Inspection Reports for
Willowcreek Wellness &Amp; Rehabilitation
250 NEW FLORISSANT RD SOUTH, FLORISSANT, MO, 63031-6716
Back to Facility ProfileDeficiencies (last 9 years)
Deficiencies (over 9 years)
21.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
284% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
66% occupied
Based on a January 2026 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 2
Date: Jan 7, 2026
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide services based on acceptable standards of practice related to diabetes care for residents, specifically failure to clarify physician orders and complete required blood sugar monitoring.
Complaint Details
The investigation was complaint-related, focusing on diabetes care deficiencies. The report states the level of harm as minimal and residents affected as few.
Findings
The facility failed to clarify a physician order for Resident #2 who was not monitored throughout the day for diabetes and failed to complete a follow-up accucheck for Resident #5 who had elevated blood sugar. Documentation and administration of insulin aspart were incomplete, and staff did not consistently follow physician orders for blood sugar monitoring and insulin administration.
Deficiencies (2)
Failure to clarify physician order and monitor blood sugar for Resident #2 with diabetes.
Failure to complete follow-up accucheck for Resident #5 with elevated blood sugar.
Report Facts
Sample size: 5
Census: 104
Blood glucose reading: 484
Insulin dosage: 6
Insulin dosage: 24
Insulin dosage: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nurses B | Assistant Director of Nurses | Interviewed regarding staff responsibilities and order clarifications |
| Medical Director | Medical Director | Interviewed regarding expectations for staff to follow physician orders and difficulties with resident refusals |
| Administrator | Administrator | Interviewed regarding follow-up on orders by Director of Nursing and ADONs |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 18, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to provide timely and appropriate pain management for a resident, and failure to provide necessary behavioral health care and services for residents with substance abuse issues.
Complaint Details
The complaint investigation focused on Resident #1 who suffered from chronic pain and experienced multiple incidents of not receiving timely pain medication, leading to severe pain episodes and hospital transports. Resident #1 called 911 multiple times due to pain medication unavailability. The investigation also included Resident #2 and others with histories of substance abuse who overdosed multiple times in the facility and community, were allowed to leave the facility unsupervised, and returned intoxicated. Behavior contracts and interventions were inadequately implemented.
Findings
The facility failed to ensure timely ordering and administration of pain medication for a resident, resulting in severe pain and multiple hospital transports. Additionally, the facility failed to provide adequate behavioral health care and management for residents with substance abuse histories, allowing residents to leave the facility unsupervised, overdose multiple times, and return intoxicated. Behavior contracts and care plans were insufficiently enforced or updated.
Deficiencies (2)
Failure to provide safe, appropriate pain management for a resident requiring such services, resulting in severe pain and hospital transports.
Failure to provide necessary behavioral health care and services for residents with substance abuse, allowing continued use and abuse of illegal substances, overdoses, and unsafe behaviors.
Report Facts
Census: 118
Total Capacity: 108
Medication dosage: 20
Medication dosage: 5
Narcan doses administered: 2
Behavior contract dates: Dates of behavior contracts signed by residents (exact dates redacted)
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Reported incidents of resident under influence and overdoses, involvement in resident care |
| LPN B | Licensed Practical Nurse | Witnessed overdose event, administered Narcan, reported to DON and physician |
| LPN C | Licensed Practical Nurse | Responded to resident unresponsive, administered Narcan, contacted ADON and physician |
| Assistant Director of Nursing | ADON | Provided interview regarding medication ordering and pharmacy issues |
| Director of Nursing | DON | Provided interview regarding medication ordering and facility expectations |
| Social Services Director | SSD | Managed behavior contracts, resident counseling, and coordination of substance abuse treatment |
| Administrator | Facility Administrator | Provided interview regarding medication management and resident care expectations |
| Resident's Physician | Physician | Provided interview regarding medication orders and resident pain management |
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 3
Date: Jun 20, 2025
Visit Reason
The inspection was conducted due to complaints and incidents involving resident neglect and failure to follow care plans, including a resident fall resulting in injury and inadequate follow-up care.
Complaint Details
The investigation was complaint-driven based on allegations of neglect resulting in a resident fall with injury and inadequate follow-up care. Immediate Jeopardy was identified and later removed after corrective actions.
Findings
The facility failed to ensure residents were free from neglect, resulting in a resident falling from an elevated bed causing a femur fracture and contusion. The facility also failed to follow physician orders and properly monitor a resident's change in condition, which contributed to the resident's decline and death. Additionally, infection control practices were inadequate during wound care for multiple residents.
Deficiencies (3)
Failure to prevent resident fall from elevated bed resulting in fracture and contusion due to staff neglect and failure to follow care plan requiring 2-person assist.
Failure to follow physician orders and properly monitor and respond to resident's change in condition after fall, leading to resident's decline and death.
Failure to implement infection prevention and control practices including hand hygiene and use of enhanced barrier precautions during wound care for multiple residents.
Report Facts
Residents affected by Immediate Jeopardy: 3
Resident census: 108
Wound care treatments missed: 12
Resident fall date: May 26, 2025
Immediate Jeopardy start date: May 26, 2025
Immediate Jeopardy removal date: Jun 18, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Named in neglect finding for leaving resident unattended resulting in fall and injury; suspended and terminated |
| LPN I | Licensed Practical Nurse | Provided interview about resident care and fall |
| CNA H | Certified Nursing Assistant | Provided interview about resident fall and care requirements |
| Regional Nurse Consultant | Provided interview about investigation and staff compliance | |
| Interim Director of Nursing | Interim DON | Provided interview about fall incident and staff expectations |
| LPN F | Licensed Practical Nurse | Provided interview about resident condition and staff performance |
| LPN A | Licensed Practical Nurse | Provided interview about resident care and staffing |
| Assistant Director of Nursing | ADON | Provided interview about fall incident and care plan compliance |
| CNA C | Certified Nursing Assistant | Witnessed fall and reported concerns about CNA D |
| LPN L | Licensed Practical Nurse | Observed performing wound care without proper hand hygiene or gown use |
| Director of Nursing | DON | Provided interview about staff compliance and resident care |
| Medical Director | Provided interview about resident condition and expectations for care | |
| LPN B | Licensed Practical Nurse | Provided interview about resident vomiting and physician notification |
| LPN J | Licensed Practical Nurse | Provided interview about review of hospital discharge paperwork |
| LPN M | Licensed Practical Nurse | Provided interview about reporting changes in resident condition |
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 2
Date: May 13, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident grievance about staff treatment and alleged abuse by a Certified Nurse Assistant (CNA A).
Complaint Details
The complaint involved Resident #1 alleging that CNA A slammed him/her into the restroom and used rough handling during transfers. The grievance was not properly investigated or resolved, and the resident was not informed of the findings or given an opportunity to express satisfaction with the outcome. The facility classified the incident as a customer service issue rather than abuse and failed to document or notify appropriate parties as required.
Findings
The facility failed to follow its grievance policy by not maintaining an effective grievance process, failing to promptly resolve the grievance, and not providing the resident with investigation findings or follow-up. The facility also failed to complete a thorough investigation of the alleged abuse, lacking documentation of investigation findings, resident statements, and notification to appropriate agencies. Training was provided but not documented for the involved CNA.
Deficiencies (2)
Failed to follow grievance policy to maintain an effective grievance process and promptly resolve grievances for one resident.
Failed to complete a thorough investigation of alleged abuse for one resident per facility policy, lacking documentation of findings and investigation steps.
