Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident’s right to be free from misappropriation of property was violated when multiple unauthorized transfers totaling over $13,000 were made from the resident’s bank account to a CNA’s mobile money transfer application. The issue came to light when the resident questioned high charges, prompting the Business Office Manager to review bank statements and identify transfers to the CNA. The DON, after obtaining permission, confirmed that the money transfer app used for the transactions was not installed on the resident’s phone or bedside computer. The resident reported keeping a debit card in a bedside dresser, denied giving anyone permission to use it, and could only vaguely recall possibly giving the card to the CNA once for a purchase, while facility-provided bank records showed multiple transfers to the CNA.
A cognitively intact resident was moved to a secured memory care unit and reported being confined in his room with a taped "do not enter" sign on the door for several days, stating the move occurred against his will. The facility lacked a physician’s incapacity statement to override the resident’s decision-making, despite only having POA paperwork that applied if he could not decide for himself. Leadership reported the move was for the safety of female residents due to the resident’s inappropriate statements and behaviors and claimed the resident agreed, but there was no signed consent. A psychologist documented the resident’s self-harm statements tied to distress over the room change, and social services confirmed he had contacted a VA suicide hotline and later denied intent to harm himself.
The facility did not test fire alarm interface equipment according to NFPA 72, risking smoke detection failure. Only five of eight duct smoke detectors were tested, with no sensitivity tests conducted, potentially endangering building occupants.
The facility failed to maintain proper sanitation and cleaning practices in the kitchen, with an unchecked ice machine, improper use of the 3-compartment sink, and unaddressed bio growth on ceilings and vents. The CDM confirmed a lack of training for staff on proper procedures, and the Maintenance Director had not addressed these issues despite being aware of them.
The facility failed to follow infection prevention practices during blood glucose monitoring and catheter care for two residents. An RN did not perform hand hygiene before and after glove use and failed to clean the glucometer. Additionally, urinary catheter drainage bags were observed touching the floor, contrary to the facility's policy.
The facility failed to document COVID-19 vaccine education and acceptance/refusal for residents, lacking proper consent forms and verification processes. The DON and ADON were unaware of any documentation procedures, and the current process did not ensure informed consent or refusal was recorded.
The facility failed to provide a safe and homelike environment, with issues such as improper storage of personal items, unsanitary conditions, and broken shower facilities. Residents expressed dissatisfaction with the lack of proper hygiene facilities and the overall living conditions. The facility's maintenance logs confirmed that these issues had persisted for months without resolution.
The facility failed to provide necessary care and assistance for activities of daily living to eight residents, including bathing and meal assistance. Residents reported not receiving showers due to broken facilities and lack of staff help. Observations confirmed inadequate meal assistance, with residents left without necessary supervision. Documentation practices were also lacking, with missing records of scheduled showers and meal assistance.
Two residents in the facility did not receive care according to their established plans, specifically regarding the application of compression stockings. One resident with chronic heart failure was observed without the prescribed stockings, despite documentation indicating they were applied. Another resident with a femur fracture was also not wearing the ordered compression sock, although records inaccurately showed it was used. Nursing staff admitted to signing off on these treatments without verification.
A resident with epilepsy was not informed in advance about the discontinuation of their seizure medication, Epidiolex, by the facility. The resident, who had intact cognition, experienced two seizures after the medication was stopped without prior notification to them or their guardian. The ADON issued a verbal order to discontinue the medication without informing the resident or guardian, and the facility's records lacked documentation of any notification.
A facility failed to create a care plan for a resident who smoked, despite the resident's agreement to the smoking policy and the need for such a plan. The resident, diagnosed with COPD, smoked outside with her sister, but the care plan lacked goals and interventions for smoking. Staff interviews confirmed the oversight.
The facility failed to ensure proper medication storage for two residents and on one unit. A resident had unsecured acetaminophen at his bedside without an evaluation for self-administration. Another resident had unsecured antacid tablets without a physician order. Additionally, a box of Ipratropium Bromide was left unattended on a nursing desk. These incidents were confirmed by LPNs and the DON.
