7 Reports
Inspection Report — Jun 24, 2026
Complaint Investigation
Date: Jun 24, 2026
Visit Reason
The report covers 45 inspections of Brookdale Phillippi Creek from July 24, 2012 to June 24, 2026, including complaint and standard visits.
Findings
Across the inspection history, 71 deficiencies were recorded with 2 serious (Class 2) deficiencies. The most recent visit recorded no deficiencies.
Citations (71)
Resident Care - Activities of Daily Living — cited January 15, 2026, corrected March 5, 2026
Resident Care - Elopement Standards — cited January 15, 2026, corrected March 5, 2026
Fiscal - Financial Stability — cited January 15, 2026, corrected March 5, 2026
Reporting Requirements; Electronic Submission — cited August 7, 2025, corrected November 2, 2025
Resident Care - Elopement Standards — cited June 5, 2025, corrected July 23, 2025
Reporting Requirements; Electronic Submission — cited June 5, 2025, corrected August 7, 2025
Resident Care - Supervision — cited January 25, 2024, corrected February 25, 2024
Resident Care - Elopement Standards — cited January 25, 2024, corrected February 25, 2024
Medication - Assistance With Self-admin — cited January 25, 2024, corrected February 25, 2024
Staffing Standards - Staff — cited January 25, 2024, corrected February 25, 2024
Training - Adrd — cited January 25, 2024, corrected February 25, 2024
Food Service - Dietary Standards — cited January 25, 2024, corrected February 25, 2024
Background Screening Clearinghouse — cited January 25, 2024, corrected April 19, 2024
Initial Comments — cited August 24, 2022, correction not recorded
Resident Care - Rights & Facility Procedures — cited March 25, 2021, corrected October 12, 2021
Medication - Assistance With Self-admin — cited March 25, 2021, corrected October 12, 2021
Training - Adrd — cited March 25, 2021, corrected October 12, 2021
Food Service - Dietary Standards — cited March 25, 2021, corrected October 12, 2021
Physical Plant - Safe Living Environ/other — cited March 25, 2021, corrected October 12, 2021
Resident Care - Supervision — cited February 1, 2021, corrected August 24, 2022
Risk Mgmt & Qa; Adverse Incident Report — cited February 1, 2021, corrected August 24, 2022
Resident Care - Activities of Daily Living — cited February 27, 2020, corrected October 12, 2021
Background Screening Clearinghouse — cited February 27, 2020, corrected March 25, 2021
Medication - Assistance With Self-admin — cited December 20, 2019, corrected March 12, 2020
Medication - Labeling and Orders — cited December 20, 2019, corrected February 27, 2020
Risk Mgmt & Qa; Adverse Incident Report — cited December 20, 2019, corrected February 27, 2020
Admissions - Health Assessment — cited December 10, 2019, corrected February 27, 2020
Admissions - Continued Residency — cited December 10, 2019, corrected March 12, 2020
Medication - Administration — cited December 10, 2019, corrected February 27, 2020
Medication - Storage and Disposal — cited December 10, 2019, corrected March 12, 2020
Staffing Standards - Levels — cited December 10, 2019, corrected February 27, 2020
Physical Plant - Safe Living Environ/other — cited December 10, 2019, corrected March 12, 2020
Emergency Environmental Control — cited April 19, 2019, corrected May 17, 2019
Medication - Self Administered Medications — cited July 3, 2018, corrected September 17, 2018
Staffing Standards - Staff — cited July 3, 2018, corrected September 17, 2018
Training - Staff In-service — cited July 3, 2018, corrected September 17, 2018
Training - Hiv/aids — cited July 3, 2018, corrected September 17, 2018
Training - Do Not Resuscitate Orders — cited July 3, 2018, corrected September 17, 2018
Food Service - Dietary Standards — cited July 3, 2018, corrected September 17, 2018
Physical Plant - New Facilities — cited July 3, 2018, corrected September 17, 2018
Records - Staff — cited July 3, 2018, corrected September 17, 2018
Records - Resident — cited July 3, 2018, corrected September 17, 2018
Resident Care - Rights & Facility Procedures — cited June 13, 2017, corrected October 24, 2017
Resident Care - Supervision — cited May 9, 2017, corrected October 24, 2017
Risk Mgmt & Qa; Adverse Incident Report — cited May 9, 2017, corrected October 24, 2017