Report Facts
Facility census: 115
Sample size: 4
Dates of in-service training: 3/5/25, 3/6/25, 3/7/25, 3/12/25 (no documented attendance by CNA A)
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Assistant | Named in the grievance and abuse allegation for rough handling of Resident #1 |
| Social Service Director | Signed grievance report and involved in resident interviews | |
| Assistant Director of Nursing | ADON | Involved in investigation and interviews regarding the grievance |
| Executive Director | Involved in grievance discussion and interview about investigation process | |
| Regional Nurse Coordinator | RNC | Interviewed regarding expectations for abuse investigation and grievance process |
| Human Resource Manager | Interviewed regarding investigation responsibilities |
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 6
Date: Mar 4, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to address Resident Council concerns and allegations of resident abuse and bullying by Resident #3.
Complaint Details
The complaint involved Resident Council concerns not being addressed and allegations of abuse by Resident #3 and a staff member threatening Resident #15. The allegation by Resident #15 was not promptly investigated or reported to the State Survey Agency as required.
Findings
The facility failed to ensure concerns voiced during Resident Council meetings were consistently addressed in writing. Resident #3 exhibited bullying, verbal abuse, and threatening behaviors towards residents and staff, which were not adequately managed. The facility also failed to promptly investigate an allegation of staff verbal threat towards Resident #15. The facility did not consistently notify physicians or psychiatric providers of Resident #3's behaviors and failed to provide ongoing behavioral health care and monitoring. The Quality Assessment & Assurance Committee did not adequately address ongoing behavioral issues.
Deficiencies (6)
Failure to ensure concerns voiced during Resident Council meetings were consistently addressed in writing and returned to the Resident Council for review in a prompt and timely manner.
Failure to protect residents from abuse by Resident #3 who bullied, cursed, threatened residents and staff, and used racial slurs.
Failure to promptly and thoroughly investigate an allegation by Resident #15 that an unknown female employee threatened to have her brothers come to the facility and whip the resident.
Failure to timely report suspected abuse to the State Survey Agency within two hours after the allegation by Resident #15.
Failure to provide a behavioral management program for Resident #3 with ongoing disruptive verbal behaviors, failure to notify physicians and psychiatric providers of behaviors, and failure to provide ongoing monitoring and evaluation of behavioral health care.
Failure to provide ongoing monitoring and evaluation of Resident #3's disruptive behaviors in Quality Assessment & Assurance Committee meetings for all months of September through December 2024.
Report Facts
Census: 120
Behavioral incidents: 16
Behavioral incidents: 8
Behavioral incidents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named in relation to failure to investigate and report abuse allegations and failure to follow facility policies | |
| Assistant Director of Nursing N | Assistant Director of Nursing | Named in relation to failure to investigate and report abuse allegations and failure to follow facility policies |
| Social Service Director (SSD) | Social Service Director | Received abuse allegation from Resident #15 and involved in investigation |
| Licensed Practical Nurse I | Licensed Practical Nurse | Interviewed regarding abuse allegation; denied involvement |
Inspection Report
Annual Inspection
Census: 107
Deficiencies: 2
Date: Oct 22, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations regarding quality of care and nutrition/hydration status at Willowcreek Wellness & Rehabilitation.
Findings
The facility failed to monitor one resident's weight weekly as recommended and did not notify the physician regarding medication related to hypotension. Additionally, the facility failed to obtain weekly weights for three residents as ordered by the Registered Dietitian and failed to communicate these missing weights to the dietitian.
Deficiencies (2)
F684 Quality of care: The facility failed to monitor one resident's weight weekly as recommended and did not notify the physician of holding blood pressure medication related to hypotension.
F692 Nutrition/Hydration Status Maintenance: The facility failed to obtain weekly weights as ordered for three residents and failed to communicate missing weights to the Registered Dietitian.
Report Facts
Resident census: 107
Sample size: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in plan of correction for weekly weight audits and staff education |
| Regional Nurse Consultant | Regional Nurse Consultant | Interviewed regarding weight monitoring and resident assessments |
| Registered Dietitian | Registered Dietitian | Responsible for ordering weekly weights and dietary assessments |
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 2
Date: Oct 22, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to monitor residents' weights weekly as ordered and failure to notify physicians about medication holds related to low blood pressure.
Complaint Details
The complaint investigation focused on failure to obtain weekly weights as ordered and failure to notify the Registered Dietitian and physicians about weight loss and medication holds. The investigation found substantiated deficiencies related to these issues.
Findings
The facility failed to monitor one resident's weight weekly as ordered by the Registered Dietitian and failed to notify the physician when blood pressure medication was held due to hypotension. Additionally, the facility failed to obtain weekly weights for three residents with weight loss and failed to communicate this to the Registered Dietitian.
Deficiencies (2)
Failed to monitor Resident #3's weight weekly as ordered and failed to notify physician when blood pressure medication was held due to hypotension.
Failed to obtain weekly weights as ordered and failed to communicate with the Registered Dietitian for three residents sampled for weight loss (Residents #3, #4, and #5).
Report Facts
Residents sampled: 7
Census: 107
Weight loss percentage: 10.1
Weight loss percentage: 15
Weight loss percentage: 16.7
Weight loss percentage: 8.7
Weight loss percentage: 12.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Licensed Practical Nurse | Interviewed about medication hold and notification procedures |
| LPN B | Licensed Practical Nurse | Interviewed about medication hold and notification procedures |
| RD | Registered Dietitian | Interviewed about weight monitoring and dietary concerns |
| DON | Director of Nursing | Interviewed about weight monitoring and medication notification responsibilities |
| Internal Medicine Physician M | Physician | Interviewed about expectations for nurse notifications regarding medication holds |
| RNC | Regional Nurse Consultant | Interviewed about weight monitoring and dietitian notes |
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 2
Date: Oct 3, 2024
Visit Reason
The inspection was conducted based on complaints regarding inadequate wound care and infection control practices at Willowcreek Wellness & Rehabilitation.
Complaint Details
The complaint investigation revealed failures in wound care management, including improper dressing changes, inadequate infection control, and failure to follow physician orders. Resident #86 was sent to the emergency room with cellulitis following these deficiencies. Additionally, Residents #99 and #67 did not receive prescribed therapeutic diets or correct portion sizes.
Findings
The facility failed to ensure proper infection control during dressing changes, did not follow wound care orders for Resident #86, and improperly used a pillowcase with a rubber band to secure a dressing. Resident #99 did not receive therapeutic diets as prescribed, and portion sizes served were inconsistent with orders.
Deficiencies (2)
Failure to ensure acceptable infection control practices during dressing change and failure to administer correct wound care orders for Resident #86.
Failure to provide therapeutic diets as prescribed and failure to serve correct portion sizes for Residents #99 and #67.
Report Facts
Sample size: 26
Census: 111
Wound measurements: 6.5
Wound measurements: 18
Wound measurements: 9
Wound measurements: 17
Deficiency counts: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Named in wound care deficiency for Resident #86 for improper dressing change |
| Wound Care Plus Nurse Practitioner | Nurse Practitioner | Provided wound care orders and rounds; noted deficiencies in wound care |
| Director of Nursing | Director of Nursing | Interviewed regarding wound care expectations and deficiencies |
| LPN A | Licensed Practical Nurse | Reported on wound care practices and communication |
| [NAME] G | Dietary Aide | Observed serving meals with incorrect portion sizes |
| Dietary Manager | Dietary Manager | Interviewed about portion size issues and meal preparation |
Inspection Report
Routine
Census: 120
Deficiencies: 15
Date: Aug 14, 2024
Visit Reason
The inspection was a routine regulatory survey of Willowcreek Wellness & Rehabilitation to assess compliance with healthcare facility regulations, including medication administration, resident care, environment, and safety.
