Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Creekside Center during CMS and state inspections, most recent first.
Kitchen food storage, equipment cleanliness, and sanitizing practices were not maintained according to standards. Surveyors found scratched mugs and worn frying pans, wet and residue-covered utensils and equipment, greasy and soiled cooking surfaces, improperly stored food items, and unlabeled or undated products. Staff also demonstrated confusion about manual warewashing and sanitizer concentration, and a resident reported receiving oversized spoons that made eating difficult and caused spillage.
A resident with depression, anxiety, PTSD, and Lewy bodies dementia was started on diazepam for anxiety, but no care plan was developed for the psychotropic medication. Another resident with an indwelling suprapubic catheter had a care plan directing staff to keep the catheter off the floor, but the drainage bag was observed on the floor in a privacy bag. The DON confirmed the expected care plan development and catheter intervention were not followed.
Food lacked palatability and pureed items were improperly prepared. Several residents reported bland, cold, or unappetizing meals, and surveyors found regular and pureed foods lacked seasoning during a test meal tasting. In the kitchen, a cook blended tofu with tomato sauce for a vegetarian pureed item without following a recipe, added thickener, then used hot water multiple times to adjust the texture before placing it in the warmer; no taste test was observed.
A facility failed to follow IPC practices in several observed events. A resident with a suprapubic catheter had the drainage bag placed on the floor, an LPN did not perform hand hygiene before and after med pass for multiple residents, and enteral feeding supplies were moved from one resident’s room to another. The IP and DON stated these practices did not meet expected infection control procedures.
Failure to obtain and document informed consent for a psychotropic dose increase. A resident with depression, anxiety, PTSD, and Lewy bodies dementia had diazepam increased from 10 mg to 1 tablet BID after an outside specialist visit, but the record did not show that the MD discussed the risks or benefits or documented consent before the new order was started. LN, the MD, and the DON all acknowledged that informed consent was missing for the dose increase.
PEG tube placement was not verified before medication administration for a resident with dysphagia, quadriplegia, and cerebral palsy. An LN prepared and gave crushed meds through the PEG tube after flushing it, but did not use a stethoscope to confirm placement before the flushes and meds, despite an order and care plan directing placement checks prior to each feeding, flush, or medication. The LN said she had checked placement earlier and did not need to recheck it, while the DON confirmed staff were expected to follow the order.
A resident with morbid obesity, muscle weakness, and multiple buttocks-related pressure injuries had a low-air loss mattress in use, but the pump was set to 110 lbs even though the resident’s documented weight was 249.78 lbs. An LPN confirmed the setting did not match the resident’s weight, and staff stated the mattress should be adjusted each shift based on current weight to support wound healing and skin integrity.
A resident with depression, anxiety, PTSD, and Lewy bodies dementia experienced a delay in the processing and start of an outside provider’s increased diazepam order. The MAR showed the prior PRN diazepam order remained active until the new scheduled 10 mg dose was started, and an LPN acknowledged the medication was initiated six days late. Staff and the MD confirmed that psychotropic orders should be reviewed and implemented without delay, but the facility waited for MD review before carrying out the change.
A cognitively intact resident reported that $120–$140 in cash was missing from his wallet after he awoke to see a laundry staff member in his room holding and then replacing the wallet. The incident was documented in progress notes and on a Theft/Loss Report, and the SSD and DON interviewed the resident and the staff member, who denied taking any money. Although the resident clearly described missing cash following the staff member’s handling of his wallet, the DON and ADM did not treat the situation as an allegation of misappropriation or abuse and did not report it to the state agency, Ombudsman, law enforcement, or other authorities, relying instead on the resident’s wish not to personally report the incident, contrary to facility policy requiring reporting of suspected staff misappropriation.
Two residents with dementia and a history of wandering or elopement were not consistently monitored according to facility policy, with one resident lacking documented checks of a Wander Guard device and another not having the device applied upon admission, resulting in an elopement incident. Staff and DON confirmed that required protocols for monitoring and documentation were not followed.
A resident with dementia eloped from the facility, but staff documented on the Visual Checks form that the resident was present in his room during the time he was actually missing. Staff interviews and record reviews confirmed that the documentation was inaccurate and inconsistent with the resident's actual whereabouts, failing to meet professional standards for medical record accuracy.
A deficiency occurred when only one licensed nurse was present for the entire night shift, despite a census of 72 residents. Staff interviews confirmed that this staffing shortage was unsafe, could compromise resident safety in emergencies, and might result in missed or delayed medication administration. Facility records and leadership acknowledged the shortage and the failure to meet established staffing guidelines.
A resident with dementia and a history of falls experienced two separate incidents resulting in head and hip injuries. In both cases, staff delayed notifying the DON and the attending physician, and the resident was not transferred to acute care for evaluation until the following day. The resident was later found to have a head injury and a hip fracture. Facility protocols requiring prompt assessment and communication were not followed, leading to delayed treatment.
The facility failed to meet food safety standards, with wet nesting of clean items, dirty and rusted equipment, and improper storage of raw chicken and open freezer bags. Staff were unable to demonstrate proper sanitation testing, and resident food from outside was improperly labeled, risking contamination and inappropriate serving. The DON acknowledged the need for proper labeling to prevent errors.
