Creekside Village Rehabilitation and Nursing LLC

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Feb 3, 2021

  Based on interviews and record review the facility failed to ensure the current CDC (Center for Disease Control and Prevention) guidelines; including social distancing, mask usage and hand hygiene occurred during the facilities' 1/12/21 COVID-19 (coronavirus disease) resident and facility staff vaccination clinic. Furthermore, the facility allowed outside community members into the facility, in resident common areas, to also participate in the COVID-19 vaccination clinic. During the time of the COVID-19 vaccination clinic the facility was in outbreak status as of 1/4/21. Due to the facility's failures, it created the likelihood of immediate and serious adverse outcomes for all of the residents in the facility who had yet to test positive for COVID-19. […]

• Immediate jeopardy, isolatedF689Feb 9, 2026

  Based on record review, interviews, and observations, the facility failed to ensure that residents received adequate supervision and were kept free from elopement for one (#13) of three residents at risk for elopement out of 24 sample residents.Specifically, the facility failed to provide Resident #13 with the supervision necessary to prevent elopement.Resident #13 had severe cognitive impairments and was assessed to require supervision to substantial assistance from staff for most activities of daily living. […]

• Immediate jeopardy, isolatedF760Feb 9, 2026

  Based on interviews and record review, the facility failed to ensure residents were free from any significant medication errors, affecting one (#11) of five residents out of 24 sample residents.Resident #11 was admitted on [DATE] with diagnoses of epilepsy (seizure disorder) and acute kidney failure that required dialysis three days a week.Resident #11 was prescribed phenobarbital (anti-seizure medication), valproic acid (anti-seizure medication), clobazam (anti-seizure medication) and Depakote (anti-seizure medication). From [DATE] to [DATE] the resident was hospitalized due to seizure activity. Within 24 hours the resident was sent back to the hospital for more seizure activity. While at the hospital, it was recommended to increase the clobazam to twice a day. […]

• Immediate jeopardy, isolatedF805Feb 9, 2026

  Based on record review, observations and interviews, the facility failed to ensure three (#4, #22, and #23) of six residents of 24 sample residents received food prepared in the form designed to meet their individual needs. Resident #4 diagnoses of dysphagia, oropharyngeal phase (difficulty swallowing), cerebral infarction (stroke), cognitive communication deficit, and unspecified dementia was admitted on [DATE]. Resident #4 had a physician's order for minced and moist diet texture (cannot bite off pieces of food but does have basic chewing ability). Resident #22 had diagnoses of dysphagia oropharyngeal phase, cognitive communication deficit, and other symptoms and signs involving cognitive functions and awareness was admitted on [DATE]. […]

• Actual harm, isolatedF760Jul 8, 2025

  Based on record review and interviews, the facility failed to ensure one (#7) of seven residents reviewed for medication management were free from significant medication errors out of nine sample residents. Resident #7 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following cerebrovascular disease (a condition that affects the blood vessels in the brain). On 6/20/25 certified nurse aide with medication authority (CNA-Med) #1 administered another resident's medications to Resident #7, including apixaban and clopidogrel (used to prevent blood clots), isosorbide (used to relax and widen the blood vessels and manage chest pain), lisinopril (used to treat high blood pressure), propranolol (used to lower heart… […]