Creekside Post-Acute

In the surveyor’s words

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

• Actual harm, isolatedF689Aug 9, 2024

  Based on interview and record review, the facility failed to ensure the safety of one of three residents (Resident 1) when the facility did not investigate thoroughly the root causes of the incidents of skin tears during transfers from bed to wheelchair and transfer to wheelchair after using the bathroom. This failure led to four recurrent incidents that resulted to lower legs skin tears for Resident 1. Resident 1 had skin tear incidents on 2/24/24, 4/2/24, 5/17/24, and 6/10/24. […]

• Actual harm, isolatedF600Aug 12, 2022

  Based on interview and record review, the facility failed to implement its abuse prevention policy and procedure for one of three sampled residents (Resident 1) by failing to: 1) Prevent Resident 1 from being sexually abused by Certified Nursing Assistant A (CNA A). 2) Protect Resident 1 from sexual abuse and mental abuse. As a result, Resident 1 has experienced uncontrollable sadness and crying spells, has expressed an increasing desire to return home, and has indicated she was not sure if she felt safe at the facility. Findings: Review of Resident 1's medical record indicated she was admitted to the facility on [DATE] and had the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF640Nov 8, 2024

  Based on interview and record review, the facility failed to timely complete and submit a Discharge Minimum Data Set (MDS, a clinical assessment tool) data to the Centers for Medicare & Medicaid Services (CMS, oversees federal healthcare programs) for three of three residents (1, 2, and 3). This failure resulted in non-compliance with CMS regulatory requirements. Findings: Review of Resident 1's clinical record indicated he was admitted to the facility on [DATE] and discharged from the facility on 9/14/24. Review of Resident 2's clinical record indicated she was admitted to the facility on [DATE] and discharged from the facility on 9/13/24. Review of Resident 3's clinical record indicated she was admitted to the facility on [DATE] and discharged from the facility on 9/17/24. […]

• No harm, potential for more than minimal, patternF605Jul 24, 2026

  Based on interview and record review, the facility failed to ensure one out of five residents who are on psychotropic medications (Resident 75) was free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medication when Resident 75 received quetiapine fumarate (an antipsychotic [drugs treat psychosis] medication that helps treat several kinds of mental health conditions) without target behavior monitoring.The Failure had the potential for increased risks associated with the use of psychotropic medications that could negatively affect the residents physical mental and psychosocial well-being.Finding:During a review of Resident 75's facesheet indicated Resident 75 was admitted to the facility with diagnoses including… […]

• No harm, potential for more than minimal, patternF698Jul 24, 2026

  Based on observation, interview, and record review the facility failed to provide dialysis services consistently with professional standards and to ensure staff had coordinated residents' care with the dialysis center for two of four sampled residents (Residents 5 and 20) receiving hemodialysis (medical procedure to remove fluid and waste products from the blood and to correct electrolyte, i.e., salts and mineral imbalances by using a machine and an artificial kidney) when:1.The Skilled Nursing Facility (SNF) Licensed nurse (LN)assessment information and communication with the facility to dialysis center prior (Pre) or before transfer - Hemodialysis Communication/assessment Records (HCAR's) to dialysis treatment center were incomplete. […]