Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0552
Ensure that residents are fully informed and understand their health status, care and treatments.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, and record review, the facility failed to inform residents in advance of the risks and benefits of
proposed care and treatment for 1 of 5 resident (Resident #257) reviewed for resident rights, in that:
Residents Affected - Some
The facility failed to obtain a signed consent for antipsychotic medication, Buspirone HCI 10MG, Klonopin
0.5 MG, Olanzapine 5 MG and Veriafaxine HCI ER 75 MG that was administered to Resident #257.
The failure could affect residents who received psychoactive medications without informed consents and
placed them at risk of receiving treatments without informed consent.
Findings include:
Record review of Resident #257's face sheet dated 03/26/24 revealed she was an [AGE] year-old female
who admitted to the facility on [DATE], with diagnoses of Cerebral infraction , Major Depressive Disorder,
Unspecified fracture of upper end of left Humerus, Bacteria Pneumonia, UTI, Esophageal Reflux Disease,
Anemia, Hypo-Osmolality and Hyponatremia, Epilepsy, Altered Mental Status.
Record review of the comprehensive MDS assessment, dated 03/26/2024, revealed Resident #257 was
able to complete MDS.
Interview on 4/22/24 at 9:00am with MDS Nurse Resident was able to complete MDS and she was not able
to put BIMS score in. Based off interaction with Resident # 257 her BIMS would be 13.
The MDS nurse stated that Resident # 257 may have had some short term and long-term memory
problems but was not sure due to Resident being in and out of facility.
Record review of Resident #257 revealed that Resident# 257 uses antipsychotic medication Venfaxine HCL
ER 75 MG related to Depressive Disorder, medication was given on the following dates 3/30,31/24,
Buspirone HCI 7.5 MG was given on3/27, 3/28,3/29,3/30,3/31, 4/1, 4/21/4/22Olanzapine 5MG was given
on the following dates3/21,3/22 and Klonopin 0.5 MG on 4/22/24
Record review of Resident #257 physician's order summary report revealed the following order:
Medication is to be given as follow: Buspirone HCI 10MG 1 tablet orally twice a day, Klonopin 0.5 MG 1
tablet once a day, Olanzapine 5 MG and Veriafaxine HCI ER 75MG 1 tablet once a day.
Record review of Resident #257 history and physical dated 3/27/24 revealed the following anti psych
medications:
(continued on next page)
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
Page 1 of 5
Event ID:
676304
Printed: 05/15/2026
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
676304
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/24/2024
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 0552
Level of Harm - Minimal harm
or potential for actual harm
Venlafaxine HCi 75 MG tablet with food orally once a day, Buspirone HCI 7.5 MG tablet orally twice a day,
Fluoxetine HCI 20 MG tablet 1 tablet orally once a day.
Record review of Resident #257 history and physical dated 3/27/24 revealed the following diagnosis of
Resident #257:
Residents Affected - Some
Seizure, HLD, GERD, HTN, Anxiety, MDD and CVA
Interview on 4/23/24 at 10:00 am with DON stated orders to give Resident#257 antipsychotic medication
came from the doctor of Oceans Behavior Hospital and our doctor here at the facility followed the orders
from the hospital and medication was for her behaviors of yelling, smearing feces and throwing herself to
the floor.
Interview on 04/23/24 at 10:43 AM, the DON stated [NAME] a nurse received an order for a psychotropic,
they should make sure they have consents. If a resident does not have consent the nurse should contact
the management nurse and the management nurse would let the doctor know. The DON stated all charge
nurse should check for signed consents on a daily basis due to medications changes on daily basis. The
DON was asked why it is important to inform a resident of the risk and benefits of the medication. The DON
stated that it is every resident's right to be informed about the treatment and medication they received.
Interview on 04/23/24 at 11:05 AM, the charge nurse stated that she was aware that Resident #257 was
diagnosed with depression and had been order the medication, related to yelling out, mood disturbance,
and agitation. The Charge Nurse stated Resident #257 was initially admitted on [DATE] with the diagnosis
of depression. The Charge Nurse stated that Resident #257 was initially ordered Venfaxine HCL ER 75 MG
1 capsule by mouth daily with a started date of 3/26/24 related to Resident #257 behavior of yelling out.
The Charge Nurse stated that Resident #257 had frequency changes to the medication on 3/29/24 and an
additional change to the medication frequency on 3/29/24 to 75 MG 2 capsule by mouth daily. The surveyor
requested the documented consent for antipsychotic medication treatment for Resident #257.
The Charge Nurse stated that the facility did not have a current consent for treatment. The Charge Nurse
stated that she was working on obtaining consent from Resident #257's POA. The Charge Nurse stated
Resident #257 was always in out of psych hospital since her admission. The Charge Nurse was asked why
it is important to inform a resident of the risk and benefits of the medication. The Charge Nurse stated that it
is every resident's right to be informed about the treatment and medication they received.
