Creekside Village

F 0583

Keep residents' personal and medical records private and confidential.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview and record review the facility failed to provide personal privacy when providing personal care for 1 (Resident #1) of 5 residents observed for personal care. -CNA A failed to provide privacy for Resident #1during incontinent care This failure placed residents at risk for their loss of dignity, respect, and psychological distress. Findings:Record review of Resident #1's face sheet dated 09/06/25 revealed a [AGE] year-old female admitted to the facility on [DATE REDACTED] and again on 05/08/24. Resident diagnoses included age related cataract, overactive bladder, hemiplegia (complete paralysis or loss of strength on one side of the body) and hemiparesis (partial weakness or loss of muscle strength on one side of the body) following cerebral infarction (when blood flow to the brain is disrupted), epilepsy (when nerve cell activity in the brain is disrupted, causing seizures), and anxiety (continuous worry, fear, and nervousness that can interfere with daily life). Record review of Resident #1's MDS dated [DATE REDACTED] reflected

a BIMS score of 15 indicating that resident cognition was intact.[JM1] Record review of Resident #1's Comprehensive Care Plan dated 05/16/24 and revised 08/01/25 revealed that resident was being care planned for bladder incontinence. Observation of incontinent care for Resident #1 on 09/26/25 at 11:30AM by CNA A. CNA A entered Resident #1's room and proceeded to transfer Resident #1 from her wheelchair to her bed. Resident #1's roommate was sitting in a chair on the left side of Resident #1's bed in a recliner chair. CNA A did not pull Resident #1's privacy curtains. CNA A proceeded to remove Resident #1's pants that were soiled in urine. Resident #1's brief was heavily soiled in urine. After cleaning resident, CNA A then placed a clean brief on resident along with clean pants. Interview on 09/26/25 at 11:45AM, CNA A said she worked at the facility full time for over 2 years. CNA A said she worked the 6AM-6PM shift. CNA A said she should have pulled Resident #1's privacy curtains when providing care for Resident #1. CNA A said she was nervous and therefore made a mistake.Interview on 09/26/25 at 12:45PM, the DON said whenever a resident is administered care including incontinent care they should be provided privacy by pulling the privacy curtains due to most of the residents having roommates. The DON said by doing this, it not only promotes resident dignity, but it also promotes a sense of security. Interview on 09/30/25 at 11:30AM, Resident #1 said when she was being provided with incontinent care, she preferred that the staff pulled her curtain for her privacy. Resident #1 said it was important to pull her privacy curtain because she never knew when someone might come into the room leaving her exposed. Resident #1 said if this happened, she would be embarrassed. Record review of the Nursing facility policy on Resident Rights dated February 2021 reflected in part: .Employees shall treat all residents with kindness, respect, and dignity.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Creekside Village

914 N Brazosport Blvd Richwood, TX 77531

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

worked at the facility from 6AM-6PM full time since July of 2025. CNA B said she was the CNA assigned to Resident #1. CNA B said the last time she provided incontinent care for Resident #1 was between 7:30AM or 7:45AM but missed the next round for incontinent care. CNA B said incontinent care should be provided to the residents at least every 2 hours and that was the facility policy. Record review of the Nursing facility policy on Perineal Care dated February 2018 reflected in part: .The purpose of this policy procedure are to provide cleanliness and comfort to the resident to prevent infection and skin irritation, and to observe the resident's skin condition.For female residents.wash perineal area front to back separate the labia and was area downward form front to back.Continue to wash the perineum moving from inside outward to the thigh, rinse perineum thoroughly in same direction, using fresh water and a clean washcloth.rinse and dry thoroughly.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Creekside Village

914 N Brazosport Blvd Richwood, TX 77531

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Record review of the facility policy on Infection Control dated October 2018 reflected in part: .This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of disease and infections. Record

review of the facility policy on Departmental (Environmental Services) Laundry and Linen dated January 2014 reflected in part: .The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen.Consider all soiled linen to be potentially infectious and handle with standard precautions. Record review of the facility policy on Handwashing/Hand Hygiene dated October 2023 reflected in part: .This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.Indications for hand hygiene.Immediately before touching resident.After touching a resident.Immediately after glove removal.The use of gloves does not replace handwashing/hand hygiene.

Event ID:

Facility ID:

If continuation sheet