The facility failed to properly puree foods for residents on a pureed diet, leading to potential nutritional deficiencies. A cook added excessive broth to meatloaf, resulting in a runny consistency that required thickener. Similarly, Au Gratin potatoes were made runny by unmeasured milk, also needing thickener. The Registered Dietitian confirmed that this process could alter taste and nutritional content, and the pureed foods did not meet IDDSI texture standards.
The facility failed to provide alternative meal options with similar protein content to the main entree, potentially leading to decreased protein intake for residents choosing these alternatives. Grilled cheese and PB&J sandwiches were served without additional protein sources, despite the Registered Dietitian confirming the discrepancy. The grilled cheese provided 15 grams of protein, PB&J provided 18 grams, while a typical meatloaf entree provided 24 grams.
A resident's dignity was compromised when a CNA stood over them while assisting with feeding due to a lack of available chairs. This practice, contrary to facility policy, was acknowledged by the DSD and DON as potentially increasing choking risk and reducing resident comfort.
The facility failed to notify physicians of critical health information for two residents. One resident's physician was not informed when vital signs were outside ordered parameters, leading to withheld medication. Another resident's abnormal lab results were not communicated promptly, delaying potential treatment. These lapses were confirmed by staff and violated facility policies.
The facility failed to maintain infection control practices, with unlabeled and improperly stored urinals, wash basins on the floor with soiled cloths, and improper reconstitution of an intramuscular injection. These practices increased the risk of infection and cross-contamination, as confirmed by staff and the DON.
A resident with severe medical conditions was not provided with necessary suction equipment at the bedside, and their change in condition was not assessed or reported to the physician in a timely manner. The resident's declining condition, including a drop in oxygen saturation, was not adequately documented or addressed, leading to a lack of timely intervention and ultimately the resident's passing.
The facility failed to update care plans to include bed rail recommendations for two residents. Despite having bed rails in place, the care plans for a resident with severe cognitive impairment and another with limited mobility assistance did not reflect these recommendations. Staff interviews confirmed that bed rail usage should be included in care plans.
The facility failed to obtain consents and physician's orders for the use of bed rails for two residents. Despite recommendations and evaluations indicating the need for these consents and orders, the facility did not have any evidence of informed consent or physician's orders in the residents' electronic health records. Interviews with staff revealed inconsistencies in the process of obtaining and documenting these consents and orders.
The facility failed to obtain a timely urine specimen for urinalysis for a resident with moderate cognitive impairment and specific medical conditions. Despite attempts on two consecutive days, the sample was only collected after a delay of over two days. Staff interviews revealed that the delay was due to the resident's incontinence and the lack of communication with the physician regarding alternative collection methods.
A resident with severe cognitive impairment did not receive a pneumococcal vaccine despite consent being given. The facility's policy requires timely vaccination, but the Infection Preventionist had not yet administered it.
The facility failed to provide COVID-19 vaccinations to two residents despite having received consent from their responsible parties. Both residents, who have severe cognitive impairments, did not receive the updated vaccine despite previous vaccinations and booster shots. The Infection Preventionist and Director of Nursing acknowledged the oversight.
Kitchen Food Storage, Equipment Cleanliness, and Sanitizing Failures
Penalty
Summary
Food storage and preparation practices were not maintained in accordance with professional standards in the kitchen serving 73 residents. During the initial kitchen tour, surveyors observed scratched coffee mugs and two frying pans with signs of overuse, including scratched surfaces, discoloration, and worn coating on the cooking surface. The Certified Dietary Manager confirmed the items should have been replaced and later stated that scratched mugs and frying pans could lead to cross-contamination. Surveyors also observed multiple food preparation and storage issues. A spoon storage area contained both standard spoons and large serving spoons, and a resident reported receiving oversized spoons with meals and spilling food on her chest because of them. Dietary staff stated the facility did not have enough regular-sized spoons and were using serving spoons and soup spoons in place of regular spoons. The Occupational Therapist and Speech Language Pathologist stated they had not ordered large spoons for residents and agreed the oversized spoon would make eating difficult and could cause food spillage. Additional observations showed food contact surfaces and equipment were not kept clean. One serving spoon ladle and three steamtable pans were stored wet, a blender was wet with light brown food residue on the blade, a can opener had light brown residue on the blade, and a drawer contained food debris next to clean scoops. The stove had greasy buildup on burners, the oven had an old spill inside, and the steam table ledge had food crumbs and old spills while holding clean pan lids. Surveyors also found fish fillets and carrots not closed properly in the freezer, an unlabeled and undated container of thickener in a plastic bag, and unlabeled containers of garlic powder and beef broth base. Staff were unfamiliar with the correct sanitizing process during manual warewashing, including how long items should remain in sanitizer and how to verify sanitizer concentration, and the Certified Dietary Manager stated staff should have been following the correct sanitization procedures.