Findings
The facility was found deficient in multiple areas including medication administration practices, resident personal funds management, environmental maintenance, resident care including activities of daily living, wound care, oxygen therapy, dialysis care, feeding tube management, dietary services, use of bed rails, and clinical documentation. Several residents lacked proper assessments, physician orders, or documentation for care and treatments. The facility also failed to provide snacks at night and appropriate assistive devices for residents during meals.
Deficiencies (15)
Facility failed to follow acceptable nursing practice when medications were left unattended at bedside without physician orders for self-administration (Resident #46).
Failed to maintain documentation of resident personal funds and access to resident trust account after ownership change affecting 61 residents.
Failed to maintain a homelike environment including damaged walls, leaking toilets, unclean bathrooms, and food debris in resident rooms.
Failed to notify State Long-Term Care Ombudsman of resident transfers and discharges since April 2024.
Failed to ensure Activities of Daily Living (ADL) care needs were met for residents #107, #38, and #88 including hygiene and grooming.
Failed to provide care consistent with professional standards for residents receiving breast radiation therapy, wound care, repositioning, and oxygen therapy (Residents #83, #75, #175, #111).
Failed to ensure two staff were present during mechanical lift transfers (Resident #509).
Failed to maintain physician orders and provide routine colostomy care as ordered (Resident #18).
Failed to ensure residents receiving tube feedings received feedings per physician orders including proper labeling, infusion rate, and documentation (Residents #175, #65, #38, #107).
Failed to ensure residents were assessed for side rail use, obtain consents, therapy/nursing assessments, and physician orders for side rails (Residents #76, #175, #25, #11, #38, #116).
Failed to provide therapeutic diets as prescribed and failed to serve correct portion sizes for meals (Residents #99 and #67).
Failed to offer and provide snacks at bedtime to residents.
Failed to provide appropriate assistive eating devices such as divided plates and built-up utensils to residents who needed them (Residents #25 and #110).
Failed to ensure residents receiving dialysis had physician orders, documented pre and post dialysis assessments, and communication with dialysis center (Residents #111, #46, #50, #26).
Failed to ensure complete and accurate clinical documentation including medication administration, skin assessments, Braden assessments, AIMS, bed safety, smoking, elopement, and fall risk assessments for multiple residents.
Report Facts
Residents affected: 61
Residents affected: 25
Sample size: 24
Census: 120
Medication administration opportunities missed: 36
Medication administration opportunities missed: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Interviewed regarding medication administration, resident care, and dialysis assessments |
| Certified Medication Technician J | Certified Medication Technician | Interviewed regarding medication administration and self-administration policies |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration, resident care, dialysis, and facility policies |
| Business Office Manager | Business Office Manager | Interviewed regarding resident personal funds management |
| Administrator | Facility Administrator | Interviewed regarding facility policies, resident care, and documentation |
| Maintenance Director | Maintenance Director | Interviewed regarding maintenance of facility environment and side rails |
| Certified Nurse Aide C | Certified Nurse Aide | Interviewed regarding resident care, snacks, and assistive devices |
| Dietary Manager | Dietary Manager | Interviewed regarding dietary services, portion sizes, and assistive devices |
| Licensed Practical Nurse D | Licensed Practical Nurse | Interviewed regarding dialysis, tube feeding, side rails, and resident assessments |
| Licensed Practical Nurse E | Licensed Practical Nurse | Interviewed regarding side rails and resident assessments |
| Certified Nurse Aide B | Certified Nurse Aide | Interviewed regarding assistive devices and resident care |
| Certified Nurse Aide H | Certified Nurse Aide | Interviewed regarding wound care and resident care |
| Wound Nurse G | Wound Nurse | Observed and interviewed regarding wound care treatments |
| Licensed Practical Nurse F | Licensed Practical Nurse | Interviewed regarding tube feeding |
| Licensed Practical Nurse LPN D | Licensed Practical Nurse | Interviewed regarding tube feeding and dialysis |
| Licensed Practical Nurse LPN A | Licensed Practical Nurse | Interviewed regarding dialysis and resident care |
| Medical Records Manager | Medical Records Manager | Interviewed regarding missing medical records after ownership change |
| Admissions Director | Admissions Director | Interviewed regarding missing signed admission paperwork after ownership change |
| Dietary Aide L | Dietary Aide | Interviewed regarding assistive devices and dietary tickets |
Inspection Report
Life Safety
Census: 120
Capacity: 158
Deficiencies: 9
Date: Aug 14, 2024
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related regulations.
Findings
The facility failed to meet several Life Safety Code requirements including means of egress being obstructed, self-closing doors not functioning properly, emergency lighting testing deficiencies, fire alarm system maintenance issues, and corridor wall penetrations. These deficiencies had the potential to affect all residents and staff.
Deficiencies (9)
K211 Means of Egress - General: The facility failed to ensure emergency exits were free of obstructions, including a refrigerator and wooden crates blocking an emergency fire exit path.
K223 Doors with Self-Closing Devices: Several doors were propped open or did not latch properly, compromising fire safety in multiple smoke compartments.
K291 Emergency Lighting: The facility failed to inspect and test emergency lighting units monthly and annually as required, with missing documentation after certain dates.
K345 Fire Alarm System - Testing and Maintenance: The fire alarm communications panel was left unlocked and accessible, and maintenance records were incomplete.
K362 Corridors - Construction of Walls: The facility failed to maintain corridor walls free of penetrations, allowing smoke to pass through in multiple smoke compartments.
K363 Corridor - Doors: Doors protecting corridor openings were damaged, missing hardware, or did not close properly, affecting fire resistance.
K761 Maintenance, Inspection & Testing - Doors: The facility failed to provide thorough documentation for annual inspection and maintenance of doors equipped with panic hardware and special locking arrangements.
K914 Electrical Systems - Maintenance and Testing: Non-hospital grade electrical receptacles in patient sleeping areas were not tested and documented annually as required.
K918 Electrical Systems - Essential Electric System: The facility failed to conduct weekly visual and monthly load tests of the emergency power generator and maintain documentation.
Report Facts
Facility capacity: 158
Resident census: 120
Inspection Report
Routine
Census: 120
Deficiencies: 3
Date: Aug 14, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident environment, therapeutic diet provision, medication administration, and clinical documentation following a change in facility ownership.
Findings
The facility failed to maintain a homelike environment with issues such as damaged walls, leaking toilets, unclean bathrooms, and food debris. Therapeutic diets were not consistently provided as prescribed, with incorrect portion sizes served. Medication administration and required clinical assessments were inadequately documented for multiple residents, partly due to a recent change in ownership and loss of electronic medical records.
Deficiencies (3)
Failure to maintain a safe, clean, comfortable, and homelike environment including damaged walls, leaking toilets, and unclean bathrooms.
Failure to ensure residents received therapeutic diets as prescribed, including incorrect portion sizes served.
Failure to maintain complete and accurate medication administration records and clinical assessments including skin assessments, Braden assessments, AIMS, bed safety, smoking, elopement, and fall risk assessments for multiple residents.
