Inspection Reports for Creekside Health and Rehabilitation Center
3114 EAST 46TH STREET, INDIANAPOLIS, IN, 46205
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 16, 2025, found the facility in compliance with no deficiencies cited during the paper review of two complaint investigations. Earlier inspections showed a pattern of deficiencies primarily related to care planning, communication with residents’ representatives, and timely notification of medication changes and hospital transfers. Prior reports also noted issues with resident dignity, assistance with activities of daily living, and coordination of specialized care such as dialysis and mental health services. Complaint investigations were mostly unsubstantiated, with substantiated complaints generally involving care coordination and documentation. The facility appears to be improving over time, with recent inspections showing corrections of earlier deficiencies and no enforcement actions or fines listed in the available reports.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
162% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 16, 2025
Visit Reason
Paper compliance review to the Investigation of Complaints IN00459914 and IN00459359 completed on May 28, 2025.
Findings
The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the investigations for the two complaints. Both complaints were corrected.
Complaint Details
Complaint IN00459914 and Complaint IN00459359 were investigated and found corrected.
Report Facts
Complaint investigation date: May 28, 2025
Inspection Report
Complaint Investigation
Census: 109
Capacity: 109
Deficiencies: 0
Jun 9, 2025
Visit Reason
This visit was for the investigation of Complaint IN00460899.
Findings
No deficiencies related to the allegations in Complaint IN00460899 were cited. Creekside Health and Rehabilitation Center was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00460899 found no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 109
Total Capacity: 109
Census Payor Type Medicare: 12
Census Payor Type Medicaid: 94
Census Payor Type Other: 3
Inspection Report
Complaint Investigation
Census: 108
Capacity: 108
Deficiencies: 2
May 27, 2025
Visit Reason
This visit was for the investigation of complaints IN00459914, IN00459359, and IN00456664 at Creekside Health and Rehabilitation Center.
Findings
The facility failed to timely notify a resident's representative of medication changes for one resident and failed to document the reason for transferring another resident to a hospital and ensure communication to the receiving facility. One complaint had no deficiencies cited.
Complaint Details
Complaint IN00459914 had deficiencies cited related to notification of medication changes (F628). Complaint IN00459359 had deficiencies cited related to discharge process (F580). Complaint IN00456664 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to timely notify a resident's representative of a medication change for 1 of 3 residents reviewed for changes of condition (Resident C). | SS=D |
| Failed to document the reason for transferring a resident to a local hospital and ensure communication to the receiving health facility for 1 of 3 residents reviewed for discharge rights (Resident B). | SS=D |
Report Facts
Census: 108
Total Capacity: 108
Medicare Census: 13
Medicaid Census: 93
Other Payor Census: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stacia Dawson | Executive Director | Signed report and interviewed regarding notification policies |
| LPN 4 | Licensed Practical Nurse | Interviewed regarding notification of medication changes for Resident C |
| Director of Nursing | Director of Nursing | Interviewed regarding notification policies and Resident B transfer |
| RN 3 | Registered Nurse | Instructed to send Resident B to ER and interviewed about transfer |
| LPN 2 | Licensed Practical Nurse | Cared for Resident B and interviewed about condition on 5/6/25 |
| Licensed Practical Nurse 5 | Licensed Practical Nurse | Interviewed regarding SBAR form completion for hospital transfers |
| Family Member 10 | Interviewed regarding Resident B's discharge and outstanding balance | |
| Social Services Director | Social Services Director | Interviewed regarding hospice referral and Resident B's discharge |
| Business Office Manager | Business Office Manager | Interviewed regarding outstanding balance and discharge of Resident B |
| Executive Director | Executive Director | Interviewed regarding facility's handling of Resident B's discharge and billing |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 1, 2025
Visit Reason
The visit was a paper compliance review related to the Investigation of Complaint IN00454080 completed on March 12, 2025.
Findings
Creekside Health and Rehabilitation Center 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 of the complaint investigation.
Complaint Details
Complaint IN00454080 was investigated and found to be corrected.
Inspection Report
Complaint Investigation
Census: 106
Capacity: 106
Deficiencies: 2
Mar 12, 2025
Visit Reason
This visit was for the investigation of complaints IN00454080 and IN00454941. Complaint IN00454080 resulted in federal/state deficiencies cited, while Complaint IN00454941 had no deficiencies related to the allegations.