Incomplete care planning for psychotropic medication and suprapubic catheter care
Penalty
Summary
A comprehensive care plan was not developed for Resident 8 after diazepam 10 mg by mouth every morning and at bedtime for anxiety was started. Resident 8’s record showed diagnoses of depression, anxiety disorder, PTSD, and Lewy bodies dementia, and the resident was identified as a responsible party. During record review, the care plan did not include a plan for the psychotropic medication diazepam, and the nurse confirmed that no care plan had been developed for that medication. Resident 47 had an indwelling suprapubic catheter and an order for suprapubic catheter care every shift that remained active. The care plan created for the catheter stated that the catheter should be kept off the floor. During observation, the catheter drainage bag was inside a privacy bag placed directly on the floor next to the resident while the resident was sitting in bed. The nurse confirmed that the drainage bag should not have been on the floor and that the care plan intervention was not followed. The DON stated that care plans should be individualized, include person-centered goals and interventions, and be used to direct nursing care. The DON also stated that the expectation was for staff to develop a care plan for Resident 8’s psychotropic medication, implement interventions, and evaluate effectiveness, and that staff should follow the suprapubic catheter care plan for Resident 47. The facility policy stated that the comprehensive care plan should include measurable objectives and timetables to meet the resident’s medical, physical, mental, and psychosocial needs.
Food Lacked Flavor and Pureed Items Were Improperly Prepared
Penalty
Summary
Food and drink were not prepared to be palatable, attractive, and at a safe and appetizing temperature for several residents. Resident 55 stated the food tasted bad and had multiple outside food items and beverages at the bedside, saying family brought food in because the facility food was not appetizing. Resident 49 said breakfast foods were cold, lacking flavor, and that the oatmeal was too runny and could be eaten through a straw. Resident 64 stated the food was bland and needed more seasoning and garnishing, and Resident 18 said the food was nasty, very bland, not visually appealing, and lacked taste and seasoning. During a test meal tasting, two surveyors found both the regular and pureed foods bland and lacking seasoning, with the stir fry entree missing Asian flavorings such as ginger and soy sauce and the green beans and rice having no seasoning added. Pureed foods were also not prepared using methods that conserved nutritive value, flavor, and appearance. During kitchen observation, the cook prepared the vegetarian lunch item by blending tofu with canned tomato sauce without following a recipe and without adding other seasonings. When the mixture was too thin, thickener was added twice, then hot water was added three times to thin it before it was placed in the warmer for lunch. No taste testing of the product was observed. The report also cited puree instructions stating not to puree with water and to use liquids such as broth, milk, juice, or nutritional supplements instead.
Infection Control Failures During Catheter Care, Medication Pass, and Enteral Supply Handling
Penalty
Summary
The facility failed to implement infection prevention and control measures for a census of 73 in multiple observed situations. One resident had a suprapubic catheter with the drainage bag observed inside a privacy bag placed directly on the floor beside the bed. The resident had diagnoses including neuromuscular dysfunction of the bladder and urogenital implants, and the active order required suprapubic catheter care every shift. During the observation, a nurse confirmed the drainage bag should have been hung from the bed frame and not placed on the floor, and the Infection Preventionist and DON stated the bag should remain off the floor and below bladder level while the resident was in bed. The resident’s care plan also included keeping the catheter off the floor. During medication administration observations, an LPN failed to perform hand hygiene after giving medications to one resident and failed to perform hand hygiene before and after administering medications to other residents. The nurse administered medications to residents in the same room and moved between residents without washing hands or using hand sanitizer as expected. The Infection Preventionist stated hand hygiene should be performed when entering and exiting the room, before and after medication administration, and when moving from one bed to another in the same room. The DON stated staff should perform hand hygiene before and after medication administration to prevent cross-contamination and the spread of infection. The facility also failed to follow infection control practices when enteral nutrition supplies were transferred from one resident’s room to another. A resident with dysphagia and a gastrostomy tube had enteral feeding supplies and unopened formula at the bedside, and the nurse took the formula cartons and a feeding tube from that room to another resident’s room. The nurse stated she should not have transferred those items and acknowledged that doing so did not follow infection control practices and increased the risk for cross contamination and infection. The DON stated that once an item was in one resident’s room, it should not be transferred to another resident’s room.
Failure to Obtain Informed Consent for Psychotropic Dose Increase
Penalty
Summary
The facility failed to obtain and document informed consent before increasing a resident’s diazepam dosage. Resident 8 had diagnoses including depression, anxiety disorder, PTSD, and Lewy bodies dementia, and was documented as self-responsible for health care decisions. The resident’s after-visit summary from an outside specialist showed diazepam 10 mg was changed to one tablet in the morning and one tablet at bedtime for generalized anxiety disorder. The resident’s MAR showed the updated diazepam order started on 3/11/26 as diazepam oral tablet 10 mg, give 1 tablet by mouth every morning and at bedtime for anxiety. The medical record did not contain documentation that the MD discussed the dosage increase with Resident 8 or documented the risks or benefits of the change. During interview, LN 3 acknowledged the lack of informed consent documentation for the diazepam dose increase and stated informed consent should have been obtained before initiating or increasing psychotropic medications. LN 5 stated that when a medication dosage was increased or a new psychotropic medication was ordered, the MD was notified and informed consent was to be obtained from the resident or representative before implementation, with signed consent documented in the record. The MD later reviewed the record and confirmed informed consent had not been obtained for the increased diazepam dosage, stating it was required prior to administration of psychotropic medications. The DON also reviewed the record and acknowledged that informed consent had not been obtained or documented for the diazepam dosage increase.
