The Broadmoor at Creekside Park

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Mar 13, 2026

  Based on observation, record review, and interviews, the facility failed to ensure residents received adequate supervision for 1 of 7 residents (CR #1) reviewed for quality of care.CR #1 eloped from the facility on 02/23/2026 from an unwitnessed point of exit, and was located at the rear of the property at a school.The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 02/23/2026 and ended on 02/23/2026. The facility corrected the non-compliance before the investigation on 03/10/2026. […]

• Immediate jeopardy, isolatedF697Oct 2, 2023

  Based on observation, interview and record review, the facility failed to ensure pain management was provided to and monitored for 2 of 4 residents (Resident #128 and Resident #228), in that: -Resident #128 experienced pain after admission without her ordered Oxycodone available for use. -Resident #228 verbalized pain that without and pharmacological or non-pharmacological treatment offered to him. An Immediate Jeopardy (IJ) was identified on 09/27/2023 at 11:15AM. While the IJ was removed on 09/29/2023 at 06:37 PM, the facility remained out of compliance at a scope and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. […]

• Immediate jeopardy, isolatedF755Oct 2, 2023

  Based on observation, interview and record review, the facility failed to provide pharmaceutical services to meet the resident needs when the facility did not acquire the prescribed pain medications for 2 of 4 residents (Resident #128 and Resident #228) reviewed for medication administration, in that: -Resident #128 experienced pain after admission when her ordered Oxycodone was not available for use at the facility. -Resident #228 verbalized pain and was not offered pharmacological or non-pharmacological treatment to relieve his discomfort. An Immediate Jeopardy (IJ) was identified on 09/27/2023 at 11:15AM. […]

• Actual harm, patternF880Jun 16, 2022

  Based on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 4 of 7 residents (Resident #1, #2, #3, and #4) reviewed for infection control. -CNA A failed to perform hand hygiene during incontinent care for Resident #1 and Resident #2. -The facility failed to provide incontinent care for Resident #2 for more than 2 hours. Resident #2's brief was saturated with urine and soaked through her pants and onto the wheelchair pad. -CNA A failed to cleanse Resident #3's buttocks area completely by not washing off the white cream that was over a reddened area. […]

• Actual harm, isolatedF684Apr 19, 2024

  Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices based on the comprehensive assessment of resident (Resident #1) 1 of 6 residents reviewed for quality of care. -The facility failed to ensure staff remained with Resident #1 after Resident #1 was found on the floor, bleeding from his head. -The facility failed to complete an appropriate assessment for Resident #1 after an unwitnessed fall, where a laceration to the head and skin tear to the shoulder were sustained. These failures could place residents at risk of not receiving needed care and services to meet their physical, mental, and psychosocial needs. […]