Findings
The facility failed to ensure that 1 of 3 residents reviewed for pressure ulcers (Resident D) had both a baseline care plan and a comprehensive care plan developed and implemented within 48 hours of admission. The facility acknowledged the issue and initiated corrective actions including staff education and audits to ensure compliance.
Complaint Details
Complaint IN00454080 was substantiated with federal/state deficiencies cited at F655 and F656. Complaint IN00454941 was not substantiated with no deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 3 residents reviewed for pressure ulcers had a baseline care plan developed and implemented within 48 hours of admission. | SS=D |
| Failed to ensure 1 of 3 residents reviewed for pressure ulcers had a comprehensive care plan developed and implemented. | SS=D |
Report Facts
Census: 106
Total Capacity: 106
Medicare Census: 19
Medicaid Census: 82
Other Payor Census: 5
Number of residents reviewed for pressure ulcers: 3
Number of nursing staff attending in-service on 1-14-25: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LaDonna Lewis-Ogundeji | RN, Director of Nursing | Named in relation to care plan deficiencies and corrective action |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 116
Deficiencies: 0
Feb 10, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00451990, IN00451648, and IN00452335, in conjunction with a Post Survey Revisit to the Recertification and State Licensure Survey and the Investigation of Complaint IN00446265 completed on 2025-01-15.
Findings
No deficiencies related to the allegations were cited for complaints IN00451990, IN00451648, and IN00452335. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regards to the investigations.
Complaint Details
Complaints IN00451990, IN00451648, and IN00452335 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 116
Total Capacity: 116
Census Payor Type Medicare: 19
Census Payor Type Medicaid: 91
Census Payor Type Other: 6
Inspection Report
Re-Inspection
Census: 116
Capacity: 116
Deficiencies: 0
Feb 10, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey and the Investigation of Complaint IN00446265 completed on 2025-01-15. It was also conducted in conjunction with the Investigation of Complaints IN00451990, IN00451648, and IN00452335.
Findings
Creekside Health and Rehabilitation Center 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 and the Investigation of Complaint IN00446265. Complaint IN00446265 was corrected.
Complaint Details
Complaint IN00446265 was corrected. The visit was also in conjunction with investigations of Complaints IN00451990, IN00451648, and IN00452335.
Report Facts
Census SNF/NF beds: 116
Total census: 116
Medicare census: 19
Medicaid census: 91
Other payor census: 6
Inspection Report
Life Safety
Census: 111
Capacity: 120
Deficiencies: 0
Feb 4, 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).
Findings
The facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers. The facility is fully sprinklered except for a single detached storage garage, and has a fire alarm system with smoke detection in corridors and resident sleeping rooms.
Report Facts
Certified beds: 120
Census: 111
Inspection Report
Annual Inspection
Census: 109
Capacity: 109
Deficiencies: 5
Jan 15, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00446265.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, failure to conduct timely care plan meetings, inadequate assistance with activities of daily living, failure to provide adequate supervision and assistance during transfers resulting in falls and injuries, and failure to conduct pre and post dialysis assessments for a resident receiving dialysis.
Complaint Details
Complaint IN00446265 was investigated during this visit, with federal/state deficiencies related to the allegations cited at F677.