PEG Tube Placement Not Verified Before Medication Administration
Penalty
Summary
The facility failed to provide appropriate care and services to a resident with dysphagia, quadriplegia, cerebral palsy, and an encounter for attention to gastrostomy when the resident's PEG tube placement was not checked before medication administration. The resident's admission record showed the resident had a feeding tube, and the MDS indicated a BIMS score of 0, meaning the resident was rarely or never understood. The physician's order for the resident directed staff to check tube placement prior to each feeding, flush, or medication administration, and the care plan identified a risk for complications related to enteral feeding via PEG tube and directed staff to verify tube placement prior to feeding or medication. During a medication administration observation, an LN prepared three medications for administration through the PEG tube, brought the crushed medications and water to the bedside, and administered them without bringing a stethoscope to the bedside. The LN disconnected the tube from the feeding formula, attached a syringe, flushed the tube with water, administered the crushed medications dissolved in water, and flushed the tube again. She did not verify PEG tube placement by injecting air and listening over the abdomen with a stethoscope before flushing and giving the medications. During interview, the LN stated she had checked placement 30 minutes earlier and did not need to check again, but acknowledged the order required placement to be checked prior to each flushing and medication administration. The DON stated staff were expected to follow the physician's order and verify PEG tube placement as ordered.
Low-Air Loss Mattress Not Set to Resident’s Current Weight
Penalty
Summary
Adequate care and services were not provided to promote healing and prevent pressure injury for one resident with multiple pressure injuries. The resident was admitted with diagnoses including morbid obesity and muscle weakness, and had active orders for a low-air loss mattress, right buttocks unstageable wound, left upper thigh posterior/buttock wound, and treatment to the groin and bilateral buttocks. During observation, the resident’s low-air loss mattress was in use, but the pump setting was calibrated to 110 lbs even though the resident’s documented weight the day before was 249.78 lbs. A nurse confirmed that the mattress setting did not match the resident’s current weight and stated the mattress was intended to promote wound healing and prevent further skin breakdown. Other nurses and the DON stated that the mattress pressure should be adjusted based on the resident’s current weight and checked each shift. They also stated that improper adjustment could affect skin integrity and allow additional pressure on the wound areas from the bed frame.
Delayed Processing and Administration of Psychotropic Medication
Penalty
Summary
The facility failed to ensure timely medication processing and administration for one resident with diagnoses of depression, anxiety disorder, PTSD, and Lewy bodies dementia. The resident’s record showed an outside specialist visit on 3/5/26 with a medication change for diazepam, increasing the dose to 10 mg to be taken one tablet in the morning and one tablet at bedtime for generalized anxiety disorder. The MAR showed the prior diazepam 5 mg as-needed order remained active until 3/11/26, and the new diazepam 10 mg order was started on 3/11/26, which LN 3 acknowledged was a six-day delay in initiating the prescribed medication. LN 3 stated that when an outside provider ordered an increase in dosage or a new psychotropic medication, the facility first notified the Medical Director and waited for review before implementation. LN 5 stated that physician orders, especially psychotropic medications, should be carried out without delay. The Medical Director confirmed the outside physician’s increased diazepam order and stated that changes from outside physicians should have been reviewed as soon as nursing staff notified the MD, with timely implementation after agreement with the order. The facility’s policies stated medications are to be administered in a safe and timely manner as prescribed, and physician orders are to include the date and time received.
Failure to Report Allegation of Financial Abuse Involving Missing Resident Cash
Penalty
Summary
The deficiency involves the facility’s failure to identify and report an allegation of financial abuse to the state Department and other required authorities after a cognitively intact resident reported missing cash and implicated a staff member. The resident, admitted in the summer of 2022, had an MDS dated 10/31/25 showing a BIMS score of 15, indicating intact cognition. On 1/19/26 at approximately 5:00 a.m., the resident reported that $120–$140 in twenty-dollar bills was missing from his wallet after he awoke and saw a laundry staff member in his room holding his wallet and putting it back on the table. Progress notes documented that the resident was calm, cognitively intact, and able to clearly verbalize his concern, and that he reported seeing the laundry staff member with his wallet while he was asleep. The facility documented the incident on a Theft/Loss Report and in progress notes, recording that the resident reported missing cash and that he had seen the laundry staff member holding his wallet. The Social Service Director (SSD) and DON met with the resident, discussed resident rights, internal and external reporting options (including the Department, police, and Ombudsman), and the facility grievance process. The resident declined to file a formal grievance or to personally report the incident externally and expressed that he wanted his money replaced. The SSD and DON interviewed the laundry staff member, who denied holding the resident’s wallet or taking any money, and the facility concluded its internal investigation without confirming theft. The resident’s inventory of personal effects did not list any cash, and the missing money was not found. Despite the resident’s allegation that his money was missing after seeing a staff member holding his wallet, the facility did not report the incident to the Department, police, or Ombudsman. The DON stated that the facility’s practice was to involve the Administrator after investigation to determine if an incident was abuse and reportable, and that they typically reported to authorities if the value of missing items exceeded $100 or if the resident wanted it reported. The DON confirmed that this allegation was not reported because the resident declined external reporting. The Administrator stated he was not aware that the incident was an alleged abuse involving a staff member and believed there was no misappropriation or malicious intent, characterizing the situation as the resident having lost money without proof of theft. This handling conflicted with the facility’s written policies on investigating theft and loss and on abuse, neglect, exploitation, or misappropriation, which require that suspected staff misappropriation of resident property and suspicions of abuse or misappropriation be reported to the state licensing/certification agency, Ombudsman, resident representative, APS, and law enforcement within specified time frames, regardless of resident preference.
