (Resident 37). This failure had the potential for the loss or diversion of controlled substances.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure menu was followed when one of 51 residents (Resident 4) was given pureed broccoli instead of minced and moist broccoli. This failure has the potential for one of 51 residents to not get the type of food texture as indicated on the planned menu which could compromise the resident's intake of food and nutritional status.

Inspectors wroteBased on interview and record review, the facility failed to implement its COVID-19 [Coronavirus disease] Vaccination policy and procedures to ensure two of two sampled Residents (46 and 249) were fully vaccinated for Coronavirus Disease-19 (an acute respiratory illness with fever, cough, and capable of progressing up to and including death). This failure resulted in Residents 46 and 249 to be unaware of the risks and benefits associated with the COVID-19 vaccine. Findings During a review of the Resident 46's admission Record printed on 04/13/23, the record showed Resident 46 was admitted to the facility 03/23. During a review of the Resident 249's admission Record printed on 04/13/23, the record showed Resident 249 was admitted to the facility 02/23. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and serve food under sanitary conditions when: 1. Two male dietary staff did not cover their beards while working in the kitchen; and 2. Two ice machines (one in the kitchen and one in the front Nursing Station) had brownish/black substances in the ice bins. This failure resulted in all 54 residents of the facility receiving food prepared under conditions not meeting professional standards and had the potential to cause food-borne illnesses.

Inspectors wroteBased on interview and record review, for one of 14 sampled residents (Resident 43) the facility failed to provide appropriate treatment and services to a resident with an indwelling catheter (a tube inserted into the body that drains the urine into an external bag) when facility staff failed to monitor the resident's intake (the measurement of fluids taken into the body) and the output (the measurement of fluids expelled from the body). This failure had the potential to negatively impact Resident 43's existing urinary conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 144) received appropriate medical care when oxygen was administered to Resident 144 without a physician's order. This failure placed Resident 144 at risk for a delay in identifying or treating any adverse effects from oxygen therapy.