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85/100CREEKSIDE CENTER FOR REHABILITATION AND HEALING Inspection Report, Violations & Safety Grade (MADISON, Tennessee)
306 W DUE WEST AVENUE, MADISON, Tennessee 37115
Phone: 6156124499
CMS Overall:5/5
Overview & Bed Count
Certified Beds
139
Avg Residents/Day
129
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Davidson
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall5/5
Health4/5
Staffing2/5
Quality5/5
Nurse Staffing Check
| Metric | This Facility | Tennessee Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.65 | 0.60 | +0.05 |
| Total Nurse Hours per Resident per Day | 3.93 | 3.82 | +0.11 |
| CMS Staffing Rating | 2/5 | 2.5/5 | - |
| Nursing Staff Turnover | 62.6% | 48.6% | - |
Health Citation History
8 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2023-07-12 | Resident Rights Deficiencies | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | D – Moderate Harm Potential |
| 2023-07-12 | Resident Rights Deficiencies | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | D – Moderate Harm Potential |
| 2023-07-12 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D – Moderate Harm Potential |
| 2019-05-01 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2018-05-16 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | D – Moderate Harm Potential |
| 2018-05-16 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2018-05-16 | Pharmacy Service Deficiencies | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | D – Moderate Harm Potential |
| 2018-05-16 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
Fire Safety Citation History
17 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2023-07-12 | Smoke Deficiencies | Provide properly protected cooking facilities. | D – Moderate Harm Potential |
| 2023-07-12 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | D – Moderate Harm Potential |
| 2023-07-12 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | D – Moderate Harm Potential |
| 2019-05-01 | Emergency Preparedness Deficiencies | Address subsistence needs for staff and patients. | E – Moderate Harm Potential |
| 2019-05-01 | Emergency Preparedness Deficiencies | Conduct risk assessment and an All-Hazards approach. | D – Moderate Harm Potential |
| 2019-05-01 | Emergency Preparedness Deficiencies | List the names and contact information of those in the facility. | D – Moderate Harm Potential |
| 2019-05-01 | Emergency Preparedness Deficiencies | Provide emergency officials' contact information. | D – Moderate Harm Potential |
| 2019-05-01 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D – Moderate Harm Potential |
| 2019-05-01 | Smoke Deficiencies | Provide properly protected cooking facilities. | D – Moderate Harm Potential |
| 2019-05-01 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | D – Moderate Harm Potential |
| 2019-05-01 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | D – Moderate Harm Potential |
| 2019-05-01 | Services Deficiencies | Install properly constructed and protected linen or trash chutes. | D – Moderate Harm Potential |
| 2019-05-01 | Miscellaneous Deficiencies | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | D – Moderate Harm Potential |
| 2018-05-16 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D – Moderate Harm Potential |
| 2018-05-16 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | D – Moderate Harm Potential |
| 2018-05-16 | Gas, Vacuum, and Electrical Systems Deficiencies | Meet requirements for the use of electrical equipment. | D – Moderate Harm Potential |
| 2018-05-16 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | D – Moderate Harm Potential |
Total Penalties & Fines
$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties
No penalty records found.
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the MADISON area at no cost.
Find Safe, Vetted Facilities Near MADISON
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.