Failure to Ensure Elopement Prevention Measures for Residents with Dementia
Penalty
Summary
The facility failed to ensure an environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents with dementia and a history of wandering or elopement. One resident, who had a documented history of elopement and was assessed as being at risk, did not have the required Wander Guard device placement and functioning checks documented every shift as ordered by the physician. Review of the Treatment Administration Records (TARs) revealed multiple dates where these checks were not performed or documented, despite facility policy and care plan interventions requiring such monitoring. Interviews with staff and the Director of Nursing (DON) confirmed that the expected protocol was not followed, and the risk for this resident was identified as elopement. Another resident, admitted with dementia, muscle weakness, unsteadiness, and a recent history of elopement, was not provided with a Wander Guard device upon admission, contrary to facility policy. This resident had been recently hospitalized after being found wandering and was discharged to the facility for close monitoring. Despite ongoing issues with wandering and a physician's assessment indicating the need for close monitoring and safety measures, the resident did not have a Wander Guard device in place prior to an elopement incident. The resident was found outside the facility by staff after the incident, and it was confirmed through interviews and record review that the device was only applied after the elopement occurred. Facility policies reviewed indicated that residents at risk for elopement should have a Wander Guard device applied and checked daily, and that interventions to reduce accident risks must be implemented and documented. The DON acknowledged that these policies were not followed for both residents, resulting in lapses in supervision and monitoring that led to one resident eloping and another being at increased risk for elopement due to inconsistent monitoring.
Inaccurate Medical Record Documentation During Resident Elopement
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate in accordance with professional standards for one resident. Specifically, documentation on the resident's Visual Checks form indicated that staff observed the resident in his bedroom at regular intervals, even though the resident had actually eloped from the facility during that time. The Visual Checks form showed the resident was present in his room every fifteen minutes from 1:00 PM to 1:45 PM, while other records and staff interviews confirmed that the resident was missing and later found outside the facility at 1:50 PM. Interviews with staff and review of the resident's records revealed inconsistencies between the Visual Checks documentation and the actual events. Staff acknowledged that the resident was missing at 1:30 PM, and the DON confirmed that the documentation did not accurately reflect the resident's whereabouts. The facility's policy required timely, accurate, and comprehensive documentation of care and monitoring, which was not followed in this instance. The inaccurate documentation resulted in a medical record that did not truthfully represent the resident's status during the period of elopement.
Inadequate Night Shift Nursing Coverage for Facility Census
Penalty
Summary
On the night shift of 5/4/25, the facility failed to provide adequate nursing staff for a census of 72 residents, as only one licensed nurse was present for the entire shift after the second nurse clocked out at 12:25 a.m. Multiple staff interviews confirmed that this staffing shortage was not a safe practice and could compromise residents' safety, particularly in emergency situations such as a code blue. Staff also expressed concerns that one nurse would be unable to handle emergencies, administer medications as scheduled, or meet residents' needs effectively during the shift. Record reviews and interviews with the Staffing Coordinator and Director of Nursing confirmed the staffing shortage and acknowledged that attempts were made to fill the gap, but were unsuccessful. The facility's own assessment tool and job descriptions emphasized the need for sufficient staffing to meet residents' needs, but these guidelines were not met on the night in question, potentially impacting the health and well-being of all residents in the facility.
Delayed Hospital Transfer and Inadequate Response After Resident Falls
Penalty
Summary
The facility failed to provide timely and adequate treatment and services for a resident who experienced two separate falls, both resulting in injuries that required acute medical evaluation. The first incident involved an unwitnessed fall with a head injury, where the resident developed a hematoma and later exhibited symptoms such as nausea, vomiting, and increased confusion. Despite these symptoms and the resident's cognitive impairment, the resident was not transferred to an acute care hospital for further evaluation until the following day. Documentation also showed that the DON was not notified immediately after the fall, contrary to facility expectations and protocols. In the second incident, the same resident suffered another fall, this time with pain and a nodule noted on the left hip. The assessment indicated marked localized bruising, swelling, and pain over the joint, suggestive of a possible fracture. However, the clinician and family were not notified until several hours later, and the resident was not transferred to the hospital until the following day. Upon hospital evaluation, the resident was found to have sustained a left hip fracture and an inferior pubic ramus fracture. The PCP stated that he was not informed of signs of fracture by the facility nurse, which delayed the decision to transfer the resident for further evaluation. Interviews with facility staff, including LNs and the DON, confirmed that the expected protocol was to notify the DON and the attending physician immediately in cases of unwitnessed falls with head injuries or significant pain. The facility's own clinical protocol required prompt collection and communication of pertinent details to the physician and escalation to the medical director if timely responses were not received. The lack of immediate notification and delayed transfer to acute care after both falls constituted a failure to provide appropriate treatment and services according to the resident's needs and the facility's policies.
