Creekside Health: Residents Left in Soiled Diapers - FL
Resident 100, described by staff as "such a large woman" who requires two people for care, received only bed baths instead of scheduled showers throughout the summer. Documentation showed gaps in care on multiple days in June, July and August, with no record of hygiene assistance provided on seven separate dates.
"She is dependent for everything else. She is not able to walk," said CNA Staff D, who worked with Resident 100 daily during the 7 a.m. to 3 p.m. shift. "I give her a full bed bath every day."
But the nursing assistant couldn't account for care on other shifts.
"Now I can't say anything about the other shifts because I don't know, I don't work them unless I do a double," Staff D told inspectors on August 18. "I don't know why she does not get showers, sometimes we don't have 2 people to do it. You can't shower her by yourself."
The facility's Director of Nursing acknowledged the staffing challenges during the same day's interview. "With Resident 100, because she is such a large woman she takes two people, and it is not always easy to find help right away," the DON said.
The nursing director said residents typically get changed every three to four hours, but admitted the facility had no set schedule. For Resident 100, staff "usually change her when she gets up and when she gets back to bed."
Resident 2 faced even more severe neglect. The patient, admitted in August 2024 with Alzheimer's disease, dementia and diabetes, was documented as "always incontinent of bowel and bladder and dependent for all care." Quarterly assessments noted the resident was "rarely, never understood."
Yet inspection records revealed extensive gaps in incontinent care documentation across all three shifts over three months.
During day shifts from 7 a.m. to 3 p.m., no incontinent care was recorded on 18 separate dates between June and August. Evening shifts from 3 p.m. to 11 p.m. showed seven days without documented care. Overnight shifts from 11 p.m. to 7 a.m. had the worst record, with 28 dates showing no care documentation.
The resident was scheduled for showers three times weekly during evening shifts on Mondays, Wednesdays and Fridays. Instead, records showed only sponge baths were provided, and on four occasions in June, July and August, documentation simply read "N/A" for not applicable.
CNA Staff C, who worked day shifts, told inspectors that standard practice called for changing residents "every 2-3 hours." The nursing assistant said staff "turn them at the same time because you have to roll them to change them."
The documentation gaps suggest Resident 2 may have remained in soiled conditions for entire shifts. On June 1, neither the evening nor overnight shift recorded providing incontinent care. Similar patterns appeared throughout the summer, with consecutive shifts failing to document basic hygiene assistance.
Federal regulations require nursing homes to ensure residents receive appropriate care to maintain dignity and prevent health complications from prolonged exposure to waste. Inadequate incontinence care can lead to skin breakdown, infections and other serious medical problems.
The inspection, conducted in response to a complaint, found the facility violated federal standards for resident care and services. Inspectors classified the violations as causing "minimal harm or potential for actual harm" affecting "some" residents.
Both residents' cases highlighted systemic problems with staffing and care coordination at the 120-bed facility. While staff acknowledged the challenges of providing adequate care, the documentation revealed a pattern of missed care that left vulnerable residents without basic hygiene assistance.
The facility's own policies appeared inconsistent with actual practice. Despite the DON's claim that residents get changed every three to four hours, the extensive documentation gaps suggested many shifts passed without recorded incontinent care for residents who were completely dependent on staff assistance.
For Resident 100, the inability to consistently provide two-person care meant scheduled showers were replaced with bed baths. For Resident 2, entire shifts passed with no documentation of the frequent diaper changes required for someone who was "always incontinent."
The August inspection occurred nearly a year after Resident 2's admission, suggesting the care gaps had persisted for months. Both residents remained at the facility during the inspection, continuing to depend on staff who had already demonstrated difficulty providing consistent basic care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Creekside Health and Rehabilitation Center from 2025-08-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
CREEKSIDE HEALTH AND REHABILITATION CENTER in SARASOTA, FL was cited for violations during a health inspection on August 19, 2025.
Documentation showed gaps in care on multiple days in June, July and August, with no record of hygiene assistance provided on seven separate dates.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.