Above 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 Terrace Rehabilitation during CMS and state inspections, most recent first.
Improper Food Storage and Kitchen Sanitation: Surveyors observed multiple unlabeled or undated food items in the cooler, freezer, kitchen, and pantry, including opened and unsealed packages, items without use-by dates, and a chipped knife on a wall magnet. The CK also did not fully clean the thermometer between food temperature checks, and the juice machine and utensil containers had buildup and debris. Interviews and the facility policy confirmed required labeling, dating, sealing, and thermometer sanitation practices.
A resident with cerebral palsy and muscle weakness did not receive a needed customized manual wheelchair because the facility failed to submit the required specialized services request within the mandated timeframe after the IDT meeting. The resident continued to use a standard wheelchair for several months, as confirmed by staff interviews and record review.
A deficiency was identified due to the failure to maintain a clean and homelike environment for a resident. The resident's room was found with dirty walls, scuffed sheetrock, and dirty air filters, as documented with photographs.
The facility's kitchen was clean and organized, but there were discrepancies between the planned menu and meals served on two days. Residents were served chicken tacos and refried beans instead of beef ravioli and sides, and undercooked pepperoni pizza instead of cheese pizza with sides. This failure to provide meals as planned is a deficiency in meeting dietary requirements.
The facility failed to maintain proper infection control during dining services, as LVN A did not practice adequate hand hygiene while distributing food and beverages to residents. Despite having a comprehensive hand hygiene policy and sufficient supplies, LVN A did not wash or sanitize hands between resident interactions, leading to potential cross-contamination. Interviews and record reviews indicated that LVN A did not attend recent infection control training sessions, which may have contributed to the observed deficiencies.
The facility failed to maintain a sanitary environment, as evidenced by nine A/C units with filters and vents covered in dust and dirt. Observations showed obstructed grates and debris falling from filters. Interviews with staff confirmed maintenance responsibilities were not met, posing respiratory risks to residents. Maintenance records lacked documentation of routine inspections, contributing to the deficiency.
A resident with PTSD and Vascular Dementia was admitted to a facility with an inaccurate PASARR Level I screening that failed to reflect his mental illness. This error was not corrected until surveyor intervention, potentially impacting the resident's access to necessary assessments and specialized services. Facility staff interviews indicated that the PASARR assessments were expected to be accurate and timely, but the oversight was due to an error by the hospital and a lack of verification by the facility.
A resident with multiple health conditions did not have their weight recorded daily as ordered by the physician for 11 days. The facility's staff, including the restorative aide and other nursing staff, failed to ensure the weights were documented, despite the resident's need for close monitoring due to conditions like heart failure and morbid obesity. The facility's policy did not specifically address daily weights, leading to a lapse in following physician orders.
A resident reported feeling humiliated after a medication aide spoke to him rudely in front of others when he requested a meal change and water refill. Witnesses confirmed the aide's unpolite behavior, and the facility's policy on resident rights was not upheld. The incident led to the resident considering leaving the facility due to concerns about dignity and respect.
Improper Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to store food in accordance with professional standards for foodservice safety in the main kitchen. During observation of the walk-in cooler, surveyors found multiple food items that were not properly labeled or dated, including unknown food items in covered containers, scrambled eggs in a Ziplock bag, ham wrapped in plastic wrap, hotdog buns, hamburger buns, and salsa, several of which had dates but no use-by dates. An unsealed package of raw hot dogs was also observed in a clear container without a date. In the walk-in freezer, opened whole kernel corn and opened pancakes were found with dates but no use-by dates. In the kitchen and pantry, surveyors observed additional food storage concerns, including two loaves of wheat bread that were undated, bins of thickener, flour, sugar, and oatmeal that were undated, a utensil container with forks and spoons containing pieces of paper, and a knife hanging on a wall magnet with a chip in the blade. The pantry contained a clear tub of mini water bottles that was undated, along with open packages of grits and oatmeal that were not sealed. The juice machine also had buildup of old juice on it. During food temperature observations, the CK took temperatures at 11:15 AM and again at 12:15 PM, but did not clean the thermometer completely before taking the temperature of another food item. Interviews with the DM, CK, DA-A, and DA-B confirmed that food items in containers or Ziplock bags should be labeled with contents, date, and use-by date, that food should be checked regularly, that the thermometer should be wiped clean between uses, and that chipped knives should be discarded. The facility Food Storage Policy also required repackaged food to be labeled with the common name, transfer date, and discard date, and required the thermometer to be cleaned and sanitized between each product tested.
