Creekside

In the surveyor’s words

From the most serious findings on record at Creekside, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF689Jul 8, 2026

  Based on facility document review, clinical record review, staff interviews, and policy review, the facility failed to identify a malfunctioning door which resulted in a resident elopement from the unit and the building for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 35.Findings include:Resident #1's Minimum Data Set (MDS) completed on 4/30/26 revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Active diagnoses included Alzheimer's disease (progressive brain disorder) and dementia (cognitive decline). Resident #1 didn't use an assistive device to walk independently. The Care Plan last reviewed on 5/18/26 identified Resident #1 as an elopement (wandering away) risk due to aimless wandering. […]

• No harm, potential for more than minimal, isolatedF880Dec 18, 2025

  Based on clinical record review, observation, staff and resident interviews, policy review, and guidance from the Centers for Disease Control and Prevention (CDC), the facility failed to implement Enhanced Barrier Precautions (EBP) for 2 of 2 residents reviewed for infection control (Resident #2 and #40).Findings include:1. The Minimum Data Set (MDS) dated [DATE] identified Resident #40 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated he received hemodialysis (mechanical process to remove wastes from the body, due to poor functioning kidneys) while a resident and upon admission. The Electronic Health Record (EHR) indicated Resident #40 had diagnoses of unspecified kidney failure and Stage 5 kidney disease. […]

• No harm, potential for more than minimal, isolatedF578May 26, 2021

  Based on observation, interview, and record review, the facility failed to ensure the code status documented in the electronic health record (EHR) matched the code status documented in the Iowa Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility reported a census of 41 residents. Findings included: Review of the Minimum Data Set (MDS) assessment for Resident #11 dated [DATE] listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS further revealed Resident #11 was severely impaired in regards to making decisions regarding tasks of daily life. The Care Plan with a focus area of Advance Directives/Care Preferences initiated [DATE] with a goal revision date of [DATE] directed staff to record any completed Advanced Directives in the resident record. […]

• No harm, potential for more than minimal, isolatedF655May 26, 2021

  Based on clinical record review, resident and staff interview, the facility failed to complete a Baseline Care Plan within 48 hours of admission and ensure the resident received information on their initial plans for service and care delivery for 1 of 3 newly admitted residents reviewed (Resident #143). The facility reported a census of 41 residents. Findings include: The Face Sheet for Resident #143 revealed an admitted [DATE] with documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The face sheet further revealed Resident #143 was the responsible decision maker in regards to her care. […]

• No harm, potential for more than minimal, isolatedF658May 26, 2021

  Based on observation, record review of manufacturer's directions and staff interviews, the facility failed to ensure professional standards of insulin administration for 1 of 2 residents reviewed (Resident #142). The facility reported a census of 41 residents. Findings include: Minimum Data Set (MDS) assessment dated [DATE] documented Resident #142 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Brief Interview for Mental Status (BIMS) documented a score of 15 indicative of intact cognition. The Care Plan with a focus area initiated date 5/18/21 revealed Resident #142 had an alteration in endocrine system related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan directed staff to administer diabetes medication as ordered by the physician. […]