Inspection Reports for Creekside Village
1420 E DOUGLAS RD, MISHAWAKA, IN, 46545
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 21, 2025, identified a deficiency related to securing a controlled narcotic medication during administration. Earlier inspections showed a pattern of deficiencies involving medication management, resident care such as skin condition assessments and individualized activities, and documentation issues including timely reporting and care planning. Complaint investigations were mostly unsubstantiated, though some substantiated complaints resulted in citations for medication mismanagement and failure to notify responsible parties after resident transfers. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s inspection history shows ongoing challenges with medication and care processes, with some improvements in complaint compliance but recurring issues over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
7.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
86% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
100% occupied
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 95
Capacity: 95
Deficiencies: 1
Date: Mar 21, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00452479. The complaint allegations were investigated and no deficiencies related to the allegations were cited.
Complaint Details
Complaint IN00452479 was investigated and found to have no deficiencies related to the allegations.
Findings
An unrelated deficiency was cited regarding the failure to ensure a controlled narcotic medication was secured or under direct observation during administration. Specifically, medications were left at a resident's bedside contrary to facility policy.
Deficiencies (1)
Failed to ensure a controlled narcotic medication was secured in a locked environment or under direct observation during administration for 1 resident.
Report Facts
Census: 95
Total Capacity: 95
Medicare residents: 16
Medicaid residents: 37
Other residents: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erin Ginter | Executive Director | Signed the report |
| LPN 2 | Named in medication administration deficiency related to leaving medications at bedside | |
| DON | Director of Nursing | Provided medication pass procedure and interview |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 21, 2025
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00452479.
Complaint Details
Investigation of Complaint IN00452479 completed on March 21, 2025; facility found in compliance.
Findings
Creekside Village 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 complaint investigation.
Inspection Report
Life Safety
Census: 98
Capacity: 100
Deficiencies: 0
Date: Feb 13, 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
Creekside Village was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Participation in Medicare/Medicaid. The facility is fully sprinklered except for a small wood shed used for storage and has a monitored fire alarm system with smoke detection throughout.
Report Facts
Facility capacity: 100
Census: 98
Generator capacity: 350
Inspection Report
Annual Inspection
Census: 89
Capacity: 89
Deficiencies: 6
Date: Jan 13, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from January 7 to January 13, 2025.
Findings
The facility was found deficient in multiple areas including failure to provide individualized activities, failure to timely assess and treat skin conditions, failure to obtain admission and weekly weights resulting in undetermined weight loss, failure to follow physician orders for enteral feeding and water flushes, improper storage and incomplete orders for CPAP therapy, and failure to administer influenza vaccine despite signed consent.
Deficiencies (6)
Failed to ensure individual and group activities were provided per individual preferences for 1 of 1 resident reviewed for activities (Resident 11).
Failed to assess a resident's skin or notify the Physician of the need for a treatment timely for 1 of 3 residents reviewed for a skin condition (Resident 30).
Failed to obtain an admission weight and weekly weights of a newly admitted resident resulting in undetermined weight loss for 1 of 3 residents (Resident 62).
Failed to follow physician's orders related to enteral feedings and water flushes for 1 of 1 resident reviewed for a gastrostomy tube (Resident 27).
Failed to ensure a CPAP machine and tubing was stored properly, water was sealed while stored, and there was a completed order regarding settings for the machine for 1 of 2 residents reviewed (Resident 140).
Failed to ensure a newly admitted resident received the influenza vaccine after signing the consent form for 1 of 5 records reviewed (Resident 141).
Report Facts
Census: 89
Total Capacity: 89
Weight loss percentage: 6.7
Enteral feeding volume: 1000
Enteral feeding rate: 85
Water flush volume: 225
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erin Ginter | Executive Director | Signed the inspection report |
| RN 2 | Registered Nurse | Interviewed regarding CPAP storage and orders |
| CNA 7 | Certified Nursing Assistant | Interviewed regarding Resident 30's scratches |
| Assistant Director of Nursing | ADON | Interviewed regarding skin assessments and wound follow-up |
| Director of Nursing | DON | Interviewed regarding weight monitoring and vaccine administration |
| Activities Director | Interviewed regarding activity program and documentation for Resident 11 | |
| Regional Clinical Nurse | RCN | Provided policies and interviewed regarding skin management and enteral feeding |
Inspection Report
Renewal
Deficiencies: 0
Date: Jan 13, 2025
Visit Reason
The inspection was conducted as a Recertification and State Licensure Survey to assess compliance with regulatory requirements.