Report Facts
Sample size: 24
Census: 120
Sample size: 26
Census: 111
Residents affected: 11
Medication administration failures: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding facility maintenance issues including leaking toilets and damaged walls | |
| Administrator | Interviewed regarding housekeeping expectations and facility maintenance reporting | |
| Housekeeping Staff I | Interviewed regarding cleaning schedules and awareness of facility maintenance issues | |
| Dietary Manager | Interviewed regarding therapeutic diet provision and portion sizes | |
| Licensed Practical Nurse (LPN) A | Interviewed regarding documentation of vital signs and assessments | |
| LPN D | Interviewed regarding admission assessment procedures and EMR changes | |
| Medical Records Manager | Interviewed regarding loss of scanned medical records after ownership change | |
| Admissions Director | Interviewed regarding loss of signed admission paperwork after ownership change | |
| Director of Nurses (DON) | Interviewed regarding EMR access issues and expectations for resident records after ownership change |
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 2
Date: Jul 24, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident-to-resident physical altercation and failure of staff to intervene and separate the residents during the incident.
Complaint Details
The complaint involved a physical altercation between Resident #1 and Resident #2 during an activity. Staff present, including the Activity Director and Activity Aide A, did not separate the residents promptly. The investigation included interviews with residents and staff, review of policies, care plans, progress notes, and training records. The facility also failed to timely respond to a resident (#9) experiencing prolonged seizure activity, delaying hospital transfer despite multiple staff observations and notifications.
Findings
The facility failed to keep residents free from physical abuse when two residents engaged in a physical altercation during an activity and staff present did not separate them. Additionally, the facility failed to adequately assess and respond to a resident experiencing prolonged seizure activity lasting 45 minutes, delaying hospital transfer.
Deficiencies (2)
Failure to protect residents from physical abuse during a resident-to-resident altercation where staff did not separate the residents.
Failure to adequately assess and respond to a resident having seizure activity lasting 45 minutes, delaying hospital transfer.
Report Facts
Census: 98
Residents sampled: 9
Seizure duration: 45
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activity Aide A | Activity Aide | Present during resident altercation; did not separate residents |
| Activity Director | Activity Director | Present during resident altercation; did not separate residents |
| Nurse D | Nurse on duty during resident seizure; delayed hospital transfer | |
| Nurse E | Charge Nurse who assisted during resident seizure incident | |
| Certified Nurse Aide B | CNA | Reported resident seizure and assisted during incident |
| Certified Nurse Aide F | CNA | Reported resident seizure and assisted during incident |
| Nurse H | Unit Manager | On call during seizure incident; assisted with paperwork |
| Regional Director of Clinical Operations | RDCO | Interviewed regarding staff expectations for resident altercation |
| Regional Corporate Nurse | RCN | Interviewed regarding expectations for seizure management |
| Resident's Physician and Medical Director | Physician/Medical Director | Interviewed regarding expectations for seizure management |
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 4
Date: Jul 24, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding abuse and neglect involving physical altercations between residents at Crystal Creek Health and Rehabilitation Center.
Complaint Details
The complaint investigation substantiated that Resident #1 and Resident #2 were involved in multiple physical altercations. Staff failed to intervene promptly and adequately. The facility also failed to properly assess and respond to a resident's prolonged seizure. The census at the time was 98 residents.
Findings
The facility failed to keep residents free from physical abuse during a verbal altercation that escalated to physical violence between two residents. The facility also failed to adequately assess and provide quality care to a resident who had a prolonged seizure lasting 45 minutes.
Deficiencies (4)
F600 Freedom from Abuse, Neglect, and Exploitation: The facility failed to keep residents free from physical abuse during a verbal altercation between Resident #1 and Resident #2, which escalated to physical violence. Staff present did not separate the residents promptly.
F684 Quality of Care: The facility failed to adequately assess and provide treatment for a resident who had a seizure lasting approximately 45 minutes, including delayed notification of emergency services and insufficient monitoring.
A4075 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. Deficiencies cited at F684.
A8023 Develop/Implement Abuse/Neglect Policies: The facility failed to develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents. Deficiencies cited at F600.
Report Facts
Census: 98
Seizure duration: 45
Psychosocial follow-up hours: 72
Inspection Report
Routine
Census: 108
Deficiencies: 1
Date: Mar 8, 2023
Visit Reason
The inspection was conducted to ensure the nursing facility met professional standards of quality, specifically focusing on wound care treatment compliance for sampled residents.
Findings
The facility failed to follow wound treatment plan orders for three sampled residents, potentially affecting all residents receiving wound care. The wound treatments were not consistently documented or ordered correctly, and treatment frequency changes were not properly recorded.
Deficiencies (1)
Failure to follow wound treatment plan orders for three sampled residents, including inconsistent documentation and treatment frequency changes.
Report Facts
Sample size: 18
Residents affected: 3
Census: 108
Stage I pressure ulcers: 1
Stage III pressure ulcers: 9
Venous and arterial ulcers: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wound Team Nurse Practitioner (NP) | Provided information about wound rounds, treatment orders, and documentation practices | |
| Wound Nurse | Discussed access to wound team notes and treatment documentation | |
| Administrator | Provided expectations for treatment order entry and adherence to policies |
Inspection Report
Plan of Correction
Census: 108
Deficiencies: 2
Date: Mar 8, 2023
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of care, specifically focusing on wound treatment plans and nursing care for residents.
Findings
The facility failed to meet professional standards by not following wound treatment plan orders for three sampled residents. Deficiencies were related to incomplete or inconsistent wound care documentation and treatment order implementation.
Deficiencies (2)
F658: The facility failed to ensure wound treatment plans were followed for Residents #14, #7, and #13, resulting in potential risk to residents with impaired skin integrity and wounds.
A4075: The facility did not provide personal attention and nursing care consistent with current acceptable nursing practice as evidenced by the deficiencies cited at F658.
Report Facts
Census: 108
Sampled residents: 3
Inspection Report
Plan of Correction
Census: 121
Deficiencies: 2
Date: Feb 3, 2023
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Crystal Creek Health and Rehabilitation Center following a survey conducted on 02/03/2023. It addresses deficiencies related to quality of care and treatment/services to prevent and heal pressure ulcers.
Findings
The facility failed to follow acceptable nursing standards for wound care and failed to ensure residents received treatment consistent with professional standards, resulting in pressure ulcers and inadequate wound management. The facility has re-educated staff and implemented corrective actions.
Deficiencies (2)
F684 Quality of care deficiency: The facility failed to document onset and treatment of a new wound for Resident #107 and did not follow acceptable nursing standards for wound care.
F686 Treatment/services to prevent/heal pressure ulcers deficiency: The facility failed to ensure Resident #102 received care consistent with professional standards to prevent and treat pressure ulcers, resulting in a stage III pressure ulcer.
Report Facts
Sample size: 8
Census: 121
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wound Nurse A | Interviewed regarding wound care assessments and treatment orders | |
| Wound Nurse B | Interviewed regarding wound care assessments and treatment orders | |
| Director of Nursing | DON | Interviewed about wound care program and staff education |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 28, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted as a complaint investigation to assess compliance with CMS and CDC recommended practices for COVID-19 preparedness.
Complaint Details
The complaint investigation was related to COVID-19 infection control. No deficiencies were found.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19. No deficiencies were cited as a result of this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 9, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted as a complaint investigation to assess compliance with CMS and CDC recommended practices for COVID-19.
Complaint Details
The complaint investigation focused on COVID-19 infection control practices and found no deficiencies.
Findings
The facility was found to be in compliance with all applicable COVID-19 emergency preparedness and infection control requirements. No deficiencies were cited as a result of this complaint investigation.
Report Facts
Regulatory compliance references: 42
Inspection Report
Immediate Jeopardy
Census: 105
Deficiencies: 15
Date: Feb 2, 2022
Visit Reason
The inspection was conducted to investigate multiple complaints and concerns related to resident care, medication administration, resident rights, facility environment, staffing, infection control, and safety.
