Creekside Center

Inspectors wroteBased on interview and record review, the facility failed to ensure quality of care was provided according to professional standards of practice for one of three sampled residents (Resident 1) when, 1. Resident 1's Continuous Positive Airway Pressure (CPAP- a medical device attached to a facemask and then placed over the resident's mouth or nose and used to deliver pressurized air into the airway to keep it open) order was not transcribed from the [ACUTE CARE HOSPITAL NAME]'s discharge orders on 5/24/26 to Resident 1's active orders at the facility upon admission on [DATE]. 2. Resident 1 was given Resident 2's medications by mistake on 6/6/26. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete an accurate assessment in a timely manner for one of two sampled residents (Resident 1) when Resident 1's stage 2 pressure ulcers (localized skin and tissue injuries caused by prolonged pressure, friction, or shear, primarily develop over bony prominences like the tailbone, heels, and hips, stage 2 is a partial-thickness skin loss) at right buttocks and left buttocks merged and worsened to stage 3 pressure ulcer (a severe wound featuring full-thickness skin loss where subcutaneous fat is visible, but muscle, tendon) at coccyx and a Significant Change in Status Assessment (SCSA- an assessment which captures a major decline or improvement in a resident's condition) was not completed .This failure placed Resident 1 at risk for not receiving the necessary services indicated for Resident 1's current condition upon change [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure assessments were completed accurately for one of two sampled residents (Resident 1) when:1. Resident 1's admission Minimum Data Set (MDS- a standardized, federally mandated clinical assessment tool used in nursing homes to evaluate a resident's overall health, functional capabilities, and care needs) assessment inaccurately reflected Resident 1 without pressure ulcer (localized skin and tissue injuries caused by prolonged pressure, friction, or shear, primarily develop over bony prominences like the tailbone, heels, and hips) upon admission to the facility,2. Resident 1's admission nursing assessment did not accurately reflect Resident 1's skin integrity, and3. Resident 1's weekly nursing assessments did not reflect Resident 1's skin condition accurately. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide necessary care and services to prevent and/or heal pressure injuries (areas of damaged skin caused by staying in one position for too long) for one of two sampled residents (Resident 1) when:1a. Resident 1 did not have any treatment orders for his stage 2 pressure ulcers on his left and right buttock for 10 days from 5/25/24 to 6/4/24,b. Low air loss (or LAL, a mattress designed to prevent and treat pressure wounds that uses a continuous, gentle flow of air through a surface of tiny holes to reduce pressure helping to prevent and treat skin breakdown and pressure wounds) mattress was not ordered timely for Resident 1, c. Resident 1's care plan interventions of turning and repositioning and wound care treatments for pressure ulcer healing were not implemented consistently,d. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide appropriate care and services for G-tube feeding (method of providing nutrients via a tube directly into the stomach or intestine when a person is unable to eat by mouth) for one of two sampled residents (Resident 1) when Resident 1's G-tube (gastrostomy tube - a medical device inserted directly through the abdomen into the stomach) dressing was not changed for more than a month. This failure had the potential for Resident 1's G-tube site to develop an infection and/or sepsis (life-threatening reaction to an infection that causes immune system to harm healthy tissues and organs).