Severity Breakdown
SS=E: 1
SS=D: 3
SS=G: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure residents were treated with dignity and respect for 5 of 6 residents reviewed. | SS=E |
| Failed to ensure care plan meetings were conducted quarterly for 2 of 2 residents reviewed. | SS=D |
| Failed to provide routine oral care and appropriate incontinence care timely to 1 of 5 residents reviewed for ADL care. | SS=D |
| Failed to provide adequate assistance of two staff members for bed mobility during perineal care and ensure transfer from wheelchair to toilet was performed according to plan of care, resulting in a fall and fracture. | SS=G |
| Failed to ensure pre and post dialysis assessments were conducted for a resident receiving dialysis. | SS=D |
Report Facts
Survey dates: 6
Census: 109
Medicare census: 16
Medicaid census: 89
Other payor census: 4
Residents reviewed for dignity: 6
Residents with dignity deficiency: 5
Residents reviewed for care plan meetings: 2
Residents reviewed for ADL care: 5
Residents reviewed for accidents: 4
Residents reviewed for dialysis: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stacia Dawson | Executive Director | Signed the report and provided facility policy |
| CNA 1 | Involved in fall incident with Resident 60 during transfer | |
| CNA 2 | Observed providing incontinent care to Resident B | |
| LPN 4 | Licensed Practical Nurse | Assisted with incontinent care and assessed skin damage on Resident B |
| Director of Nursing | Director of Nursing | Provided interviews and facility policies, and described staff training and corrective actions |
| Social Service Director | Social Service Director | Provided interview regarding care plan meetings |
| CNA 3 | Provided interview about resident care routines |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 107
Deficiencies: 0
Sep 30, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00443705.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00443705 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 107
Total Capacity: 107
Medicare Census: 15
Medicaid Census: 88
Other Payor Census: 4
Inspection Report
Complaint Investigation
Census: 109
Capacity: 109
Deficiencies: 0
Sep 12, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00442789.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaint IN00442789 found no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 109
Census Payor Type Medicare: 16
Census Payor Type Medicaid: 90
Census Payor Type Other: 3
Inspection Report
Complaint Investigation
Census: 105
Capacity: 105
Deficiencies: 0
Sep 4, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00441450.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00441450 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 11
Medicaid census: 90
Other payor census: 4
Inspection Report
Complaint Investigation
Census: 108
Capacity: 108
Deficiencies: 0
Aug 12, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00439557.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00439557 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 108
Total Capacity: 108
Medicare Residents: 17
Medicaid Residents: 88
Other Payor Residents: 3
Inspection Report
Complaint Investigation
Census: 112
Capacity: 112
Deficiencies: 0
Feb 10, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00427234.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Investigation of Complaint IN00427234 with no deficiencies related to the allegations cited.
Report Facts
Census SNF/NF: 112
Total Capacity: 112
Census Payor Type Medicare: 10
Census Payor Type Medicaid: 89
Census Payor Type Other: 13
Inspection Report
Complaint Investigation
Census: 106
Capacity: 106
Deficiencies: 0
Jan 23, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00426497 and IN00426536.
Findings
No deficiencies related to the allegations in complaints IN00426497 and IN00426536 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaints IN00426497 and IN00426536 found no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 106
Total Capacity: 106
Census Payor Type Medicare: 7
Census Payor Type Medicaid: 90
Census Payor Type Other: 9
Inspection Report
Re-Inspection
Census: 106
Capacity: 120
Deficiencies: 0
Jan 17, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 12/15/23 was performed to verify compliance with fire safety and licensure requirements.
Findings
Creekside Health and Rehabilitation Center was found in compliance with the Requirements for Participation Medicare/Medicaid, Life Safety from Fire, and the 2012 Edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered except for a detached storage garage and had appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 120
Census: 106
Inspection Report
Renewal
Deficiencies: 0
Jan 11, 2024
Visit Reason
The visit was conducted for paper compliance related to the Recertification, State Licensure, and Investigation of Complaints IN00421422 and IN00411851.
Findings
Creekside Health and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance to the Recertification, State Licensure, and Complaints survey.
Inspection Report
Life Safety
Census: 112
Capacity: 120
Deficiencies: 1
Dec 15, 2023
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. However, during the Life Safety Code survey, the facility was found not in compliance due to the oxygen transfilling rooms having vinyl tile flooring instead of the required concrete or ceramic flooring, which could affect 15 residents in one smoke compartment.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 2 oxygen transfilling rooms had concrete or ceramic flooring as required by NFPA 99, Health Care Facilities Code, 2012 edition, Section 11.5.2.3.1 (2). | SS=E |
Report Facts
Certified beds: 120
Census: 112
Residents potentially affected: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding oxygen transfilling room flooring | |
| Assistant Administrator | Present at exit conference reviewing findings |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 104
Deficiencies: 2
Dec 5, 2023
Visit Reason
The visit was conducted for the investigation of Complaint IN00423107, in conjunction with a Recertification and State Licensure Survey, and investigations of Complaints IN00421422 and IN00411851.
Findings
Complaint IN00423107 had no deficiencies related to the allegations. Complaints IN00421422 and IN00411851 had federal/state deficiencies cited at F565, F550, and F684. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding Complaint IN00423107.
Complaint Details
Complaint IN00423107 was investigated with no deficiencies related to the allegations. Complaints IN00421422 and IN00411851 had deficiencies cited at F565, F550, and F684.
