Inspection visit
Inspection
Citations
26 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0009GeneralS&S Dpotential for harm
Include a process for Emergency Preparedness collaboration.
- 0015GeneralS&S Dpotential for harm
Address subsistence needs for staff and patients.
- 0024GeneralS&S Dpotential for harm
Establish policies and procedures for volunteers.
- 0039GeneralS&S Dpotential for harm
Conduct testing and exercise requirements.
- 0041GeneralS&S Dpotential for harm
Implement emergency and standby power systems.
- 0161GeneralS&S Dpotential for harm
Use approved construction type or materials.
- 0325GeneralS&S Dpotential for harm
Have properly installed hallway dispensers for alcohol-based hand rub.
- 0351GeneralS&S Dpotential for harm
Install an approved automatic sprinkler system.
- 0353GeneralS&S Dpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Dpotential for harm
Install corridor and hallway doors that block smoke.
- 0373GeneralS&S Dpotential for harm
Have enough space near smoke barriers to protect residents.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
F557 - Respect and Dignity
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
FAQ · About this visit
Common questions about this visit
What happened during the March 17, 2022 survey of Creekside Post Acute?
This was a inspection survey of Creekside Post Acute on March 17, 2022. The surveyor cited 26 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Creekside Post Acute on March 17, 2022?
Yes, 26 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Include a process for Emergency Preparedness collaboration."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.