Mrc Creekside

Inspectors wroteBased on interviews and record reviews, the facility failed to develop a person-centered comprehensive care for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet the resident's needs for 1 of 6 residents (Residents #48) reviewed for comprehensive care plans. The facility failed to ensure Resident #48's comprehensive care plan was revised to reflect the resident requiring a wound vacuum for wound treatments. This failure could place residents at risk of inadequate monitoring of equipment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 3 (treatment cart) carts reviewed. The Treatment Nurse failed to ensure the medication cart for treatments was locked and secured on 5/4/2026. This deficient practice could place residents at risk for adverse reactions to medications and misappropriation of medications.

Inspectors wroteBased on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 5 staff (Treatment Nurse and LVN B) reviewed for infection control. The facility failed to ensure the Treatment Nurse did not touch clean items with dirty gloves when wound care was provided to Resident #48 on 5/4/2026. The facility failed to ensure LVN B wore a gown during high-contact resident care activities for Resident #48 on 5/5/2026. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for 1 of 1 kitchen reviewed for food service safety. The facility failed to close food product bags in the walk-in freezer, to prevent exposure to air. This failure placed residents who ate food served by the kitchen at risk of cross contamination and food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the accurate administration of medications to meet the needs of each resident for 1 of 5 residents observed for medication administration. (Resident #19) MA B administered an incorrect dose of felodipine (used to treat high blood pressure) to Resident #19 on 03/04/25 during medication pass. This failure could place residents who received medications administered at risk of not receiving the intended therapeutic benefit of their medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident's drug regimen was free of unnecessary medication for 1 of 14 residents reviewed for unnecessary medication (Resident #244) The facility did not monitor Resident #244 for side effects of the anticoagulation medication, Eliquis (a blood thinning medication). This failure could place the residents at risk for adverse consequences of the anticoagulant medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were labeled and stored in accordance with currently accepted professional principles in 1 of 2 medication carts reviewed. (Hall 200 Nurses medication cart) in that: An insulin pen of Lispro insulin (short acting insulin used to lower blood sugar) labeled for Resident #4 with an open date of [DATE], had been expired for 12 days and not removed from use. An insulin pen of Lispro insulin (used to lower blood sugar) labeled for Resident #31 with an open date of [DATE], had been expired for 29 days and not removed from use. This failure could place residents at risk for accidents, hazards, and not receiving therapeutic effects of medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles for 1 of 2 medication carts (medication aide cart for the second floor) reviewed for pharmacy services. The facility failed to ensure a bottle of morphine sulfate in a medication cart on the second floor was labeled properly in accordance with professional principles for Resident #8 on 1/13/2025. The bottle had a label without any writing on it. This failure could place residents at risk for adverse effects and improper administration of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen. *An uncovered and unlabeled personal use cup was stored in refrigerator #1. *Food items were not properly labeled with product and expiration date in refrigerator #2. *Food items were uncovered and exposed to air in the walk-in freezer. These failures could place residents who consumed food prepared by staff in the kitchen at risk of cross contamination and food-borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure that each employee received the required training that at a minimum educated staff on dementia management for 2 of 13 employees (Maintenance Director and Housekeeping Supervisor) reviewed for required annual trainings. The facility did not ensure dementia management training was completed by the Maintenance Director and Housekeeping Supervisor. This failure could place residents with dementia at risk of a poor quality of care by staff with inadequate training when caring for dementia residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that were complete and accurately documented for 2 of 17 residents (Residents #7 and #28) reviewed for accuracy of clinical records. The facility did not ensure the wound assessments for Residents #7 and #28 were completely and accurately documented. This failure could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure preadmission screening for individuals identified with MI, DD, or ID were evaluated for services for 1 of 17 residents reviewed for PASRR (Residents #17). The facility did not have an accurate PASRR level 1 screening for Residents #17 upon admission therefore a PASRR Evaluation was not conducted. This failure could place residents who have a diagnosis of mental disorder, developmental disability, or intellectual disability at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the residents' environment remained as free of accident hazards as was possible for 1 of 17 (Resident #12) residents reviewed for hazards. The facility failed to ensure an oxygen cylinder (a tank that contains oxygen) in Resident #12's room was properly stored. This failure could place the residents at risk of accidents or injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs when used without adequate monitoring for 1 of 17 residents (Resident #256) reviewed for unnecessary medication. The facility failed to monitor Resident #256 for side effects from 02/05/24 to 02/20/24 of the anticoagulant medication Eliquis (a blood thinning medication). This failure could place residents at risk for adverse consequences such as bleeding, bruising, and black colored stools related to the use of the anticoagulant medication.