Findings
The facility was found to have multiple deficiencies including failure to follow medication administration policies, failure to ensure resident safety and rights, inadequate staffing including lack of RN coverage, failure to maintain a safe and sanitary environment, failure to provide appropriate nutritional and hydration services, failure to ensure proper infection control practices, and failure to maintain safe physical environment such as secure handrails. An Immediate Jeopardy was identified related to a choking incident caused by failure to follow diet orders.
Deficiencies (15)
Failure to follow medication administration policies including self-administration, medication left at bedside without orders, and failure to sign drug count sheets for controlled substances.
Failure to ensure resident rights including failure to get resident up as requested, failure to notify physician of changes in condition, and failure to follow grievance policy.
Failure to maintain a safe, clean, and homelike environment including broken furniture, low water pressure, cold water, unclean bathrooms, and unsafe bed controls.
Failure to ensure proper financial management of resident funds.
Failure to ensure residents can communicate freely with surveyors without intimidation.
Failure to implement required staff screening including criminal background checks, employee disqualification list checks, and nurse aide registry checks.
Failure to follow professional standards for nursing care including timely orders for CPAP, urinary catheters, tracheostomy care, and dialysis assessments.
Failure to provide nutritional and hydration services consistent with resident assessments and physician orders including missing tube feeding formula orders and weights.
Failure to ensure adequate RN staffing and failure to ensure the Director of Nursing did not serve as charge nurse.
Failure to ensure medication error rate less than 5%, including failure to administer phosphate binder and antipsychotic injections as ordered.
Failure to store and label drugs and biologicals properly including expired medications and unlocked medication carts.
Failure to ensure menus meet nutritional needs and failure to follow diet orders resulting in choking incident due to activity staff providing inappropriate food.
Failure to serve food at safe and appetizing temperatures and failure to maintain sanitary food handling practices including handwashing and glove use.
Failure to maintain an infection prevention and control program including failure to complete required two-step tuberculin skin testing for staff.
Failure to ensure corridors are equipped with firmly secured handrails on each side.
Report Facts
Medication error rate: 23
Residents affected by financial mismanagement: 11
Residents identified as smokers: 36
Residents with tube feeding: 3
Residents with tracheostomy: 4
Residents receiving dialysis: 7
Residents on dysphagia puree diet: 4
Residents on antipsychotic injection: 1
Residents on phosphate binder medication: 1
Residents on liberalized medication administration: Policy referenced but no specific count
Residents with cognitive impairment: 8
Residents with psychiatric mood disorders: 162
Residents with dialysis: 19
Residents with injections: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT C | Certified Medication Technician | Named in medication administration and self-administration findings |
| Director of Nursing | Director of Nursing | Named in multiple interviews related to findings |
| CNA E | Certified Nurse Aide | Named in resident care and smoking findings |
| Housekeeping Supervisor | Housekeeping Supervisor | Named in smoking and environment findings |
| Maintenance Manager | Maintenance Manager | Named in environment and handrail findings |
| Activity Assistant DD | Activity Assistant | Named in choking incident and diet findings |
| LPN B | Licensed Practical Nurse | Named in medication storage and administration findings |
| LPN A | Licensed Practical Nurse | Named in medication storage and dialysis findings |
| Human Resource Director | Human Resource Director | Named in staff screening findings |
| Dietary Manager | Dietary Manager | Named in food temperature and sanitation findings |
| Medical Director | Medical Director | Named in medication and resident care findings |
| LPN Y | Licensed Practical Nurse | Named in medication administration findings |
| LPN CC | Licensed Practical Nurse | Named in medication administration findings |
Inspection Report
Life Safety
Census: 105
Capacity: 158
Deficiencies: 8
Date: Feb 2, 2022
Visit Reason
The inspection was a Life Safety Code survey to assess compliance with fire safety and emergency preparedness regulations.
Findings
The facility failed to meet several provisions of the 2012 Life Safety Code, including means of egress obstructions, delayed-egress locking arrangements, fire alarm system testing and maintenance, smoke barrier construction, electrical wiring compliance, smoking regulations, and oxygen storage safety. Multiple deficiencies were observed during the Life Safety Code tour and interviews with facility staff.
Deficiencies (8)
K211 Means of Egress - General: The facility failed to maintain aisles, passageways, and means of egress free from obstructions at emergency exit doors.
K222 Egress Doors: Doors in required means of egress were equipped with locks requiring a tool or key from the egress side, and delayed-egress exit doors lacked proper signage and did not release during fire alarm tests.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to ensure only authorized personnel could access, silence, and reset the fire alarm panel, which was left unlocked and accessible to residents and visitors.
K372 Subdivision of Building Spaces - Smoke Barrier: The facility failed to maintain smoke barriers to provide the required fire resistance rating due to unsealed penetrations and incomplete drywall work.
K511 Utilities - Gas and Electric: The facility failed to maintain electrical wiring and equipment in compliance with the National Electric Code, including improper use of extension cords and power strips near nurse stations and medication rooms.
K741 Smoking Regulations: The facility failed to properly dispose of cigarette butts and maintain designated smoking areas free of trash and cigarette waste.
K918 Electrical Systems - Essential Electric System: The facility failed to maintain the emergency generator with required fuel supply and testing, risking power loss during emergencies.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to maintain oxygen cylinder storage in accordance with NFPA code, including improper segregation and storage of full and empty tanks.
Report Facts
Facility capacity: 158
Resident census: 105
Inspection Report
Annual Inspection
Census: 103
Deficiencies: 2
Date: Sep 16, 2021
Visit Reason
The inspection was an annual survey conducted to assess compliance with professional standards related to pressure ulcer prevention and treatment at Crystal Creek Health and Rehabilitation Center.
Findings
The facility failed to follow its skin care and wound management policy by not adequately assessing, documenting, and treating pressure ulcers for certain residents. Three residents with pressure ulcers were identified, with problems found in two of them.
Deficiencies (2)
F686 Treatment/Services to Prevent/Heal Pressure Ulcer: The facility failed to ensure a resident received care consistent with professional standards to prevent and treat pressure ulcers, including failure to assess, document, and follow nurse practitioner orders for pressure ulcer treatment.
A4082 Pressure Sore Prevention/Treatment: The facility did not keep residents free from avoidable pressure sores and failed to provide adequate treatment as evidenced by the deficiency cited at F686.
Report Facts
Census: 103
Number of residents with pressure ulcers identified: 3
Number of Stage II pressure ulcers: 1
Number of Stage III pressure ulcers: 1
Number of unstageable pressure ulcers: 1
Number of Stage IV pressure ulcers: 1
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 16, 2021
Visit Reason
A COVID-19 focused infection control survey and a COVID-19 focused emergency preparedness survey were conducted as a complaint investigation.
Complaint Details
The complaint investigation found no deficiencies and the facility was compliant with 42 CFR 483.73 related to emergency preparedness.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control. No deficiencies were cited during the complaint investigation.
Inspection Report
Abbreviated Survey
Census: 114
Deficiencies: 3
Date: May 4, 2021
Visit Reason
The abbreviated survey was conducted due to an Immediate Jeopardy (IJ) situation that began on 10/23/20 related to substance abuse and protective oversight issues at Crystal Creek Health and Rehabilitation Center.
Findings
The facility failed to provide protective oversight for residents with substance abuse issues, resulting in an Immediate Jeopardy that was removed on 5/4/21. Deficiencies were found related to free of accident hazards, supervision, and behavioral health services for residents with substance abuse diagnoses.
