Inspection Report
Complaint Investigation
Census: 64
Capacity: 107
Deficiencies: 0
Jun 10, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00457709.
Findings
No deficiencies related to the allegations were cited. Creasy Springs Health Campus was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the complaint investigation.
Complaint Details
Complaint IN00457709 - No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type: 29
Census Bed Type: 35
Census Bed Type: 43
Total Capacity: 107
Census Payor Type: 27
Census Payor Type: 22
Census Payor Type: 15
Current Census: 64
Inspection Report
Life Safety
Census: 53
Capacity: 71
Deficiencies: 0
Feb 27, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
At the Emergency Preparedness survey, Creasy Springs Health Campus was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. At the Life Safety Code survey, the facility was found in compliance with Requirements for Participation in Medicare/Medicaid and the 2012 edition of the NFPA 101 Life Safety Code.
Report Facts
Certified beds: 71
Census: 53
Inspection Report
Annual Inspection
Census: 48
Capacity: 110
Deficiencies: 12
Feb 5, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey including a State Residential Licensure Survey conducted on January 30, 31 and February 3, 4 and 5, 2025.
Findings
The facility was found to have multiple deficiencies including failure to ensure resident dignity during feeding, failure to promptly implement DNR orders, inaccurate PASARR submissions, medication administration errors, lack of physician orders for oxygen therapy, improper medication storage, incorrect diet orders, failure to wear gloves during medication administration, and failure to provide timely influenza and COVID-19 vaccinations. Corrective actions and education plans were implemented for all findings.
Severity Breakdown
SS=D: 12
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to ensure a resident was treated with respect and dignity by a staff member during meal service. | SS=D |
| Failed to promptly implement a do not resuscitate (DNR) order based on a resident's signed advance directive wishes. | SS=D |
| Failed to ensure a revised PASARR level I was submitted to reflect a resident's current diagnoses and medications. | SS=D |
| Failed to ensure medications were held according to physician's ordered parameters for unnecessary medications. | SS=D |
| Failed to ensure a physician's order was obtained for the administration of oxygen for residents requiring respiratory care. | SS=D |
| Failed to ensure an order to discontinue a duplicate antibiotic dose resulting in double dosing. | SS=D |
| Failed to ensure compromised controlled substance medications were disposed of and unopened insulin was stored properly; supplies stored under sink in medication room. | SS=D |
| Failed to accurately initiate the correct diet orders upon admission and provide lunch trays in the correct consistency. | SS=D |
| Failed to ensure staff wore gloves when touching a resident's medication. | SS=D |
| Failed to ensure the antibiotic stewardship program included a system to monitor duplicate dosing antibiotic use. | SS=D |
| Failed to provide influenza vaccination during the current influenza season when requested with a signed consent form. | SS=D |
| Failed to provide COVID-19 vaccination when requested with a signed consent form. | SS=D |
Report Facts
Census: 48
Total Capacity: 110
Deficiencies cited: 12
Audit frequency: 5
Audit duration: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Isaac Zull | Administrator | Signed the inspection report |
| Pharmacist 4 | Provided information about duplicate antibiotic orders and pharmacy procedures | |
| Assistant Director of Nursing/Infection Preventionist | Provided information on antibiotic stewardship and infection prevention | |
| Legacy Director | Described admission process for advance directives | |
| Director of Nursing | Provided policies and information on medication storage and oxygen administration | |
| Social Service Director | Discussed PASARR completion and audits | |
| Speech Therapist | Provided information on diet orders and swallowing evaluations | |
| QMA 3 | Observed not wearing gloves during medication administration | |
| LPN 5 | Described procedure for handling duplicate medication orders | |
| LPN 10 | Observed medication cart narcotic count | |
| LPN 11 | Described insulin storage procedures |
Inspection Report
Renewal
Deficiencies: 0
Feb 5, 2025
Visit Reason
The visit was a paper compliance review related to the Recertification and State Licensure survey completed on February 5, 2025.
Findings
Creasy Springs Health Campus was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 60
Capacity: 111
Deficiencies: 0
Oct 23, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00444079 at Creasy Springs Health Campus.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00444079 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 111
Census Payor Type: 60
Inspection Report
Complaint Investigation
Census: 118
Deficiencies: 0
Sep 20, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00441252 and IN00442399 at Creasy Springs Health Campus.
Findings
No deficiencies related to the allegations in complaints IN00441252 and IN00442399 were cited. The facility was found to be in compliance with relevant federal and state regulations.
Complaint Details
Complaint IN00441252 and Complaint IN00442399 were investigated with no deficiencies found related to the allegations.
