Creekside Health and Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF689Jan 15, 2025

  Based on observation, interview, and record review, the facility failed to provide a resident with adequate assistance of two staff members for bed mobility during perineal care resulting in a fall from bed, and ensure a transfer from the wheelchair to the toilet was performed in accordance with the plan of care for 2 of 4 residents reviewed for accidents and 1 of 5 residents reviewed for Activities of Daily Living (ADLs). This deficient practice resulted in Resident 60 falling and sustaining a fracture of the left upper arm. (Resident 1, Resident 60, and Resident B) Findings include: 1a. The clinical record for Resident 60 was reviewed on 1/9/25 at 9:55 a.m. […]

• Actual harm, isolatedF740Aug 9, 2022

  Based on interview and record review, the facility failed to implement their Behavior Management policy and review and revise behavioral health care plans, which had not been effective, for a resident's behavior of rummaging for linens and combativeness, which resulted in escalating physical behaviors and the resident being sent to the emergency room for due to pain and swelling of her left ankle and arm. (Resident 55, 30 and 37). Findings include: 1. The clinical record for Resident 55 was reviewed on 8/3/22 at 10:04 a.m. The Resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) Assessment, completed 3/11/22, indicated she had unclear speech, and was usually able to understand what was said to her. […]

• Actual harm, isolatedF697May 10, 2022

  Based on interview and record review, the facility failed to timely address a resident's continued pain resulting in a delayed hospitalization with rib fracture and [CONDITION(S)] related to a [CONDITION(S)] (urinary tract infection) and to monitor the effectiveness of pain medication timely for 2 of 3 residents reviewed for falls and hospitalization . (Residents B and D) Findings include: 1. The clinical record for Resident B was reviewed on 5/9/22 at 10:50 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The [CONDITION(S)] care plan indicated he was at risk for urinary tract infections. […]

• Actual harm, isolatedF689Jun 16, 2021

  Based on interview and record review, the facility failed to ensure a resident did not fall from her bed during resident care that resulted in a fracture with hospitalization and surgical repair for 1 of 3 residents reviewed for accidents. (Resident C) Findings include: The clinical record for Resident C was reviewed on 6/16/21 at 12:00 p.m. The diagnoses included, but were not limited to, [CONDITION(S)] and [CONDITION(S)] (paralysis of one side of the body) following cerebral infarction (ischemic stroke), muscle weakness, reduced mobility, need for assistance with personal care, and [CONDITION(S)]. A Physical Therapy (PT) discharge summary, dated 3/21/21, indicated total dependence with bed mobility, specifically with rolling to the left for Resident C. […]

• Actual harm, isolatedF684May 19, 2021

  Based on interview and record review, the facility failed to monitor a resident's toe as ordered and obtain a venous Doppler ultrasound timely that resulted in a hospitalization with the need for surgical intervention for a necrotic toe for 1 of 2 residents reviewed for hospitalization , provide a wound dressing as ordered for 1 of 2 residents reviewed for wounds, and ensure a resident received care in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident L, Resident N and Resident T) Findings include: 1. The clinical record for Resident L was reviewed on 5/18/21 at 11:30 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident L was admitted to the facility on [DATE] and discharged to hospital on 5/8/21. […]