Deficiencies (3)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to provide protective oversight for three residents with substance abuse issues, allowing illegal drugs to be brought into and used in the facility.
F740 Behavioral Health Services: The facility failed to provide necessary behavioral health care services to residents with known substance abuse problems, including assessment, treatment, and monitoring.
A4073 Protective Oversight, Voluntary Leave: The facility failed to provide twenty-four hour protective oversight and supervision for residents on voluntary leave, resulting in an imminent danger Class I level violation.
Report Facts
Resident sample size: 4
Residents affected: 12
Census: 114
Immediate Jeopardy start date: Oct 23, 2020
Immediate Jeopardy removal date: May 4, 2021
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 5, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted from 11/03/2020 through 11/05/2020 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Complaint Details
The survey was complaint-related and no deficiencies were cited as a result of the complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19. No deficiencies were cited as a result of this complaint investigation.
Inspection Report
Abbreviated Survey
Census: 110
Deficiencies: 8
Date: Sep 21, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted from 09/06/20 through 09/21/20 to assess compliance with emergency preparedness and infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness but had deficiencies related to advance directives, quality of care, pressure ulcer prevention and treatment, infection control, and advance directive requirements. The facility failed to ensure accurate documentation and timely reporting of critical lab results and proper care for residents with pressure ulcers.
Deficiencies (8)
F-578: The facility failed to have a process to ensure a resident's right to have advanced directives and refuse medical treatment was accurately documented in the medical record for one resident.
F-684: The facility failed to provide needed care and services in accordance with professional standards and resident preferences, including timely reporting of critical lab results and follow-up care for one resident.
F-686: The facility failed to ensure that a resident with pressure ulcers received necessary treatment and care consistent with professional standards, including accurate documentation and timely wound care orders.
F-880: The facility failed to maintain proper infection control practices during the COVID-19 pandemic, including failure to ensure staff wore masks properly and to prevent the spread of infection among residents and staff.
A4074: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by deficiencies cited at F684.
A4082: Facilities shall keep residents free from avoidable pressure sores and provide adequate treatment. This regulation was not met as evidenced by deficiencies cited at F686.
A4085: Residents shall be cared for by using acceptable infection control procedures to prevent the spread of infection. This regulation was not met as evidenced by deficiencies cited at F880.
A8010: Prior to or upon admission and at least annually thereafter, residents or their representatives shall be informed of advance directive requirements. This regulation was not met as evidenced by deficiencies cited at F578.
Report Facts
Resident census: 110
Resident sample size: 7
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 1, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted from 08/24/2020 through 09/01/2020 to assess compliance with CMS and CDC recommended practices for COVID-19.
Complaint Details
The complaint investigation found no deficiencies and the facility was compliant with infection control requirements.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices. No deficiencies were cited as a result of this complaint investigation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 24, 2020
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted from 06/15/2020 through 06/24/2020 to assess compliance with CMS and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Census: 124
Deficiencies: 25
Date: Feb 5, 2020
Visit Reason
The inspection was a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide reasonable accommodations for residents, incomplete financial notifications, lack of resident computer access, environmental issues in the dining room, improper use of restraints, failure to follow physician orders for treatments and medications, inadequate personal care, insufficient activity programming, medication errors, unsafe transfers, smoking policy violations, improper catheter care, dialysis care deficiencies, infection control lapses, and incomplete staff training documentation.
Deficiencies (25)
Failed to provide reasonable accommodations for residents by not ensuring grab bars in bathrooms were properly installed and maintained.
Failed to complete and send Third Party Liability forms within 30 days after resident deaths for funds used for funeral expenses.
Failed to provide residents reasonable access to computers and communication methods despite providing wifi.
Failed to maintain comfortable sound levels and wall conditions in the dining room.
Failed to ensure one resident remained free from restraints, conduct restraint assessment, and obtain physician's order for restraint use.
Failed to ensure physician orders were followed for wound treatments, tube feeding, oxygen administration, support stockings, blood sugar checks, lab tests, and care plan updates for multiple residents.
Failed to ensure residents received showers/baths as scheduled, failed to shave one resident consistently, and failed to provide fingernail care for one resident.
Failed to provide ongoing activity programming based on resident preferences and needs for multiple residents.
Failed to provide appropriate treatment and care according to orders and resident preferences for one resident with wounds, including failure to investigate a dressing left in place for months.
Failed to provide appropriate care to maintain or improve range of motion and restorative therapy for residents with contractures or mobility limitations.
Failed to follow policy and manufacturer guidelines for safe use of mechanical lifts, resulting in injury to one resident and unsafe transfers of others.
Failed to follow smoking policy including assessment of smoking safety, supervision, and storage of smoking materials; residents had smoking paraphernalia on their person and smoked in unauthorized areas.
Failed to obtain physician orders for independent leave of absence for residents and failed to ensure safety during leave.
Failed to secure razors in resident rooms, leaving them accessible to residents who could move freely.
Failed to obtain complete physician orders for indwelling urinary catheters and failed to maintain proper placement of catheter tubing and drainage bags.
Failed to provide thorough assessments, orders, monitoring and communication with dialysis center for residents receiving dialysis.
Failed to ensure certified nurse aides received required 12 hours of training annually and lacked a system to track training hours.
Failed to ensure attending physician documented timely review and actions for irregularities identified during monthly medication regimen reviews for multiple residents.
Failed to ensure PRN psychiatric medications were re-evaluated by physicians after 14 days of use for multiple residents.
Failed to ensure medication error rate was less than 5%, with errors including improper administration of nasal sprays and medication substitution errors.
Failed to ensure insulin vials and pens were dated when opened, labeled with resident's name, and discarded when outdated.
Failed to ensure proper infection control practices during wound treatment and blood glucose testing; failed to ensure timely tuberculosis testing for employees.
Failed to ensure safe food handling practices during food preparation and service and failed to maintain air conditioning vents and filters free of dust.
Failed to ensure outdoor garbage dumpsters were kept closed to prevent access to rodents and pests.
Failed to develop a baseline care plan for a new resident receiving hospice care, include hospice provider on physician orders, and establish communication process with hospice aides.
Report Facts
Sample size: 25
Census: 124
Medication error rate: 14.81
Missed documentation: 46
Missed documentation: 62
Missed documentation: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse D | Verified insulin vials and flexpens were not dated or labeled properly on Harmony Hall medication cart | |
| Nurse E | Verified insulin vials and flexpens were not dated or labeled properly on Tranquility and Serenity Hall medication carts | |
| CNA L | Certified Nurse Aide | Described unsafe transfer technique with Hoyer lift that caused resident injury |
| CNA K | Certified Nurse Aide | Described unsafe transfer technique with Hoyer lift that caused resident injury |
| LPN B | Licensed Practical Nurse | Observed performing blood glucose testing without hand hygiene and improper glucometer handling |
| Nurse C | Observed performing wound care without proper infection control practices | |
| Director of Nursing | Director of Nursing | Provided multiple clarifications on expected nursing practices and deficiencies |
| Corporate Nurse N | Provided clarifications on restorative therapy referrals and medication regimen reviews | |
| Dietary Manager | Reported on food handling deficiencies and dining room environment | |
| Administrator | Administrator | Provided clarifications on facility policies and deficiencies |
| Social Worker I | Social Worker | Discussed dental care scheduling and smoking policy responsibilities |
| Business Office Manager | Discussed Medicaid approval and financial notifications | |
| Activity Director | Activity Director | Discussed activity programming and one-on-one visits |
| Restorative Therapy Aide M | Restorative Therapy Aide | Discussed restorative therapy referrals and programming |
| Therapy Manager T | Therapy Manager | Discussed therapy evaluation and equipment ordering process |
| Human Resource Manager | Human Resource Manager | Discussed tuberculosis testing process for new hires |
Inspection Report
Annual Inspection
Census: 124
Capacity: 124
Deficiencies: 22
Date: Feb 5, 2020
Visit Reason
Annual inspection survey conducted to assess compliance with state and federal regulations at Crystal Creek Health and Rehabilitation Center.