Resident Care - Rights & Facility Procedures — cited December 28, 2016, corrected February 15, 2017
Training - Documentation & Monitoring — cited December 28, 2016, corrected February 15, 2017
Background Screening Clearinghouse — cited December 28, 2016, corrected February 15, 2017
Resident Care - Supervision — cited July 27, 2015, corrected August 27, 2015
Medication - Labeling and Orders — cited July 27, 2015, corrected August 27, 2015
Risk Mgmt & Qa; Adverse Incident Report — cited July 27, 2015, corrected August 27, 2015
Resident Care - Supervision — cited August 7, 2014, corrected October 2, 2014
Resident Care - Activities of Daily Living — cited August 7, 2014, corrected October 2, 2014
Resident Care - Rights & Facility Procedures — cited August 7, 2014, corrected October 2, 2014
Medication - Assistance With Self-admin — cited August 7, 2014, corrected October 2, 2014
Do Not Resuscitate Orders (Dnros) — cited August 7, 2014, corrected October 2, 2014
Staffing Standards - Levels — cited August 7, 2014, corrected October 2, 2014
Training - Staff In-service — cited August 7, 2014, corrected October 2, 2014
Training - Hiv/aids — cited August 7, 2014, corrected October 2, 2014
Training - First Aid and Cpr — cited August 7, 2014, corrected October 2, 2014
Training - Adrd — cited August 7, 2014, corrected October 2, 2014
Training - Do Not Resuscitate Orders — cited August 7, 2014, corrected October 2, 2014
Training - Documentation & Monitoring — cited August 7, 2014, corrected October 2, 2014
Food Service - Dietary Standards — cited August 7, 2014, corrected October 2, 2014
Physical Plant - Existing Facilities — cited August 7, 2014, corrected October 2, 2014
Medication - Records — cited September 12, 2012, corrected November 15, 2012
Medication - Over the Counter (Otc) Products — cited September 12, 2012, corrected November 15, 2012
Admissions - Health Assessment — cited July 24, 2012, corrected September 12, 2012
Medication - Storage and Disposal — cited July 24, 2012, corrected September 12, 2012
Training - Assis Self-admin Meds & Med Mgmt — cited July 24, 2012, corrected September 12, 2012
Resident Care - Supervision — cited July 24, 2012, corrected September 12, 2012
Report Facts
Inspections: 45
Visits with deficiencies: 24
Clean visits: 7
Deficiencies: 71
Serious deficiencies: 2
Legal actions: 16
Total fines: 33550
Inspection Report — Aug 19, 2025
Complaint Investigation
Date: Aug 19, 2025
Visit Reason
The inspection was conducted due to complaints regarding inadequate care and assistance with activities of daily living, specifically personal hygiene and incontinent care for residents.
Complaint Details
The investigation was complaint-driven, focusing on allegations that residents were not receiving proper hygiene care and incontinent care. The complaint was substantiated based on observations, record reviews, and staff interviews.
Findings
The facility failed to provide necessary personal hygiene and incontinent care to two residents reviewed, including failure to provide showers and timely changing of incontinent residents. Documentation of care was incomplete or missing for multiple dates, and staff interviews confirmed inconsistent care provision.
Citations (1)
F 0677: The facility failed to provide adequate care and assistance for activities of daily living, including hygiene and incontinent care, for residents dependent on staff. Documentation showed multiple instances where incontinent care and showers were not provided as scheduled.
Report Facts
Residents reviewed for activities of daily living: 3
Dates with no documentation of incontinent care for Resident #100: 22
Scheduled shower days for Resident #100: 3
Dates with no documentation of incontinent care for Resident #2: 30
Scheduled shower days for Resident #2: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding scheduling and care provision for Resident #100 |
| CNA Staff D | Certified Nursing Assistant | Interviewed about care provided to Resident #100 and staffing challenges |
| CNA Staff C | Certified Nursing Assistant | Interviewed about care and turning schedule for Resident #2 |
Inspection Report — Feb 20, 2025
Routine
Date: Feb 20, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, environment, grievance policies, and treatment in a nursing home setting.
