Belton, TX

Creekside Terrace Rehabilitation

4-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

1555 Powell Avenue, Belton, TX

(254) 831-6200

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

126

Certified beds

Average residents

102

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Fundamental Healthcare

Operator or chain grouping

Approved since

1984-10-25

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.47

Registered nurse staffing

LPN hours / resident day

0.62

Licensed practical nurse staffing

Aide hours / resident day

2.17

Nurse aide staffing

Weekend hours

2.93

Weekend nurse staffing

RN turnover

29%

Annual RN turnover

Total nurse turnover

52%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 1.7
2.1
0.4 pts better
1.9
0.2 pts better
Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days 0.5
2.1
1.6 pts better
1.8
1.3 pts better
Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 98.7%
97.1%
1.6 pts better
93.4%
5.3 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 95.6%
97.9%
2.3 pts worse
95.5%
0.1 pts better
Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury 2.9%
3.3%
0.4 pts better
3.3%
0.4 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms 0.0%
2.7%
2.7 pts better
11.4%
11.4 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight 3.5%
3.3%
0.2 pts worse
5.4%
1.9 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication 22.2%
18.9%
3.3 pts worse
19.6%
2.6 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication 9.5%
10.8%
1.3 pts better
16.7%
7.2 pts better
Long Stay · 2024Q4-2025Q3
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
Percentage of long-stay residents whose ability to walk independently worsened 17.0%
15.4%
1.6 pts worse
16.3%
0.7 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased 15.8%
16.1%
0.3 pts better
14.9%
0.9 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.3%
0.5%
0.2 pts better
1.0%
0.7 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection 1.3%
0.8%
0.5 pts worse
1.7%
0.4 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 5.3%
15.0%
9.7 pts better
19.8%
14.5 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers 2.3%
4.2%
1.9 pts better
5.1%
2.8 pts better
Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 87.7%
89.7%
2 pts worse
81.7%
6 pts better
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit 10.1%
12.0%
1.9 pts better
12.0%
1.9 pts better
Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication 1.1%
1.5%
0.4 pts better
1.6%
0.5 pts better
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 91.0%
88.0%
3 pts better
79.7%
11.3 pts better
Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission 22.9%
25.9%
3 pts better
23.9%
1 pts better
Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-01-09 · Fire 2025-01-09

4 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 2 Health 2023-11-30 · Fire 2023-11-30

10 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 3 Health 2022-09-29 · Fire 2022-09-29

1 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)

3 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-01-09

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-02-14

D · Potential for more than minimal harm 2023-11-30

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2023-12-01

F · Potential for more than minimal harm 2022-09-29

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2022-11-17

F · Potential for more than minimal harm 2022-09-29

K352 · Smoke Deficiencies

Fire Safety

Properly install and monitor supervisory attachments on automatic sprinkler systems.

Corrected 2022-11-17

E · Potential for more than minimal harm 2022-09-29

K344 · Smoke Deficiencies

Fire Safety

Have an alternate power supply for its alarm system.

Corrected 2022-11-17

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-12-12

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2025-12-19

E · Potential for more than minimal harm 2025-01-09

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-02-12

E · Potential for more than minimal harm 2025-01-09

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2025-02-12

D · Potential for more than minimal harm 2025-01-09

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2025-02-12

D · Potential for more than minimal harm 2024-12-04

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-12-05

D · Potential for more than minimal harm 2024-08-07

F550 · Resident Rights Deficiencies

Health

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

Corrected 2024-08-11

F · Potential for more than minimal harm 2023-11-30

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 2023-12-08

E · Potential for more than minimal harm 2023-11-30

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 2023-12-08

E · Potential for more than minimal harm 2023-11-30

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2023-12-08

E · Potential for more than minimal harm 2023-11-30

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 2023-12-08

E · Potential for more than minimal harm 2023-11-30

F803 · Nutrition and Dietary Deficiencies

Health

Ensure 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.

Corrected 2023-12-08

D · Potential for more than minimal harm 2023-11-30

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-12-08

D · Potential for more than minimal harm 2023-11-30

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2023-12-08

D · Potential for more than minimal harm 2023-11-30

F919 · Environmental Deficiencies

Health

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

Corrected 2023-12-08

D · Potential for more than minimal harm 2023-11-21

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2023-11-22

Penalties and ownership

What sits behind the stars

Ownership

South Limestone Hospital District

5% Or Greater Direct Ownership Interest · Organization

100% 24 facilities 2017-04-01
Bell, Wendy

Operational/Managerial Control · Individual

0% 1 facilities 2019-06-12
Crestview Manor Nursing And Rehabilitation Center LLC

Operational/Managerial Control · Organization

0% 1 facilities 2017-04-01
Price, Larry

Corporate Director · Individual

0% 25 facilities 2017-04-01

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