A facility failed to support a resident's right to voice grievances without fear of reprisal. A resident with multiple sclerosis and other conditions was found in unsanitary conditions, indicating a lack of care. After discussing her situation with a survey team, the resident was approached by management staff, making her feel guilty and insecure. The ADON confirmed asking about the interview but did not file a grievance, violating the resident's rights.
The facility's Memory Care unit was found to have several environmental deficiencies, including peeling wallpaper, missing cove moldings, cracked sheetrock, and missing pull cords on overbed lights. The shower room had a broken blind, broken lights, and tiles covered with an orange and brown film. These issues were confirmed by the Administrator.
Failure to Protect Resident From Misappropriation of Funds
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of property, specifically unauthorized transfers of money from the resident’s bank account to a CNA’s money transfer application. The facility’s ANEMMI policy defines misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent. During November 2025, the facility initiated an investigation into an allegation that funds had been transferred from Resident #1’s bank account to CNA Staff A via a mobile money transfer application. Documentation from local law enforcement, reviewed as part of the facility’s investigation, showed that between 10/6/25 and 10/31/25, transactions totaling $13,250.00 were transferred from the resident’s bank account to CNA Staff A’s money transfer account. The Business Office Manager reported that during her rounds on 11/13/25, the resident questioned why he was being charged $14,000 per month for his stay, and she informed him that the Veterans Administration paid for his stay and that the facility did not receive any funds from him. At the resident’s request, she reviewed his bank statements and observed transfers made to CNA Staff A through the money transfer application, after which the resident asked for help and requested that the police be called. The DON interviewed the resident the same day; with the resident’s permission, he reviewed the resident’s cell phone and bedside computer and confirmed that the money transfer application used for the transactions was not linked to either device. The resident stated he kept his debit card in his bedside dresser, did not give anyone permission to use it, and could only recall possibly giving the card to CNA Staff A once to purchase items, though he was unsure. Bank statements from October 2025 provided by the facility showed multiple transfers to CNA Staff A through the application, supporting the allegation of misappropriation.
Failure to Protect Resident From Involuntary Seclusion and Unconsented Transfer to Secured Unit
Penalty
Summary
The facility failed to protect a resident’s right to be free from involuntary seclusion when a cognitively intact resident was moved to a secured memory care unit and restricted in his room without clear consent or appropriate capacity determination. The resident, who had a BIMS score of 15 indicating intact cognition, reported that he had been moved "back here against my will" and that his door had been taped with a sign stating "do not enter," leaving him locked in his room for three days. Although the clinical record contained Power of Attorney paperwork authorizing his children to make health care decisions if he could not decide for himself, the record lacked a physician’s incapacity statement indicating that he was unable to make his own decisions. The Director of Regional Operations stated that the resident was moved to the secured memory care unit for the safety of female residents due to his inappropriate statements and behaviors, and asserted that the resident had confusion but made the decision himself, referencing progress notes but acknowledging there was nothing signed by the resident agreeing to the move. She also confirmed there was no physician statement of lack of capacity. A stop sign was placed across the resident’s door as an intervention to prevent others from entering his room. A psychology progress note documented that the resident made self-harm statements related to distress about being moved to a different room and that he linked these statements directly to his upset about the room change, stating he would not make such statements if moved back to his previous room. Social services confirmed that the resident had contacted the VA suicide hotline, denied intent to harm himself when interviewed, and that psychiatry had been notified. A Regional Nurse reported that an audit of advance directives and incapacity statements had been completed but did not determine whether residents actually needed incapacity statements.