Deficiencies (2)
| Description |
|---|
| Federal/State deficiencies related to Complaint IN00421422 cited at F565. |
| Federal/State deficiencies related to Complaint IN00411851 cited at F550 and F684. |
Report Facts
Census: 104
Total Capacity: 104
Medicare Census: 1
Medicaid Census: 88
Other Payor Census: 15
Inspection Report
Annual Inspection
Census: 104
Capacity: 104
Deficiencies: 8
Dec 5, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey including investigations of three complaints (IN00421422, IN00411851, IN00423107).
Findings
The facility was found deficient in multiple areas including resident rights and dignity, resident council grievance follow-up, comprehensive care plan development and revision, medication administration timeliness, behavior documentation, pain management, hospice coordination, neurochecks after falls, accident prevention interventions, dialysis care, and medication storage and labeling.
Complaint Details
Complaints IN00421422 and IN00411851 were substantiated with federal/state deficiencies cited. Complaint IN00423107 had no deficiencies related to the allegations.
Severity Breakdown
SS=E: 2
SS=D: 6
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure residents' respect and dignity was maintained; staff were disrespectful and residents were not supported in exercising their rights to vote. | SS=E |
| Failed to follow up with resolutions to grievances reported in resident council meetings. | SS=E |
| Failed to develop and implement a comprehensive care plan addressing a resident's seizure diagnosis. | SS=D |
| Failed to ensure care plan meetings were completed quarterly and after significant changes for some residents; failed to include non-pharmacological pain interventions and re-evaluation of pain management effectiveness. | SS=D |
| Failed to administer a resident's morning medications timely; failed to adequately document behaviors per policy; failed to manage pain per policy; failed to coordinate hospice care and perform neurochecks after an unwitnessed fall. | SS=D |
| Failed to timely implement fall interventions, update care plans with safety interventions, and implement safety interventions to prevent accidents. | SS=D |
| Failed to assess dialysis fistula as ordered and complete post dialysis assessments timely. | SS=D |
| Failed to ensure medications stored in medication carts were not expired or without current orders and failed to ensure blood collection tubes were not expired. | SS=D |
Report Facts
Census: 104
Total Capacity: 104
Deficiencies cited: 8
Residents reviewed for dignity: 104
Residents reviewed for activities: 23
Residents reviewed for unnecessary medications: 5
Residents reviewed for hospice: 1
Residents reviewed for accidents: 3
Residents reviewed for dialysis: 1
Medication carts reviewed: 8
Medication rooms reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stacia Dawson | Executive Director | Signed report and involved in interviews |
| Van Driver 14 | Involved in resident transportation incidents | |
| Resident Council President | Interviewed regarding resident council grievances and voting issues | |
| Assistant Director of Nursing | ADON | Involved in medication administration and fall incident follow-up |
| Nurse Consultant | NC | Reviewed care plans and policies |
| Social Services Director | SSD | Involved in behavior documentation and care plan meetings |
| Licensed Practical Nurse 3 | LPN | Interviewed about dialysis and medication administration |
| Licensed Practical Nurse 10 | LPN | Interviewed about medication storage and expired medications |
| Physical Therapist 12 | PT | Interviewed about fall incidents and wheelchair safety |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 110
Deficiencies: 0
Jun 21, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00408059 and IN00410633.
Findings
No deficiencies related to the allegations in complaints IN00408059 and IN00410633 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaints IN00408059 and IN00410633 found no deficiencies related to the allegations.
Report Facts
Census Bed Type: 110
Census Payor Type - Medicare: 14
Census Payor Type - Medicaid: 94
Census Payor Type - Other: 2
Inspection Report
Complaint Investigation
Census: 113
Capacity: 113
Deficiencies: 0
Apr 25, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00404385, IN00404423, IN00405747, and IN00406150 at Creekside Health and Rehabilitation Center.
Findings
No deficiencies related to the allegations in complaints IN00404385, IN00404423, IN00405747, and IN00406150 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding these complaints.
Complaint Details
Complaints IN00404385, IN00404423, IN00405747, and IN00406150 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 113
Census Payor Type Medicare: 7
Census Payor Type Medicaid: 95
Census Payor Type Other: 11
Inspection Report
Complaint Investigation
Census: 110
Capacity: 110
Deficiencies: 2
Mar 14, 2023
Visit Reason
This visit was for the investigations of Complaints IN00402786, IN00388819, and IN00400626, including a COVID-19 Focused Infection Control Survey.
