Creekside Village Rehabilitation and Nursing LLC

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Administration Deficiencies

Have a plan that describes the process for conducting QAPI and QAA activities.

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Based on record review and interviews, the facility failed to report alleged violations of physical abuse to the State Survey and Certification Agency in accordance with state law for two of three alleged abuse violations.Specifically, the facility failed to:-Submit a final report of the facility' s investigation of a physical abuse allegation involving Resident #3 and Resident #4 to the State Agency timely; and,-Submit a final report of the facility' s investigation of a physical abuse allegation involving Resident #5 and Resident #6 to the State Agency timely.Findings include:I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy dated 4/11/25 was provided by the nursing home administrator (NHA) on 7/7/25 at 2:50 p.m. The policy revealed the facility would provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which could include staff to resident abuse and certain resident-to-resident altercations. Abuse also included the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It included verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.Physical Abuse included, but was not limited to hitting, slapping, punching, biting, and kicking. It also included controlling behavior through corporal punishment.The facility would have written procedures that included reporting of all alleged violations to the NHA, State Agency, adult protective services and to all other required agencies (law enforcement when applicable) .. A complaint survey, prompted by #CO40520, #CO40545, Incident #40199, Incident #40494 and Incident #40546 was conducted on 7/7/25 to 7/8/25. Two deficiencies were cited.

A complaint survey, prompted by #CO40002, #CO40004, #CO40017, #CO40019, #CO40035 and Incident #39828 was completed on 5/12/25 to 5/13/25. Three deficiencies were cited. Based on observations and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public.Specifically, the facility failed to: -Repair detached and soiled hallway ceiling tiles; -Repair improperly secured light fixtures;-Maintain swamp coolers in a safe, functional, and sanitary condition; and, -Repair sagging drywall caused by inadequate attachment to the supporting framing.Findings include:I. Facility policy and procedureA request was made to the nursing home administrator (NHA) on 5/13/25 for the facility' s policy for maintaining a safe and sanitary environment; however, the policy was not provided by the end of the survey (on 5/13/25). II. ObservationsOn 5/12/25, environmental observations of the facility were conducted throughout the day, beginning at 10:21 a.m. The following was observed. A. Ceiling tiles Several ceiling tiles were detached from their mounts. Additionally, ceiling tiles revealed structural weakening and visible wear. The surfaces of the ceiling ti.. Based on observations, record review and interviews, the facility failed to ensure two (#10 and #13) of five residents out of 11 sample residents were kept free from abuse.Specifically, the facility failed to: -Protect Resident #10 from physical abuse by Resident #12; and,-Protect Resident #13 from verbal abuse by Resident #12.Findings include:I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy, dated 4/11/25, was provided by the nursing home administrator (NHA) on 5/13/25 at 5:59 p.m. It read in pertinent part, "It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property."' Abuse' means the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations.. Based on record review and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#1) of three residents reviewed for medication errors out of 11 sample residents.Specifically, the facility failed to ensure Resident #1 was administered antibiotic medications per physician' s orders.Findings include:I. Resident #1A. Resident status Resident #1, age 83, was admitted on 5/2/25. According to the May 2025 computerized physician orders (CPO), diagnoses included diverticulitis of intestine part unspecified with perforation and abscess without bleeding (disease that causes inflammation and infection in the intestine), abscess of intestine, lower abdominal pain unspecified and bipolar disorder (mental illness). The 5/6/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. B. Resident interviewResident #1 was interviewed on 5/12/25 at 3:28 p.m. She said the facility did not admini..

A complaint survey, prompted by #CO39128, #CO39133, #CO39138, #CO39187, Incident #39064, Incident #39163, Incident #39290 and Incident #39333 was conducted on 2/20/25 to 2/25/25. One deficiency was cited. Based on record review and interviews, the facility failed to ensure one (#13) of four residents investigated for abuse out of 13 sample residents was kept free from physical abuse. Specifically, the facility failed to protect Resident #13 from physical abuse by Resident #12. Findings include: I. Facility policy and procedure The Abuse policy, revised on 6/11/24, was provided by the interim nursing home administrator (INHA) on 2/20/25 at 2:42 p.m. The policy read in pertinent part, "Every resident has the right to be free from abuse. All occurrences of resident abuse shall be promptly reported to the abuse coordinator for investigation. "The facility will ensure that all residents are protected during and after abuse investigations by:-Responding immediately to protect the alleged victim;-Increasing supervision of the alleged victim and the other residents as indicated; and,-Providing emotional support to the resident during and after the investigation. "Sexual abuse is non-consensual contact of any type with a resident." II. Sexual abuse of Resident #13 by Resident #12 A. Facility investigation The 2/18/25 facility investigation was provided by the regional director of quality and compliance (RDQC) on 2/24/25 at 10:10 a.m. The investigation documented that on 2/18/25 at 11:45 a.m., registered nurse (RN) #1 observed Resident #12 kiss Resident #13 on her mouth. The facility staff responded immediately and separated the residents. RN #1 completed assessments on both residents and no injuries were apparent on either resident. Resident #13 told RN #1 that she was okay, said she did not like the kiss and understood that Resident #12 was confused. After the occurrence, both residents were placed on frequent monitoring for behavioral changes and were provided redirection to prevent reoccurrence. The facility investigation documented that Resident #12 had a history of making unwanted sexual advances toward other residents when agitated. Resident #12 was not interviewable during the facility investigation ..