CREEKWOOD

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by 1 of 1 medication storage rooms with the door open without staff present which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/27/2024 Plan of Correction Licensee agrees to submit self certification stating that the medication room will remain locked with the door closed when staff are not actively utilizing the medication room.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above by which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/14/2024 Plan of Correction Administrator agrees to submit proof of disaster drills being conducted on each shift with a log of employee attendance. Administrator agrees to submit a plan for how often these drills will be conducted.

Official classification

Type A

Official code

87464(f)(c)

Regulation authority

CCR

What the official deficiency says

8746(f)(c) Basic Services. This requirement isn't meet as evidenced by: Based on incident reports Resident R1 & R2 eleoped from facility without staff knowledge on 6/18/22 the facility didn't comply on safetymeasures to address behaviors such as wandering for residents R1 & R2 which poses an immediate Health,Safety risk to residents in care.Per staff interviews,SIRs, & physician's reports, R1 & 2 left the facility w/out staff knowledge. (see copies)

Official plan of correction

Facility agreed and conducted all staff training regarding elopment and have facility elopement plan reviewed and in place. Both have been submitted to CCLD on 7/12/2022. POC Cleared

Deadline recorded: Aug 5, 2022. A deadline is not proof that correction was completed.