Creekwood Nursing & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Creekwood Nursing & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Sep 16, 2021

  Based on observation, interview, record review and review of the facility's policy it was determined the facility failed to have an effective system to ensure three (3) of eighty-three (83) sampled residents were free from abuse (Residents #1, #2 and #3). Interviews and review of witness statements, revealed the facility failed to protect Residents #1, #2 and #3 from physical and verbal abuse. Licensed Practical Nurse (LPN) #1 yelled, screamed, and hit Resident #1. She also yelled, taunted and pulled Resident #2's hair and yelled, hit and scolded Resident #3. On 06/24/2021, Resident #3 was in the common area getting something to drink when LPN #1 slapped his/her hand and scolded him/her like a child. On 07/17/2021, Resident #2 was in the common area waiting on breakfast. […]

• Immediate jeopardy, isolatedF609Sep 16, 2021

  Based on observation, interview, record review and review of the facility's policy it was determined the facility failed to have an effective system in place to ensure allegations of abuse were reported to state agencies for three (3) of eighty-three (83) sampled residents (Residents #1, #2 and #3). Interviews and review of witness statements, revealed the facility failed to report allegations of abuse. Staff reported the allegations to the nurse, who reported to the Director of Nursing (DON). However, the facility failed to report the allegations to the State agencies. Staff witnessed physical and verbal abuse by Licensed Practical Nurse (LPN) #1 who yelled, screamed, and hit Resident #1. […]

• Immediate jeopardy, isolatedF610Sep 16, 2021

  Based on observation, interview, record review and review of the facility's policy it was determined the facility failed to conduct thorough abuse investigations for three (3) of eighty-three (83) sampled residents (Residents #1, #2 and #3). On 06/24/2021, the former Administrator and the Director of Nursing (DON) were made aware that three (3) staff members had witnessed verbal and physical abuse by Licensed Practical Nurse (LPN) #1 related to Residents #1 and #3. However, the DON and former Administrator failed to identify it as an allegation of abuse, and failed to thoroughly investigate the allegation. Again on 07/17/2021, the DON and Administrator were made aware that two (2) staff had witnessed verbal and physical abuse by LPN #1 related to Resident #2. […]

• No harm, potential for more than minimal, widespreadF812Oct 31, 2024

  Based on observation, interview, and review of the facility's policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, which had the potential to affect 85 of the facility's 86 residents who consumed food from the kitchen. Observation of the walk-in freezer revealed multiple food items in their original containers but were not sealed or dated when opened. The findings include: Review of facility's undated policy titled, Food Receiving and Storage, revealed foods should be received and stored in a manner that complies with safe food handling practices. Further review revealed all foods stored in the refrigerator or freezer would be covered, labeled, and dated (use-by date). […]

• No harm, potential for more than minimal, isolatedF684Oct 31, 2024

  Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one of one residents (Resident (R) 81) reviewed who received tube feeding. Observation and interview on 10/30/2024 at 3:02 PM revealed Certified Nurse Aide (CNA) 2 had detached and placed R81's feeding pump on hold while she gave resident care which was not within her job description. […]