Inners Creek Skilled Nursing and Rehabilitation Ce

In the surveyor’s words

From the most serious findings on record at Inners Creek Skilled Nursing and Rehabilitation Ce, in the surveyor’s own words.

• Immediate jeopardy, patternF805Oct 25, 2024

  Based on facility policy review, observations, clinical record review, review of facility master menu diet guide sheets, and staff and resident caregiver interviews, it was determined that the facility failed to provide an altered texture diet, as prescribed by the physician, for nine residents (Resident's 37, 41, 57, 59, 78, 112, 155, 162, and 167) observed. This failure placed 31 residents that had similar diet needs at a high risk for death, and resulted in an Immediate Jeopardy (IJ) situation for Residents 1, 3, 4, 5, 6, 7, 9, 10, 13, 15, 16, 17, 18, 19, 21, 22, 23, 24, 26, 27, 30, 31, 32, 33, 34, 36, 38, 39, 58, and 92. […]

• Actual harm, isolatedF600Sep 16, 2025

  Based on clinical record review, review of facility policy, and staff interview, it was determined that the facility failed to ensure that residents were free from sexual abuse, which resulted in actual harm as evidenced by emotional distress and a vaginal wound for one of four residents reviewed for abuse (Resident 1). Findings include:Review of facility policy, Abuse Prohibition, revised October 24, 2022, revealed, Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/patient property, and exploitation for all patients .Sexual abuse is a non-consensual sexual contact of any type with a patient. […]

• Actual harm, isolatedF600Jul 26, 2022

  Based on facility policy review, clinical record review, facility incident reports, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure that residents were free of neglect which resulted in actual harm, evidenced by arm and leg fractures requiring surgical intervention, for one of three residents reviewed (Resident 1). Findings include: Review of facility policy, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Patient Property Prevention reviewed February 1, 2021, revealed, The most critical step toward detecting and preventing abuse is acknowledging that no one should be subjected to violent, abusive, humiliating or neglectful behavior. […]

• Actual harm, isolatedF689Jul 26, 2022

  Based on facility policy review, clinical record review, review of facility investigation documentation, and staff interview, it was determined that the facility displayed past non-compliance in its failure to ensure that interventions were put into place to prevent accident hazards, resulting in arm and leg fractures requiring surgical intervention following a fall, for one of three residents reviewed (Resident 1). Findings include: Review of facility poilicy, Bed Positioning, updated February 2019, revealed, Verify transfer assist needed per Kardex [Resident care guide]. […]

• No harm, potential for more than minimal, widespreadF838Nov 30, 2023

  Based on document review and staff interview, it was determined that the facility failed to ensure its Facility Assessment addresses the resources necessary to care for its residents, including staff competencies necessary to provide the level and types of care needed for its resident population, for one facility assessment reviewed (Dated November 16, 2023-December 7, 2023). Findings Include: The intent of the Facility Assessment is for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the residents require. Review of the information documented in the Facility Assessment revealed no information outlining the staff competencies necessary to care for the facility's resident population. […]