Inspectors wroteBased on observation, interview, and record review the facility failed to provide food storage and preparation, as well as maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for the 73 residents who ate facility prepared meals when: 1. Dishware not kept according to standard; 2. Food preparation equipment not kept clean per food safety standards; 3. Food items not properly labeled and/or stored and; 4. Staff unfamiliar with correct sanitizing process. These failures had the potential to put residents at risk for foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan (a dynamic, individualized, and multidisciplinary document outlining a resident's medical, functional, and psychosocial needs) for 2 out of 20 sampled residents when:1. A care plan for the use of psychotropic medication (mind altering medication) was not developed for Resident 8.2. The care plan interventions for an indwelling suprapubic catheter were not followed for Resident 47. These failures had the potential to place Resident 8 for not receiving effective and person-centered care, and Resident 47 at increased risk for infection. Overall, these could negatively impact the health, safety, and well-being of Residents 8 and 47.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to prepare meals adequately when; 1. Meals prepared were bland and lacked flavor for 4 out of 73 residents (Resident 18, Resident 49, Resident 55 and Resident 64), and 2. Pureed foods (a smooth, thick, pudding-like consistency created by blending, mashing, or straining food, requiring no chewing) were not prepared by methods that conserve nutritive value, flavor, and appearance when recipes were not followed, and water was used to thin the prepared foods. These failures had the potential for malnutrition, weight loss, impaired wound healing, and increased susceptibility to disease.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement appropriate infection prevention and control measures for a census of 73, when:1. Resident 47's suprapubic catheter (a thin, flexible tube surgically inserted through the lower abdomen directly into the bladder to drain urine. Potential complications include infections such as urinary tract infection [UTI, a common infection caused by bacteria entering the bladder, or kidneys]) drainage bag was observed positioned on the floor; 2. Staff failed to perform proper hand hygiene during medication administration for Resident 4, Resident 23, Resident 42, Resident 58, and Resident 77; and,3. Staff failed to follow infection control protocols when nutritional drinks were transferred from one resident's room to another. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform and document an informed consent (a signed document requires healthcare providers to disclose risks, benefits, alternatives to ensure patients make educated decisions about their care or medication use) for increasing the diazepam (a mental health drug used to treat anxiety) dosage in one out of 5 sampled residents (Resident 8) that were reviewed for unnecessary drug use based on facility's policy on resident's rights. This failure had the potential to violate Resident 8's right to be aware of the consequences (risks versus benefits) of higher drug dosage usage that could contribute to adverse effects including dizziness, excessive sedation, fall risk and bone fracture.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and services to one of six residents (Resident 1) who receive nutrition, fluids, and medications through a gastrostomy tube (GT- also referred to as an enteral feeding/tube feeding- a tube inserted through the abdomen directly into the stomach to deliver nutrition, fluids, and medications when swallowing is not possible or safe) when Resident 1's percutaneous endoscopic gastrostomy tube (PEG tube-a tube inserted through the skin and abdominal wall directly into the stomach for the delivery of nutrition, fluids, and medications) placement was not checked before medication administration. This failure had the potential to result in Resident 1 developing infection and even death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate care and services to promote healing and prevent pressure injury (a localized injury to the skin and/or underlying tissue because of prolonged pressure) for one of 20 sampled residents (Resident 3), when Resident 3's low-air loss mattress (LAL mattress, a mattress designed to prevent and treat pressure wounds that uses a continuous, gentle flow of air through a surface of tiny holes to reduce pressure helping to prevent and treat skin breakdown and pressure wounds) was not correctly calibrated according to her current weight. This deficient practice had the potential to delay wound healing and place Resident 3 at increased risk for developing pressure injury and/or skin breakdown.

Inspectors wroteBased on interview, and record review, the facility failed to ensure timely medication processing and administration when there was a delay in both processing and administration of a prescribed mental health medication for one of 20 sampled residents (Resident 8). This failure had the potential to negatively impact Resident 8's health and place him at increased risk for a decline in psychological status.

Inspectors wroteBased on interview, and record review, the facility failed to identify and report to the Department, an allegation of financial abuse for one of three sampled residents (Resident 1) when Resident 1 reported that his money was missing from his wallet after seeing a staff member holding his wallet. This failure resulted in a delay of the Department's investigation into Resident 1's allegation of theft and had the potential to affect other residents of the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure an environment free of accidents or hazards for two of four sampled residents (Resident 3 and Resident 4) when:Resident 3 did not have Wander Gard device (a wearable device that tracks movement and triggers automated security responses when a resident nears a restricted area) placement and functioning checks documented every shift daily per physician order after an elopement (when a resident leaves a healthcare facility against medical advice when doing so poses an imminent threat to the resident's health or safety) episode; andResident 4 did not have a Wander Gard device placed upon admission to the facility despite a recent history of elopement and according to facility policy. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure medical records were complete and accurate in accordance with professional standards for one of four sampled residents (Resident 4) when Resident 4's Visual Checks (a document detailing staff observations of Resident 4's activity in timed increments), dated 10/06/25 indicated that Resident 4 was in the facility during the time that he had eloped from the facility. This failure resulted in inaccurate documentation in Resident 4's medical record for twenty minutes, with staff documenting safety observations that they did not perform.