Failure to Test Fire Alarm Interface Equipment
Penalty
Summary
The facility failed to test fire alarm interface equipment in accordance with NFPA 72, which could result in smoke detection devices failing to operate as designed, thereby endangering the occupants of the building. During a review of the facility's fire alarm inspection report, it was found that the report did not include complete results for the differential pressure testing of the duct smoke detectors. The report listed eight detectors in the system, but only four were reported as having been tested. Additionally, the report did not indicate that the sensitivity had been tested on any of the duct detectors. Further communication with the facility revealed that only five out of the eight detectors were tested, and there was still no indication that sensitivity tests were completed on any of the detectors. Differential pressure testing of tube-type duct detectors is a requirement of NFPA 72, and the failure to conduct these tests as required could compromise the safety of the building's occupants in the event of a fire.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. 1. What corrective actions will be accomplished for those residents found to have been affected by this deficient practice. On 04/10/25 differential pressure testing of the smoke detectors was completed. The report lists 8 detectors in the system and all 8 were tested. Sensitivity testing was completed on 04/21/2025 for the 8 duct detectors. No specific residents were affected by this alleged deficient practice. 2. How will you identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken. No residents affected by the alleged deficient practice. On 04/21/25 the Maintenance Director/designee completed an audit of smoke detectors and duct detectors to ensure documentation in place for completion of biennial smoke detector sensitivity testing and annual duct detector differential testing; no other concerns identified. 3. What measures will be put into place or what systematic changes will you make to ensure that the deficient practice does not recur. The Maintenance Director was educated on 04/17/2025 related to maintaining documentation of the Fire Alarm System in accordance with National Fire Protection Association (NFPA) 101 by the Administrator. 4. How the corrective actions will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. Random audits will be completed by the NHA/designee of smoke detectors and duct detectors to ensure documentation in place for completion of biennial smoke detector sensitivity testing and duct detector differential testing once a week for 4 weeks and then monthly for 2 months. Findings and audits will be reported to the QAPI committee for follow-up and recommendations monthly.
Improper Sanitation and Maintenance Practices in Kitchen
Penalty
Summary
The facility failed to adhere to proper sanitation and cleaning practices in the kitchen, which could potentially lead to foodborne illness. During an initial tour, it was observed that the ice machine had not been checked since August 2024, despite having a maintenance log indicating monthly checks. The Certified Dietary Manager (CDM) confirmed that no checks had been conducted since her employment began three months prior. Additionally, a Dietary Aide was observed improperly using the 3-compartment sink, failing to fully submerge dishes in the sanitizing solution as required by the instructions. The CDM could not provide documentation that the Dietary Aide had been trained on the proper use of the sink. Further observations revealed a staff member entering the kitchen without a hair restraint, citing the absence of hairnets at the entrance. The kitchen also had multiple areas of black bio growth on the ceiling and vents, which had not been cleaned since the CDM's employment began. The Maintenance Director, who had been employed for three weeks, acknowledged ongoing issues but had not addressed the bio growth or ceiling maintenance. The Administrator confirmed that kitchen ceilings should be cleaned monthly and that appliances with a monthly sign-in sheet require monthly servicing.
Infection Control Deficiencies in Blood Glucose Monitoring and Catheter Care
Penalty
Summary
The facility failed to ensure proper infection prevention practices during blood glucose monitoring for two residents. A registered nurse (RN) was observed not performing hand hygiene before donning gloves and after removing them while conducting fingerstick blood glucose tests and administering insulin to two residents. The RN also failed to clean or disinfect the glucometer before and after use, and did not perform hand hygiene after handling the glucometer and before accessing the medication cart and computer. The RN admitted to not being aware of the need for hand hygiene before and after glove use and believed that using a sanitizing wipe on the glucometer was sufficient. Additionally, the facility did not maintain urinary catheter drainage bags in a sanitary manner for two residents. Observations revealed that the drainage bags were touching the floor, which is against the facility's catheter care policy. The policy requires that the drainage spigot should not touch the floor and that the catheter should be kept at an appropriate level to promote urine flow. These deficiencies indicate a lack of adherence to infection control guidelines, potentially increasing the risk of infection for the residents involved.