Record review of the facility's policy last revised January 2023, titled Psychotropic medication use, revealed
the following:
o
Prior to administration of or with a change in the dosage of an antipsychotic medication, the facility shall
obtain informed consent from the resident/resident representative. This will be documented on form 3713 in
conjunction with the resident/resident representative, attending physician and/or psychiatrist and the facility
staff.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676304
If continuation sheet
Page 2 of 5
Printed: 05/15/2026
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
676304
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/24/2024
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 0640
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure resident assessments were completed,,
electronically transmitted, encoded accurately and , MDS data entered to the CMS System within 7 to14
days after the death for 1 of 16 residents (CR #56) reviewed for encoding and transmitting resident
assessments:
Residents Affected - Few
- The facility failed to encode and transmit MDS data after the a Death in Facility for CR #56 within the
required timeframe
This failure could place discharged residents at risk of not having their assessments transmitted/exported
timely.
Findings include:
Record review of Resident #56's electronic face sheet dated 4/24/24 revealed a -[AGE] year-old female
admitted to facility 03/12/24. Her diagnoses included Malignant neoplasm (Cancer) of left lung.
Record review of CR #56's MDS assessment dated [DATE] indicated section A identifying information was
initiated and signed by the MDS coordinator as completed on 04/01/24. Record review of the MDS revealed
no RN signature as completed.
Record review of nurse's notes dated 03/15/24 read in part 3/15/2024 04:55 Nursing Progress Note:
Hospice nurse notified local PD and res son. Meds released to [NAME] PD.
Nursing
3/15/2024 04:01 Nursing Progress Note: Hospice nurse here and pronounced time of death.
Nursing
3/15/2024 03:40 Nursing Progress Note: Resident noted to have no respiration, no heartbeat. Pupils
non-reactive to light. Notified Hospice.
During an interview with MDS Coordinator and the DON on 04/24/24 at 4:50PM, she looked at the MDS
and said CR #56 came to the facility to die. She said the MDS was not completed because she had to work
on the floor. She said that was when she was needed to work the floor.
Policy on MDS completion was requested on 04/24/24 at 5:00 PM The MDS Coordinator said she followed
the RAI manual in submitting the MDS.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676304
If continuation sheet
Page 3 of 5
Printed: 05/15/2026
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
676304
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/24/2024
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 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being
admitted
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
Record review and interview, the facility failed to develop and implement a Baseline Care Plan for resident
1 of 1 (CR #56) reviewed for baseline care plans.
The facility failed to initiate a Baseline Care plan within 48 hours of admission for CR # 56 admitted for
respite care on 03/12/24.
This failure could place the resident at risk of not receiving person-centered care that is needed for
communicating with staff to ensure the resident's needs are met.
Findings include:
Record review of Resident #56's electronic face sheet dated 4/24/24 revealed a -[AGE] year-old female
admitted to facility 03/12/24. Her diagnoses included Malignant neoplasm (Cancer) of left lung.
Record review of CR #56's MDS assessment dated [DATE] indicated section A identifying information was
initiated and signed by the MDS coordinator as completed on 04/01/24. Record review of the MDS revealed
no RN signature as completed.
Record review of nurse's notes dated 03/15/24 read in part 3/15/2024 04:55 Nursing Progress Note:
Hospice nurse notified the local PD and responsible party. Meds released to local PD.
3/15/2024 04:01 Nursing Progress Note: Hospice nurse here and pronounced time of death.
3/15/2024 03:40 Nursing Progress Note: Res noted to have no respiration, no apical heartbeat. Pupils
non-reactive to light. Notified Hospice.
Record review of Resident #56's physician orders 03/12/24 revealed Resident #56 was admitted to the
facility on hospice. Record review of Resident # 56 clinical records revealed no further documentation.
During an interview with DON and the MDS coordinator on 04/24/24 at 4:00pm, the MDS coordinator said
Resident # 56 came to the facility to die. The DON said there was no interim plan of care. She said it was
the facility's policy to complete and interim plan of care within 48 hours of admission by the admitting nurse
or the next nurse on duty. She said this was overlooked due to the fact that the resident was at the facility
for a short stay.
Record review of facility's policy titled Baseline care plan dated 2001 updated 2016 read in partPolicy Statement
A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within
forty-eight (48) hours of admission.
Policy Interpretation and Implementation
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676304
If continuation sheet
Page 4 of 5
Printed: 05/15/2026
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
676304
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/24/2024
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 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be
developed within forty-eight (48) hours of the resident's admission.
2. The Interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs,
medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate
care needs including but not limited to:
a. Initial goals based on admission orders.
b. Physician orders.
c. Dietary orders.
d. Therapy services.
e. social services; and
f. PASARR recommendation, if applicable.
3. The baseline care plan will be used until the staff can conduct the comprehensive assessment and
develop an interdisciplinary person-centered care plan.
4. The resident and their representative will be provided a summary of the baseline care plan that includes
but is not limited to:
a. The initial goals of the resident.
b. A summary of the resident's medications and dietary instructions.
c. Any services and treatments to be administered by the facility and personnel acting on behalf of the
facility; and
d. Any updated information based on the details of the comprehensive care plan, as necessary.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676304
If continuation sheet
Page 5 of 5
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F640 - Automated data processing requirement-
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F552 - Planning and Implementing Care
Ensure that residents are fully informed and understand their health status, care and treatments.
FAQ · About this visit
Common questions about this visit
What happened during the April 24, 2024 survey of CREEKSIDE VILLAGE?
This was a inspection survey of CREEKSIDE VILLAGE on April 24, 2024. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CREEKSIDE VILLAGE on April 24, 2024?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.