Inspectors wroteThese findings represent past non compliance with this regulatory requirement. There was significant evidence the facility corrected the non compliance as of 08/15/25 and there were no other occurrences of the same deficient practice at the time of the survey. The facility was in substantial compliance with this regulatory requirement and there for doesn't not require a plan of correction. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide an environment to ensure residents' needs related to nursing services were met for a census of 72 when only one scheduled nurse worked the entire night shift on 5/4/25. This failure had the potential for residents' care services not being met by nursing staff and could affect the health and well-being of all residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate treatment and services were provided for one of three sampled residents (Resident 1) when, Resident 1 was not transferred to an acute care hospital (provides short-term treatment for illnesses, injuries, or surgeries that require immediate medical attention) in a timely manner for further evaluation after Resident 1 had an unwitnessed fall with a head injury on 2/17/25 and Resident 1 had a fall again on 2/28/25 with noted pain to Resident 1 ' s left hip. This failure placed Resident 1 at risk for delayed treatment and services that could possibly result in a decline in health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when: 1) Clean food service items were found put away wet (e.g. trays, steam table pans, scoops, and blender); 2) Can opener, food processor, and large saucepan were found dirty and/or rusted; 3) Raw chicken was prepared on a metal rack that had an uncovered container of dessert cups underneath; 4) Three bags in the freezer were open to the environment (sausage patties, biscuits, and mixed vegetables); 5) Staff were unable to demonstrate/explain the testing of sanitation concentration for the dish machine and red buckets/manual dish washing); and, 6) Resident refrigerator contained multiple food items with no name and/or date; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to puree (blend foods to smooth consistency) foods using methods that conserve nutritive value and flavor when excessive fluid was added, necessitating the addition of thickener. This failure had the potential of leading to poor intake, nutrient deficiencies, and weight loss for the 4 out of 62 residents eating facility prepared pureed meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide alternative meal options of similar protein content to the meal entrée when grilled cheese and peanut butter and jelly (PB&J) sandwiches were provided in place of the entree. This had the potential of leading to decreased protein intake for those choosing these alternatives.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure one of five sampled residents (Resident 16) was treated with dignity and respect when Certified Nursing Assistant (CNA) 1 stood over Resident 16 while assisting with feeding. This failure had the potential to impact Resident 16's self-esteem and negatively affect dining experience.

Inspectors wroteBased on interview and record review, the facility failed to provide services which met professional standards of quality for 2 of 16 sampled residents (Resident 60 and Resident 179) when, 1. The physician was not notified when vital signs were outside of ordered parameters for Resident 60; and, 2. The physician was not notified timely of abnormal lab results for Resident 179. These failures had the potential for unsafe medication use and risk of adverse effects for Resident 60, and the potential for a delay in treatment for Resident 179.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection prevention and control practices for a census of 67 residents when: 1. Urinals (a urine collection container) were not labeled and stored in a sanitary manner; 2. Two resident wash basins were stored on the floor in the bathroom, one was not labeled, and contained a soiled cloth; and, 3. Intramuscular Muscular Injection (an injection deep in the muscles) reconstitution (adding liquid to dry medication) was not properly handled; These failures increased the risk of infectious diseases for residents in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to ensure adequate treatment and services were provided for one of five sampled residents (Resident 1) when, a. Resident 1 needed to be suctioned (secretions from the mouth and throat are removed with a device for individuals who are not able to swallow or clear their own secretions) and the suction machine was not present at his bedside; and, b. Resident 1's change in condition was not assessed and reported to the physician in a timely manner. These failures placed Resident 1 at risk for aspirating (when liquid or solids are inhaled and may cause breathing difficulty and pneumonia), and his condition to be unrecognized and untreated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents' (Resident 1) needs were accommodated promptly, when Resident 1's call light was not within her reach. This failure had the potential of Resident 1's needs not being met and to cause psychosocial and/or physical harm for Resident 1 when Resident 1 was unable to contact staff for assistance if needed.

