North Creek Retirement & Assisted Living Community

The licensee failed to ensure four staff members completed the required two-step tuberculin skin test (TST) within three days of employment.

The licensee failed to ensure a resident or their representative signed the Negotiated Service Agreement (NSA) annually for one resident.

The licensee failed to ensure one resident had Nurse Delegation (ND) in place when non-licensed staff performed blood glucose monitoring through finger-sticks and insulin administration.

The licensee failed to implement systems that support and promote safe medication services for one resident who required medication assistance, resulting in the resident not receiving prescribed medication and being placed at risk for health complications.

The facility failed to notify the Department when a resident was hospitalized, preventing the initiation of a timely bed-hold.

The facility failed to provide requested records (Medication Administration Record and Negotiated Care Plan) to the Department within a reasonable time, requiring multiple email and in-person requests.

The facility failed to train staff on policies for unresponsive residents; staff did not call 911 for approximately eight hours after discovering a resident without vital signs, and non-licensed staff incorrectly determined the resident was deceased.

Deficiency corrected

Deficiency corrected

Facility failed to ensure 1 of 4 sampled residents received medications as prescribed by a physician, specifically an antibiotic for a UTI.

The facility failed to ensure 1 of 2 sampled residents had prescribed insulin available, resulting in a gap in medication administration from 08/10/2024 through 08/13/2024.

Facility failed to ensure 3 of 4 sampled residents had prescribed medications available in the facility, including insulin, blood pressure, thyroid, diabetes, depression, pain, and heartburn medications.

The facility failed to include hospice (end of life care) information in the Negotiated Service Agreement (NSA) for 1 of 1 sampled residents receiving hospice services.

Staff B performed delegated tasks (blood sugar checks and insulin administration for Residents 1 and 2) without being properly delegated by a Registered Nurse.

The Department found that previously cited deficiencies for intermittent nursing services systems were corrected.

Facility demonstrated continued non-compliance regarding the medication delivery system.