Findings
The facility was found to have multiple deficiencies related to resident care, safety, medication management, and environmental conditions. Corrective actions were planned and documented in the Plan of Correction.
Deficiencies (22)
F558 Reasonable Accommodations Needs/Preferences: Facility failed to provide reasonable accommodations for individual resident needs and preferences, including grab bars in bathrooms for stabilization and proper walking order.
F569 Notice and Conveyance of Personal Funds: Facility failed to complete and send a Third Party Liability form within 30 days of resident discharge or death.
F576 Right to Forms of Communication w/Privacy: Facility failed to protect and facilitate resident's right to communicate with individuals and entities within and external to the facility, including reasonable access to a computer.
F584 Safe Environment: Facility failed to provide a safe, clean, comfortable, and homelike environment, including maintenance of dining room conditions and noise levels.
F604 Free from Physical Restraints: Facility failed to ensure residents remain free from restraints without proper assessment and documentation.
F658 Comprehensive Care Plans: Facility failed to ensure all residents had comprehensive care plans that met professional standards of quality.
F677 ADL Care Provided for Dependent Residents: Facility failed to ensure residents received assistance with activities of daily living including grooming and hygiene.
F679 Activities Meet Interest/Needs: Facility failed to provide activities consistent with resident interests and needs, including documentation of participation.
F684 Quality of Care: Facility failed to provide appropriate treatments and services to prevent pressure ulcers and other conditions.
F688 Increase/Decrease in ROM/Mobility: Facility failed to provide restorative services to maintain or improve residents' range of motion and mobility.
F689 Free of Accident Hazards/Supervision/Devices: Facility failed to ensure residents were free of accident hazards and received adequate supervision to prevent accidents.
F690 Bowel/Bladder Incontinence, Catheter, UTI: Facility failed to provide appropriate care for residents with urinary catheters and incontinence.
F698 Dialysis: Facility failed to ensure dialysis patients received appropriate care and monitoring.
F730 Nurse Aide Perform Review - 12hrly In-Service: Facility failed to ensure certified nurse aides received required in-service training hours.
F756 Drug Regimen Review, Report Irregular, Act On: Facility failed to ensure attending physician reviewed medication irregularities timely and took appropriate action.
F758 Free from Unnecessary Psychotropic Meds/PRN Use: Facility failed to ensure psychotropic medications were used appropriately and monitored.
F761 Label/Store Drugs and Biologicals: Facility failed to properly label and store medications, including insulin vials and pens.
F790 Routine/Emergency Dental Services in SNFs: Facility failed to provide dental services as required to residents.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: Facility failed to prevent cross contamination and maintain sanitary food handling practices.
F814 Dispose Garbage and Refuse Properly: Facility failed to ensure garbage dumpsters were kept closed to prevent access to rodents and pests.
F849 Hospice Services: Facility failed to ensure hospice care was provided according to regulations and documented properly.
F880 Infection Prevention & Control: Facility failed to implement acceptable infection control practices including TB testing and surveillance.
Report Facts
Deficiencies cited: 21
Census: 124
Total Capacity: 124
Inspection Report
Life Safety
Census: 124
Capacity: 158
Deficiencies: 6
Date: Feb 5, 2020
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code of the National Fire Protection Association and related fire safety regulations.
Findings
The facility failed to maintain smoke barrier doors to close completely during fire alarm activation, did not ensure quarterly fire drills were conducted on each shift, failed to properly dispose of cigarette butts in designated smoking areas, did not conduct annual testing of non-hospital grade electrical receptacles, and failed to maintain oxygen cylinder storage according to NFPA regulations.
Deficiencies (6)
K374: The facility failed to maintain smoke barrier doors to close completely during fire alarm activation, affecting occupants in two of eight smoke compartments.
K712: The facility failed to ensure quarterly fire drills were conducted on each shift, including night shifts, with incomplete documentation of drills.
K741: The facility failed to properly dispose of cigarette butts and maintain smoking areas, with cigarette butts found in non-designated areas and lack of self-closing ashtrays.
K914: The facility failed to ensure annual testing of non-hospital grade electrical receptacles in patient sleeping areas was conducted and documented.
K918: The facility failed to ensure weekly visual inspections of the emergency power generator and components were completed and documented.
K923: The facility failed to maintain oxygen cylinder storage according to NFPA code, with empty and full tanks stored together and combustible materials within 3 feet of tanks.
Report Facts
Facility capacity: 158
Resident census: 124
Fire drills reviewed: 4
Cigarette butts observed: 30
Cigarette butts observed: 50
Empty oxygen tanks: 13
Full oxygen tanks: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in relation to smoke barrier door repairs, fire drill compliance, smoking area maintenance, electrical system inspections, and oxygen storage corrections | |
| Maintenance Supervisor | Interviewed regarding fire drills and electrical receptacle testing | |
| Administrator | Interviewed regarding fire drill scheduling and smoking area policies | |
| Activities Director | Interviewed regarding smoking area usage |
Inspection Report
Plan of Correction
Census: 129
Deficiencies: 2
Date: Oct 4, 2019
Visit Reason
The inspection was conducted to investigate and document deficiencies related to nutrition and hydration status maintenance at Crystal Creek Health and Rehabilitation Center, including follow-up on corrective actions.
Findings
The facility failed to maintain acceptable nutritional parameters for a resident who experienced an 8.3% weight loss over four months. The facility did not follow through with a Registered Dietitian's recommendations, lacked documentation of physician orders for nutritional supplements, and failed to provide prescribed nutritional treats.
Deficiencies (2)
F692 Nutrition/Hydration Status Maintenance: The facility failed to maintain acceptable nutritional parameters for a resident with significant weight loss and did not follow through with dietary recommendations or physician orders for nutritional supplements.
A4074 Nursing Care per Resident Condition: The facility did not provide personal attention and nursing care consistent with the resident's condition, as evidenced by the deficiency cited at F692.
Report Facts
Resident census: 129
Weight loss percentage: 8.3
Weight loss percentage: 9.4
Weight loss percentage: 10.8
Weight loss percentage: 6.8
Weight values (lbs): 133
Weight values (lbs): 129.4
Weight values (lbs): 126
Weight values (lbs): 120.5
Weight values (lbs): 118
Weight values (lbs): 118.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Dietitian (RD) | Named in relation to dietary recommendations and evaluation | |
| Unit Manager | Provided resident weight information and interviewed regarding nutritional status | |
| Director of Nursing (DON) | Discussed recommendations and corrective actions | |
| Nurse A | Interviewed about nutritional supplement storage and administration |
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 2
Date: Aug 9, 2019
Visit Reason
The inspection was conducted as a complaint investigation related to quality of care and safety concerns at Crystal Creek Health and Rehabilitation Center.
Complaint Details
The complaint investigation substantiated deficiencies related to medication administration and resident supervision resulting in harm to residents.
