Three Creeks Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure Preadmission Screenings and Resident Reviews (PASRR, a mental disorder and intellectual disabilities screening) were completed prior to admission as required for 3 of 9 sampled residents (Residents 26, 34 and 36) reviewed. Additionally, 1 of 9 sampled residents (Resident 30) reviewed were not referred for an evaluation after a 30-day hospital exemption (when the resident was expected to be at the facility less than 30 days) expired and the resident remained at the facility. These failures placed the residents at risk of not having their behavioral health needs met and possible decline in their mental health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safety risk preventative measures were assessed and implemented for 2 of 3 sampled residents (Residents 18 and 19), reviewed for smoking. In addition, the facility failed to monitor 1 of 1 sampled residents (Resident 4) reviewed for falls. This failure resulted in Resident 4 not being monitored for 72 hours after a multiple unwitnessed falls. These failures placed the residents at risk of fires, injury, health complications and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were given as ordered for 3 of 11 sampled residents (Residents 4, 30, and 48) reviewed for medication administration. This failure resulted in Resident 4 not having their blood pressure medication held when indicated by ordered parameters, and Residents 4, 30, and 48 had doses of medications omitted when medications were unavailable. This failure placed the residents at risk of decline in their medical conditions and decreased quality of life.

Inspectors wroteBased on observation and interview, the facility failed to perform hand hygiene during the meal service for 2 of 2 staff (Staff S and T) and to maintain the cleanliness of 1 of 1 ice machines (ice machine). These failures placed residents at risk for foodborne illnesses.

Inspectors wroteBased on interview and record review the facility failed to routinely maintain documentation of staff's COVID-19 (a highly contagious viral illness that caused fever, breathing difficulty and potential hospitalization) vaccination status, provide education regarding the risks versus (vs) benefits and offer the COVID-19 vaccine if desired to 4 of 6 sampled staff (Staff I, J, K, and L), reviewed for immunizations. In addition, the facility failed to develop and implement 1 of 1 policies (COVID-19 immunization policy) to educate and offer each staff the COVID-19 vaccine. This failure placed residents and staff at risk of exposure to and illness from COVID-19.

Inspectors wroteBased on observation and interview the facility failed to maintain a safe and sanitary environment for staff and residents. 1 of 1 Laundry Rooms (Laundry Room) had significantly large holes from water damage and a majority of the cement floor contained large cracks, chips and had large sections missing. This failure placed staff at risk for potentially avoidable accidents and residents at risk of receiving unsanitary laundry services.

Inspectors wroteBased on interview and record review, the facility failed to issue notices of potential insurance non-coverage of services for 2 of 3 sampled residents (Residents 30 and 31) reviewed for beneficiary notices. This failure placed the residents at risk of not being informed of their insurance coverage changes and paying for services they no longer wanted.

