Creekside Post Acute

Inspectors wroteBased on interview and record reviews, the facility failed to ensure the physician was notified of an abnormal laboratory results for one of five sampled residents (Resident 1) when a sputum culture (a laboratory test performed on mucus coughed up from the lungs or airways to identified the type of infection) results showed heavy growth (a large of bacteria grew from the sputum) of extended-spectrum beta-lactamase (ESBL - producing Klebsiella pneumoniae, a type of bacteria that can cause infection and is resistant to many commonly used antibiotics) received on June 23, 2026. This failure placed Resident 1 at risk for delayed medical evaluation and treatment of a potentially serious respiratory infection (a severe infection affecting the lungs or airways that, if worsens or spreads, may lead to a serious complications.)

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate supervision was provided for one of three sampled residents (Resident 1) when Resident 1 fell out of bed during wound care treatment. This failure resulted in Resident 1 falling off the bed, placing his safety at risk. During a review of Resident 1's admission Records (general demographics information), the admission Records indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included quadriplegia (partial or total loss of sensory or motor function), respiratory failure (lungs cannot supply oxygen), type 2 diabetes mellitus (body has trouble controlling blood sugar) and pressure ulcer on the left hip (wound to hip). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their Medication Administration policy and procedure for one (1) of three (3) sampled residents (Resident 1) when Resident 1's scheduled dose for 8:00 PM to 10:00 PM medications were not recorded as administered on Resident 1's Medical Administration Record (MAR) on December 31, 2025. This failure has the potential for Resident 1 to be at risk of overdose or missed doses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication was administered in accordance with the facility's policies and procedures (P&P) for one (1) of three (3) sampled residents (Resident 1) when Resident 1 did not receive his medication, Pirfenidone (a medication for Idiopathic Pulmonary Fibrosis (IPF- a serious lung disease where the lungs scar and stiffen, making it hard to breathe), on three occasions, December 26, 2025 at 2:00 PM, December 27, 2025, at 2:00 PM, and December 28, 2025, at 10:00 PM. This failure had the potential to place Resident 1 at risk for adverse effect such as a return or worsening of idiopathic pulmonary fibrosis (IPF) symptoms, which includes shortness of breath, extreme tiredness, and dry hacking cough.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff who had appropriate competencies and skill set completed the resident's Quarterly Nutrition Assessment (a detailed evaluation of eating habits, weight and overall health related to food, done every 3 months). This failure had the potential to place 52 highly vulnerable residents' health at risk due to not receiving an adequate nutritional assessment. During a review of Residents 5, 8, 25 and 26's Quarterly Nutrition Assessments (comprehensive evaluation of an individual's nutritional status, aiming to identify any nutritional deficiencies or risks, and guide personalized interventions) between November 2024, through June 2025, it indicated the assessments were completed and signed by the Dietary Service Supervisor (DSS 1). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store resident food safely when:1. The resident refrigerator had multiple food items that were not labeled or dated. 2. The temperature of the refrigerator had not been monitored in June 2025 and July 2025. These failures had the potential for food borne illness (any illness resulting from eating contaminated/spoiled foods) in 25 medically compromised residents who were able to store food in this refrigerator. During a concurrent observation and interview on July 16, 2025, at 9:57 AM, with the Social Worker (SW), in the dining room, the resident refrigerator was found to have multiple food items that were not labeled or dated. Two thermometers were located outside of the fridge. The SW stated the food items stored in the refrigerator should be dated and labeled with the resident's name. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the acceptable parameters of nutritional status (factors that reflect that an individual's nutritional status is adequate, relative to his/her overall condition and prognosis, such as weight, food/fluid intake, and pertinent laboratory values), recognize, evaluate, and address the nutritional needs of one of three residents reviewed for nutrition (Resident 26) when: 1. Resident 26's tube feeding (method of providing nutrition directly into the stomach or small intestine when a person is unable to eat enough or at all by mouth) formula was administered as ordered by the physician on July 15, 2025, and July 16, 2025. Resident 26's had an order to receive 95 ml (milliliters, a unit of volume) per hour. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used were labeled in accordance with professional standards, and storage of medications were properly secured for two of 11 medication carts (Med Cart - used to transport medication to resident's rooms) when: 1. Two bubble packs (small package enclosing goods in transparent dome-shaped plastic on a flat cardboard backing) containing Resident 18's Eliquis (a medication used for blood thinner) were found without expiration dates. This failure had the potential to cause the medication to lose its potential effects and be used for Resident 18. 2. Eight tubes of Santyl (a medication used for wounds) ointment were found without resident's identification labels. This failure had the potential to be accessed and administered in error. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide evidence staff discussed with two of seven residents (Resident 7 and 54) whether the residents had an existing advance directive (a legal document that explains how an individual wants medical decisions to be made if the individual is incapable of making their own decisions) and were educated on their rights to establish a new advance directive if desired. This failure had the potential for Residents 7 and 54 to receive end of life care not in accordance with their wishes and for life sustaining measures to be rendered against what the residents (or their representatives) wanted.1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Minimum Data Set (MDS- a computerized assessment instrument) Assessment was accurately completed to reflect the resident's status, care, and services for one of five sampled residents (Resident 2) reviewed for MDS, when Resident 2's schizophrenia diagnosis (a chronic and severe mental health disorder that affects how a person thinks, feels, and behaves) was not accurately coded on Resident 2's quarterly Minimum Data Set (a standardized, federally mandated evaluation of nursing home residents' health status, conducted every three months or more frequently if there's a significant change in condition) assessment. This failure had the potential to cause inaccuracy in identifying Resident 2's care and support needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR - federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) was re-submitted for one of five sampled residents reviewed for PASARR Assessment (Resident 2). This failure had the potential to result in Resident 2 not being accurately assessed regarding supplemental treatment and services to better meet the needs of the resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one resident (Resident 4) reviewed for pressure ulcers (a localized injury to the skin and/or underlying tissue resulting from pressure on the skin) received care for skin breakdown as specified in the resident's care plan (an individualized plan for the medical care of a resident) and physician's orders when there was no documented evidence to indicate Resident 4 received physician ordered wound care treatment for multiple days in May, June, and July 2025. This failure had the potential for Resident 4 to experience worsening pressure ulcer wounds and delayed wound healing. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two residents (Resident 43) reviewed for environment/accidents was free from accident hazards when Resident 43 fell from bed while receiving care from a Certified Nursing Assistant (CNA) on April 22, 2025. This failure may have contributed to Resident 43 to experience uncontrolled pain in the resident's coccyx area (often referred to as the tailbone, a small bone at the base of the spine) which resulted in the resident needing treatment and evaluation at a hospital. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their manual resuscitation (process of assisting or taking over a patient's breathing using a handheld device) policy was implemented for one of three residents (Resident 4) reviewed for respiratory care, when Resident 4 did not have an Artificial Manual Breathing Unit bag (AMBU bag - a hand-held medical device used to provide respiratory support to patients who are not breathing or are having difficulty breathing. Also known as a bag-valve-mask (BVM) or a manual resuscitator) at the bedside. This failure had the potential for Resident 4 to receive delayed emergency resuscitative measures during an emergency as a result of not having the required medical equipment immediately available. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the documentation in the Electronic Health Record (EHR) was accurate for one of four residents (Resident 4) reviewed for advance directives (a legal document that outlines a person's healthcare wishes in the event that they become unable to make medical decisions for themselves due to illness, injury, or incapacity) when Resident 4's code status (refers to a patient's preferences regarding cardiopulmonary resuscitation [CPR] and other life-sustaining measures in the event of cardiac or respiratory arrest) contradictorily indicated Resident 4 was both Do Not Resuscitate (DNR - a medical order that instructs healthcare providers not to perform CPR if a patient's heart stops or breathing ceases) and Full-Code (indicates a patient's wish to receive all possible medical interventions, including CPR in the event the heart [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure facility staff follow the Infection Control Policies and Procedure 's standards for Transmission-Based Precautions (actions implemented in addition to standard precautions that are based upon the means of transmission in order to prevent or control infections) when a staff member was observed entering a Contact Precaution (measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment) room without wearing the required Personal Protective Equipment (PPE- protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-transmission.). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate treatment and management of a gastrostomy tube (G-tube- tube inserted through the abdomen into the stomach that delivers nutrition, hydration, and medications) was implemented in accordance with the facility's policy and procedure for three of six residents (Residents 18, 19, and 6) reviewed for g-tube when a Licensed Vocational Nurse (LVN 2) did not check Residents 18, 19, and 6's G-tube placement (listening to gurgling sound when flushing air through the g-tube to confirm for correct position) before administering medications. These failures had the potential to place Residents 18, 19, and 6 at increased risk of aspiration (when food or liquids enter the lungs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications being received by the residents were explained prior to administration to three of eight residents (Residents 18, 19, and 6) reviewed for medication administration. These failures had the potential to result in Residents 18, 19, and 6 being denied their right to know what medication is being given and breaking one of the seven rights of medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure storage of medications was secure for one of one medication room, when the medication refrigerator inside the medication room was found unlocked. This failure had the potential to increase the risk of unauthorized access, misuse, and/or harm to highly vulnerable population of 49 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document the Restorative Nursing [nursing interventions that promote the residents' ability to adapt and adjust] Weekly Summary for one of six residents (Resident 6) reviewed for limited range of motion (ROM- full movement potential of a joint.). This failure had the potential to result in inaccurate progress or regression in range of motion exercises which could negatively impact the range of motion for Resident 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 2) call light remained within reach and accessible for a distressed resident (Resident 2) while in bed. This failure resulted in Resident 2 ' s needs not being met in a timely manner and deprived this mentally compromised resident of assistance when needed.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to prevent entry of outside contaminants into the bulk container of thickener (a starch added to liquids and foods to make it firmer). This failure had the potential to cause contamination of food prepared with thickener, and possible foodborne illness in 47 of 48 medically compromised residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility did not properly dispose of trash when the outside garbage bin for trash was overflowing, and the lid was not closed for one of one dumpster. This failure had the potential to attract vermin (pests or nuisance animals that spread diseases) in a facility that cares for 48 medically compromised residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their daily menu for lunch on March 15, 2022, by substituting the penne pasta with mashed potatoes for three of three puree (food is blended until it is a thick, smooth, lump-free consistency) lunch trays. Puree mashed potatoes were also served according to the menu on March 14, 2022. This failure had the potential for residents to lose their appetite because they were served the same starch two times in a row, which could compromise the nutritional status of three of three residents (Residents 6, 11, and 28) who are medically compromised.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper consistency of the spinach served on the puree (food is blended until it is a thick, smooth, lump-free consistency) lunch trays for three of three residents (Residents 6, 11, 28). This failure had the potential to cause difficulties in swallowing and possible aspiration (when something swallowed enters the airway or lungs) in these medically compromised residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary, and comfortable environment to help prevent the possible development and transmission of a Coronavirus, COVID-19 (a highly contagious respiratory infection) when, three nursing staff were observed not following proper personal protective equipment, PPE (equipment and cloths for protection against infectious diseases) guidelines when entering rooms in yellow zone (Residents under isolation observation for suspected COVID-19). This failure had the potential to result in the spread of Coronavirus (COVID-19) infection to 48 medically compromised residents.