Findings
Creekside Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 during the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 88
Capacity: 88
Deficiencies: 0
Date: Dec 17, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00448160.
Complaint Details
Complaint IN00448160 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 10
Medicaid census: 51
Other payor census: 27
Inspection Report
Complaint Investigation
Census: 91
Capacity: 91
Deficiencies: 1
Date: Jul 2, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00434201 and IN00434011. Complaint IN00434201 resulted in federal/state deficiencies related to the allegations, while complaint IN00434011 had no deficiencies cited.
Complaint Details
Complaint IN00434201 was substantiated with federal/state deficiencies cited related to the allegations. Complaint IN00434011 was not substantiated with no deficiencies cited.
Findings
The facility failed to complete and submit a timely 5-day follow-up report regarding a fall investigation for one resident (Resident D) that had been reported to the Indiana State Department of Health. The fall occurred on 6/13/2024, and the follow-up report was not submitted within the required timeframe but was completed on 6/24/2024 after re-education and implementation of a monitoring system.
Deficiencies (1)
Failure to complete and submit a timely 5-day follow-up report regarding a fall investigation reported to the state agency.
Report Facts
Census: 91
Total Capacity: 91
Medicare Census: 18
Medicaid Census: 51
Other Payor Census: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed regarding failure to submit timely follow-up report and re-education on reporting policy | |
| Director of Nursing | Notified of resident fall incident | |
| Medical Director | Notified of resident fall incident and change in condition |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 93
Deficiencies: 0
Date: May 1, 2024
Visit Reason
This visit was for the investigation of complaints IN00433572 and IN00431246.
Complaint Details
Complaint IN00433572 - No deficiencies related to the allegations are cited. Complaint IN00431246 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations in complaints IN00433572 and IN00431246 were cited. Creekside Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding these complaints.
Report Facts
Census: 93
Total Capacity: 93
Medicare Census: 24
Medicaid Census: 51
Other Payor Census: 18
Inspection Report
Life Safety
Census: 93
Capacity: 100
Deficiencies: 0
Date: Mar 5, 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
Creekside Village 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 small wood shed used for storage and has a monitored fire alarm system with smoke detection in corridors and resident rooms.
Report Facts
Facility capacity: 100
Census: 93
Generator power: 350
Wood shed size: 80
Inspection Report
Annual Inspection
Census: 87
Capacity: 87
Deficiencies: 6
Date: Feb 9, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from February 5 to 9, 2024.
Findings
The facility was found deficient in multiple areas including baseline care plans, care plan timing and revision, drug regimen review, psychotropic medication management, medication labeling and storage, and infection prevention and control practices.
Deficiencies (6)
Failed to create a Baseline Care Plan for residents with communication barriers and infection precautions.
Failed to ensure comprehensive care plans were updated related to self administration of eye drops, isolation, and NPO status.
Failed to follow pharmacist's recommendation related to use of diuretic medication and monitoring vital signs.
Failed to ensure psychotropic medication was not increased without adequate indication and consistent non-pharmacological interventions.
Failed to ensure medication carts were free from loose pills and medications were dated when opened.
Failed to ensure proper infection control practices during blood sugar checks.
Report Facts
Survey dates: 5
Residents reviewed for baseline care plan: 19
Residents reviewed for care plan timing and revision: 22
Residents reviewed for unnecessary medications: 5
Medication carts observed: 3
Blood sugar checks observed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 2 | Provided immediate education regarding blood glucose meter testing procedure after improper infection control observed. | |
| Executive Director | Indicated residents lacked baseline care plans and provided facility policies. | |
| Director of Nursing | Indicated care plan deficiencies and lack of vital sign documentation. | |
| Social Service Director | Reviewed psychotropic medication management and behavior health documentation. | |
| LPN 5 | Observed medication cart with loose pills and undated medications. | |
| LPN 3 | Observed medication cart with loose pills. | |
| CNA 6 | Provided information about resident behaviors related to psychotropic medication use. |
Inspection Report
Renewal
Deficiencies: 0
Date: Feb 9, 2024
Visit Reason
The visit was conducted as a Recertification and State Licensure Survey to assess compliance with regulatory requirements.
