Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 Creekview Health And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found multiple food safety and storage deficiencies, including dietary staff with visible facial hair working in the kitchen without required beard restraints, unlabeled dry cereal and meat packages lacking names and dates, and a walk-in freezer operating at a temperature that left numerous food items not frozen solid while still available for use. Additionally, a half-full carton of nutritional supplement with a past expiration date was found on a medication cart and confirmed by an LPN to be expired yet still available for resident use. No residents were reported to have signs of foodborne illness at the time of the survey.
A resident with Parkinsonism, spastic quadriplegic cerebral palsy, dementia, and moderate cognitive impairment required total assistance with eating per the care plan. During a lunch meal, a CNA was observed standing over the resident while providing feeding assistance. The DON confirmed that this manner of assistance did not promote dignity, resulting in a failure to honor the resident’s right to be treated with dignity and respect during ADL care.
The facility failed to update the PASRR for a resident whose pre-admission Level I screen listed only an anxiety disorder and psychotropic use, while the admission record and subsequent MDS and care plan documented additional mental health diagnoses including PTSD, schizoaffective disorder, and schizophrenia, along with severe cognitive impairment. Despite facility policy requiring PASRR resident review when there is a change in condition that may trigger a new evaluation, the PASRR was not resubmitted to reflect these diagnoses, as confirmed by the admissions LPN and the DON.
A resident with a Stage 4 sacral pressure ulcer, chronic Hepatitis C, and a urogenital herpes infection was placed on transmission-based precautions per physician orders due to copious wound drainage and viral hepatitis, and staff implemented these precautions with appropriate signage and PPE at the room. However, review of the comprehensive care plan showed it only addressed pressure ulcers with enhanced barrier precautions and did not include the ordered transmission-based precautions, contrary to facility policy requiring comprehensive person-centered care plans. The IP and DON both confirmed that the resident was on transmission-based precautions and that these precautions were not incorporated into the resident’s care plan.
Surveyors found that opened insulin pens and an ophthalmic solution on a medication cart were not labeled with open dates as required by manufacturer guidelines and facility policy. One resident with Type 2 DM, chronic pain syndrome, and HTN had an opened Tresiba FlexTouch pen at room temperature labeled only with a 56-day discard instruction but no open date. Another resident with Type 2 DM, COPD, and HTN had an opened NovoLog pen at room temperature labeled only with a 28-day discard instruction and no open date. A third resident with glaucoma, major depressive disorder, and HTN had an opened latanoprost eye drop bottle labeled with a 42-day discard instruction but no open date. An LPN and the DON confirmed that these medications were not stored and labeled properly.
Staff failed to follow infection control practices during wound care for a resident with COPD, dementia, hypertension, and a stage 4 pressure ulcer who was receiving hospice services and had severe cognitive impairment per MDS. Facility policy required removal of soiled dressings by pulling the glove over the dressing, discarding it, sanitizing hands, and donning new gloves before continuing care. During an observed wound treatment to the sacral area, a Wound Care Nurse donned gloves and a gown, removed a soiled dressing, and then cleansed the wound without changing gloves or sanitizing hands. In interviews, the nurse acknowledged not removing gloves or sanitizing hands after removing the soiled dressing, and the DON confirmed that infection control practices were not followed.
Food Safety, Labeling, and Storage Deficiencies in Dietary and Medication Areas
Penalty
Summary
Surveyors identified that dietary staff did not follow the facility’s sanitary standards and food safety policies. Two dietary aides with visible facial hair were observed working in the kitchen without required beard restraints, despite the policy stating that hair and beard restraints must be worn at all times in the kitchen. In the dry food storage area, a 6-quart clear plastic container holding about one-third full of dry cereal was found without any label identifying the food item and without an open date, discard date, or expiration date, contrary to the facility’s food storage policy requiring foods to be labeled and dated. In the walk-in refrigerator, 14 packages of meat were stored without labels identifying the type of meat and without expiration dates. Further observations in the walk-in freezer showed the thermometer reading 30 degrees, and multiple frozen food items, including salisbury steaks, pork chops, sweet potato puffs, cinnamon rolls, pork patties, chicken tenders, ice cream cups, pork franks, smile fry potatoes, and hamburger patties, were not frozen solid, despite the facility’s policy that foods must be stored at a temperature that keeps them frozen solid. These items were confirmed to be available for resident use and should have been discarded per the CDM. Additionally, on a medication cart, a 32-ounce carton of nutritional supplement that was half full was found with an expiration date that had already passed, and an LPN confirmed the supplement was expired and still available for resident use. The Infection Preventionist reported that no residents had shown signs of foodborne illness at the time of the survey.
Failure to Promote Dignity During Assisted Feeding
Penalty
Summary
The facility failed to ensure a resident was treated with dignity during feeding assistance. The facility’s undated Resident Rights policy stated that residents have the right to be treated with dignity and respect in a manner that promotes or enhances quality of life. Resident #19 was admitted with diagnoses including Parkinsonism, spastic quadriplegic cerebral palsy, and dementia, and a quarterly MDS assessment showed a BIMS score of 12, indicating moderate cognitive impairment. The resident’s comprehensive care plan, revised 6/30/2025, documented an ADL self-care performance deficit related to cerebral palsy and Parkinson’s disease and indicated the resident required total assistance with eating. During an observation on 9/28/2025 at 12:47 PM, CNA B was seen standing over Resident #19 while assisting with the lunch meal, and during an interview at 12:56 PM, the DON confirmed that CNA B failed to promote dignity for the resident by standing over the resident during feeding assistance. This conduct constituted a failure to honor the resident’s right to be treated with dignity and respect and to receive assistance with eating in a manner consistent with the facility’s Resident Rights policy and the resident’s assessed needs.
