Health inspection·June 19, 2025

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 within 14 days after a facility completed a resident assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System for 1 of 15 residents (Resident #34) reviewed for MDS transmission. Residents Affected - Few The facility failed to transmit a completed Quarterly MDS assessment for Resident #34 within 14 days of completion. This failure could place residents at-risk of not having their assessment/s completed timely, which could result in denial of services and or denial of payment for services. Findings include: Record review of Resident #34's admission Record revealed a [AGE] year-old male who admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #34 had diagnoses which included Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors), benign prostatic hyperplasia (age-associated prostate gland enlargement that can cause urination difficulty), Alzheimer's Disease with late onset (a progressive disease that destroys memory and other important mental functions), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (complete paralysis and weakness on one side of the body caused by damage to brain after a blood clot or stroke), dysphagia (difficulty swallowing foods or liquids), type 2 diabetes mellitus (long-term condition in which the body has trouble controlling blood sugar and using it for energy) and gastrostomy status (surgical procedure that creates an opening through the abdominal wall into the stomach for the purpose of feeding or receiving nutrition). Record review of Resident #34's Quarterly MDS assessment, dated 1/14/25, revealed the assessment was signed as completed on 1/15/25 and accepted by the CMS system on 1/31/25. The date of 1/31/25 was highlighted in red. Telephone interview on 6/18/25 at 1:01 PM with the Director of Reimbursement, she said the red highlighted date of 1/31/25 meant that the Quarterly assessment was accepted and or transmitted late. She said if the ARD was 1/14/25 and the assessment was signed as completed on 1/15/25, but the accepted transmission date was on 1/31/25, that was a 16- day instead of 14-day transmission timeframe and 16 days would be late. The Director of Reimbursement said the completion, submission, and transmission of any facility MDS assessments were the responsibility of the facility MDS Coordinator, but the facility was without an on-site MDS Coordinator for many months. She said the facility used the RAI as the policy and procedure for completion, accuracy, submission, and transmission of MDS (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 2 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 06/19/2025 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)