Findings
The facility failed to properly assess, monitor, and administer anticoagulant medication to a resident, resulting in blood clots and hospitalization. Additionally, the facility failed to ensure adequate supervision and safety measures for a resident who eloped from the facility.
Deficiencies (2)
F684 Quality of care: The facility failed to assess, monitor, and administer anticoagulant medication to a resident, leading to blood clots and hospitalization.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure adequate supervision and safety devices to prevent elopement of a resident who left the facility unsupervised.
Report Facts
Resident census: 119
Deficiencies cited: 2
Inspection Report
Plan of Correction
Census: 130
Deficiencies: 17
Date: Mar 20, 2019
Visit Reason
The document is a Plan of Correction submitted by Crystal Creek Health and Rehabilitation Center following a survey conducted on 03/20/2019 to address identified deficiencies.
Findings
The facility was found deficient in multiple areas including resident self-administration of medications, self-determination, safe environment, abuse/neglect policies, quality of care, and other regulatory requirements. Specific issues included failure to ensure residents' rights, inadequate staff training, improper medication administration, and failure to maintain a safe and clean environment.
Deficiencies (17)
F 554: Resident self-administration of medications was not properly supported, with failure to ensure residents' rights and proper staff oversight.
F 561: The facility failed to support resident self-determination and choice, including restrictions on access to coffee and dining room doors.
F 584: The facility did not maintain a safe, clean, and homelike environment, including issues with mattresses, odors, and cleanliness.
F 600: The facility failed to prevent abuse, neglect, and misappropriation of resident property, and did not properly investigate or report incidents.
F 606: The facility did not properly screen new employees against the nurse aide registry and failed to develop and implement abuse prevention policies.
F 607: The facility failed to investigate and protect residents from abuse and neglect, including failure to separate residents involved in altercations.
F 658: The facility failed to develop and implement comprehensive care plans addressing residents' needs and risks, including diabetes and cognitive impairments.
F 677: The facility failed to provide adequate care for residents with pacemakers and failed to document related care.
F 684: The facility failed to provide adequate nursing services, including monitoring of residents' conditions and medication administration.
F 692: The facility failed to provide adequate nutrition and hydration, including failure to follow physician orders for tube feeding and weight monitoring.
F 693: The facility failed to provide adequate care for residents receiving enteral nutrition, including monitoring and documentation.
F 695: The facility failed to provide adequate respiratory care, including tracheostomy and suctioning.
F 696: The facility failed to provide adequate care for residents with sleep apnea and CPAP machines.
F 730: The facility failed to provide adequate training and in-service education for nursing staff.
F 745: The facility failed to provide adequate social services to meet residents' psychosocial needs.
F 804: The facility failed to ensure food safety and proper food handling procedures.
F 880: The facility failed to maintain an effective infection prevention and control program.
Report Facts
Census: 130
Deficiencies cited: 16
Inspection Report
Life Safety
Census: 130
Capacity: 158
Deficiencies: 3
Date: Mar 20, 2019
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code of the National Fire Protection Association and related fire safety regulations.
Findings
The facility failed to maintain the kitchen range hood grease drip tray and smoke barriers to meet NFPA standards. Deficient practices were observed in eight smoke compartments and three smoke barrier doors did not close properly during fire alarm activation.
Deficiencies (3)
K324 Cooking Facilities: The facility failed to maintain the kitchen range hood grease drip tray according to NFPA standards, risking fire safety in eight smoke compartments.
K372 Subdivision of Building Spaces - Smoke Barrier: The facility failed to maintain smoke barriers to provide the required fire resistance rating, affecting six of eight smoke compartments.
K374 Subdivision of Building Spaces - Smoke Barrier Doors: The facility failed to maintain smoke barrier doors to close completely during fire alarm activation, affecting three of eight smoke compartments.
Report Facts
Facility capacity: 158
Resident census: 130
Inspection Report
Annual Inspection
Census: 112
Deficiencies: 2
Date: Aug 17, 2018
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal regulations regarding pressure ulcer prevention and treatment at Crystal Creek Health and Rehabilitation Center.
Findings
The facility failed to prevent and properly treat pressure ulcers in residents, as evidenced by multiple residents with pressure ulcers and inadequate treatment documentation. The facility also lacked consistent wound care and timely physician notification.
Deficiencies (2)
F686: The facility failed to prevent pressure ulcers and provide necessary treatment and services consistent with professional standards. Resident #1 had multiple pressure ulcers that were not properly treated or documented, leading to worsening conditions.
A4082: The facility did not keep residents free from avoidable pressure sores by failing to provide adequate treatment and prevention measures.
Report Facts
Resident census: 112
Number of residents with pressure ulcers: 8
Inspection Report
Annual Inspection
Census: 125
Deficiencies: 13
Date: May 4, 2018
Visit Reason
Annual inspection survey conducted at Crystal Creek Health and Rehabilitation Center to assess compliance with federal and state regulations.
Findings
The facility was found to have multiple deficiencies including failure to respond promptly to resident call lights, inadequate baseline care plans, improper use and monitoring of restraints, insufficient incontinence care, and medication administration errors. Plans of correction were submitted addressing these issues.
Deficiencies (13)
F550 Resident Rights: The facility failed to promptly respond to a resident's call light, resulting in a 58-minute delay before assistance was provided.
F604 Right to be Free from Physical Restraints: The facility failed to assess and monitor the use of a resident's lap tray restraint and did not have a physician's order for its use.
F655 Baseline Care Plan: The facility failed to develop and implement baseline care plans within required timeframes for sampled residents.
F657 Care Plan Timing and Revision: The facility failed to revise care plans to address recent falls for sampled residents.
F658 Services Provided Meet Professional Standards: The facility failed to notify physicians and follow orders regarding a resident's weeping edema and specialized care needs.
F677 ADL Care Provided for Dependent Residents: The facility failed to provide adequate incontinence care and personal hygiene for sampled residents.
F679 Activities Meet Interest/Needs: The facility failed to provide an ongoing activity program that meets residents' interests and needs.
F688 Increase/Prevent Decrease in ROM/Mobility: The facility failed to assess and provide restorative therapy services to a resident qualified for such services.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to monitor and document wander guard bracelets and ensure residents' safety from elopement.
F690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to provide services to maintain continence for residents with bladder and bowel incontinence.
F692 Nutrition/Hydration Status Maintenance: The facility failed to ensure residents with weight loss received supplements and diet evaluations.
F759 Free of Medication Error Rates 5 Percent or More: The facility had an 8% medication error rate exceeding the 5% threshold.
F761 Label/Store Drugs and Biologicals: The facility failed to label and store insulin vials properly and ensure medication expiration dates were followed.
Report Facts
Resident census: 125
Medication error rate: 8
Medication error opportunities: 25
Insulin vials observed: 11
Inspection Report
Life Safety
Census: 125
Capacity: 158
Deficiencies: 3
Date: May 4, 2018
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related reference documents.
Findings
The facility failed to maintain clear exit discharge routes in the main dining room and did not provide a remote manual stop station for the generator. These deficiencies affected all occupants and posed safety risks.
Deficiencies (3)
K211 Means of Egress - General: The facility failed to ensure exit discharge was accessible and free of impediments, with dining room chairs blocking exits during meal times.
K918 Electrical Systems - Essential Electric System: The facility failed to provide a remote manual stop station for the generator, which is required for safety and emergency operation.
A3001 19 CSR 30-85.032(2) Substantially Constructed/Maintained: The building was not maintained in compliance with construction standards, as evidenced by the deficiencies at K211 and K918.
Report Facts
Facility capacity: 158
Resident census: 125
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