Findings
The facility failed to inform a resident and guardian about medication discontinuation, maintain a safe and clean environment, support residents' rights to voice grievances, provide adequate assistance with activities of daily living including bathing and showering, and ensure care was provided according to established plans, including application of compression stockings.
Citations (5)
F 0552: The facility failed to inform Resident #18 and guardian in advance about the discontinuation of the seizure medication Epidiolex, resulting in seizures.
F 0584: The facility failed to maintain a safe, clean, and homelike environment in 9 residents' rooms and 2 shower rooms, including soiled linens, broken showers, and unsafe storage of items.
F 0585: The facility failed to support Resident #103's right to voice grievances without fear of reprisal, as staff questioned her about her survey interview and made her feel guilty.
F 0677: The facility failed to provide adequate care and assistance with activities of daily living, including bathing and showering, for 8 residents dependent on staff.
F 0684: The facility failed to provide care according to orders and plans for Residents #6 and #123 by not applying prescribed compression stockings as ordered.
Report Facts
Residents affected: 1
Residents affected: 9
Residents affected: 1
Residents affected: 8
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | ADON | Wrote verbal order to discontinue medication without informing resident or guardian; verified lack of notification and documentation |
| Registered Nurse Staff D | RN | Verified signing TAR for compression stockings without verifying application |
| Licensed Practical Nurse Staff J | LPN | Signed MAR for compression sock application without verifying application |
| Director of Nursing | DON | Confirmed environmental and care deficiencies; verified observations of residents not wearing compression stockings |
Inspection Report — Feb 20, 2025
Annual Inspection
Date: Feb 20, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with health, safety, and care standards at Creekside Health and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including environmental safety and cleanliness, resident care and assistance with activities of daily living, medication storage and administration, infection control practices, and food sanitation. Several residents did not receive scheduled showers or proper care, and infection prevention protocols were not consistently followed.
Citations (9)
F 0584: The facility failed to ensure a safe, clean, and homelike environment for 9 of 22 residents' rooms and 2 shower rooms, including issues with soiled linens, broken fixtures, and improper storage of personal items.
F 0585: The facility failed to support a resident's right to voice grievances without fear of discrimination or reprisal, as evidenced by staff questioning a resident about her interview with surveyors.
F 0656: The facility failed to develop a care plan addressing smoking for a resident who smoked while residing at the facility.
F 0677: The facility failed to provide scheduled showers and assistance with activities of daily living for multiple residents dependent on staff care.
F 0684: The facility failed to provide care in accordance with physician orders for compression stockings for 2 residents, with staff documenting application without verification.
F 0761: The facility failed to ensure proper storage of medications, with unsecured medications observed at residents' bedsides and nursing stations.
F 0812: The facility failed to follow proper sanitation and cleaning practices in the kitchen, including improper use of the sanitizing sink, unclean air vents, and lack of hair restraints.
F 0880: The facility failed to ensure licensed nurses followed infection prevention practices during blood glucose monitoring and failed to store urinary catheter drainage bags in a safe and sanitary manner.
F 0887: The facility failed to properly document resident education, acceptance, or refusal of COVID-19 vaccination for 5 residents reviewed.
