CREEKSIDE VILLAGE HEALTHCARE

Nursing Home Inspector

914 N BRAZOSPORT BLVD
CLUTE, TX 77531
Brazoria County
Phone: 979-265-4794
Provider Number: 676304
Last Inspection: 12/15/2016

About the Nursing Home

Number of Beds: 119
Number of Residents: 67
Beds Available: 52
Percent Occupancy: 56%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Individual
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

 

18

Facility
24

County
22

TX
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

18

2016
39

2015
16

2014

Medicare Ratings

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

 

Details by Inspection Date

12/15/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that residents are fully informed and understand their health status, care and treatments. Pattern : Minimal 4 12/22/2016
 
Failed To: Keep residents' personal and medical records private and confidential. Isolated : Minimal 3 12/28/2016
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 12/28/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 12/28/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 1/15/2017
 

12/10/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Pattern : Minimal 4 12/28/2015
 
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 12/28/2015
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 12/28/2015
 
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 12/28/2015
 
Failed To: Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. Pattern : Minimal 4 12/28/2015
 
Failed To: Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. Pattern : Minimal 4 12/28/2015
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Pattern : Minimal 4 12/28/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 12/28/2015
 
Failed To: Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. Isolated : Minimal 3 12/28/2015
 
Failed To: Train all employees on what to do in an emergency, and carry out unannounced staff drills. Pattern : Minimal 4 12/28/2015
 

12/11/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep each resident free from physical restraints, unless needed for medical treatment. Pattern : Minimal 4 12/21/2014
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 12/21/2014
 
Failed To: Provide activities to meet the interests and needs of each resident. Pattern : Minimal 4 12/21/2014
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Pattern : Minimal 4 12/29/2014
 

Complaint Investigation Deficiencies

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

6/5/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Receive registry verification that a nurse aide has met the required training and skills that the State requires; and 2) ensure nurse aides receive the required retraining after 24 months if nursing related services were not provided for monetary compe Pattern : Minimal 4 7/25/2017
 
Failed To: Employ staff that are licensed, certified, or registered in accordance with state laws. Pattern : Minimal 4 7/25/2017
 

10/8/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Pattern : Minimal 4 10/27/2016
 

8/18/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep each resident free from physical restraints, unless needed for medical treatment. Pattern : Minimal 4 9/18/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg TX State Avg
Number of Residents 67 83.92 75.11
Registered Nurses 0.40 0.61 0.59
Licensed Practical / Vocational Nurses 0.80 0.97 0.94
Certified Nursing Assistants 4.35 2.53 2.20
Total Staff Hours 5.55 4.11 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 8 10 6
of long-stay residents assessed and appropriately given the pneumococcal vaccine 79 91 91
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 88 92 92
of long-stay residents experiencing one or more falls with major injury 2 3 3
of long-stay residents who have depressive symptoms 42 12 3
of long-stay residents who lose too much weight 10 6 5
of long-stay residents who received an antianxiety or hypnotic medication 21 26 26
of long-stay residents who received an antipsychotic medication 21 14 17
of long-stay residents who self-report moderate to severe pain 7 3 5
of long-stay residents who were physically restrained 4 0 0
of long-stay residents whose ability to move independently worsened 28 22 20
of long-stay residents whose need for help with daily activities has increased 24 18 18
of long-stay residents with a catheter inserted and left in their bladder 1 2 2
of long-stay residents with a urinary tract infection 7 5 3
of low risk long-stay residents who lose control of their bowels or bladder 45 47 49
of short-stay residents assessed and appropriately given the pneumococcal vaccine 9 73 77
of short-stay residents who had an outpatient emergency department visit 17 14 13
of short-stay residents who newly received an antipsychotic medication 0 61 59
of short-stay residents who self-report moderate to severe pain 29 1 2
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 5 10 12
of short-stay residents who were rehospitalized after a nursing home admission 24 66 74
of short-stay residents with pressure ulcers that are new or worsened 0 22 23