CREEKSIDE CENTER FOR REHABILITATION AND NURSING Nursing Home


CREEKSIDE CENTER FOR REHABILITATION AND NURSING (CCN: 215113) is a Non profit - Corporation facility located in HAGERSTOWN, MD (21740). The facility has an overall rating of 1/5, health inspection rating of 1/5, and a staffing rating of 2/5. It offers 80 certified beds and maintains an average of 73.9 residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 3.49114 total hours per resident per day. It has been certified since April 3, 1978 and the last listed health inspection was on July 25, 2019, The facility is located in Washington county and provides senior and nursing home care.

CREEKSIDE CENTER FOR REHABILITATION AND NURSING Summary


Patient Ratings
Please rate how you felt your loved one or yourself have been treated at Creekside Center For Rehabilitation And Nursing below to help others make a more informed decision. Thank you.
Current Rating: Loading...

Provider Name: CREEKSIDE CENTER FOR REHABILITATION AND NURSING

Address: 1183 LUTHER DRIVE, HAGERSTOWN, MD 21740

Phone: (301) 790-1000

County: Washington (210)

Ownership Type: Non profit - Corporation

Certified Beds: 80

Average Residents Per Day: 73.9 ()

Provider Type: Medicare and Medicaid, Resides in Hospital: No

Legal Business Name: CREEKSIDE SNF OPERATING COMPANY LLC

First Approved Date: April 3, 1978

Affiliated Entity: ()

Retirement Community: Y, Special Focus Status:

Ownership Change in Last 12 Months: N

Resident Family Council: Resident

Sprinkler System Status: Yes

Overall Rating: 1 ()

Health Inspection Rating: 1 ()

QM Rating: 4 ()

Long Stay QM Rating: 3 ()

Short Stay QM Rating: 4 ()

Staffing Rating: 2 ()

Staffing Report Note:

PT Staffing Note:

Nurse Aide Staff Hours Per Day, per resident: 1.73452, LPN Staff Hours Per Day: 0.6528, RN Staff Hours Per Day: 1.1038, Licensed Staff Hours Per Day: 1.7566

Total Nurse Staff Hours Per Day, per resident: 3.49114

Weekend Nurse Staff Hours: 3.12633, Weekend RN Staff Hours: 0.9797

PT Staff Hours Per Day, per resident: 0.0381

Nurse Staff Turnover: 70.6, Nurse Turnover Note:

RN Turnover: 69.2, RN Turnover Note:

Admin Left Number: 0, Admin Turnover Note:

Case Mix Nurse Aide Hours Per Day, per resident: 2.2108, Case Mix LPN Hours Per Day: 0.8165, Case Mix RN Hours Per Day: 0.5209

Adjusted Nurse Aide Hours Per Day, per resident: 1.59833, Adjusted LPN Hours Per Day: 0.5900, Adjusted RN Hours Per Day: 0.7984

Total Adjusted Nurse Hours Per Day, per resident: 3.10129

Adjusted Weekend Nurse Hours Per Day, per resident: 2.77722

Health Survey Dates and Scores: Cycle 1: 2019-07-25 (Score: 219), Cycle 2: 2018-02-05 (Score: 152), Cycle 3: 2016-11-01 (Score: 168)

Total Weighted Health Score: 257.16

Reported Incidents: 0, Substantiated Complaints: 0

Infection Control Citations:

Fines and Penalties: Number of Fines: 2, Total Fines in Dollars: 1649.11, Payment Denials Number: 0, Total Penalties Number: 2

Location and GPS: 1183 LUTHER DRIVE,HAGERSTOWN,MD,21740 (39.6168, -77.716)

Process Date: 2024-03-01


Health Inspection Citations Details

Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2019-07-25

Type: Health, Deficiency: Reasonably accommodate the needs and preferences of each resident.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-09-25

Citation on 2019-07-25

Type: Health, Deficiency: Honor the resident's right to organize and participate in resident/family groups in the facility.

