Inspection Reports for
The Healthcare Center at Buck Creek

The complaint investigation was substantiated for physical abuse between residents RI #4 and RI #5. The investigation found that RI #5 slapped RI #4 on the face, witnessed by CNA #5. The facility failed to submit timely investigation results for two other abuse allegations involving RI #6 and RI #22. The Administrator acknowledged the failures in timely reporting.

The facility failed to protect RI #4 from physical abuse by RI #5, which was substantiated by staff interviews and investigation. The facility also failed to timely submit investigation results for two other abuse allegations involving RI #6 and RI #22. Corrective actions were implemented including separation of residents, staff education, reporting to authorities, and ongoing monitoring.

The complaint investigation involved allegations that LPN #12 verbally abused Resident #5 by calling the resident's deceased mother a derogatory name and physically poking the resident. It also included allegations that the Business Office Manager misappropriated over $16,000 from Resident #1's personal bank account. The investigation found substantiated verbal and mental abuse of Resident #5, failure to notify Resident #5 of a room change, and confirmed misappropriation of Resident #1's funds by the Business Office Manager.

The facility failed to notify Resident #5 of a room change prior to the move and failed to protect Resident #5 from verbal, mental, and physical abuse by Licensed Practical Nurse (LPN) #12. Additionally, the facility failed to prevent misappropriation of funds from Resident #1's personal bank account by the Business Office Manager (BOM). Staff also failed to immediately report an allegation of verbal abuse involving Resident #5 and LPN #12.

The facility failed to ensure initial CNA registry and criminal background checks were completed before employment for two CNAs, did not properly complete daily associate posting forms with required census and facility name information, and failed to obtain required dual signatures on non-controlled medication destruction sheets.

The facility failed to ensure initial registry and criminal background checks were completed for two CNAs before hire, daily associate posting forms lacked required information such as facility name, census, and date, and medication disposal sheets for non-controlled drugs lacked the required two signatures.

The complaint investigation found substantiated issues related to missed morphine doses for Resident #11 due to delayed reorder and supply problems, missed Oxcarbazepine dose for Resident #55 due to late reorder, and improper storage of controlled medications in a refrigerator lacking a locked compartment.

The facility failed to administer morphine as ordered to Resident Identifier #11 on 10/12/2022 and 10/13/2022 due to delayed medication reorder and supply issues, resulting in missed doses and inadequate pain relief. Additionally, the facility failed to reorder Oxcarbazepine timely for Resident Identifier #55, causing a missed dose. Controlled medications were also found improperly stored in a refrigerator without a permanently affixed locked compartment.

The facility failed to ensure a staff member changed gloves and performed hand hygiene when providing incontinent care to a resident, posing a risk for cross contamination and infection spread.