Inspectors wroteBased on interview, and record review, the facility failed to implement an antibiotic stewardship program (an effort to measure and improve how antibiotics are prescribed by physicians and used by residents) when Resident 29 was prescribed antibiotics and there were no criteria used to ensure that they had been prescribed appropriately. This failure had a potential to ineffectively treat infections, protect patients from harm caused by unnecessary antibiotic use and combat antibiotic resistance, for one resident reviewed for antibiotics.

Inspectors wroteBased on observation, interview, and record review, the facility failed to respect the rights and dignity of one resident (Resident 15) reviewed for urinary catheter, when Resident 15's urinary catheter bag (a hollow, flexible tube that collects urine from the bladder and leads to a drainage bag) was not covered with a dignity bag and was visible to public view. This failure had the potential to compromise Resident 15's dignity and violate his right to privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS - resident care assessment tool) for two of 18 sampled residents (Residents 17 and 42). These failures had the potential to result in unmet care needs for Residents 17 and 42, which could adversely affect their safety and health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the Registered Dietician's (RD) recommendations for one of four residents sampled (Resident 11) when she lost 5 pounds each month since her admission date of December 29, 2021. The RD recommended that nursing document how many milliliters (mL) of a nutritional supplement (Resource 2.0) the resident consumed and for Resident 11 to be seen by a Speech-Language Pathologist (SLP) for evaluation. This failure had the potential to cause further impaired nutrition and weight loss in Resident 11 who is medically compromised.

Inspectors wroteBased on interview, and record review, the facility failed to ensure narcotics (government controlled medication due to its addictive nature) used to relieve pain was signed on the resident's electronic medication administration record (E-MAR) as given for one of eighteen sampled resident (Resident 33). This failure had the potential for drug diversion, theft, and loss of the controlled medication that could affect the health and safety of Resident 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medication was secured to be administered per the facility policy, when Silvadene Cream® (a topical medication used commonly on wounds to prevent and treat infections) was left unattended on the bedside table of one out of 18 sampled residents (Resident 12). This had the potential to cause harm due to medication being accessible to staff and residents who lacked knowledge, training, and the necessary qualifications to administer medication.