Findings
The facility failed to coordinate mental health services for 1 of 3 residents reviewed and ensure timely dental services for 2 of 3 residents reviewed. Deficiencies related to complaint IN00400626 were cited at F745, while no deficiencies were found for the other complaints.
Complaint Details
Complaint IN00402786 and IN00388819 had no deficiencies related to the allegations. Complaint IN00400626 had federal/state deficiencies cited at F745 related to failure in coordinating mental health and dental services.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to coordinate mental health services between facility providers for 1 of 3 residents reviewed for mental health services. | SS=D |
| Failure to ensure residents received recommended dental services timely for 2 of 3 residents reviewed for dental services (Resident B and Resident D). | SS=D |
Report Facts
Census: 110
Total Capacity: 110
Medicare Census: 9
Medicaid Census: 86
Other Payor Census: 15
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 14, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00400626 and a COVID-19 Focused Infection Control Survey.
Findings
Creekside Health and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation and COVID-19 focused infection control survey.
Complaint Details
Investigation of Complaint IN00400626; facility found in compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 5, 2022
Visit Reason
This document is a paper compliance review related to the Post Survey Revisit (PSR) for the Recertification, State Licensure, and Complaint surveys completed previously on September 20, 2022, and August 9, 2022.
Findings
Creekside Health and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the Paper Compliance to the PSR for the Recertification, State Licensure, and Complaint surveys.
Inspection Report
Re-Inspection
Census: 112
Capacity: 112
Deficiencies: 1
Sep 19, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 8/9/2022, including a PSR to the Investigation of Complaint IN00386617 completed on 8/9/2022.
Findings
The facility failed to follow through with a resident's dental referral for 1 of 3 residents reviewed (Resident 41), resulting in delayed dental care and lack of communication with outside dental providers. The facility had not obtained necessary dental notes or referrals and had no scheduled follow-up appointment for the resident until after the survey. The facility had not implemented a systemic plan of correction to prevent recurrence.
Complaint Details
Complaint IN00386617 was investigated and corrected as part of this revisit.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to follow through with a resident's dental referral, resulting in delayed dental care and lack of communication with dental providers. | SS=D |
Report Facts
Census: 112
Total Capacity: 112
Medicare residents: 7
Medicaid residents: 92
Other payor residents: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Provided copy of dental referral and discussed referral process | |
| Unit Manager 2 | Interviewed regarding follow-up on dental referral | |
| Case Manager | Observed resident's oral cavity and discussed dental issues | |
| Registered Nurse 15 | Observed resident's oral cavity and discussed dental issues | |
| Clinical Coordinator from local hospital's School of Dentistry | Interviewed regarding appointment scheduling and referral requirements |
Inspection Report
Life Safety
Census: 113
Capacity: 120
Deficiencies: 3
Sep 19, 2022
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. However, the Life Safety Code survey identified deficiencies including propped open self-closing doors in the kitchen dry storage and a resident room corridor door, and the use of a multiplug adapter as a substitute for fixed wiring in a resident room.
Severity Breakdown
SS=D: 1
SS=E: 1
SS=B: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure the kitchen dry storage door to a hazardous area enclosure was self-closing and kept closed; door was held open by wedges. | SS=D |
| Failed to ensure a corridor door to resident room 229 was provided with a means suitable for keeping the door closed and was propped open with a dumbbell weight. | SS=E |
| Failed to ensure multiplug adapters were not used as a substitute for fixed wiring; a multiplug adapter was found powering devices in resident room 223. | SS=B |
Report Facts
Certified beds: 120
Census: 113
Residents potentially affected: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Plant Operations | Interviewed and involved in observations related to door and electrical deficiencies | |
| Administrator | Informed of findings at time of exit |
Inspection Report
Life Safety
Deficiencies: 0
Sep 19, 2022
Visit Reason
The visit was a Life Safety Code Recertification and State Licensure Survey conducted to assess compliance with fire safety and health care occupancy regulations.
Findings
Creekside Health and Rehabilitation Center was found in compliance with Medicare/Medicaid participation requirements, the Life Safety Code, and related state regulations.
Inspection Report
Annual Inspection
Census: 103
Capacity: 103
Deficiencies: 18
Aug 9, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey. This visit included the Investigation of Complaint IN00386617.
