Creekside Terrace Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jun 8, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF684Jun 29, 2022

  Based on observation, interview, and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 12 residents reviewed for quality of care. The facility failed to administer Resident #1's life-sustaining medication, [MEDICATION(S)] (anti-rejection medication), as ordered by the physician. Resident #1 missed 57 doses of [MEDICATION(S)] medication in a 105-day period. This failure likely contributed to Resident #1 developing multi-organ failure, which resulted in his death on [DATE]. This failure could place residents at risk for not receiving care and services to meet resident needs, which could lead to hospitalization and death. On [DATE] at 6:10 p.m. […]

• Immediate jeopardy, isolatedF755Jun 29, 2022

  Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 resident (Resident #1) of 12 residents reviewed for pharmacy services. The facility failed to administer Resident #1's life-sustaining medication, [MEDICATION(S)] (anti-rejection medication), as ordered by the physician. Three bottles of the medication dated [DATE] were in the DON's office, however facility staff were documenting that the medication was not available and waiting for the pharmacy to deliver. Resident #1 missed 57 doses of [MEDICATION(S)] medication in a 105-day period. […]

• Immediate jeopardy, isolatedF760Jun 29, 2022

  Based on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors for 1 (Resident #1) of 12 residents reviewed for medication errors. The facility failed to administer Resident #1's life-sustaining medication, [MEDICATION(S)] (anti-rejection medication), as ordered by the physician. Resident #1 missed 57 doses of [MEDICATION(S)] medication in a 105-day period. This failure likely contributed to Resident #1 developing multi-organ failure, which resulted in his death on [DATE]. This failure could place residents at risk for not receiving care and services to meet resident needs, which could lead to hospitalization and death. On [DATE] at 6:10 p.m. an Immediate Jeopardy (IJ) was identified. […]

• No harm, potential for more than minimal, widespreadF812Nov 30, 2023

  Based 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. […]