Three Creeks Post Acute

In the surveyor’s words

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

• Immediate jeopardy, widespreadF812Dec 22, 2025

  Based on observation, interview, and record review the facility failed to keep Potentially Hazardous Foods (PHFs) within safe temperature guidelines during an extended power outage during which the facility backup generator did not power kitchen appliances, PHFs that were above safe temperatures were not discarded and served above safe temperature PHFs (specifically milk) to residents during two subsequent meal services for 33 of 33 residents. These failures placed residents at risk of serious food borne illness and constituted immediate jeopardy (IJ).The facility failed to consistently monitor refrigerator and food temperatures during a power outage on 12/17/2025 from 5:10 AM until 3:30 PM, with kitchen staff identifying one refrigerator temperature above 45 degrees Fahrenheit (F) after… […]

• Immediate jeopardy, widespreadF880Sep 10, 2021

  Based on observation, interview, and record review, the facility failed to maintain an infection control program that included adequate, timely surveillance, oversight, and follow up of staff COVID-19 testing (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death). Failure to ensure all unvaccinated staff completed the required COVID-19 testing, put all residents at risk for COVID infection when staff continued to work with unknown COVID status. […]

• Immediate jeopardy, widespreadF886Sep 10, 2021

  Based on interview and record review, the facility failed to conduct COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death)specimen collection, per Centers for Disease Control and Prevention (CDC) guidance and manufacturer's instructions. Failure to collect nasal specimens from both nostrils increased the likelihood for inaccurate test results, and failure to identify COVID positive residents and staff. In addition, the facility failed to perform COVID-19 testing per the county positivity rate as required. […]

• Actual harm, isolatedF684May 24, 2024

  Based on observation, interviews and record review, the facility failed to perform a thorough and timely assessment of a lower leg injury at the time a fall occurred, and evaluate for changes in condition for 1 of 3 residents (Resident 1) reviewed for assessments. Resident 1 experienced harm when they developed a necrotic (death of cells or tissue), contagious (spreads from one person to another), wound infection which extended their stay in the facility, and a delay in treatment. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] from the hospital with diagnoses which included right hip fracture with surgical repair and dementia. […]

• Actual harm, isolatedF697Feb 13, 2023

  Based on interview and record review, the facility failed to ensure staff provided adequate pain management for 1 of 4 residents (1), who requested narcotic pain medication and did not receive it timely. Failure to provide narcotic pain medication resulted in harm to Resident 1 due to the severity of pain and emotional distress. Findings included . Review of Resident 1's medical record showed they were admitted to the facility on [DATE] from the hospital, following surgery on 01/27/2023 for a left patellar tendon avulsion (a condition in which the tendon separates from the kneecap - caused by an overload to the tendon during activity in an individual at risk). Ten days prior to that surgery, the resident had a total left knee replacement surgery. […]