Failure to Timely Submit Specialized Services Request for Customized Wheelchair
Penalty
Summary
The facility failed to submit a complete and accurate request for nursing facility specialized services (NFSS) in the LTC Online Portal within 20 business days after the Interdisciplinary Team (IDT) meeting for a resident requiring a customized manual wheelchair. The resident, a female with diagnoses including cerebral palsy, unspecified lack of coordination, and muscle weakness, was identified as needing a customized wheelchair during an IDT meeting. Despite this, the required NFSS request was not submitted by the deadline, and the resident had not received the necessary equipment after seven months in the facility. Observations and interviews confirmed that the resident continued to use a standard wheelchair rather than the customized one recommended for her needs. Both the Administrator and the MDS Coordinator acknowledged that the request should have been submitted within the required timeframe, and that the MDS nurse was responsible for ensuring timely submission of all necessary documentation. The delay in submitting the request resulted in the resident not having access to the specialized equipment identified as necessary for her mobility and care.
Deficiency in Maintaining a Clean and Homelike Environment
Penalty
Summary
The deficiency involves the failure to maintain a safe, clean, comfortable, and homelike environment for residents. Specifically, the report highlights that a resident's room was observed with dirty walls, scuffed sheetrock, and dirty air filters. These observations were documented with photographs, indicating a lack of adequate maintenance and cleanliness in the resident's living space.
Menu Discrepancies and Unappetizing Meals
Penalty
Summary
The facility's kitchen was found to be clean and well-organized during an initial walkthrough, with all food items properly stored and dated. However, there was a significant discrepancy between the planned menu and the meals actually served to residents on two consecutive days. On January 7, 2025, the menu was supposed to include beef ravioli, lima beans, garlic toast, and cream pie, but residents were served chicken tacos, refried beans, and a cup of fruit instead. Similarly, on January 8, 2025, the menu was supposed to feature cheese pizza, tossed salad, breadstick, and cinnamon baked apples, but residents received undercooked pepperoni pizza without the breadstick or cinnamon baked apples, and a tasteless cup of fruit. This indicates a failure to provide meals that are palatable, attractive, and in accordance with the planned menu, which is a deficiency in meeting dietary requirements for residents.
Inadequate Hand Hygiene Practices During Dining Services
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN A during dining services. LVN A did not practice proper hand hygiene while distributing food and beverages to residents in the dining room. Specific instances included failing to wash or sanitize hands after handling a contaminated cup, touching a resident's wheelchair, and serving drinks and food items without proper hand hygiene. These actions were observed during a dining service session, highlighting a significant lapse in infection control practices. Interviews with facility staff, including the MS, ADON, ADM, and DON, revealed that the facility had adequate supplies of hand sanitizer and a comprehensive hand hygiene policy. The ADON and ADM emphasized the importance of hand hygiene in preventing infection spread and stated that staff are trained and expected to sanitize or wash their hands between resident interactions. Despite this, LVN A did not adhere to these protocols, as evidenced by the lack of hand hygiene between resident contacts and food service tasks. Record reviews showed that the facility had established infection prevention and control policies, including regular staff education and competency evaluations. However, LVN A did not attend recent in-service sessions on infection control and hand hygiene, as indicated by the absence of his signature on attendance records. This lack of participation in training may have contributed to the observed deficiencies in hand hygiene practices during dining services.
Facility Fails to Maintain Sanitary A/C Units
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, as evidenced by the condition of the air conditioning (A/C) units and filters. Observations revealed that all nine A/C units inspected had filters and vents covered with a thick layer of dust and dirt, with a grayish-brown coating. In some cases, the holes in the grates were completely obstructed, preventing light from passing through, and clumps of dust and debris fell to the floor when filters were lifted. This unsanitary condition was observed in various locations, including the facility conference room and multiple resident rooms. Interviews with facility staff, including the maintenance staff (M S), Director of Nursing (DON), and Administrator (ADM), confirmed that the maintenance department was responsible for the routine upkeep of the A/C units. M S, who was solely responsible for maintenance, acknowledged the poor condition of the filters and admitted that the situation did not meet their expectations. Both the DON and ADM recognized the potential risks to residents, such as respiratory issues and other illnesses, due to the unsanitary conditions of the A/C units. A review of the facility's maintenance records and policies revealed inadequacies in the documentation and execution of routine maintenance. The forms used to track monthly inspections of A/C units were incomplete, with no specific rooms listed as inspected. The facility's maintenance director's job description emphasized the importance of maintaining equipment for resident safety and comfort, yet the observed conditions indicated a failure to adhere to these responsibilities. The lack of proper maintenance and documentation contributed to the deficiency identified by the surveyors.
