Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

CREEKSIDE CENTER FOR REHABILITATION AND HEALING

MADISON, TN · 139 certified beds · Last Life Safety survey July 12, 2023

CMS Certification Number 445516 · first certified January 2014

Ownership

Operated by CARERITE CENTERS · For profit - Limited Liability company

No change of ownership on CMS record since January 1, 2016, when the records begin.

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within TN

17 citations — more than 86% of the 303 certified nursing homes in TN. Compared within TN rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 3 citations; the earlier surveys in the window averaged 7. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window is open now: October 2024 to March 2027. This facility’s last Life Safety survey was July 2023. Facilities in TN are typically surveyed 15–44 months after the last one (median 33), measured over 279 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

4 of the 17 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 17 Life Safety citations above. The Physical Environment Index

F-0584 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.
F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in TN, and nationally. Surveyors differ markedly between states, so the TN figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	17
Median facility in TN	8
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
May 16, 2018	4
May 1, 2019	10
July 12, 2023	3

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0353	Inspect, test, and maintain automatic sprinkler systems.	3	2023-07-12
K-0324	Provide properly protected cooking facilities.	2	2023-07-12
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	2	2019-05-01
K-0920	Ensure proper usage of power strips and extension cords.	2	2023-07-12
K-0919	Meet requirements for the use of electrical equipment.	1	2018-05-16
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	1	2019-05-01
E-0030	List the names and contact information of those in the facility.	1	2019-05-01
E-0015	Address subsistence needs for staff and patients.	1	2019-05-01

What the citations cover

Citations by CMS category

Smoke Deficiencies 7
Emergency Preparedness Deficiencies 4
Gas, Vacuum, and Electrical Systems Deficiencies 3
Services Deficiencies 2
Other 1

Citations by CMS category
Category	Citations
Smoke Deficiencies	7
Emergency Preparedness Deficiencies	4
Gas, Vacuum, and Electrical Systems Deficiencies	3
Services Deficiencies	2
Miscellaneous Deficiencies	1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

July 12, 2023 — 3 citations

Citations issued on July 12, 2023
Tag	What the surveyor checks	Status
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (August 7, 2023)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (August 7, 2023)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (August 7, 2023)

May 1, 2019 — 10 citations

Citations issued on May 1, 2019
Tag	What the surveyor checks	Status
E-0006	Conduct risk assessment and an All-Hazards approach.	Deficient, Provider has date of correction (June 15, 2019)
E-0015	Address subsistence needs for staff and patients.	Deficient, Provider has date of correction (June 15, 2019)
E-0030	List the names and contact information of those in the facility.	Deficient, Provider has date of correction (June 15, 2019)
E-0031	Provide emergency officials' contact information.	Deficient, Provider has date of correction (June 15, 2019)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (July 3, 2019)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (June 15, 2019)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (June 15, 2019)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (May 22, 2019)
K-0541	Install properly constructed and protected linen or trash chutes.	Deficient, Provider has date of correction (July 3, 2019)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (July 3, 2019)

May 16, 2018 — 4 citations

Citations issued on May 16, 2018
Tag	What the surveyor checks	Status
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (May 28, 2018)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (May 28, 2018)
K-0919	Meet requirements for the use of electrical equipment.	Deficient, Provider has date of correction (May 28, 2018)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (May 14, 2018)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.