Cycle 1
Health 2025-02-20 · Fire 2025-02-20
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Sarasota, FL
Creekside Health And Rehabilitation Center
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
5511 Swift Road, Sarasota, FL
(941) 921-7462
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
178
Certified beds
Average residents
132
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1984-01-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.50
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.79
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.12
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.42
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.14
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.41
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
26%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,448
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.19
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.94
Baseline 20.34% · Performance 21.00% · Measure score 0.94 · Achievement 0.94 · Improvement 0
Healthcare-associated infections
0
Baseline 8.00% · Performance 7.87% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.32
Baseline 26.89% · Performance 54.21% · Measure score 2.32 · Achievement 2.32 · Improvement 0
Adjusted total nurse staffing
1.62
Baseline 4.05 hours · Performance 3.54 hours · Measure score 1.62 · Achievement 1.62 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.08% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 229 · Observed rate 12.66% · Lower 95% interval 9.08% |
| Discharge to community | 40.77% |
50.57%
9.8 pts worse
|
Worse than the National Rate · Eligible stays 212 · Observed rate 36.32% · Lower 95% interval 35.48% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 154 · Denominator 154 |
| Falls with major injury | 1.3% |
0.77%
0.5 pts worse
|
Numerator 2 · Denominator 154 |
| Discharge self-care score | 42.31% |
53.69%
11.4 pts worse
|
Numerator 44 · Denominator 104 |
| Discharge mobility score | 46.15% |
50.94%
4.8 pts worse
|
Numerator 48 · Denominator 104 |
| Pressure ulcers or injuries, new or worsened | 3.9% |
2.29%
1.6 pts worse
|
Numerator 6 · Denominator 154 · Adjusted rate 3.34% |
| Healthcare-associated infections requiring hospitalization | 7.87% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 134 · Observed rate 8.21% · Lower 95% interval 4.88% |
| Staff COVID-19 vaccination coverage | 100% |
8.2%
91.8 pts better
|
Numerator 122 · Denominator 122 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 53.85% |
56.45%
2.6 pts worse
|
Numerator 56 · Denominator 104 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 46 · Denominator 46 |
| Transfer of health information to patient | 98.31% |
96.28%
2 pts better
|
Numerator 58 · Denominator 59 |
| Resident COVID-19 vaccinations up to date | 5.95% |
25.2%
19.2 pts worse
|
Numerator 5 · Denominator 84 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.7 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
1.2
0.9 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.3 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
97.8%
2 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.2% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
99.2%
0.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
2.6%
0.3 pts worse
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 1.6% · Q3 2.6% · Q4 5.6% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.0% |
3.7%
0.7 pts better
|
11.4%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.7% · Q4 7.9% · 4Q avg 3.0% |
| Percentage of long-stay residents who lose too much weight | 8.7% |
5.9%
2.8 pts worse
|
5.4%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 9.8% · Q3 8.2% · Q4 7.6% · 4Q avg 8.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.2% |
15.7%
11.5 pts worse
|
19.6%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.6% · Q2 29.2% · Q3 30.3% · Q4 24.7% · 4Q avg 27.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.1% |
9.8%
1.3 pts worse
|
16.7%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 12.0% · Q3 12.3% · Q4 16.0% · 4Q avg 11.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.3% |
11.7%
5.6 pts worse
|
16.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 11.9% · Q3 18.3% · Q4 28.6% · 4Q avg 17.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.0% |
9.8%
0.8 pts better
|
14.9%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 10.5% · Q3 8.9% · Q4 13.6% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.4%
0.2 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.7% |
12.5%
5.2 pts worse
|
19.8%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 15.3% · Q3 17.5% · Q4 18.9% · 4Q avg 17.7% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
5.1%
0.1 pts worse
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 6.2% · Q3 5.3% · Q4 5.2% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.9% |
94.3%
0.6 pts better
|
81.7%
13.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.8% · Q2 92.0% · Q3 95.3% · Q4 99.4% · 4Q avg 94.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.6% |
9.3%
0.7 pts better
|
12.0%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.6% · Observed 9.1% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.5%
0.3 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 1.8% · Q4 1.1% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.3% |
94.7%
7.4 pts worse
|
79.7%
7.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.3% |
26.2%
0.9 pts better
|
23.9%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.3% · Observed 25.0% · Expected 23.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-11 · Fire 2022-08-11
6 health deficiencies
Top issue: Resident Rights (2 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2021-02-11 · Fire 2021-02-11
0 health deficiencies
No concentrated health issue counts in this cycle.
8 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-02-20
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-02-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-03
F · Potential for more than minimal harm
2022-08-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-09-11
F · Potential for more than minimal harm
2022-08-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-09-11
F · Potential for more than minimal harm
2022-08-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-09-11
D · Potential for more than minimal harm
2022-08-11
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-09-11
D · Potential for more than minimal harm
2022-08-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-09-11
D · Potential for more than minimal harm
2022-08-11
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-09-11
F · Potential for more than minimal harm
2021-02-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-03-10
F · Potential for more than minimal harm
2021-02-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-03-10
F · Potential for more than minimal harm
2021-02-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-03-10
F · Potential for more than minimal harm
2021-02-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-05-05
F · Potential for more than minimal harm
2021-02-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-03-10
F · Potential for more than minimal harm
2021-02-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-03-10
E · Potential for more than minimal harm
2021-02-11
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2021-03-10
D · Potential for more than minimal harm
2021-02-11
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2021-03-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-19
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-09-18
F · Potential for more than minimal harm
2025-02-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-20
E · Potential for more than minimal harm
2025-02-20
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-03-20
E · Potential for more than minimal harm
2025-02-20
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-03-20
E · Potential for more than minimal harm
2025-02-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-20
E · Potential for more than minimal harm
2025-02-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-20
E · Potential for more than minimal harm
2025-02-20
F887 · Infection Control Deficiencies
Health
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.
Corrected 2025-03-20
D · Potential for more than minimal harm
2025-02-20
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-03-20
D · Potential for more than minimal harm
2025-02-20
F585 · Resident Rights Deficiencies
Health
Honor 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.
Corrected 2025-03-20
D · Potential for more than minimal harm
2025-02-20
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-20
D · Potential for more than minimal harm
2025-02-20
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-03-20
D · Potential for more than minimal harm
2024-09-18
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-10-18
F · Potential for more than minimal harm
2022-08-11
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-09-11
D · Potential for more than minimal harm
2022-08-11
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-09-11
D · Potential for more than minimal harm
2022-08-11
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-09-11
D · Potential for more than minimal harm
2022-08-11
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2022-09-11
Penalties and ownership
What sits behind the stars
Ownership
Creekside Rehab Holdings, LLC
5% Or Greater Direct Ownership Interest · Organization
Bp Creekside Trust
5% Or Greater Indirect Ownership Interest · Organization
Lf Creekside Trust
5% Or Greater Indirect Ownership Interest · Organization
Butler, David
Operational/Managerial Control · Individual
Johnson, Susan
Operational/Managerial Control · Individual
Richards, John
Operational/Managerial Control · Individual
Wilder, Lori
Operational/Managerial Control · Individual
Wildes, Donna
Operational/Managerial Control · Individual
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#3
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1-star overall rating with 1-star inspections with $41,885 in total fines with 16 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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