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Inspection visit

Inspection

CREEKSIDE CENTER FOR REHABILITATION AND NURSINGCMS #21511330 citations on this visit
30 citations recorded

Citations

30 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.

  • 0550GeneralS&S Dpotential for harm

    F550 - Resident Rights

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  • 0578GeneralS&S Epotential for harm

    F578 - The right to request, refuse, and/or discontinue treatment, to participate in or

    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

  • 0636GeneralS&S Dpotential for harm

    F636 - Resident Assessment

    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

  • 0641GeneralS&S Dpotential for harm

    F641 - Accuracy of Assessments

    Ensure each resident receives an accurate assessment.

  • 0657GeneralS&S Dpotential for harm

    F657 - Comprehensive Care Plans

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • 0684GeneralS&S Dpotential for harm

    F684 - Quality of care

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0686GeneralS&S Dpotential for harm

    F686 - Skin Integrity

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  • 0689GeneralS&S Dpotential for harm

    F689 - Accidents

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0697GeneralS&S Dpotential for harm

    F697 - Pain Management

    Provide safe, appropriate pain management for a resident who requires such services.

  • 0756GeneralS&S Dpotential for harm

    F756 - Drug Regimen Review

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  • 0760GeneralS&S Dpotential for harm

    F760 - Residents are free of any significant medication errors

    Ensure that residents are free from significant medication errors.

  • 0812GeneralS&S Fpotential for harm

    F812 - Food safety requirements

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0880GeneralS&S Dpotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

  • 0887GeneralS&S Dpotential for harm

    F887 - Infection control

    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

  • 0919GeneralS&S Dpotential for harm

    F919 - Resident Call System

    Make sure that a working call system is available in each resident's bathroom and bathing area.

  • 0947GeneralS&S Dpotential for harm

    F947 - Training Requirements

    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

  • 0580GeneralS&S Dpotential for harm

    F580 - Notification of Changes

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  • 0609GeneralS&S Dpotential for harm

    F609 - The facility must develop and implement written policies and procedures that:

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  • 0677GeneralS&S Dpotential for harm

    F677 - A resident who is unable to carry out activities of daily living receives

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • 0026GeneralS&S Fpotential for harm

    Establish roles under a Waiver declared by secretary.

  • 0100GeneralS&S Epotential for harm

    Meet other general requirements.

  • 0211GeneralS&S Epotential for harm

    Keep aisles, corridors, and exits free of obstruction in case of emergency.

  • 0223GeneralS&S Epotential for harm

    Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

  • 0345GeneralS&S Fpotential for harm

    Have approved installation, maintenance and testing program for fire alarm systems.

  • 0353GeneralS&S Fpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0362GeneralS&S Epotential for harm

    Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

  • 0363GeneralS&S Epotential for harm

    Install corridor and hallway doors that block smoke.

  • 0761GeneralS&S Fpotential for harm

    F761 - Labeling of Drugs and Biologicals

    To conduct inspection, testing and maintenance of fire doors by qualified individuals.

  • 0918GeneralS&S Fpotential for harm

    F918 - Bathroom Facilities

    Have generator or other power source capable of supplying service within 10 seconds.

  • 0920GeneralS&S Epotential for harm

    F920 - Dining and Resident Activities

    Ensure proper usage of power strips and extension cords.

FAQ · About this visit

Common questions about this visit

What happened during the February 6, 2026 survey of CREEKSIDE CENTER FOR REHABILITATION AND NURSING?

This was a inspection survey of CREEKSIDE CENTER FOR REHABILITATION AND NURSING on February 6, 2026. The surveyor cited 30 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at CREEKSIDE CENTER FOR REHABILITATION AND NURSING on February 6, 2026?

Yes, 30 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."

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.

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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.