Creekside Center for Rehabilitation and Nursing

In the surveyor’s words

From the most serious findings on record at Creekside Center for Rehabilitation and Nursing, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 23, 2025

  Based on record review and interviews with the resident and staff it was determined the facility staff failed to ensure the doors to the facility laundry room and the mechanical/boiler room were locked when unattended by staff, to prevent unauthorized access by residents and others. This was evident for 1 (Resident #1) of 1 resident reviewed for accident hazards during the complaint survey. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy. The facility implemented effective and thorough corrective measures following this incident and prior to the start of this complaint survey. […]

• Immediate jeopardy, isolatedF604Aug 5, 2024

  Based on medical record review and interview with facility staff, it was determined that the facility failed to protect residents after substantiating that GNA staff that restrained a resident (#926) continued to have access to other vulnerable residents. This was evident during the review of 1of 13 incidents involving abuse. The findings include: On July 31, 2024 At 5:10 PM, an immediate jeopardy was called by the Office of Health Care Quality related to the facility's failure to remove from duty the GNA staff who restrained a resident and continued to have access to other vulnerable residents. A plan to remove the immediacy was accepted on July 31, 2024 at 6:32 PM and abated the following day at 9:30 AM. […]

• Immediate jeopardy, isolatedF684Aug 5, 2024

  Based on observation, record review, and interview, it was determined that the facility failed to recognize and address changes in the condition of residents. This was evident for 2 of 14 residents reviewed for hospitalization s and quality of care. (#127 and #921) This failure resulted in an immediate jeopardy. The findings include: 1.On 7/23/24, upon entry to the facility, Resident #127 was observed sitting in a wheelchair in a common area near the nurses' station. A medical record review on 7/25/24 at 9:08 AM revealed that the resident had returned from the hospital 7/19/2024. Review of the orders revealed that, on 7/19/24, the resident was ordered a Hospice evaluation (end-of-life care) and Morphine 0.25 mg by mouth every 3 hours for pain. […]

• Actual harm, isolatedF689Oct 17, 2025

  Based on interviews and record review it was determined that the facility failed to 1.) provide sufficient supervision, prevent an avoidable accident, follow appropriate safety procedures and to utilize the use of two staff persons and 2) provide an appropriate mattress and bed to prevent a fall. This was evident for 2 residents (R10 and R23) of 4 residents reviewed who required a bariatric bed and mattress. The deficient practice resulted in harm to both R10 and R23. The facility implemented effective and thorough corrective measures following the incidents and prior to the start of this survey. […]

• Actual harm, isolatedF689Aug 5, 2024

  Based on record review and interview with facility staff, it was determined that the facility failed to have a process in place to ensure that staff 1.provided care in a manner to ensure residents were not injured. 2. provide safe equipment for residents and 3. provide care in a safe and professional manner. This was evident during the review of 1 (Resident #928) of 5 falls with injury. This deficient practice resulted in harm to resident #9 and resident #928. This was evident for 1 (#9) of 10 residents reviewed for accidents/hazards. The findings include: On 7/23/24 at 9:13 AM, a review of complaint #MD00206718 revealed that Resident #9 had been brought to the Emergency Department (ED) for treatment of a 15-centimeter (cm) leg laceration on the lower right leg. […]