Creekside Center for Rehabilitation and Nursing

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

Rule F0550. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

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

Rule F0578. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

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

Rule F0636. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

Ensure each resident receives an accurate assessment.

Rule F0641. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

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

Rule F0657. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

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

Rule F0684. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

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

Rule F0686. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

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

Rule F0689. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

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

Rule F0697. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

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

Rule F0756. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

Ensure that residents are free from significant medication errors.

Rule F0760. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

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

Rule F0812. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

Provide and implement an infection prevention and control program.

Rule F0880. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

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

Rule F0887. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

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

Rule F0919. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

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

Rule F0947. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 31, 2026.

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

Rule F0580. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Mar 31, 2026.

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

Rule F0609. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Mar 31, 2026.

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

Rule F0677. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Mar 31, 2026.

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

Rule F0689. J: immediate jeopardy to health or safety. From a complaint. Correction date, as CMS recorded it: Nov 24, 2025.

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

Rule F0689. G: actual harm. From a complaint. Correction date, as CMS recorded it: Feb 4, 2025.

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

Rule F0609. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Dec 3, 2025.

Respond appropriately to all alleged violations.

Rule F0610. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Dec 3, 2025.

Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured.

Rule F0656. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Mar 31, 2025.

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

Rule F0684. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Mar 31, 2025.

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Rule F0757. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Mar 31, 2025.

Provide and implement an infection prevention and control program.

Rule F0880. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Mar 31, 2025.

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

Rule F0550. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 7, 2024.

Reasonably accommodate the needs and preferences of each resident.

Rule F0558. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 8, 2024.

Honor the resident’s right to organize and participate in resident/family groups in the facility.

Rule F0565. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 8, 2024.

Give residents a notice of rights, rules, services and charges.

Rule F0572. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 8, 2024.

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

Rule F0578. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Nov 22, 2024.

Protect each resident from the wrongful use of the resident’s belongings or money.

Rule F0602. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 8, 2024.

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

Rule F0609. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 8, 2024.

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Rule F0623. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Nov 22, 2024.

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Rule F0625. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Nov 22, 2024.

Assess the resident when there is a significant change in condition

Rule F0637. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 8, 2024.

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Rule F0688. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 8, 2024.

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Rule F0698. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 8, 2024.

Obtain a doctor’s order to admit a resident and ensure the resident is under a doctor’s care.

Rule F0710. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 8, 2024.

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Rule F0727. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 8, 2024.

Observe each nurse aide’s job performance and give regular training.

Rule F0730. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Nov 22, 2024.

Post nurse staffing information every day.

Rule F0732. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 8, 2024.

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Rule F0740. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 8, 2024.

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Rule F0755. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 8, 2024.

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

Rule F0756. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 8, 2024.

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Rule F0757. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 8, 2024.

Ensure medication error rates are not 5 percent or greater.

Rule F0759. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 8, 2024.

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Rule F0835. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Nov 22, 2024.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Rule F0842. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 8, 2024.

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Rule F0867. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Nov 22, 2024.

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Rule F0868. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 8, 2024.

Provide and implement an infection prevention and control program.

Rule F0880. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Nov 22, 2024.

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Rule F0883. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 8, 2024.

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Rule F0941. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Nov 22, 2024.

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Rule F0943. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 8, 2024.

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Rule F0945. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 8, 2024.

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

Rule F0947. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Nov 22, 2024.

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Rule F0949. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Nov 22, 2024.

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

Rule F0684. J: immediate jeopardy to health or safety. From a complaint. Correction date, as CMS recorded it: Nov 22, 2024.

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

Rule F0677. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 8, 2024.

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

Rule F0686. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 8, 2024.

Provide enough food/fluids to maintain a resident’s health.

Rule F0692. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 8, 2024.

Provide safe and appropriate respiratory care for a resident when needed.

Rule F0695. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 8, 2024.

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

Rule F0697. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 8, 2024.

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Rule F0838. F: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Nov 22, 2024.

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Rule F0604. J: immediate jeopardy to health or safety. From a complaint. Correction date, as CMS recorded it: Nov 22, 2024.

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

Rule F0689. G: actual harm. From a complaint. Correction date, as CMS recorded it: Nov 22, 2024.

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

Rule F0580. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 8, 2024.

Respond appropriately to all alleged violations.

Rule F0610. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 8, 2024.

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Rule F0622. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Nov 22, 2024.

Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured.

Rule F0656. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 8, 2024.

Ensure services provided by the nursing facility meet professional standards of quality.

Rule F0658. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Nov 22, 2024.

Plan the resident’s discharge to meet the resident’s goals and needs.

Rule F0660. F: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Nov 22, 2024.

Ensure the resident’s doctor reviews the resident’s care, writes, signs and dates progress notes and orders, at each required visit.

Rule F0711. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 8, 2024.

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Rule F0712. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Nov 22, 2024.

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Rule F0744. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 8, 2024.