Creekside Village

In the surveyor’s words

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

• Actual harm, isolatedF686Dec 2, 2022

  Based on record review, observation, and interview, the facility failed to identify a pressure ulcer on admission and provide a treatment for the pressure for 1 of 2 residents reviewed for pressure ulcers. (Resident 224) Finding includes: A clinical record review of Resident 224 was completed on 11/30/2022 at 8:34 A.M. Diagnoses included, but were not limited to: acute cystitis, dementia, diabetes mellitus type 2, and peripheral vascular disease. A Clinical Hospital Rehabilitation Record on 10/27/2022 at 1:44 P.M., indicated, an unstageable pressure ulcer to the sacrum. The measurements were 1.6 centimeters by 0.8 centimeters by 0.1 centimeters. The pressure ulcer was not staged due to necrotic tissue with 100 percent adherent yellow slough. […]

• No harm, potential for more than minimal, patternF684Dec 2, 2022

  Based on record review, observation and interview, the facility failed to provide treatment for worsening skin integrity, proper physician ordered treatment for skin integrity, and lack of investigation and documentation for bruises with an improper transfer. (Residents 6, 5 & 28) Findings include: 1. During an initial interview with Resident 6, she indicated she had dry skin and picks at her skin especially when it is dry. She indicated her legs are dry, she had picked at her legs causing scabbing to both legs. Resident 6 indicated she had requested for lotion to be applied. A clinical record review was completed on 11/20/2022 at 3:16 P.M. for Resident 6. […]

• No harm, potential for more than minimal, patternF761Dec 2, 2022

  Based on observation, record review and interview, the facility failed to ensure medications were labeled appropriately in 2 of 2 medication carts reviewed and failed to ensure non-pharmalogicals were stored appropriately for 1 of 1 medication carts and refrigerators reviewed. Findings include: 1. During an observation of the medication cart for the 400 unit, conducted on [DATE] at 2:21 P.M., the following was noted: There was an opened bottle of refresh tears eye drops for Resident 31 with an open date of [DATE], there was an opened inhaler for Resident 23 with an open date of [DATE]. During an interview with LPN 15 indicated she thought the eye drops and the inhaler medications expired after 45 days. […]

• No harm, potential for more than minimal, isolatedF684Jul 13, 2026

  Based on interview and record review, the facility failed to ensure a medication was administered as ordered by the physician for 1 of 3 residents reviewed for medication administration, (Resident B).Finding includes:Resident B's clinical record was reviewed on 7/13/26 at 10:04 A.M. Diagnoses included but were not limited to senile degeneration of brain, chronic respiratory failure with hypoxia, chronic kidney disease, cerebral cysts, and anxiety. Resident B was under the care of hospice services.Review of Resident B's physician orders included but were not limited to:Hydromorphone, take 1/2 of a 2 mg (1 mg) tablet by mouth two times daily between 7:00 A.M. and 11:00 A.M., and between 7:00 P.M. to 11:00 P.M., for Shortness of Breath or difficulty in breathing. […]

• No harm, potential for more than minimal, isolatedF658Mar 31, 2026

  Based on interview and record review, the facility failed to ensure staff accurately administered physician ordered medications and treatments for 2 of 2 residents reviewed for standards of care. (Residents 1 and 18)Finding includes:1. During an observation on 3/25/2025 at 2:22 P.M. Resident 1's oxygen concentrator was dirty and dusty. The filter on the back of the concentrator had a clump of dust clinging to it. A record review for Resident 1 was completed on 3/27/2026 at 8:40 A.M. […]