Inspectors wroteBased on interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from verbal abuse when Certified Nursing Assistant (CNA) 1 told Resident 1, I could kill you. This failure resulted in verbal abuse and potential psychological harm for Resident 1.

Inspectors wroteBased on interview and record review, the facility staff failed to report an abuse allegation for one of three residents (Resident 1), when Certified Nursing Assistant (CNA) 2 witnessed CNA 1 telling Resident 1 that she could kill him on 1/26/24 . This failure resulted in delayed immediate protection of Resident 1 and a delayed investigation of the alleged abuse and placed other residents in the facility at risk of abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident 2) of three sampled residents was free from abuse when Resident 1 hit Resident 2 with Resident 1 ' s fist causing ecchymosis (a bruise, with skin discoloration from damaged, leaking blood vessels underneath the skin) in Resident 2 ' s left eye. This failure resulted in Resident 2 not free from abuse by Resident 1.

Inspectors wroteBased on observations, record reviews, interviews, and facility policy review, the facility failed to update comprehensive care plans to include bed rail recommendations for 2 (Resident #26 and Resident #31) of 3 sampled residents reviewed for bed rail usage.

Inspectors wroteBased on observations, record reviews, interviews, and facility policy review, the facility failed to obtain consents and physician's orders for the use of bed rails for 2 (Resident #26 and Resident #31) of 3 sampled residents reviewed for bed rail usage.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to obtain a timely urine specimen for urinalysis for 1 (Resident #54) of 2 sampled residents reviewed for hospitalization.

Inspectors wroteBased on interviews, record review, and facility document and policy review, the facility failed to provide a pneumococcal vaccination for 1 (Resident #37) of 5 sampled residents reviewed for immunizations.

Inspectors wroteBased on interviews, record reviews, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidance titled Interim Clinical Considerations for Use of COVID-19 Vaccines in the United States, the facility failed to provide a COVID-19 vaccination for 2 (Resident #37 and Resident #16) of 5 sampled residents reviewed for immunizations.

Inspectors wroteBased on interviews, clinical record review, and facility documents review, the facility failed to ensure Resident 1 was treated with dignity and respect when Certified Nursing Assistant (CNA 1) stated, You know how to pee on the toilet. You need to pee on the toilet. I don't know why you are peeing in your diaper. You're going to have a pissy bed. This failure had the potential for Resident 1 to feel emotional distress.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate infection prevention and control measures were practiced for a census of 71, when, 1. Staff donned (put on) an N95 (type of mask that offers the highest level of respiratory protection) on top of a surgical facemask (does not filter or block very small particles in the air that may be transmitted by coughs, sneezes, or certain medical procedures), 2. Staff did not don a faceshield/goggles before entering a COVID room (in which COVID positive residents reside for isolation), and 3. Staff did not change an N95 between the care of a resident in a COVID room and non-COVID room. These failures had the potential to spread COVID-19 infection among residents and staff which could cause serious illness and/or even death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate care and services to promote healing and prevent pressure ulcers (a localized injury to the skin and/or underlying tissue because of pressure) for one of three sampled residents (Resident 2), when an air mattress was not provided to Resident 2 as ordered. This failure had the potential to worsen the pressure ulcer and to develop new pressure ulcers for Resident 2.