Federal inspection record · CMS data as of October 1, 2026
Creekstone Health And Wellness
1500 Southgate Drive, Kissimmee, FL · (407) 846-7201
- Certified beds
- 161
- Residents per day
- 129
- Ownership
- Non-Profit
- Chain
- Good Samaritan Society
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- May 20, 1987
1
How this home got 2 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Florida.
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Staffing
★★★★★−1 star
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★2 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Florida homes
Creekstone Health And Wellness carries 42 inspection points. That is fewer than 46% of Florida's 691 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Florida: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–8 pts
- 4★ 8–25 pts
- 3★ 25–46 pts
- 2★ 46–85 pts
- 1★ over 85 pts
Bars show every rated home in Florida by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
16 health citations on record since 2022. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (1)
-
G
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Everything else, by area of care
Resident Assessment and Care Planning3D
- D
Ensure each resident receives an accurate assessment.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Pharmacy Service3D
- D
Ensure medication error rates are not 5 percent or greater.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Implement 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.
Freedom from Abuse, Neglect, and Exploitation3E
- D
Respond appropriately to all alleged violations.
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Nutrition and Dietary2F
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
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.
Resident Rights2E
- D
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.
- E
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Quality of Life and Care1D
- D
Provide activities to meet all resident's needs.
Nursing and Physician Services1C
- C
Post nurse staffing information every day.
Inspection history
2025-12-11
7 health deficiencies · 5 fire-safety deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2024-02-01
4 health deficiencies · 2 fire-safety deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2022-03-24
5 health deficiencies · 4 fire-safety deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 1 h 14 min of nursing staff time a day, 16 min of it from a registered nurse.
This home
1 h 14 min
Florida average
3 h 51 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 38% of nursing staff and 50% of registered nurses left in the past year, along with 1 administrator.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$11,629 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2023-11-10 | Fine | $11,629 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine0.9 pts worse | 97.5% | 98.4% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine0.2 pts worse | 99.2% | 99.4% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury0.8 pts better | 1.7% | 2.5% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms4.7 pts better | 0.7% | 5.4% | 13.5% |
| Percentage of long-stay residents who lose too much weight1.8 pts worse | 7.3% | 5.5% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication9.5 pts better | 4.4% | 13.9% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication6.9 pts better | 1.8% | 8.7% | 15.4% |
| Percentage of long-stay residents who were physically restrainedAbout the same | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened23.2 pts worse | 31.6% | 8.4% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased26 pts worse | 34.3% | 8.3% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.1 pts worse | 0.4% | 0.3% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.6 pts better | 0.0% | 0.6% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence11.9 pts worse | 21.4% | 9.5% | 18.3% |
| Percentage of long-stay residents with pressure ulcers0.6 pts better | 3.8% | 4.4% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine7.3 pts worse | 88.3% | 95.6% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit4 pts worse | 12.9% | 8.9% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.3 pts better | 1.1% | 1.4% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine16.3 pts worse | 80.0% | 96.3% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission0.2 pts better | 25.6% | 25.8% | 23.4% |
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Who owns and runs it
22 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Cain, James | Corporate Director · Individual | 0% | 20 facilities |
| Chappel, Christopher | Contracted Managing Employee · Individual | 0% | 3 facilities |
| Dykhouse, Dana | Corporate Director · Individual | 0% | 85 facilities |
| Engbrecht, Wesley | Corporate Director · Individual | 0% | 89 facilities |
| Fluit, Joel | W-2 Managing Employee · Individual | 0% | 87 facilities |
| Gassen, William | Corporate Director · Individual | 0% | 89 facilities |
| Gassen, William | Corporate Officer · Individual | 0% | 89 facilities |
| Gulsvig, Neil | Corporate Director · Individual | 0% | 89 facilities |
| Herseth Sandlin, Stephanie | Corporate Director · Individual | 0% | 86 facilities |
| Lundeen, Mark | Corporate Director · Individual | 0% | 89 facilities |
| Middleton, Aimee | Corporate Officer · Individual | 0% | 87 facilities |
| Molbert, Lauris | Corporate Director · Individual | 0% | 89 facilities |
| Morrison, Tony | W-2 Managing Employee · Individual | 0% | 89 facilities |
| North, Andrew | Corporate Director · Individual | 0% | 89 facilities |
| Olson, Nicholas | Corporate Officer · Individual | 0% | 87 facilities |
| Rogers, Michael | Corporate Officer · Individual | 0% | 18 facilities |
| Sanford | 5% Or Greater Direct Ownership Interest · Organization | 0% | 89 facilities |
| Schema, Nathan | Corporate Officer · Individual | 0% | 87 facilities |
| Shulkin, David | Corporate Director · Individual | 0% | 85 facilities |
| Spies, Dorene | W-2 Managing Employee · Individual | 0% | 1 facilities |
| Teiken, Brent | Corporate Director · Individual | 0% | 89 facilities |
| Ventling-Herrmann, Marnie | Corporate Director · Individual | 0% | 90 facilities |
·
Fire safety
11 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke4F
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Inspect, test, and maintain automatic sprinkler systems.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- E
Inspect, test, and maintain automatic sprinkler systems.
Emergency Preparedness2F
- F
Develop and maintain an Emergency Preparedness Program (EP).
- F
Develop and maintain an Emergency Preparedness Program (EP).
Gas, Vacuum, and Electrical Systems2E
- E
Meet requirements for the installation and maintenance of electrical systems.
- E
Have power receptacles that are properly grounded.
Construction1F
- F
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Egress1F
- F
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Services1F
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
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Other homes nearby
-
Kissimmee Health And Rehabilitation Center
Kissimmee, FL · Simcha Hyman & Naftali Zanziper
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 3 h 35 min
- Fines
- $0
-
Terrace Of Kissimmee, The
Kissimmee, FL
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 53 min
- Fines
- $38,724
-
Aviata At Kissimmee Gardens
Kissimmee, FL · Aviata Health Group
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 3 h 22 min
- Fines
- $0