Inaccurate PASARR Level I Screening for Resident with PTSD
Penalty
Summary
The facility failed to ensure the accuracy of the Pre-Admission Screening and Resident Review (PASARR) Level I assessment for a resident, which did not reflect the resident's diagnosis of mental illness. The resident, who was admitted with a diagnosis of Post-Traumatic Stress Disorder (PTSD) and Vascular Dementia, had a PASARR Level I screening that incorrectly marked the absence of mental illness. This oversight was not corrected until surveyor intervention, which led to the completion of a PASARR Level II evaluation. The resident's medical records indicated that he was a male with PTSD and Vascular Dementia, requiring various levels of assistance for daily activities. Despite these diagnoses, the PASARR Level I screening failed to acknowledge the mental illness, which could have impacted the resident's access to necessary assessments and specialized services. The resident's care plan did recognize the PTSD diagnosis and included interventions related to medication management and psychological services. Interviews with facility staff revealed that the PASARR assessments were typically completed by the MDS Coordinators, with the expectation that they be accurate and timely. However, the PASARR Level I for this resident was completed incorrectly by the hospital, and the facility did not verify or correct the information until prompted by the surveyor. This lapse in procedure could have resulted in the resident not receiving the appropriate services and care tailored to his mental health needs.
Failure to Record Daily Weights as Ordered
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, the facility did not record the resident's weight daily as ordered by the physician from November 22, 2024, through December 2, 2024. This oversight was identified during a review of the resident's medical records, which showed weights recorded only on November 19, 20, and 21, 2024, with no entries for the subsequent 11 days. The resident, a male with intact cognition, had multiple health conditions including atrial fibrillation, heart failure, hypertension, cirrhosis, morbid obesity, and diabetes mellitus, which necessitated close monitoring of his weight to assess changes in fluid balance or nutritional status. Interviews with facility staff revealed a lack of clarity and accountability regarding the responsibility for recording the resident's weight. The restorative aide, who was primarily responsible for weighing residents, was not present, and other staff members did not ensure the weights were recorded. The Director of Nursing (DON) found a weight recorded on paper for November 26, 2024, but it was not entered into the electronic medical record. The facility's policy on weighing residents did not specifically address daily weights, and the expectation that physician orders be followed was reiterated by both the DON and the Administrator.
Resident Dignity and Respect Violation
Penalty
Summary
The facility failed to treat a resident with dignity and respect, as observed in an incident involving a medication aide (MA A) and a resident. The resident, who had intact cognition and was dealing with several health issues including severe protein-calorie malnutrition and mood disorder, reported feeling humiliated after an interaction with MA A. The resident was waiting at the dining room door to request a meal change and refill his water pitcher when MA A approached him. She informed him that meal changes had to be made earlier and directed him to fill his water pitcher elsewhere, speaking in a manner that the resident perceived as rude and dismissive. Witnesses to the incident, including a CNA and another MA, corroborated the resident's account to varying degrees. The CNA reported hearing MA A tell the resident to read her name tag instead of providing her name, which he found to be unpolite and unhelpful. Another MA noted that MA A could be stubborn and sometimes argumentative with residents. The Assistant Director of Nursing (ADON) confirmed that there was no policy requiring meal changes to be made by a specific time and that residents could collect water from any hall, contradicting MA A's statements to the resident. The facility's policy on resident rights emphasizes the importance of treating residents with dignity and respect, which was not upheld in this instance. The incident led to the resident feeling upset and considering leaving the facility due to concerns about being treated with dignity and respect. The facility initiated an investigation, and MA A was suspended pending its outcome. The ADON and Administrator reiterated the facility's commitment to ensuring all staff treat residents with dignity and respect.
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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 Belton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Belton | 2.4 mi | ★★★★★ | 16 | 1 |
| Morada Temple | 6.7 mi | ★★★★★ | 5 | 0 |
| Avir At Temple West | 6.8 mi | ★★★★★ | 1 | 0 |
| Avir At Temple East | 7 mi | ★★★★★ | 3 | 0 |
| Avir At Weston | 7 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.