Deficiency in COVID-19 Vaccination Documentation and Education
Penalty
Summary
The facility failed to ensure that residents or their representatives were given the opportunity to accept or refuse a COVID-19 vaccine, and that their medical records included documentation of education regarding the benefits and potential risks associated with the vaccine. This deficiency was identified for five residents reviewed for vaccinations. The facility's policy indicated that COVID-19 vaccines should be offered in accordance with CDC guidance, particularly emphasizing the importance for residents aged 65 and older, those at high risk for severe COVID-19, or those living in long-term care facilities. However, the facility did not have proper documentation to verify that education or acceptance/refusal discussions took place. During the survey, it was revealed that the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), who also served as the Infection Preventionist, were unaware of any forms or documentation being used to record these discussions. The ADON acknowledged that they had not been using consent forms for COVID vaccinations and that the current process did not allow for verification of resident or representative education or acceptance/refusal. The documentation provided by the Regional Nurse showed historical vaccination dates for some residents, but did not include any recent vaccination status or evidence of informed consent or refusal.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations and interviews. In several rooms, including Rooms #238, #240, and #243, there were issues such as personal items and food stored improperly, soiled linens and towels left on the floor, and unlabeled personal care items stored inappropriately. Additionally, some rooms had damaged or missing fixtures, such as frayed mattresses and missing ceiling tiles, which contributed to an unsafe and uncomfortable living environment. Residents were observed with personal care items stored in unsanitary conditions, such as urinary catheter drainage bags placed on the floor and urinals left on bedside tables. In one instance, a resident's room had a pungent smell of urine and feces, and soiled gloves and linens were left unbagged on the floor. Interviews with residents revealed dissatisfaction with the lack of proper storage and the inability to maintain personal hygiene due to broken shower facilities. The facility's shower rooms on Units 2A and 2B were found to be in disrepair, with broken and missing shower heads, leaving only two functioning showers for the entire floor. This situation had persisted for months, as confirmed by staff and residents, and was documented in the facility's maintenance logs. Residents expressed frustration over the lack of access to showers, feeling neglected and disrespected in their living environment. The facility's failure to address these maintenance issues and provide adequate personal care facilities contributed to the overall deficiency in maintaining a homelike environment.
Deficiencies in Resident Care and Assistance
Penalty
Summary
The facility failed to provide necessary care and assistance for activities of daily living to eight residents who were dependent on staff for such care. Residents reported not receiving showers for extended periods due to broken facilities and lack of staff assistance. For instance, one resident stated that the showers had been broken for several months, and they had to resort to sponge baths. Another resident mentioned that they had not received a shower in five weeks, and any bathing was provided by a family member. In addition to bathing issues, there were significant deficiencies in meal assistance. One resident, who required supervision and assistance during meals, was observed without staff assistance in the dining room. The resident's family member expressed concerns about the lack of staff during mealtimes, fearing the resident could choke. Observations confirmed that the resident did not receive necessary cueing and encouragement during meals, and there was no documentation of meal assistance for several days. The facility's documentation practices were also inadequate, as there was a lack of records indicating that residents received scheduled showers or meal assistance. Several residents' care plans and Kardexes did not include shower schedules, and staff were unaware of residents' needs. The Assistant Director of Nursing verified the absence of documentation for scheduled showers, highlighting a systemic issue in the facility's care provision and record-keeping.
Failure to Apply and Document Compression Stockings
Penalty
Summary
The facility failed to provide care in accordance with the established plan for two residents, leading to deficiencies in their treatment. Resident #6, who was admitted with chronic diastolic congestive heart failure, was observed multiple times without the prescribed compression stockings, which were ordered to manage her bilateral lower extremity edema and orthostatic hypotension. Despite the absence of these stockings, the Treatment Administration Record (TAR) was inaccurately documented by nursing staff, indicating that the stockings were applied daily. Interviews with the resident and nursing staff revealed that the stockings were never provided or applied, and documentation was completed without verification. Similarly, Resident #123, admitted with a fracture of the lower end of the right femur, was not wearing the prescribed compression sock on her right leg during observations. The Medication Administration Record (MAR) was inaccurately signed by nursing staff, indicating the sock was applied and removed as ordered, despite the resident stating it was never applied. The compression sock was found in the resident's drawer, unused, and the nursing staff admitted to signing the MAR without verifying the application of the sock. These actions demonstrate a failure to adhere to the care plans and accurately document the care provided.
