CREEKSIDE TERRACE REHABILITATION

Nursing Home Inspector

1555 POWELL AVENUE
BELTON, TX 76513
Bell County
Phone: 254-831-6200
Provider Number: 455497
Last Inspection: 05/11/2017

About the Nursing Home

Number of Beds: 126
Number of Residents: 102
Beds Available: 24
Percent Occupancy: 81%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

5

Facility
13

County
22

TX
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

5

2017
20

2016
70

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

5/11/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Have a program that investigates, controls and keeps infection from spreading. Widespread : Minimal 5 6/10/2017
 

4/29/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 5/29/2016
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Pattern : Minimal 4 5/29/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 5/29/2016
 
Failed To: Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. Pattern : Minimal 4 5/29/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 5/29/2016
 

6/2/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give specialized rehabilitative services that are medically necessary by qualified personnel, when ordered by a doctor. Pattern : Minimal 4 7/16/2015
 
Failed To: Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. Pattern : Minimal 4 7/16/2015
 
Failed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . Pattern : Immediate 6 7/16/2015
 
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Pattern : Immediate 6 7/16/2015
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Pattern : Immediate 6 7/16/2015
 
Failed To: Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. Pattern : Minimal 4 7/16/2015
 
Failed To: Provide proper discharge planning and communication, of the resident's health status and summary of the resident's nursing home stay. Pattern : Minimal 4 7/16/2015
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Pattern : Minimal 4 7/16/2015
 
Failed To: Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. Pattern : Minimal 4 7/16/2015
 
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Widespread : Minimal 5 7/16/2015
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Widespread : Minimal 5 7/16/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 7/16/2015
 
Failed To: Provide or obtain laboratory services only when ordered by the attending physician. Pattern : Minimal 4 7/16/2015
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Pattern : Minimal 4 7/16/2015
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Pattern : Immediate 6 7/16/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

7/6/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 7/27/2017
 

10/14/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Pattern : Minimal 4 10/21/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 10/21/2016
 
Failed To: Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. Pattern : Minimal 4 10/21/2016
 

6/30/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern : Minimal 4 7/20/2016
 
Failed To: Provide routine and 24-hour emergency dental care for each resident. Pattern : Minimal 4 7/20/2016
 

12/31/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Use a registered nurse at least 8 hours a day, 7 days a week. Widespread : Minimal 5 12/31/2015
 

5/6/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 5/20/2015
 

3/13/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 4/10/2015
 
Failed To: Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. Pattern : Minimal 4 4/10/2015
 

1/2/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care by qualified persons according to each resident's written plan of care. Pattern : Immediate 6 1/30/2015
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Pattern : Minimal 4 1/30/2015
 
Failed To: Ensure that residents are safe from serious medication errors. Pattern : Immediate 6 1/30/2015
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Pattern : Immediate 6 1/30/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg TX State Avg
Number of Residents 102 85.73 75.11
Registered Nurses 0.44 0.82 0.59
Licensed Practical / Vocational Nurses 0.87 1.05 0.94
Certified Nursing Assistants 2.15 2.49 2.20
Total Staff Hours 3.46 4.37 3.73

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% TX State Avg%
of high risk long-stay residents with pressure ulcers 3 4 6
of long-stay residents assessed and appropriately given the pneumococcal vaccine 65 92 91
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 78 92 92
of long-stay residents experiencing one or more falls with major injury 2 4 3
of long-stay residents who have depressive symptoms 6 2 3
of long-stay residents who lose too much weight 10 6 5
of long-stay residents who received an antianxiety or hypnotic medication 24 22 26
of long-stay residents who received an antipsychotic medication 11 12 17
of long-stay residents who self-report moderate to severe pain 12 7 5
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 34 20 20
of long-stay residents whose need for help with daily activities has increased 22 17 18
of long-stay residents with a catheter inserted and left in their bladder 2 1 2
of long-stay residents with a urinary tract infection 4 4 3
of low risk long-stay residents who lose control of their bowels or bladder 52 47 49
of short-stay residents assessed and appropriately given the pneumococcal vaccine 54 80 77
of short-stay residents who had an outpatient emergency department visit 10 10 13
of short-stay residents who made improvements in function 47 58 59
of short-stay residents who newly received an antipsychotic medication 2 2 2
of short-stay residents who self-report moderate to severe pain 31 13 12
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 61 77 74
of short-stay residents who were rehospitalized after a nursing home admission 24 24 23
of short-stay residents who were successfully discharged to the community 62 54 46
of short-stay residents with pressure ulcers that are new or worsened 1 0 0