Food Safety and Sanitation Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple deficiencies observed during a survey. Clean food service items, such as trays, steam table pans, scoops, and a blender, were found stored while still wet, which could lead to contamination. The Dietary Director acknowledged that wet nesting could lead to contamination, and the facility's policy required all dishware to be air-dried before storage. Additionally, equipment such as a can opener, food processor, and large saucepan were found dirty and/or rusted, contrary to the facility's policy that all food contact equipment should be cleaned and sanitized after each use. Further observations revealed that raw chicken was prepared on a metal rack above uncovered dessert cups, posing a risk of contamination. The walk-in freezer contained open bags of food, which were exposed to the environment, potentially leading to cross-contamination and freezer burn. Staff were also unable to demonstrate proper testing of sanitation concentration for the dish machine and manual dishwashing, with inconsistencies in the understanding of desired concentration levels and water temperatures for effective cleaning and sanitizing. In the resident dining room, food brought in from outside the facility was improperly labeled, with missing names, dates, and room numbers, leading to potential confusion and inappropriate food being served to residents. Staff were uncertain about the criteria for labeling and reheating outside food, and the Director of Nursing acknowledged the need for proper labeling to prevent errors. The facility's policy required food to be labeled with the resident's name, room number, and a use-by date, but this was not consistently followed, as observed during the survey.
Improper Pureeing of Foods for Residents on Pureed Diet
Penalty
Summary
The facility failed to properly puree foods for residents on a pureed diet, which could lead to poor intake, nutrient deficiencies, and weight loss. During a kitchen visit, a cook was observed preparing pureed meals for four residents. The cook added excessive amounts of broth to the meatloaf, resulting in a runny consistency that required the addition of thickener multiple times to achieve the desired texture. Similarly, when pureeing Au Gratin potatoes, the cook added unmeasured milk, leading to a runny consistency that also required thickener. The pureed meatloaf did not hold its shape on the plate, forming a puddle, and during a taste test, the pureed meatloaf and peas were found to be flavorless and gummy. The Registered Dietitian confirmed that the process of adding liquids and thickener could alter the taste and nutritional content of the food. The facility's failure to puree foods using methods that conserve nutritive value and flavor was observed to potentially impact the residents' nutritional intake. The report highlights that the pureed foods did not meet the texture characteristics outlined by the International Dysphagia Diet Standardization Initiative (IDDSI), which requires pureed foods to be smooth, free of lumps, and thick enough to hold shape on a plate or spoon.
Inadequate Protein in Alternative Meal Options
Penalty
Summary
The facility failed to provide alternative meal options with similar protein content to the main entree, which could potentially lead to decreased protein intake for residents choosing these alternatives. During a kitchen tour, it was observed that the alternative menu included grilled cheese and other sandwiches. During lunch meal plating, some residents received sandwiches like grilled cheese and PB&J without an additional protein source, despite these meals including other side items from the lunch meal. The Registered Dietitian confirmed that some residents received these sandwiches without additional protein. The grilled cheese sandwich provided 15 grams of protein, and the PB&J provided 18 grams, while a typical meatloaf entree provided 24 grams of protein, indicating a discrepancy in protein content.
Resident Dignity Compromised During Meal Assistance
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect during meal assistance. A Certified Nursing Assistant (CNA) was observed standing over a resident while assisting with feeding, which is contrary to the facility's expectations that staff should sit with residents during meals. The CNA stated that standing was necessary due to the unavailability of a chair. This practice was observed during a meal and was confirmed through interviews with the CNA and other staff members. The Director of Staff Development (DSD) and the Director of Nursing (DON) both acknowledged that the facility's policy requires CNAs to sit while feeding residents to maintain their dignity. The DSD also noted that standing while feeding could increase the risk of choking and reduce eye contact, potentially making the resident feel rushed. The facility's document on dignity emphasizes the importance of caring for residents in a manner that promotes their well-being and self-esteem, which was not adhered to in this instance.