Report Facts
Residents affected by environmental deficiencies: 9
Residents affected by grievance issue: 1
Residents affected by care plan deficiency: 1
Residents affected by ADL care deficiencies: 8
Residents affected by compression stocking care deficiency: 2
Residents affected by medication storage deficiency: 2
Residents affected by infection control deficiency: 2
Residents affected by urinary catheter storage deficiency: 2
Residents reviewed for COVID-19 vaccination documentation: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Registered Nurse (RN) | Named in infection control deficiency related to blood glucose monitoring and insulin administration without proper hand hygiene |
| Staff K | Licensed Practical Nurse (LPN) | Confirmed unsecured medication at Resident #107's bedside |
| Staff L | Licensed Practical Nurse (LPN) | Confirmed unsecured medication at Resident #81's room |
| Staff J | Licensed Practical Nurse (LPN) | Verified signing MAR for compression sock application without verifying actual application |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies including medication storage, infection control, and COVID-19 vaccination documentation |
| Assistant Director of Nursing | ADON | Infection Preventionist, acknowledged lack of documentation for COVID-19 vaccination education and consent |
| Certified Dietary Manager | CDM | Interviewed regarding kitchen sanitation and cleaning deficiencies |
| Dietary Aide Staff E | Dietary Aide | Observed improper use of sanitizing sink and lack of training |
| Maintenance Director | Maintenance Director | Interviewed regarding lack of cleaning and maintenance in kitchen |
Inspection Report — Sep 18, 2024
Date: Sep 18, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with maintaining a safe, clean, comfortable, and homelike environment for residents, focusing on maintenance services in the Memory Care unit.
Findings
The facility failed to maintain the environment in the Memory Care unit, with issues including peeling wallpaper, missing cove moldings, cracked sheetrock with holes, missing pull cords on overbed lights, broken blinds, broken lights in bathroom and shower stalls, and floor tiles covered with orange and brown film.
Citations (1)
F 0584: The facility failed to maintain a safe, clean, and comfortable environment in the Memory Care unit, including peeling wallpaper, missing cove moldings, cracked walls, missing pull cords on overbed lights, broken blinds, broken lights, and stained floor tiles.
Inspection Report — Aug 11, 2022
Annual Inspection
Date: Aug 11, 2022
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with regulatory requirements in the nursing home.
Findings
The facility was found deficient in providing meaningful activities for residents, proper medication storage and labeling, maintaining a clean and sanitary kitchen environment, and designating a qualified infection preventionist. Deficiencies were noted with minimal harm or potential for actual harm to residents.
Citations (4)
F 0679: The facility failed to implement a person-centered, meaningful activity program for Resident #72, who was observed not participating in any activities over multiple days.
F 0761: The facility failed to remove and discard expired medications from medication carts and storage rooms, risking administration of expired drugs to residents.
F 0812: The facility failed to maintain a clean and sanitary kitchen and nourishment rooms, with dirty appliances, food storage issues, and damaged equipment posing a risk of foodborne illness.
F 0882: The facility failed to designate a qualified infection preventionist with required education, training, or certification.
Report Facts
Residents reviewed for activities: 7
Residents affected: 1
Medication carts observed: 4
Medication storage rooms observed: 2
Nourishment rooms observed: 2
Duration of Levemir insulin use before discard: 42
One-to-one visit duration: 10
One-to-one visit duration: 15
CDC training modules: 23
CDC training hours: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activity Assistant Staff H | Activity Assistant Staff | Reported inability to access activity documentation and described friendly visits |
| Activity Director | Activity Director | Reported lack of one-to-one activity documentation and staffing shortages |
| LPN Staff A | Licensed Practical Nurse | Verified expired Levemir insulin on medication cart |
| LPN Staff B | Licensed Practical Nurse | Confirmed expired tuberculin injection in medication room |
| LPN Staff C | Licensed Practical Nurse | Verified expired aspirin in medication cart |
| Director of Nursing | Director of Nursing | Acknowledged awareness of expired medications and infection preventionist certification status |
| Food Service Director | Food Service Director | Reported kitchen cleaning schedule and knowledge of nourishment room refrigerator use |
| Regional Dietary Consultant | Regional Dietary Consultant | Participated in kitchen tour and nourishment room inspection |
| Assistant Director of Nursing | Assistant Director of Nursing | Designated Infection Preventionist, reported incomplete CDC training |
| Maintenance Director | Maintenance Director | Verified cleaning of air conditioning vents and need for kitchen repairs |
| Administrator | Administrator | Verified signage issues with nourishment room refrigerator |
Inspection Report — Feb 11, 2021
Date: Feb 11, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction related to a regulatory survey of Creekside Health and Rehabilitation Center.
Findings
No health deficiencies were found during the survey.
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