Inspectors wroteBased on observation and interview, the facility failed to provide a clean, comfortable, and homelike environment for 1 of 3 sampled residents (Resident 41), reviewed for environment. This failure placed residents at risk for possible illness from unclean equipment, a lack of dignity, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents or representatives were provided the opportunity to participate in care planning conferences for 1 of 1 sampled residents (Resident 4) reviewed for care planning. This failure placed the residents at risk for unmet needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to seek podiatry services (a physician that specialized in care and treatment of the feet) and implement provider orders for a skin ointment for 1 of 3 sampled residents (Resident 36) reviewed for skin conditions. This failure placed the resident at risk for further skin breakdown and unintended health consequences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement preventative measures to prevent avoidable pressure ulcer/pressure injuries (PU/PI) for 1 of 3 sampled residents (Resident 36) reviewed for PU/PI prevention. This failure caused Resident 36 to develop an avoidable deep tissue injury (DTPI, a pressure injury to deep layers of the skin that may resolve without opening or that may open to reveal a serious injury that involved muscle or even bone) on their left heel and created a risk for further skin compromise and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nutritional requirements and assessments were completed timely by the Registered Dietician for 2 of 4 sampled residents (Residents 22 and 30) reviewed for nutritional services. This failure placed the residents at risk of nutritional decline and unintended health consequences.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately reconcile all controlled medications in 2 of 2 medication carts (North and South Carts), reviewed for medication storage. In addition, the facility failed to discard expired medication in 1 of 1 medication rooms. This failure placed residents at risk for misappropriation of their controlled medications, placed the facility at increased risk for controlled substance drug diversion and residents receiving medications that may not be effective.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nutritional requirements and assessments were completed timely by the Registered Dietician for 2 of 4 sampled residents (Residents 22 and 30) reviewed for nutritional services. This failure placed the residents at risk of nutritional decline, and unintended health consequences.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 4 sampled residents (Resident 1) received mental health services. This failure placed residents at risk for worsening mental health status, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to keep Potentially Hazardous Foods (PHFs) within safe temperature guidelines during an extended power outage during which the facility backup generator did not power kitchen appliances, PHFs that were above safe temperatures were not discarded and served above safe temperature PHFs (specifically milk) to residents during two subsequent meal services for 33 of 33 residents. These failures placed residents at risk of serious food borne illness and constituted immediate jeopardy (IJ). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure Preadmission Screening and Resident Reviews (PASRR, a two-part screening assessment; Level I was determined by the presence of a Severe Mental Illness [SMI] or Developmental Disability. If present, a Level II evaluation by a specialized evaluator would then occur where it would be determined if nursing home placement was the appropriate level of care, and if behavioral health or other community services were recommended for the given resident. A Level I, and if indicated, a Level II PASRR was required to be completed prior to nursing home admission) were completed correctly and PASSR Level II were referred for evaluation prior to admission as required for 1of 6 sample residents (Resident 1). This failure placed residents at risk of behavioral health needs not being met and diminished quality of life.

Inspectors wroteBased on interviews, observation and record review, the facility failed to provide an environment with a comfortable temperature during an extended power outage, for 33 of 33 residents admitted to the facility on [DATE]. This failure placed Residents at risk for discomfort and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1) remained free from abuse. This failure placed residents at risk for abuse and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were given their medications as ordered for 2 of 3 sampled residents (Resident's 2 and 3) reviewed for medication management. This failure placed residents at risk of exacerbations of their chronic health conditions, and unintended consequences when doses of their medications were omitted.

Inspectors wroteBased on interviews and record review, the facility failed to complete testing for COVID-19 (infectious disease by a new virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) per federal guidelines for 8 of 10 staff (Staff A, B, C, D, F, G, I, J) during a COVID-19 outbreak. This failure increased the likelihood for delayed identification, diagnosis and treatment of COVID-19. In addition, the facility failed to implement their respiratory protection program in a timely manner for 4 of 10 staff (Staff A, B, D, H) every year within 12 months of the date of the last fit test. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store, discard and distribute food in accordance with professional standards for food safety for 1 of 1 facility kitchens reviewed. This failure placed residents at risk for food borne illness and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was a completed Physician's Order for Life-Sustaining Treatment [POLST] (a form which instructed medical staff what treatment the resident wished to have done in the event they are seriously ill, or their heart stopped beating for 1 of 2 sampled residents (Resident 6) reviewed for Advance Directives. This failure placed the resident at risk for not having their wishes and choices regarding end-of life care honored.

Inspectors wroteBased on interview and record review, the facility failed to provide a Notification of Medicare Non-Coverage (NOMNC) two days prior to a planned discharge, as required, for 1 of 3 residents (Resident 136) reviewed for liability notices. This failure prevented the resident from exercising the right to appeal and dispute the termination of Medicare covered services.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's medical record contained documentation of a hospital transfer and/or that the receiving hospital had received information of the resident's condition, for 1 of 2 sampled residents (Resident 31), reviewed for hospitalization. This failure placed the resident at risk for a delay in treatment and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to provide a bed-hold notice, a notice that informed the resident of their right to pay the facility to hold their room/bed while they were hospitalized , to the resident and/or their representative at the time of discharge, or within 24 hours of transfer to the hospital, for 1 of 2 sampled residents (Resident 31), reviewed for hospitalization. This failure placed the resident at risk for a lack of knowledge regarding the right to a bed-hold while they were hospitalized .

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that 1 of 2 sampled residents (Resident 5) had current and complete oxygen orders for respiratory care. This failure placed the resident at risk for respiratory complications and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to employ sufficient staff with the appropriate certifications necessary to carry out the functions of nutritional services for 30 residents. Specifically, the facility failed to ensure Staff E, Dietary Manager, had the required certification. This failure placed the residents at risk for unmet nutritional needs and a diminished quality of life.