Failure to Notify Physicians of Critical Health Information
Penalty
Summary
The facility failed to meet professional standards of quality for two residents, Resident 60 and Resident 179, by not notifying physicians of critical health information. For Resident 60, who was admitted with diagnoses including end-stage renal disease, dependence on renal dialysis, and congestive heart failure, the facility did not notify the physician when vital signs were outside of ordered parameters. Specifically, on two occasions, the resident's heart rate was outside the parameters set by the physician, leading to the withholding of Metoprolol, a medication for hypertension. However, there was no documentation that the physician was informed of these deviations, as confirmed by Licensed Nurse 1 and the Director of Nursing (DON). Resident 179, admitted with conditions such as cerebral infarction, anemia, and hyponatremia, also experienced a lapse in care when abnormal lab results were not promptly communicated to the physician. The lab results, which included low red blood cell count, hemoglobin, and sodium levels, as well as high alkaline phosphatase levels, were reported to the facility but not communicated to the physician until several days later. This delay was acknowledged by both Licensed Nurse 2 and the DON, who confirmed that the physician was only notified on December 4, 2024, despite the results being available on November 20, 2024. The facility's policies and procedures, which require timely notification of physicians regarding abnormal lab results and vital signs, were not followed in these instances. The DON and the involved licensed nurses confirmed the lack of documentation and communication, which could have led to potential risks for the residents. The facility's failure to adhere to its own protocols and the expectations of timely physician notification were evident in both cases, as highlighted by the interviews and record reviews conducted during the survey.
Infection Control Deficiencies in Urinal Storage, Wash Basin Handling, and Injection Reconstitution
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by several observations. Urinals in a resident bathroom were not labeled and were stored improperly, with one placed upside down on the toilet and another on the assistive handrail. This improper storage and lack of labeling were acknowledged by a Certified Nursing Assistant (CNA) and the Infection Preventionist (IP), who both noted the increased risk of infection and cross-contamination due to these practices. In another instance, two resident wash basins were found on the floor of a shared bathroom, with one basin unlabeled and a soiled cloth hanging between them. A Licensed Nurse (LN) confirmed that the basins should not be stored on the floor and should be labeled, as the shared room and bathroom increased the risk of infection spread. The Director of Nursing (DON) also acknowledged that the condition of the urinals and basins did not meet the facility's expectations and posed a risk of infection. Additionally, there was an issue with the reconstitution of an intramuscular injection for a resident. A Licensed Nurse (LN) used the same syringe and needle twice to draw up lidocaine, leaving the needle exposed on a contaminated surface. The DON explained that this practice could lead to cross-contamination and infection at the injection site. The Centers for Disease Control (CDC) guidelines were cited, indicating that a new needle and syringe should be used for each entry into a medication vial to prevent unsafe medical injections.
Failure to Provide Adequate Treatment and Timely Assessment
Penalty
Summary
The facility failed to provide adequate treatment and services for a resident who required suctioning due to an inability to swallow or clear secretions. The resident, who had diagnoses including end-stage renal disease, dysphagia following a stroke, and hemiplegia, was found without a suction machine at the bedside when needed. This oversight was discovered when the resident's family member noticed the resident had vomited, and there was no equipment available to clear the secretions, which was necessary to maintain a patent airway. Additionally, the facility did not assess and report the resident's change in condition to the physician in a timely manner. The resident's condition was noted to be declining, with a significant drop in oxygen saturation levels, yet there was no documentation of vital signs being checked after a certain time, nor was the physician notified promptly. The resident's clinical records lacked documentation of suctioning and vital signs, indicating a failure in monitoring and responding to the resident's deteriorating condition. The Director of Nursing acknowledged that the nurses should have assessed, reported, and documented the change in the resident's condition, and the resident should have been transferred to a hospital for a higher level of care. The physician also confirmed that the resident should have been transferred when the condition started to deteriorate. The lack of timely intervention and communication with the physician contributed to the resident's condition being unrecognized and untreated, ultimately leading to the resident's passing.
Failure to Update Care Plans with Bed Rail Recommendations
Penalty
Summary
The facility failed to update comprehensive care plans to include bed rail recommendations for two residents, Resident #26 and Resident #31, who were reviewed for bed rail usage. Resident #26, who had severe cognitive impairment and required assistance with bed mobility and transfers, had a bed rail recommendation for one-quarter side rails on both sides of the bed. However, the resident's care plan, last reviewed on 11/27/2023, did not address this recommendation. Similarly, Resident #31, who was cognitively intact but required limited assistance with bed mobility and transfers, had a bed rail recommendation for one-quarter side rails on both sides of the bed. The care plan for Resident #31, last reviewed on 12/18/2023, also did not include this recommendation. Observations confirmed that both residents had the recommended bed rails in place, but their care plans were not updated accordingly. Interviews with various staff members, including the Director of Rehabilitation, Registered Nurse #7, Licensed Vocational Nurse #3, Licensed Vocational Nurse #2, the Director of Nursing, and the Administrator, revealed a consensus that the use of bed rails should be included in the residents' care plans. The staff indicated that the nurse conducting the bed rail assessment should update the care plan, and nursing managers should also review and update care plans for new admissions. Despite these procedures, the care plans for Resident #26 and Resident #31 were not updated to reflect the bed rail recommendations, leading to the identified deficiency.