Report Facts
Census Bed Type: 118
Census Payor Type: 66
SNF/NF beds: 28
SNF beds: 38
Residential beds: 52
Medicare residents: 26
Medicaid residents: 21
Other payor residents: 19
Inspection Report
Complaint Investigation
Census: 64
Capacity: 116
Deficiencies: 0
Aug 2, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00439066 at Creasy Springs Health Campus.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00439066 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type Total: 116
Census Payor Type Total: 64
Inspection Report
Re-Inspection
Census: 64
Capacity: 114
Deficiencies: 0
Feb 23, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on December 20, 2023, including a PSR to the State Residential Licensure Survey.
Findings
Creasy Springs Health Campus was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey.
Report Facts
Census SNF/NF: 29
Census SNF: 35
Census Residential: 50
Census Total: 114
Census Payor Medicare: 29
Census Payor Medicaid: 25
Census Payor Other: 10
Census Payor Total: 64
Inspection Report
Re-Inspection
Census: 59
Capacity: 71
Deficiencies: 0
Feb 22, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 01/09/24 was performed to verify compliance with prior deficiencies.
Findings
At this PSR survey, Creasy Springs Health Campus was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Report Facts
Facility capacity: 71
Census: 59
Inspection Report
Life Safety
Census: 58
Capacity: 71
Deficiencies: 1
Jan 9, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements due to failure to maintain access and working space in enclosures housing electrical apparatus in the kitchen utility room.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure access and working space was maintained in enclosures housing electrical apparatus in 1 of 1 kitchen utility rooms, with expandable tray holders stored in front of an electrical panel. | SS=E |
Report Facts
Certified beds: 71
Census: 58
Staff potentially affected: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Justin Rife | Area Executive Director | Signed the report |
| Director of Plant Operations | Interviewed during the survey regarding the deficiency |
Inspection Report
Recertification
Census: 47
Capacity: 105
Deficiencies: 10
Dec 20, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted on December 13, 14, 18, 19 and 20, 2023.
Findings
The facility was found to have multiple deficiencies including failure to invite a cognitively intact resident to care plan meetings, failure to provide preferred activities to a resident in isolation, failure to monitor weight loss and notify providers, improper feeding tube management, medication errors including insulin administration errors, inadequate dental assessments, infection control lapses including improper PPE use and catheter bag placement, and incomplete antibiotic stewardship documentation.
Severity Breakdown
SS=D: 8
SS=G: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to ensure a resident with intact cognition was invited to participate in care plan meetings. | SS=D |
| Failed to provide preferred activities to a resident in isolation for Covid-19. | SS=D |
| Failed to reweigh a resident with weight loss and notify provider. | SS=D |
| Failed to clear a clogged feeding tube using approved procedure. | SS=D |
| Failed to hold insulin according to physician orders resulting in hypoglycemia and hospitalization. | SS=G |
| Failed to accurately assess and document dental status and need for dental appointment. | SS=D |
| Failed to wear required PPE in isolation rooms and follow PPE protocol; catheter bag touching the ground. | SS=D |
| Failed to follow antibiotic stewardship program including monitoring antibiotic use. | SS=D |
| Failed to ensure service plans were signed and dated by residents or representatives. | — |
| Failed to maintain infection control practices to prevent disease transmission in memory care unit. | SS=D |
Report Facts
Survey dates: 5
Census: 47
Total licensed capacity: 105
Weight loss percentage: 6.3
Residents with Covid-19: 21
Staff with Covid-19: 11
Antibiotic stewardship review months missing: 6
Residents reviewed for service plan signatures: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Justin Rife | Executive Director | Signed report and plan of correction |
| RN 7 | Nurse who found Resident 29 unresponsive and involved in insulin administration error | |
| LPN 13 | Nurse observed not removing N95 mask after leaving isolation room | |
| Clinical Support Nurse | Provided multiple interviews regarding findings and policies | |
| Legacy Neighborhood Director | Provided interviews regarding resident care and infection control |
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 0
Oct 20, 2023
Visit Reason
This visit was conducted for the investigation of three complaints: IN00419098, IN00417266, and IN00417055.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with relevant federal and state regulations.
Complaint Details
Complaints IN00419098, IN00417266, and IN00417055 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF: 37
Census Bed Type - SNF/NF: 29
Census Bed Type - Residential: 46
Total Census: 112
Census Payor Type - Medicare: 22
Census Payor Type - Medicaid: 22
Census Payor Type - Other: 22
Total Census Payor: 66
Inspection Report
Complaint Investigation
Census: 66
Capacity: 111
Deficiencies: 0
Sep 6, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00416130.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations regarding the complaint investigation.
Complaint Details
Complaint IN00416130 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 66
Total Capacity: 111
Inspection Report
Complaint Investigation
Census: 57
Capacity: 99
Deficiencies: 0
Jun 14, 2023
Visit Reason
This visit was for the investigation of complaints IN00400505 and IN00410410.