Findings
Creekside Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 during the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 87
Capacity: 87
Deficiencies: 0
Date: Nov 1, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00420610 and IN00419538.
Complaint Details
Complaint IN00420610 - No deficiencies related to the allegations are cited. Complaint IN00419538 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations in complaints IN00420610 and IN00419538 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type: 87
Census Payor Type - Medicare: 9
Census Payor Type - Medicaid: 35
Census Payor Type - Other: 43
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 13, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00418819 completed on October 13, 2023.
Complaint Details
Investigation of Complaint IN00418819; paper compliance review completed with findings of compliance.
Findings
Creekside Village 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 complaint investigation.
Inspection Report
Complaint Investigation
Census: 94
Capacity: 94
Deficiencies: 2
Date: Oct 5, 2023
Visit Reason
This visit was for the investigation of complaint IN00418819 regarding allegations of misappropriation and improper disposal of resident narcotic medication.
Complaint Details
Complaint IN00418819 was substantiated with federal/state deficiencies cited at F602 and F755 related to misappropriation and improper disposal of narcotic medication.
Findings
The facility failed to prevent the misappropriation and improper disposal of liquid narcotic medication for 1 of 3 residents reviewed (Resident B). The investigation revealed that an LPN improperly disposed of liquid hydromorphone by pouring it into the trash instead of following proper destruction procedures.
Deficiencies (2)
Failed to prevent misappropriation of resident narcotic medication.
Failed to provide pharmaceutical services assuring accurate acquiring, receiving, dispensing, and administering of drugs.
Report Facts
Census: 94
Total Capacity: 94
Medication quantity received: 90
Medication administration times: 5
Compliance date: Oct 27, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Reviewed video footage and provided policies related to the investigation | |
| LPN 2 | Involved in misappropriation and improper disposal of liquid hydromorphone | |
| LPN 3 | Provided statement regarding narcotic counts |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 85
Deficiencies: 0
Date: Sep 28, 2023
Visit Reason
This visit was conducted for the investigation of three complaints: IN00415685, IN00416001, and IN00416687.
Complaint Details
Complaint IN00415685, IN00416001, and IN00416687 were investigated with no deficiencies related to the allegations cited.
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.
Report Facts
Census Bed Type: 85
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 46
Census Payor Type - Other: 31
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 25, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00413673 completed on August 18, 2023.
Complaint Details
Investigation of Complaint IN00413673 completed on August 18, 2023; facility found in compliance.
Findings
Creekside Village 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 complaint investigation.
Inspection Report
Complaint Investigation
Census: 75
Capacity: 75
Deficiencies: 2
Date: Aug 16, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00413463 and IN00413673. Complaint IN00413463 had no deficiencies related to the allegations, while complaint IN00413673 resulted in federal/state deficiencies cited at F580 and F622.
Complaint Details
Complaint IN00413463 - No deficiencies related to the allegations are cited. Complaint IN00413673 - Federal/State deficiencies related to the allegations are cited at F580 and F622.
Findings
The facility failed to notify a resident's responsible party of a transfer to the emergency room following an unwitnessed fall for one resident (Resident B). Additionally, the facility failed to ensure the resident or responsible party received discharge instructions for medication administration and gastrostomy feedings upon discharge.
Deficiencies (2)
Failed to notify resident's responsible party of transfer to emergency room following an unwitnessed fall.
Failed to ensure resident received discharge instructions for medication administration and gastrostomy feedings.
Report Facts
Census: 75
Total Capacity: 75
Medicare Census: 11
Medicaid Census: 48
Other Payor Census: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erin Ginter | Executive Director | Signed report as Laboratory Director's or Provider/Supplier Representative |
| RN 2 | Registered Nurse | Named in failure to notify resident's representative of fall and transfer |
| Director of Nursing | Interviewed regarding notification failures and discharge procedures | |
| Administrator | Interviewed regarding discharge follow-up failures |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 81
Deficiencies: 0
Date: Jul 14, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00408953, IN00412099, and IN00412222.
Complaint Details
Investigation of complaints IN00408953, IN00412099, and IN00412222 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00408953, IN00412099, and IN00412222 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census SNF/NF: 81
Total Census: 81
Medicare Census: 8
Medicaid Census: 44
Other Payor Census: 29
Inspection Report
Complaint Investigation
Census: 87
Capacity: 87
Deficiencies: 0
Date: Apr 21, 2023
Visit Reason
This visit was conducted to investigate complaints IN00406412, IN00405505, IN00405034, and IN00399618 at Creekside Village.
