Creekside Terrace Rehabilitation

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the residents' environment remained as free of accident hazards as possible and ensure each resident received adequate supervision and assistance devices to prevent accidents for one of three residents (Resident #1) reviewed for accidents and hazards. The facility failed to prevent Resident #1 from eloping from the facility. Resident #1 eloped from the facility and was found by local PD on a nearby highway with a speed limit of 70 mph on a sunny day with outside temperatures ranging from 88 to 89 degrees on 06/06/2026 at about 3:30 pm to 4:40 pm. The noncompliance was identified as PNC. The IJ began on 06/06/2026 and ended on 06/07/2026. The facility had corrected the noncompliance before the survey began. [...]

Inspectors wroteBased on interviews and records review the facility failed to ensure each resident Quarterly Review Assessment A was completed not less frequently than once every 3 months for one (Resident #1) three residents review for assessment in that:The facility failed to complete Resident #1's quarterly MDS assessment and elopement assessment for more than 3 months. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store food in accordance with professional standards for foodservice safety in 1 of 1 kitchen reviewed food and nutrition services. The facility failed to ensure food safety on 03/24/2026 by not consistently monitoring and discarding expired food, not sanitizing the food thermometer between each food item, not storing food items that were not labeled and/or dated, and keeping racks where the serving utensils and dishes were stored dirty. Have knives that was chipped and not in good condition. These failures could place residents who received meals from the main kitchen at risk for foodborne illness.

Inspectors wroteBased on observations, interviews and record review, the facility failed to submit a complete and accurate request for nursing facility specialized services in the LTC Online Portal within 20 business days after the date of the Interdisciplinary Team meeting for 1of 1 resident (Resident #1) reviewed for PASARR nursing facility specialized services. The facility failed to submit a Nursing Facility Specialized Service (NFSS) request by the specific deadline for Resident #1 for a customized manual wheelchair. This failure could place residents at risk of not receiving or benefiting from specialized equipment and services required and could affect her quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections in 1 of 1 dining room observed for infection control in that: LVN A failed to practice proper hand hygiene between residents while distributing food in the dining room. This failure placed residents at risk of cross contamination and the spread of infection.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 9 of 9 A/C units/filters inspected in that: The facility failed to ensure air conditioner filters and vents were safe and sanitary. This deficient practice could place residents at risk of respiratory and other illness and cause significantly restricted airflow and reduced efficiency of the heating and cooling system. Being in an environment that is not safe and/or sanitary.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR) Level I assessment accurately reflected the resident's status for 1 of 3 residents (Resident #92) reviewed for PASARR Level I screenings. 1. The facility failed to ensure the accuracy of the PASARR Level 1 screening for Resident #92. The PASARR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (post-traumatic stress disorder PTSD with an onset date of 11/08/2024) was present upon Resident #92's admission date on 11/11/24. The facility did not complete a 1012 form to update the PASARR Level 1 with the new diagnosis until surveyor intervention on 01/08/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 4 residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1's weight was recorded daily as ordered from 11/22/24 through 12/02/24. This failure could place residents at risk of not receiving care to maintain optimum health and placing them at risk for decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with dignity and respect and care for residents in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one (Resident #1) of six residents reviewed for dignity. The facility failed to ensure MA A treated Resident #1 with dignity and respect when she spoke to the resident in a rude manner in front of others . This failure could place residents at the risk for psychosocial harm due to diminished self-esteem and quality of life.

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 for one of one kitchens reviewed for food and nutrition services. 1. The facility failed to ensure all food items were covered, labeled, dated and discarded prior to their use-by date. 2. The facility failed to ensure CK N washed and sanitized the food processor between uses 3. The facility failed to ensure CK N wore gloves when handling ready-to-eat foods 4. The facility failed to ensure CK N washed her hands for 20 seconds after handling trash 5. The facility failed to ensure DA P removed his gloves and washed his hands after touching a contaminated object These failures could place residents at risk of foodborne illness.

Inspectors wroteBased on interview, observation, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 4 of 19 residents (Resident #85, #90, #92, #297) reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #85 and Resident #90's Comprehensive Care plan reflected a care plan for post-traumatic stress disorder. 2. The facility failed to ensure Resident #92's Comprehensive Care plan reflected Resident #92 utilized a wearable cardioverter defibrillator (a vest worn by the resident which detects and treats life-threatening rapid heart rhythms in residents at risk of sudden cardiac death). 3. The facility failed to ensure Resident #297's Comprehensive Care plan reflected his communication deficits and devices used for communication. This facility placed residents at risk for unmet needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 6.82 % based on 3 errors out of 44 opportunities, which involved 3 of 4 residents (Resident #88, Resident #57 and Resident #351) reviewed for pharmacy services. 1. LVN E administered multivitamin with minerals instead of the ordered multivitamins with folic acid to Resident #88. 2. MA G administered calcium carbonate 500 mg instead of the ordered calcium carbonate-vitamin D3 500 mg-5 mcg to Resident #57. 3. MA G administered calcium carbonate 500 mg instead of the ordered calcium carbonate 600 mg to Resident #351. These failures could affect residents and put them at risk for not receiving the intended therapeutic benefit of their medication and or adverse outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure storage of medications used in the facility was in accordance with currently accepted professional principles and include the appropriate expiration dates 3 of 4 medication carts (100 hall nurse cart, 200 hall nurse cart, and 300/400 hall med aide cart) reviewed for pharmacy services. -1. The facility failed to date a multi-use product (eye drops and inhalers) when the products were first opened according to manufacturer and professional standards. -2. The facility failed to ensure an expired insulin pen was removed from the medication cart. These failures could place residents at risk of not receiving the intended therapeutic effect of the medications or a contaminated medication. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure menus were followed for 9 of 9 (Resident #8, Resident #18, Resident #24, Resident #29, Resident #46, Resident #52, Resident #60, Resident #73, Resident #91) residents reviewed for menus. 1. The facility failed to ensure CK N followed recipes when preparing pureed food items 2. The facility failed to ensure CK N served adequate portion sizes for residents on a pureed diet. These failures placed residents at risk of decreased intake, malnutrition, and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for 1 of 7 residents (Resident #15) reviewed for accidents. The facility failed to ensure staff did not hand Resident #15 a cup of hot coffee and two sweetener packets while his hands were full or offered to assist him, leading to Resident #15 spilling the coffee on his leg (with no injury). This failure placed residents at risk of burns and embarrassment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of two residents reviewed for quality of care (Resident #88). The facility failed to ensure Resident #88's catheter was secured to his body with a catheter secure device. This failure to secure catheters placed residents with urinary catheters at risk for traumatic removal and catheter acquired infections. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately equip all residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 of 8 (Resident #56) residents reviewed for call light function. The facility failed to ensure Resident #56 had a functioning call light. This placed Resident #56 at risk of not having her needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to be free from misappropriation of proper for 1 of 5 residents (Resident #1) reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #1's Belsomra, a medication to help with sleeping. This failure could place residents at risk for not receiving prescribed medications.