Failure to Update PASRR for Resident With Additional Mental Health Diagnoses
Penalty
Summary
The facility failed to resubmit a Pre-admission Screening and Resident Review (PASRR) for a resident who was admitted with additional mental health diagnoses not reflected on the original PASRR. Facility policy stated that the PASRR process applies to all admissions, particularly for individuals with serious mental illness, intellectual disability, or related conditions, and that a resident review is to be conducted when there is a change in the resident's condition that may trigger a new PASRR evaluation. The resident’s Level I PASRR screen, completed prior to admission, documented an anxiety disorder and use of Buspar 10 mg daily, but did not include diagnoses of PTSD or schizoaffective disorder. The medical record showed that upon admission the resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction, schizoaffective disorder, anxiety disorder, and PTSD. A subsequent quarterly MDS assessment documented severe cognitive impairment with a BIMS score of 5 and active diagnoses of anxiety disorder, schizophrenia, and PTSD. The comprehensive care plan further identified antidepressant use related to depression and schizoaffective disorder, antipsychotic use related to schizophrenia, risk for re-traumatization related to PTSD, and potential mood problems related to depression, anxiety, and schizoaffective disorder. During interviews, the Admissions/LPN Nurse Case Manager and the DON confirmed that a new PASRR to include PTSD and schizoaffective disorder was not submitted after the resident’s admission.
Failure to Include Transmission-Based Precautions in Resident Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan that included transmission-based precautions for one resident. Facility policy dated 12/2023 required development of a comprehensive person-centered care plan for each resident with all information necessary to properly care for them. The resident was admitted with diagnoses including a Stage 4 sacral pressure ulcer, chronic Hepatitis C, and a herpes viral infection of the urogenital system. An admission MDS showed the resident was cognitively intact and documented the presence of a pressure ulcer and viral hepatitis. Physician orders dated 9/26/2025 placed the resident on transmission-based precautions for a wound organism, and an order dated 9/27/2025 directed staff to paint lesions on the inner vulva with betadine daily. Review of the comprehensive care plan dated 7/15/2025 showed the resident was care planned for pressure ulcers with enhanced barrier precautions, but there was no care plan addressing the ordered transmission-based precautions. Observations on 9/28/2025 confirmed that transmission-based precautions were in place at the resident’s room, with appropriate signage and PPE available at the door. In an interview, the Infection Preventionist confirmed the resident was on transmission-based precautions due to copious wound drainage and a diagnosis of viral Hepatitis C. In a separate interview, the DON confirmed that the resident’s care plan had not been developed to include transmission-based precautions, despite the existing orders and implemented precautions.
Failure to Properly Label Opened Insulin Pens and Ophthalmic Drops
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were labeled in accordance with professional standards and the facility’s own Medication Labeling and Storage policy, which states that nursing staff are responsible for maintaining medication storage in a safe manner and ensuring medications are labeled accordingly. Manufacturer guidelines for Tresiba (insulin degludec) FlexTouch pens require opened pens stored at room temperature to be discarded after 56 days, NovoLog (insulin aspart) pens after 28 days, and Xalatan (latanoprost) ophthalmic solution after 6 weeks at room temperature. Residents involved included one with Type 2 diabetes, chronic pain syndrome, and hypertension; another with Type 2 diabetes, COPD, and hypertension; and a third with unspecified glaucoma, major depressive disorder, and hypertension, each with active physician orders for these medications. During an observation of a medication cart, surveyors found an opened Tresiba FlexTouch insulin pen for one resident stored at room temperature without an open date, bearing only a label instructing discard after 56 days. They also observed an opened NovoLog insulin pen for another resident at room temperature without an open date, labeled only to discard after 28 days. Additionally, an opened 2.5 mL bottle of latanoprost ophthalmic solution for a third resident was found undated, with a label to discard after 42 days. Both an LPN and the DON confirmed that these medications were not stored properly for the three residents, specifically acknowledging the lack of appropriate labeling with open dates as required.
Failure to Follow Infection Control Practices During Wound Care
Penalty
Summary
Facility staff failed to follow infection prevention and control guidelines during wound care for one resident. The facility’s wound care policy directed staff to put on exam gloves, remove the dressing, pull the glove over the dressing and discard, sanitize hands, and then put on new gloves. Resident #44 was admitted with diagnoses including COPD, dementia, and hypertension, had a physician’s order to cleanse a sacral wound with normal saline, apply calcium alginate and collagen particles, and cover with a foam dressing three times per week and as needed, and had a comprehensive care plan noting hospice services, potential for further pressure ulcer development, and a stage 4 pressure ulcer. The resident’s MDS showed a BIMS score of 00, indicating severe cognitive impairment. During an observed wound care procedure in the resident’s room, the Wound Care Nurse donned gloves and a gown, removed a soiled dressing, and then, without changing gloves or sanitizing hands, proceeded to cleanse the resident’s wounds. In subsequent interviews, the Wound Care Nurse confirmed he failed to remove gloves or sanitize his hands after removing the soiled dressing, and the DON confirmed that the nurse did not follow infection control practices during this wound care.
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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 Knoxville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nhc Healthcare, Knoxville | 0.7 mi | ★★★★★ | 0 | 0 |
| Fort Sanders Tcu | 3.1 mi | ★★★★★ | 0 | 0 |
| Nhc Healthcare, Ft Sanders | 3.1 mi | ★★★★★ | 7 | 0 |
| Beverly Park Place Health And Rehab | 3.3 mi | ★★★★★ | 0 | 0 |
| Island Home Park Health And Rehab | 3.6 mi | ★★★★★ | 3 | 0 |
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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.