Severity: B - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-09-25

Citation on 2019-07-25

Type: Health, Deficiency: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-09-25

Citation on 2019-07-25

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

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-09-25

Citation on 2019-07-25

Type: Health, Deficiency: Protect each resident from the wrongful use of the resident's belongings or money.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-09-25

Citation on 2019-07-25

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

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-09-25

Citation on 2019-07-25

Type: Health, Deficiency: Respond appropriately to all alleged violations.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-09-25

Citation on 2019-07-25

Type: Health, Deficiency: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-09-25

Citation on 2019-07-25

Type: Health, Deficiency: Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-09-25

Citation on 2019-07-25

Type: Health, Deficiency: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-09-25

Citation on 2019-07-25

Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-09-25

Citation on 2019-07-25

Type: Health, Deficiency: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-11-19

Citation on 2019-07-25

Type: Health, Deficiency: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-09-25

Citation on 2019-07-25

Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-09-25

Citation on 2019-07-25

Type: Health, Deficiency: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-09-25

Citation on 2019-07-25

Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Severity: J - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-09-25

Citation on 2019-07-25

Type: Health, Deficiency: Provide enough food/fluids to maintain a resident's health.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-09-25

Citation on 2019-07-25

Type: Health, Deficiency: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-11-19

Citation on 2019-07-25

Type: Health, Deficiency: Post nurse staffing information every day.

Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-11-19

Citation on 2019-07-25

Type: Health, Deficiency: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-09-25

Citation on 2019-07-25

Type: Health, Deficiency: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-09-25

Citation on 2019-07-25

Type: Health, Deficiency: Ensure each resident’s drug regimen must be free from unnecessary drugs.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-11-19

Citation on 2019-07-25

Type: Health, Deficiency: Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-09-25

Citation on 2019-07-25

Type: Health, Deficiency: Ensure medication error rates are not 5 percent or greater.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-11-19

Citation on 2019-07-25

Type: Health, Deficiency: Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-09-25

Citation on 2019-07-25

Type: Health, Deficiency: Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-09-25

Citation on 2019-07-25

Type: Health, Deficiency: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-11-19

Citation on 2019-07-25

Type: Health, Deficiency: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-09-25

Citation on 2018-02-05

Type: Health, Deficiency: Reasonably accommodate the needs and preferences of each resident.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-03-28

Citation on 2018-02-05

Type: Health, Deficiency: Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-03-28

Citation on 2018-02-05

Type: Health, Deficiency: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-03-28

Citation on 2018-02-05

Type: Health, Deficiency: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-03-28

Citation on 2018-02-05

Type: Health, Deficiency: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-03-28

Citation on 2018-02-05

Type: Health, Deficiency: Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-03-28

Citation on 2018-02-05

Type: Health, Deficiency: Ensure each resident receives an accurate assessment.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-03-28

Citation on 2018-02-05

Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-03-28

Citation on 2018-02-05

Type: Health, Deficiency: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-03-28

Citation on 2018-02-05

Type: Health, Deficiency: Honor each resident's preferences, choices, values and beliefs.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-03-28

Citation on 2018-02-05

Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-03-28

Citation on 2018-02-05

Type: Health, Deficiency: Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-03-28

Citation on 2018-02-05

Type: Health, Deficiency: Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-03-28

Citation on 2018-02-05

Type: Health, Deficiency: Observe each nurse aide's job performance and give regular training.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-03-28

Citation on 2018-02-05

Type: Health, Deficiency: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-03-28

Citation on 2018-02-05

Type: Health, Deficiency: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-03-28

Citation on 2018-02-05

Type: Health, Deficiency: Ensure each resident’s drug regimen must be free from unnecessary drugs.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-03-28

Citation on 2018-02-05

Type: Health, Deficiency: Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-03-28

Citation on 2018-02-05

Type: Health, Deficiency: Ensure medication error rates are not 5 percent or greater.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-03-28

Citation on 2018-02-05

Type: Health, Deficiency: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-03-28

Citation on 2018-02-05

Type: Health, Deficiency: Provide timely, quality laboratory services/tests to meet the needs of residents.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-03-28