Failure to Inform Resident and Guardian of Medication Discontinuation
Penalty
Summary
The facility failed to inform a resident and their guardian in advance about the discontinuation of a critical medication, Epidiolex, which was prescribed to manage the resident's epilepsy. The resident, who had intact cognition and a diagnosis of seizure disorder, was admitted from an acute care hospital with a discharge summary indicating the need for Epidiolex. Despite this, the facility stopped administering the medication on 12/29/24 without notifying the resident or the guardian beforehand. The resident experienced two seizures shortly after the medication was discontinued. The Assistant Director of Nursing (ADON) wrote a verbal order to discontinue the medication while working from home, and the physician signed the order a week later. The facility's records did not document any prior notification to the resident or the guardian about the discontinuation or the reasons behind it. The guardian discovered the discontinuation only after checking the medication list and was informed by the facility's administrator that the corporate office had instructed them not to administer the medication. This lack of communication and failure to involve the resident and guardian in care decisions led to the deficiency.
Failure to Develop Smoking Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was identified as a smoker. The resident, who was admitted with a diagnosis of Chronic Obstructive Pulmonary Disease, was evaluated for smoking and agreed to the facility's smoking policy, including the removal of the oxygen source before smoking. However, the care plan did not include any goals or interventions related to the resident's smoking habits. Interviews with the resident and staff revealed that the resident smoked outside with her sister during visits, and staff acknowledged that a smoking care plan should have been in place but was not developed.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure proper storage of medications for two residents and on one unit. Resident #107 was observed with an unsecured bottle of acetaminophen at his bedside, which he used as needed for headaches. However, there was no documentation in his clinical record indicating that the Interdisciplinary Team had evaluated his ability to safely self-administer the medication or ensure its secure storage. Licensed Practical Nurse (LPN) Staff K confirmed the lack of evaluation and the unsafe storage of the medication. Similarly, Resident #81 was found with two unsecured bottles of antacid tablets, one on his computer desk and another on the floor next to his wheelchair. There was no physician order or assessment in his clinical record to self-administer the medication. LPN Staff L confirmed the unsecured medications and the absence of necessary documentation. Additionally, on Unit 1A, a box of Ipratropium Bromide belonging to another resident was left unsecured on the nursing desk without staff presence, as confirmed by the Director of Nursing.
Failure to Support Resident's Right to Voice Grievances
Penalty
Summary
The facility failed to uphold a resident's right to voice grievances without fear of discrimination or reprisal. Resident #103, who was readmitted with diagnoses including multiple sclerosis, anxiety, and major depressive disorder, was observed in her room with a strong odor of urine and feces, indicating she had not received incontinent care since the previous night. The resident, who was bedbound and dependent on staff for toileting, expressed awareness of her condition and discomfort with the situation. Following an interview with a survey team member, Resident #103 reported that two management team staff members approached her to inquire about the interview, which made her feel guilty and insecure. The Assistant Director of Nursing confirmed asking the resident about the interview but did not file a grievance on her behalf. This interaction suggests a failure to support the resident's right to voice grievances without fear of reprisal, as required by the facility's policy.
Deficiencies in Memory Care Unit Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment in the Memory Care unit, as observed on two separate occasions. The observations included peeling wallpaper along the seams and ceiling in the Memory Care Hallway, missing cove moldings, and cracked sheetrock with holes in the walls of certain rooms. Additionally, resident rooms were missing pull cords on the overbed lights. The Memory Care shower room had a broken blind, broken lights in the bathroom and shower stall, and floor tiles covered with an orange and brown film. These deficiencies were verified by the Administrator during the survey.
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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.
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Nursing homes near Sarasota
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crescent Health And Rehabilitation Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Springs At Lake Pointe Woods | 2.6 mi | ★★★★★ | 8 | 0 |
| Aviata At Sarasota | 3.1 mi | ★★★★★ | 4 | 0 |
| Sarasota Health And Rehabilitation Center | 3.2 mi | ★★★★★ | 2 | 0 |
| Bay Village Of Sarasota | 3.3 mi | ★★★★★ | 0 | 0 |
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