Failure to Obtain Consents and Physician's Orders for Bed Rails
Penalty
Summary
The facility failed to obtain consents and physician's orders for the use of bed rails for two residents. Resident #26, who had severe cognitive impairment and multiple medical conditions, was observed with quarter bed rails up on both sides of the upper bed. Despite the bed rail evaluation recommending the use of bed rails and indicating the need for consent and a physician's order, the facility did not have any evidence of informed consent or a physician's order in the resident's electronic health record (EHR). The Director of Nursing (DON) confirmed that consents were not obtained for Resident #26's bed rails use. Similarly, Resident #31, who was cognitively intact and required limited assistance with bed mobility and transfers, was also observed with quarter bed rails up on both sides of the upper bed. The bed rail evaluation for Resident #31 recommended the use of bed rails and indicated the need for consent and a physician's order. However, there was no evidence of informed consent or a physician's order in the resident's EHR. The DON confirmed that consents were not obtained for Resident #31's bed rails use. Interviews with various staff members, including the Director of Rehabilitation (DOR), Registered Nurse (RN) #7, and Licensed Vocational Nurses (LVNs) #2 and #3, revealed inconsistencies in the process of obtaining consents and physician's orders for bed rail use. The staff acknowledged the need for these consents and orders but failed to ensure they were obtained and documented. The Administrator was also unsure about the need for bed rail consents, indicating a lack of clarity and adherence to the facility's policy on bed safety and bed rails.
Failure to Obtain Timely Urine Specimen for Urinalysis
Penalty
Summary
The facility failed to obtain a timely urine specimen for urinalysis for a resident with moderate cognitive impairment and specific medical conditions, including unspecified cirrhosis of the liver and a left clavicle fracture. The resident was admitted on 08/31/2023 and required substantial assistance with activities of daily living. On 11/01/2023, a physician ordered a urinalysis with culture and sensitivity due to the resident's symptoms of tiredness, weakness, confusion, or drowsiness. Despite attempts to collect the urine specimen on 11/02/2023 and 11/03/2023, the sample was only successfully collected on 11/03/2023 at 1:28 PM, resulting in a delay of over two days. Interviews with staff revealed that the delay was due to the resident's incontinence and inability to use a urinal. The Licensed Vocational Nurse (LVN) and Registered Nurse (RN) involved stated that if a clean catch urine sample could not be obtained, a physician's order for straight catheterization should have been requested. The Director of Nursing (DON) confirmed that there was no documentation indicating that the physician was informed of the unsuccessful attempts to collect the urine sample over the two-day period. The DON acknowledged that nursing staff should have contacted the physician to discuss alternative methods for obtaining the urine specimen.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to provide a pneumococcal vaccination to Resident #37, who was admitted on 05/12/2022 and had a diagnosis of unspecified dementia. Despite the responsible party giving verbal consent for the vaccine on 09/15/2023, the resident did not receive the vaccination. The facility's policy, revised in October 2019, mandates that all residents be offered pneumococcal vaccines unless medically contraindicated, already given, or refused. However, the resident's immunization record showed that the vaccine was not administered, and the Infection Preventionist (IP) confirmed that the vaccination had not been given because she had not yet attended to it. Interviews with the Director of Nursing (DON) and the Administrator revealed that the IP was responsible for obtaining consents and physician's orders for vaccines upon admission and seasonally. The DON stated that once consent was obtained, the vaccine should be administered as soon as there was a physician's order, typically within a few days. The Administrator emphasized that after providing education on the risks and benefits of the vaccine, it should be administered. Despite these protocols, Resident #37 did not receive the pneumococcal vaccine, indicating a lapse in the facility's vaccination process.
Failure to Administer COVID-19 Vaccinations
Penalty
Summary
The facility failed to provide COVID-19 vaccinations to two residents, despite having received consent from their responsible parties. Resident #37, who has severe cognitive impairment and a history of dementia, had consent provided by their responsible party on 09/15/2023. Despite this, the resident did not receive the updated COVID-19 vaccine. The Infection Preventionist (IP) mentioned that the resident refused the vaccine twice, but these refusals were not documented. Resident #37 had previously received two doses of the Moderna vaccine and two booster shots, the last one being on 08/26/2022. Similarly, Resident #16, who also has severe cognitive impairment and chronic kidney disease with heart failure, had consent provided by their conservator on 09/18/2023. Despite the consent, the resident did not receive the updated COVID-19 vaccine. The IP confirmed that there was no reason for the vaccine not being administered. Resident #16 had previously received two doses of the Pfizer vaccine and two booster shots, the last one being on 08/26/2022. The Director of Nursing (DON) and the Administrator both stated that once consent is obtained, the vaccine should be administered promptly, which did not happen in these cases.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 496 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Stockton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crystal Creek Post-acute | 1.1 mi | ★★★★★ | 28 | 0 |
| Delta Oaks Post Acute | 1.5 mi | ★★★★★ | 34 | 0 |
| Meadowood A Health And Rehabilitation Center | 1.6 mi | ★★★★★ | 1 | 0 |
| Clearwater Healthcare Center | 2.3 mi | ★★★★★ | 15 | 0 |
| Riverwood Health Care | 2.9 mi | ★★★★★ | 60 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.