Creekside Center for Rehabilitation and Healing

In the surveyor’s words

From the most serious findings on record at Creekside Center for Rehabilitation and Healing, in the surveyor’s own words.

• Actual harm, isolatedF760Feb 1, 2021

  Amended 2/18/2021 This is an amended Statement of Deficiencies. Based on facility policy review, medical record review and interview, the facility failed to prevent a significant medication error for 1 of 4 residents (Resident #1) reviewed for medication administration. Actual Harm was identified related to the facility's failure to administer the correct prescribed medications when Resident #1 received previously discontinued medications causing the resident to become unresponsive. The findings include: Review of the facility policy titled, Discontinued Medications, dated April 2007, showed .Staff shall destroy discontinued medications or shall return them to the dispensing pharmacy in accordance with facility policy . […]

• No harm, potential for more than minimal, isolatedF557Jul 12, 2023

  Based on policy review, medical record review, observation, and interview, the facility failed to promote dignity and respect for 1 of 28 sampled residents (Resident #80). Resident #80 had been assisted to his wheelchair and left partially dressed in a T-shirt and an adult brief. The findings include: Review of the policy titled, Resident Rights, dated 5/19/2023, revealed, . Federal and state laws guarantee certain basic rights to all residents of this facility .rights include the resident's right to: a. a dignified existence; b. […]

• No harm, potential for more than minimal, isolatedF584Jul 12, 2023

  Based on facility policy review, observations and interviews, the facility failed to ensure a safe and clean environment in 6 of 101 resident rooms (room [ROOM NUMBER], #99, #100, #103, #106, and #113) observed. The findings include: Review of the policy titled, Homelike Environment, dated 5/19/2023, revealed, .Residents are provided with a safe, clean, comfortable and homelike environment .facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting .clean, sanitary . Observation in room [ROOM NUMBER] on 7/9/2023 at 1:08 PM, revealed debris, which included food and paper scattered on the floor under B bed, behind B bedside table, and beside A bed. […]

• No harm, potential for more than minimal, isolatedF657Jul 12, 2023

  Based on facility policy review, facility document review, medical record review, and interview, the facility failed to conduct quarterly care conferences for 15 of 28 (Resident #9, #15, #17, #18, #22, #27, #31, #53, #65, #66, #72, #81, #93, #95 and #111) sample residents reviewed. The findings include: Review of the facility policy titled, Care Plans Comprehensive dated 5/18/2023 revealed, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The interdisciplinary team [IDT], in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person centered care plan for each resident… […]

• No harm, potential for more than minimal, isolatedF888Mar 15, 2022

  Based on facility policy review, record review and interviews the facility failed to ensure 100% of staff were up to date on Covid-19 vaccinations. Based on Centers for Medicare and Medicaid (CMS) guidelines, policy review, and interview, the facility failed to perform documentation and tracking of staff vaccinations for COVID-19 (an infectious disease caused by [CONDITION(S)]-CoV-2 virus) according to current guidance to prevent the spread of COVID-19. The findings include: Review of the facility's policy titled, Staff Covid 19 Vaccine Policy for States TN [Tennessee] and FL [Florida], dated 1/25/2022, revealed, To establish the process to comply with the Federal mandate that all staff are vaccinated against COVID-19 unless they have a medical or religious exemption to help reduce the… […]