Citation on 2018-02-05

Type: Health, Deficiency: Provide routine and 24-hour emergency dental care for each resident.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-03-28

Citation on 2018-02-05

Type: Health, Deficiency: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-03-28

Citation on 2018-02-05

Type: Health, Deficiency: Have a plan that describes the process for conducting QAPI and QAA activities.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-03-28

Citation on 2016-11-01

Type: Health, Deficiency: Let residents voice a complaint or grievance without being treated differently or badly.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2017-01-12

Citation on 2016-11-01

Type: Health, Deficiency: Allow residents to easily view the results of the nursing home's most recent inspection.

Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2017-01-12

Citation on 2016-11-01

Type: Health, Deficiency: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2017-01-12

Citation on 2016-11-01

Type: Health, Deficiency: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2017-01-27

Citation on 2016-11-01

Type: Health, Deficiency: Reasonably accommodate the needs and preferences of each resident.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2017-01-12

Citation on 2016-11-01

Type: Health, Deficiency: Provide housekeeping and maintenance services.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2017-01-12

Citation on 2016-11-01

Type: Health, Deficiency: Conduct initial and periodic assessments of each resident's functional capacity.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2017-01-12

Citation on 2016-11-01

Type: Health, Deficiency: Review or revise the resident's care plan after any major change in physical or mental health.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2017-01-12

Citation on 2016-11-01

Type: Health, Deficiency: Ensure each resident receives an accurate assessment by a qualified health professional.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2017-01-12

Citation on 2016-11-01

Type: Health, Deficiency: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2017-01-12

Citation on 2016-11-01

Type: Health, Deficiency: Allow residents the right to participate in the planning or revision of care and treatment.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2017-01-12

Citation on 2016-11-01

Type: Health, Deficiency: Provide care by qualified persons according to each resident's written plan of care.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2017-01-12

Citation on 2016-11-01

Type: Health, Deficiency: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2017-01-12

Citation on 2016-11-01

Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2017-01-12

Citation on 2016-11-01

Type: Health, Deficiency: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2017-01-12

Citation on 2016-11-01

Type: Health, Deficiency: Ensure that residents are safe from serious medication errors.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2017-01-12

Citation on 2016-11-01

Type: Health, Deficiency: Have enough nurses to care for every resident in a way that maximizes the resident's well being.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2017-01-12

Citation on 2016-11-01

Type: Health, Deficiency: Store, cook, and serve food in a safe and clean way.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2017-01-12

Citation on 2016-11-01

Type: Health, Deficiency: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2017-01-12

Citation on 2016-11-01

Type: Health, Deficiency: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2017-01-12

Citation on 2016-11-01

Type: Health, Deficiency: Have a program that investigates, controls and keeps infection from spreading.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2017-01-12

Citation on 2016-11-01

Type: Health, Deficiency: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2017-01-12

Citation on 2016-11-01

Type: Health, Deficiency: Keep accurate, complete and organized clinical records on each resident that meet professional standards.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2017-01-12

Citation on 2016-11-01

Type: Health, Deficiency: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2017-01-12


Fire Safety Citations Details

Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2018-02-14

Type: Fire Safety, Tag: 0916, Version: New

Description: Have a battery powered remote alarm panel in a location accessible by operating personnel.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-04-11

Citation on 2018-02-14

Type: Fire Safety, Tag: 0923, Version: New

Description: Have proper medical gas storage and administration areas.

Severity: B - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-04-11

Citation on 2016-10-28

Type: Fire Safety, Tag: 0062, Version: New

Description: Automatic sprinkler systems that have been maintained in working order.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2016-12-15

Citation on 2016-10-28

Type: Fire Safety, Tag: 0144, Version: New

Description: Weekly inspections and monthly testing of generators.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2016-12-15

Citation on 2016-10-28

Type: Fire Safety, Tag: 0147, Version: New

Description: Properly installed electrical wiring and equipment.

Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2016-12-15