Triple Creek Retirement Community

In the surveyor’s words

From the most serious findings on record at Triple Creek Retirement Community, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF760Jul 11, 2025

  Based on record review, interview, and facility document review the facility failed to ensure residents were free of significant medication errors for four (Residents #46, #103, #107, and #199) of four sampled residents reviewed for medication errors. The facility census was 50.Findings included: 1. Review of Resident Face Sheet revealed the facility admitted Resident #199 on 02/08/2025. The resident had a medical history that included diagnoses of cellulitis of the right and left lower limbs and methicillin-resistant Staphylococcus aureus (MRSA) infection. […]

• No harm, potential for more than minimal, patternF880Jan 6, 2021

  Based on observation, staff interview, facility policy review and review of Centers for Medicare and Medicaid (CMS) and Centers for Disease Control (CDC) guidelines, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) in the facility to prevent the spread of COVID-19. This had the potential to affect 12 residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11 and #12) of 30 residents residing in the facility. Findings include: During an observation of the COVID-19 quarantine (yellow zone) unit with the Administrator on 12/16/20 at 9:33 A.M. revealed State tested Nurses Aides (STNAs) #40 and #41 were observed to have exited Resident #1's room wearing KN95 respirators with ear loops that secured behind their ears. […]

• No harm, potential for more than minimal, isolatedF684Jun 18, 2026

  Based on medical record review, staff interview, and physician interview, the facility failed to obtain weights in a timely manner to monitor a resident's need for medications as an intervention per physician orders. This affected one (#5) of three residents reviewed for medication administration and orders. The census was 48. Findings include:Record review for Resident #5 revealed the resident was admitted to the facility on [DATE], and discharged on 05/14/26, with diagnoses including achalasia of cardia, hypertension, chronic kidney disease, congestive heart failure, dysphagia, diabetes, lymphoma, osteoarthritis, and hypothyroidism. […]

• No harm, potential for more than minimal, isolatedF880Mar 25, 2026

  Based on record review, observation, staff interview, and policy review, the facility failed to ensure proper personal protective equipment (PPE) was worn while providing care and services for a resident on Enhanced Barrier Precautions (EBP). This affected one (Resident #29) of three residents reviewed for infection control. The facility census was 45. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including toxic encephalopathy, Parkinson's disease, and gastrostomy status. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #29 was moderately cognitively impaired, was dependent on staff for toileting and lower body dressing and occasionally incontinent of urine and frequently incontinent of bowels. […]

• No harm, potential for more than minimal, isolatedF580Jul 11, 2025

  Based on record review, interview, and facility policy review, the facility failed to notify a physician of the facility's failure to administer ordered medications in a timely manner to three (Residents #46, #107, and #199) of four residents reviewed for notification of changes. Additionally, the facility failed to notify the Infectious Disease specialist of the addition of an antifungal medication for Resident #107. The facility census was 50. Findings included:1. Review of Resident Face Sheet revealed the facility admitted Resident #199 on 02/08/2025 with diagnoses of cellulitis of the right and left lower limbs and methicillin-resistant Staphylococcus aureus (MRSA) infection. […]