14 Reports
Inspection Report — May 6, 2026
Complaint Investigation
Date: May 6, 2026
Visit Reason
The visit resulted from an investigation of facility reported incident #3005295-I concerning a resident elopement. The facility investigated the malfunctioning of a door that allowed Resident #1 to exit the unit and building unsupervised.
Complaint Details
Facility reported incident #3005295-I.
Findings
The facility failed to identify and promptly repair a malfunctioning door that allowed Resident #1, who had severe cognitive impairment, to elope from the unit and building. The door did not latch properly, and the hallway exit door lacked locks or alarms, enabling the resident to exit freely.
Violations (1)
483.25(d) Accidents: The facility failed to ensure the resident environment was free of accident hazards by not identifying a malfunctioning door that allowed Resident #1 to elope from the unit and building. The door did not latch completely, and the hallway exit door did not lock or alarm.
Inspection Report — Jan 8, 2026
Plan of Correction
Date: Jan 8, 2026
Visit Reason
The facility submitted a credible allegation of substantial compliance and a Plan of Correction.
Findings
The facility will be certified in compliance with health requirements effective December 19, 2025. No regulatory insufficiencies were cited.
Inspection Report — Dec 18, 2025
Date: Dec 18, 2025
Visit Reason
The inspection was conducted to evaluate the facility's implementation of infection prevention and control practices, specifically the use of Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices.
Findings
The facility failed to implement Enhanced Barrier Precautions for two residents who declined the precautions and signed waivers. Staff did not use gowns or display EBP signage as required, and the facility's policy lacked documentation regarding resident refusal of EBP and signing waivers.
Violations (1)
F 0880: The facility failed to provide and implement an infection prevention and control program by not maintaining Enhanced Barrier Precautions for residents with wounds or indwelling devices who declined precautions and signed waivers.
Report Facts
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Household Coordinator | Documented removal of Enhanced Barrier Precautions materials for Resident #40 |
| Staff D | Certified Nurse Assistant | Interviewed regarding Resident #40's status with Enhanced Barrier Precautions |
| Staff E | Licensed Practical Nurse | Interviewed regarding Resident #40's waiver of Enhanced Barrier Precautions |
| Staff F | Infection Preventionist | Interviewed about facility's use of Enhanced Barrier Precautions and resident refusals |
| Staff B | Certified Nurse Assistant | Observed emptying Resident #2's catheter without gown use per EBP policy |
| Nurse A | Licensed Practical Nurse | Verbalized that Enhanced Barrier Precautions were not used per Resident #2's request |
| Director of Nursing | Director of Nursing | Interviewed regarding resident refusals of Enhanced Barrier Precautions and waiver process |
Inspection Report — Dec 18, 2025
Annual Inspection
Date: Dec 18, 2025
Visit Reason
The visit was the facility's annual recertification survey conducted from December 15 to December 18, 2025.
Findings
The facility failed to implement Enhanced Barrier Precautions (EBP) properly for residents #2 and #40, including lack of signage and staff not following EBP protocols. No other regulatory insufficiencies were cited.
Violations (1)
F880: The facility failed to implement Enhanced Barrier Precautions as required, evidenced by residents refusing EBP, lack of PPE signage, and staff not consistently using gowns or PPE when caring for residents #2 and #40.
Inspection Report — Jan 9, 2025
Annual Inspection
Date: Jan 9, 2025
Visit Reason
Annual inspection survey of the nursing home facility Creekside was conducted to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report — Jan 6, 2025
Renewal
Date: Jan 6, 2025
Visit Reason
Annual recertification survey conducted from January 6, 2025 to January 9, 2025 to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
Creekside Nursing Home was found to be in compliance with all applicable requirements during the annual recertification survey. No regulatory insufficiencies were cited.
Inspection Report — Feb 15, 2024
Annual Inspection
Date: Feb 15, 2024
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at the nursing home facility.
Findings
No health deficiencies were found during the inspection.
Inspection Report — Feb 12, 2024
Renewal
Date: Feb 12, 2024
Visit Reason
An annual recertification survey was conducted from February 12, 2024 to February 15, 2024.
Findings
The facility was found to be in substantial compliance.
Inspection Report — Nov 28, 2022
Renewal
Date: Nov 28, 2022
Visit Reason
An annual recertification survey was conducted from 11/28/2022 to 12/1/2022.
Findings
The facility was found to be in substantial compliance.
Inspection Report — Sep 12, 2022
Routine
Date: Sep 12, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted from September 12, 2022 to September 19, 2022. A complaint investigation for complaints #102244-C, #106669-C and facility reported incident #99758-I was also conducted during this period.
Complaint Details
Complaints #102244-C, #106669-C and facility reported incident #99758-I were investigated and found to be in substantial compliance.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. The complaint investigation found the facility to be in substantial compliance.
Inspection Report — Jun 9, 2021
Plan of Correction
Date: Jun 9, 2021
Visit Reason
The facility submitted a credible allegation of compliance and plan of correction for review.
Findings
Based on acceptance of the credible allegation of compliance and plan of correction, the facility was certified in compliance effective 6/9/21.
Inspection Report — May 23, 2021
Renewal
Date: May 23, 2021
Visit Reason
This was a Medicare Recertification Survey combined with an investigation of multiple complaints (#97256-C, #92700-C, #93725-C, #94677-C), all of which were not substantiated.
Complaint Details
Complaint #97256-C not substantiated; Complaint #92700-C not substantiated; Complaint #93725-C not substantiated; Complaint #94677-C not substantiated
Findings
The facility was found to be not in compliance with Medicare Conditions of Participation. Deficiencies were cited related to advanced directives documentation, baseline care plans for newly admitted residents, professional standards for insulin administration, and infection prevention and control practices.
Violations (4)
F578: The facility failed to ensure that the code status documented in the electronic health record matched the code status in the Physician Order for Scope of Treatment (IPOST) binder for Resident #11. Nursing staff education was planned to address this.
F655: The facility failed to complete a baseline care plan within 48 hours of admission for Resident #143. The resident had not received a baseline plan of care with information on initial service and care delivery plans.
F658: The facility failed to ensure professional standards of insulin administration for Resident #142. Staff administered insulin using a FlexTouch pen incorrectly by holding it in place for only 2 seconds instead of the required 2-3 seconds.
F880: The facility failed to clean and disinfect carpeting properly. Resident #4's room carpet had bowel movement smears that were not cleaned promptly despite staff observations and reports. The facility lacked records of carpet cleaning schedules and documentation.
Inspection Report — Sep 14, 2020
Routine
Date: Sep 14, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 9-14-20 to 9-15-20.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. No regulatory insufficiencies were cited.
Inspection Report — Jun 5, 2020
Routine
Date: Jun 5, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on 6/5/20 to assess compliance with CMS and CDC recommended practices to prepare for COVID-19.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. No regulatory insufficiencies were cited.
3 CMS Surveys
CMS Survey — Feb 15, 2024
Feb 15, 2024
CMS Survey — Jan 9, 2025
Jan 9, 2025
CMS Survey — Dec 18, 2025
Dec 18, 2025
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