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CREEKSTONE HEALTH AND WELLNESS Inspection Report, Violations & Safety Grade (KISSIMMEE, Florida)

1500 SOUTHGATE DRIVE, KISSIMMEE, Florida 34746

Phone: 4078467201

CMS Overall:2/5

Overview & Bed Count

Certified Beds
161
Avg Residents/Day
129.3
Ownership
Non profit - Corporation
Provider Type
Medicare and Medicaid
County
Osceola
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall2/5
Health3/5
Staffing1/5
Quality3/5

Nurse Staffing Check

MetricThis FacilityFlorida AvgDifference
RN Hours per Resident per Day0.260.73-0.47
Total Nurse Hours per Resident per Day1.243.86-2.62
CMS Staffing Rating1/53.3/5-
Nursing Staff Turnover38.2%41.5%-

Health Citation History

16 health citations on record

DateCategoryDescriptionSeverity
2025-12-11Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F – Moderate Harm Potential
2025-12-11Nutrition and Dietary DeficienciesEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.E – Moderate Harm Potential
2025-12-11Resident Rights DeficienciesHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.D – Moderate Harm Potential
2025-12-11Resident Assessment and Care Planning DeficienciesEnsure each resident receives an accurate assessment.D – Moderate Harm Potential
2025-12-11Resident Assessment and Care Planning DeficienciesCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.D – Moderate Harm Potential
2025-12-11Quality of Life and Care DeficienciesProvide activities to meet all resident's needs.D – Moderate Harm Potential
2025-12-11Pharmacy Service DeficienciesEnsure medication error rates are not 5 percent or greater.D – Moderate Harm Potential
2024-02-01Freedom from Abuse, Neglect, and Exploitation DeficienciesRespond appropriately to all alleged violations.D – Moderate Harm Potential
2024-02-01Resident Assessment and Care Planning DeficienciesPASARR screening for Mental disorders or Intellectual DisabilitiesD – Moderate Harm Potential
2024-02-01Pharmacy Service DeficienciesProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.D – Moderate Harm Potential
2024-02-01Pharmacy Service DeficienciesImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.D – Moderate Harm Potential
2023-11-10Quality of Life and Care DeficienciesProvide safe, appropriate dialysis care/services for a resident who requires such services.G – Actual Harm
2022-03-24Freedom from Abuse, Neglect, and Exploitation DeficienciesTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.E – Moderate Harm Potential
2022-03-24Resident Rights DeficienciesProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.E – Moderate Harm Potential
2022-03-24Freedom from Abuse, Neglect, and Exploitation DeficienciesDevelop and implement policies and procedures to prevent abuse, neglect, and theft.D – Moderate Harm Potential
2022-03-24Nursing and Physician Services DeficienciesPost nurse staffing information every day.C – Minimal Harm Potential

Fire Safety Citation History

11 fire safety citations on record

DateCategoryDescriptionSeverity
2025-12-11Emergency Preparedness DeficienciesDevelop and maintain an Emergency Preparedness Program (EP).F – Moderate Harm Potential
2025-12-11Smoke DeficienciesHave approved installation, maintenance and testing program for fire alarm systems.F – Moderate Harm Potential
2025-12-11Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.F – Moderate Harm Potential
2025-12-11Gas, Vacuum, and Electrical Systems DeficienciesMeet requirements for the installation and maintenance of electrical systems.E – Moderate Harm Potential
2025-12-11Gas, Vacuum, and Electrical Systems DeficienciesHave power receptacles that are properly grounded.E – Moderate Harm Potential
2024-02-01Smoke DeficienciesHave approved installation, maintenance and testing program for fire alarm systems.F – Moderate Harm Potential
2024-02-01Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.E – Moderate Harm Potential
2022-03-24Emergency Preparedness DeficienciesDevelop and maintain an Emergency Preparedness Program (EP).F – Moderate Harm Potential
2022-03-24Construction DeficienciesSatisfy building requirements after a repair, renovation, modification, or change of user/occupancy.F – Moderate Harm Potential
2022-03-24Egress DeficienciesProvide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.F – Moderate Harm Potential
2022-03-24Services DeficienciesEnsure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.F – Moderate Harm Potential

Total Penalties & Fines

$11,629
Total Fine Amount (CMS)
1
Number of Fines
1
Total Penalties
DateTypeFine AmountPayment Denial
2023-11-10Fine$11,629-

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