Findings
No deficiencies related to the allegations in complaints IN00400505 and IN00410410 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00400505 - No deficiencies related to the allegations are cited. Complaint IN00410410 - No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type Total: 99
Census Payor Type Total: 57
SNF Beds: 28
SNF/NF Beds: 29
Residential Beds: 42
Medicare Residents: 18
Medicaid Residents: 18
Other Payor Residents: 21
Inspection Report
Re-Inspection
Census: 66
Capacity: 71
Deficiencies: 0
Jan 19, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 11/09/22 was performed to verify compliance with prior deficiencies.
Findings
Creasy Springs Health Campus was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered with appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 71
Census: 66
Inspection Report
Re-Inspection
Census: 63
Capacity: 103
Deficiencies: 0
Nov 10, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on October 6, 2022, including a PSR to the Investigation of Complaints IN00374336 and IN00374363 and the State Residential Licensure Survey completed on October 6, 2022.
Findings
Creasy Springs Health Campus was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the PSR to the Recertification and State Licensure Survey and Investigation of Complaints IN00374336 and IN00374363. Both complaints were corrected.
Complaint Details
Complaint IN00374336 and Complaint IN00374363 were investigated and found to be corrected.
Report Facts
Census SNF/NF: 27
Census SNF: 36
Census Residential: 40
Total Census: 63
Total Capacity: 103
Medicare Census: 28
Medicaid Census: 16
Other Payor Census: 19
Inspection Report
Life Safety
Census: 63
Capacity: 71
Deficiencies: 3
Nov 9, 2022
Visit Reason
The survey was conducted as a Life Safety Code Recertification and State Licensure inspection by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 standards.
Findings
The facility was found not in compliance with Life Safety Code requirements, including obstructions in means of egress corridors, improper installation and obstruction of portable fire extinguishers, and failure to ensure timely inspection and maintenance of fire dampers within the facility.
Severity Breakdown
SS=E: 2
SS=F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Means of egress in 1 of 5 corridors was obstructed by small drawer carts not on wheels. | SS=E |
| Portable fire extinguisher in the kitchen was obstructed by a 55-gallon trash can and not installed according to NFPA 10 standards. | SS=E |
| Fire dampers within the facility were not inspected and maintained as required; last inspection was in 2016, exceeding the 4-year requirement. | SS=F |
Report Facts
Certified beds: 71
Census: 63
Residents potentially affected: 18
Staff potentially affected: 4
Visitors potentially affected: 2
Staff potentially affected: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Justin Rife | Executive Director | Signed the report and involved in education of Director of Plant Operations |
| Director of Plant Operations | Named in findings related to means of egress obstruction, fire extinguisher obstruction, and fire damper maintenance | |
| Facilities Management Support person | Interviewed and involved in observations related to deficiencies |
Inspection Report
Annual Inspection
Census: 42
Capacity: 103
Deficiencies: 10
Oct 6, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey, including investigation of Nursing Home Complaints IN00374336 and IN00374363.
Findings
The facility was found to have multiple deficiencies including failure to complete PASARR assessments, incomplete care plans, inadequate skin condition assessments, failure to notify physicians of significant weight changes, incomplete respiratory care orders, insufficient nursing staff for medication administration, inappropriate psychotropic medication use, improper medication storage, and unsafe resident transfers.
Complaint Details
Complaint IN00374336 - Substantiated. Federal/State deficiencies related to the allegations are cited at F725. Complaint IN00374363 - Substantiated. Federal/State deficiencies related to the allegations are cited at F725.
Severity Breakdown
SS=D: 6
SS=E: 1
SS=G: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Resident 1 missing required updated PASARR with diagnosis of delirium and medication Risperdal. | SS=D |
| Residents 1, 11, 17, 19 and 20 missing documentation in comprehensive care plan to support appropriateness of services and communication. | SS=E |
| Resident 17 failed to access and document skin condition after laceration resulting in complicated infection. | SS=G |
| Resident 15 had 8.23% weight gain in 17 days without documentation of physician notification. | SS=D |
| Residents 49 and 11 had incomplete physician orders for BIPAP settings. | SS=D |
| Facility failed to ensure adequate nursing staff to administer medications within time frames. | SS=D |
| Residents 1, 17 and 20 lacked documentation of appropriate diagnosis for psychotropic medication use and missing AIMs assessments. | SS=D |
| Facility failed to label eye drops with an opened date and dispose of loose pills and compromised controlled substances properly. | SS=D |
| Resident 8 transferred from wheelchair to recliner without use of gait belt. | — |
| Resident 1's medications were not securely stored in locked drawer for self-administration. | — |
Report Facts
Survey dates: 2022-09-29 to 2022-10-06
Census Bed Type: 103
Current Census: 42
Weight gain: 8.23
Late medication administrations: 25
Sutures: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jenny McCurdy | RN, Clinical support nurse | Named as facility representative on report |
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