Creekside Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF600Aug 5, 2026

  Based on interview and record review, the facility failed to protect one of three sampled residents (Resident 1), Resident 1's right to be free from neglect, when Resident 1 did not receive the ordered treatment and care to maintain good foot health due to failure of staff to follow-up and arrange routine Podiatry (foot specialty) services to Resident 1.These failures resulted in Resident 1:Developing long, severely curved, thick, discolored toenails digging into the adjacent skin for not having podiatry services for almost six months following initial admission that resulted in Resident 1 experiencing prolonged foot pain and discomfort.Potential to result in worsening skin breakdown and/or injury and fungal infection (disease caused by fungi) of toes and/or feet.A review of Resident 1's… […]

• No harm, potential for more than minimal, widespreadF925May 24, 2024

  Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for flies and gnats in three of three units designated for resident care. A dead kitten was found outside Resident 24's window for more than 22 hours. The failure to effectively treat flies and gnats and leaving the dead kitten outside Resident 24's room resulted in Resident 24 feeling ugly and grossed out and had the potential to result in infection for all residents residing at the facility. Findings: During an observation on [DATE] at 10:05 a.m., three flies were observed in Resident 322's room. During a concurrent observation and interview on [DATE] at 10:24 a.m., three flies were observed in Resident 42's room. […]

• No harm, potential for more than minimal, patternF644Aug 8, 2025

  Based on interview and record review, the facility failed to ensure three of four sampled residents (Resident 3, Resident 18, and Resident 45) Preadmission Screening and Resident Review (PASRR) were screened and referred to the appropriate state mental authority for Level II PASRR evaluation and determination.(PASRR is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are appropriately placed in nursing homes for long term care). This failure had the potential to prevent residents from receiving appropriate required mental health services. […]

• No harm, potential for more than minimal, patternF880Aug 8, 2025

  Based on observation, interview and record review, the facility failed to ensure infection control practices were observed by one of one sampled laundry staff (LS) when the LS was not wearing a gown while moving soiled linen from the soiled linen hamper in to the washer.This failure had the potential for cross contamination and spread of infections among 72 residents at the facility.During a concurrent observation and interview on 8/7/25 at 10:09 a.m. with the LS and Certified Nursing Assistant (CNA) 1 in the laundry room, the LS was observed grasping soiled linen from the hamper in to the washer only with gloved hands. The LS stated she had never used a gown or was told to use a gown when putting the dirty linen in to the machine. […]

• No harm, potential for more than minimal, patternF759May 24, 2024

  Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5 %. During the medication pass, three medication errors were observed out of 32 opportunities for three of six residents, resulting in an error rate of 9.38%. 1. Amlodipine (medication for management of high blood pressure) for Resident 1 was unavailable and not administered as ordered. This failure had the potential to result in uncontrolled high blood pressure. 2. Semglee pen U-100 insulin (Insulin Glargine, a long acting insulin) subcutaneous injection was administered to Resident 45 without following manufacturer's recommendation. This failure had the potential to affect the insulin dose's effectiveness and the resident's blood sugar. 3. […]