Inspectors wroteBased on observation, interviews and record review, the facility failed to perform a thorough and timely assessment of a lower leg injury at the time a fall occurred, and evaluate for changes in condition for 1 of 3 residents (Resident 1) reviewed for assessments. Resident 1 experienced harm when they developed a necrotic (death of cells or tissue), contagious (spreads from one person to another), wound infection which extended their stay in the facility, and a delay in treatment.

Inspectors wroteBased on interviews and record review the facility failed to notify the resident's representative of changes in condition in a timely manner for 1 of 3 residents (Resident 1) reviewed for notification of changes. The failure to notify the representative placed the resident at risk of not having them involved in the health care decision making process for timely care and services.

Inspectors wroteBased on interviews and record review the facility failed to ensure an incident of neglect was reported to the State Survey Agency, as required, for 1 of 1 resident (Resident 1) reviewed for neglect. Failure to report a worsening wound on Resident 1's left lower leg due to a lack of timely staff assessments and delay in receiving medical treatment placed all residents at risk for continued neglect and poor quality of care.

Inspectors wroteBased on interviews and record review the facility failed to conduct a thorough investigation in a timely manner for 1 of 3 residents (Resident 1) reviewed for falls. Failure to conduct a thorough investigation to identify the root cause and all contributing factors related to Resident 1's fall placed residents at risk for ineffective care planning interventions to prevent further falls with injury.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure sufficient nursing staff were available to respond to call lights timely and to meet the care needs of 8 of 15 residents (Residents 3,1,4,5,6,2,7,8) reviewed for sufficient nursing staff. This failure resulted in feeling of frustration and vulnerability, diminished quality of life and unmet care needs of the residents.

Inspectors wroteBased on observation, interviews and record review the facility failed to serve meals that were at a safe temperature for 2 of 7 residents (Residents 1 and 2) reviewed for food temperatures. This failed practice placed residents at risk for decreased nutritional intake and food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of potential abuse was reported immediately to the facility Administration as required for 1 of 3 residents (Resident 2), reviewed for abuse. Failure to report an incident of potential abuse placed Resident 2 and other residents in the facility at risk for additional abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received consistent showers for 1 of 3 dependent sampled residents (Resident 1), reviewed for activities of daily living. This failure placed the resident at risk for poor hygiene.

Inspectors wroteBased on interviews and record review the facility failed to implement their respiratory protection program for fit testing procedures which included a medical evaluation, fit testing (a 20 to 30 minute procedure to ensure a proper seal between the respirator face piece and the staff member's face) and training on the use and wearing of the respirator mask) of the N95 respirator mask (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) for staff. The facility had not implemented the respiratory protection program for 53 of 53 staff initially upon date of hire or transfer and then every year within 12 months of the date of the last fit test. [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure sufficient preparation for a safe and orderly discharge home for 1 of 3 residents (Resident 1), reviewed for discharge to home. Resident 1 was discharged home without current referrals for in-home caregivers and home health for wound management and therapy services, supplies for diabetic testing, incontinent supplies, phone service, evaluation of the resident's home, and no assessment by staff to Resident 1 was able to perform blood sugar testing and administration of insulin. This placed Resident 1 at risk for medical complications, unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide wound management that met quality standards of care for 3 of 3 sampled residents, (Residents 5, 9 and 82) reviewed for wound care. The facility failed to follow provider orders for wound care, follow infection control standards during wound care, and fully document the wounds in the medical record. These failures placed the residents at risk of wound complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure processes for proper holding temperatures were maintained for prepared foods, between when they were prepared in the kitchen, and when the residents received the food, opened foods were labeled and/or dated as required for 1 of 3 refrigerators, expired food in 1 of 1 dry storage area. This failure placed residents served from the kitchen at risk for onsuming expired food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dialysis services consistent with professional standards, and ensure consistent, ongoing communication and collaboration with the dialysis facility for 1 of 1 sampled resident (Resident 330), reviewed for dialysis. In addition, the facility failed to process a medication order from the dialysis center timely for Resident 330, which resulted in a delay in the medication being administered. These failures placed the residents at risk for unmet care needs and medical complications.