Findings
The facility was cited for multiple deficiencies including failure to ensure clinically appropriate self-administration of medications, inadequate grievance investigations and resolutions, failure to timely report and investigate abuse allegations, inaccurate MDS assessments, incomplete care plans, failure to provide personal hygiene assistance, lack of ongoing activities for cognitively impaired residents, failure to ensure activities program was directed by a qualified professional, failure to notify medical providers of abnormal blood pressure and administer medications as ordered, failure to ensure timely dental care, incomplete dialysis assessments, failure to monitor behaviors and revise behavioral care plans, failure to maintain lab reports in clinical records, and failure to conduct timely COVID-19 outbreak testing.
Complaint Details
Complaint IN00386617 was substantiated. Federal/State deficiencies related to the allegations were cited at F0680.
Severity Breakdown
SS=D: 13
SS=E: 3
SS=G: 1
SS=F: 1
Deficiencies (18)
| Description | Severity |
|---|---|
| Failure to ensure clinically appropriate self-administration of medications for residents. | SS=D |
| Failure to thoroughly investigate grievances and inform residents of grievance results. | SS=D |
| Failure to timely report an allegation of abuse to the state agency. | SS=D |
| Failure to timely provide notice of facility-initiated transfer or discharge to the Long-Term Care Ombudsman. | SS=D |
| Inaccurate MDS assessments for dental services and PASRR. | SS=D |
| Failure to provide resident and/or representative with a summary of the baseline care plan. | SS=E |
| Failure to revise care plans to reflect current needs and failure to conduct care plan meetings with resident/representative participation. | SS=E |
| Failure to provide personal hygiene assistance including shaving. | SS=D |
| Failure to provide ongoing activity program for cognitively impaired residents. | SS=E |
| Activities program not directed by a qualified professional. | SS=D |
| Failure to notify medical provider of abnormal blood pressure readings and failure to administer medications as ordered. | SS=D |
| Failure to follow physician's orders for wound treatment and timely treatment of infected toe wound. | SS=D |
| Failure to ensure hearing consultation was arranged for resident with hearing loss. | SS=D |
| Failure to conduct assessments for dialysis fistula as ordered and delay in ordering fistulagram. | SS=D |
| Failure to implement behavior management policy and revise behavioral care plans for residents with behaviors. | SS=G |
| Failure to maintain laboratory reports in the clinical record. | SS=D |
| Failure to timely address dental conditions and schedule dental appointments. | SS=D |
| Failure to conduct timely COVID-19 outbreak testing of staff with symptoms, increasing exposure risk. | SS=F |
Report Facts
Census: 103
Total Capacity: 103
Deficiencies cited: 18
Blood sugar readings out of parameter: 26
Blood pressure readings out of parameter: 12
Weight loss percentage: 13.6
Behavior incidents: 4
COVID-19 positive staff: 5
COVID-19 positive residents: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 45 | Licensed Practical Nurse | Named in medication self-administration deficiency |
| LPN 4 | Licensed Practical Nurse | Named in medication self-administration deficiency |
| Resident 57's Social Services Director | Social Services Director | Named in grievance and complaint investigation |
| LPN 8 | Licensed Practical Nurse | Named in wheelchair and dental care deficiencies |
| UM 2 | Unit Manager | Named in wheelchair and dental care deficiencies |
| DON | Director of Nursing | Named in multiple deficiencies including grievance, dental, and medication administration |
| ED | Executive Director | Named in multiple deficiencies including grievance, dental, and COVID-19 testing |
| LPN 22 | Licensed Practical Nurse | Named in behavior management deficiency |
| CNA 23 | Certified Nursing Assistant | Named in behavior management deficiency |
| LPN 13 | Licensed Practical Nurse | Named in dental care deficiency |
| LPN 24 | Licensed Practical Nurse | Named in behavior management deficiency |
| LPN 25 | Licensed Practical Nurse | Named in behavior management deficiency |
| CNA 20 | Certified Nursing Assistant | Named in activities deficiency |
| AA 17 | Activity Assistant | Named in activities deficiency |
| NC | Nurse Consultant | Named in multiple deficiencies including dialysis and dental |
| OT 12 | Occupational Therapist | Named in wheelchair and care plan deficiencies |
| PTD | Physical Therapy Director | Named in wheelchair deficiency |
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