Complaint Details
Complaints IN00406412, IN00405505, IN00405034, and IN00399618 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the complaints were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census: 87
Total Capacity: 87
Medicare Census: 22
Medicaid Census: 40
Other Payor Census: 25
Inspection Report
Follow-Up
Census: 77
Capacity: 100
Deficiencies: 0
Date: Feb 21, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 01/05/23 by the Indiana Department of Health.
Findings
At this PSR, Creekside Village 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, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinklered except for a small wood shed used for storage.
Report Facts
Facility capacity: 100
Census: 77
Inspection Report
Re-Inspection
Census: 71
Capacity: 71
Deficiencies: 0
Date: Jan 18, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Licensure and Recertification Survey completed on December 2, 2022.
Findings
Creekside Village 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 Licensure and Recertification Survey.
Report Facts
Census Payor Type - Medicare: 15
Census Payor Type - Medicaid: 41
Census Payor Type - Other: 15
Inspection Report
Life Safety
Census: 75
Capacity: 100
Deficiencies: 4
Date: Jan 5, 2023
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) to assess compliance with fire safety and life safety code requirements.
Findings
The facility was found not in compliance with several Life Safety Code requirements including a locked kitchen door that could not be opened from the inside, unclear exit signage on two doors, failure to maintain sprinkler system inspection records, and unsealed penetrations in smoke barrier walls.
Deficiencies (4)
Failed to ensure 1 of 2 kitchen doors were able to open from the inside if locked, potentially trapping staff inside.
Failed to clearly identify 2 of 8 exit doors leading to the public way, with signs incorrectly stating 'not an exit'.
Failed to maintain 1 of 2 sprinkler systems in accordance with NFPA 25; no documentation for 12 months of gauge and valve checks for the wet sprinkler system.
Failed to ensure penetrations through 1 of 6 smoke barrier walls were protected to maintain smoke resistance; an unsealed one-inch hole was found.
Report Facts
Facility capacity: 100
Census: 75
Exit doors with unclear signage: 2
Smoke barrier walls inspected: 6
Unsealed penetrations found: 1
Kitchen doors inspected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erin Ginter | Executive Director | Named as facility representative during exit conference |
| Maintenance Supervisor | Interviewed and involved in observations related to deficiencies | |
| Maintenance Director | Performed corrective actions and responsible for ongoing maintenance checks | |
| Administrator | Participated in exit conference and review of findings |
Inspection Report
Annual Inspection
Census: 70
Capacity: 70
Deficiencies: 9
Date: Dec 2, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted on November 28, 29, 2022 and December 1 & 2, 2022.
Findings
The facility was found deficient in multiple areas including comprehensive assessments, care plan development and implementation, quality of care related to skin integrity and transfers, respiratory care, dialysis assessments, medication labeling and storage, and infection control practices.
Deficiencies (9)
Failed to ensure bowel and bladder incontinence assessment was accurate for Resident 23.
Failed to develop and implement comprehensive care plans related to antipsychotic medication use and PTSD diagnosis for several residents.
Failed to invite Resident 51 to care plan meeting and document invitation.
Failed to provide treatment for worsening skin integrity, proper physician ordered treatment for skin integrity, and lack of investigation and documentation for bruises with an improper transfer.
Failed to identify a pressure ulcer on admission and provide treatment for the pressure ulcer for Resident 224.
Failed to ensure oxygen was administered by a nurse and CPAP equipment was cleaned/changed for residents requiring respiratory care.
Failed to ensure residents receiving dialysis were assessed before and after dialysis.
Failed to ensure medications were labeled appropriately and non-pharmacological items were stored properly in medication carts and refrigerators.
Failed to follow infection control policies regarding cleaning of a glucometer during medication administration.
Report Facts
Census: 70
Total Capacity: 70
Deficiencies cited: 9
Pressure ulcer size: 1.6
Pressure ulcer size: 3
Pressure ulcer size: 5.1
Dialysis events missing: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erin Ginter | Executive Director | Signed report |
| Employee | Social Wellness and Enrichment Consultant | Initiated PTSD care plans for residents |
| Employee | Social Service Designee | Handled care plan invitations and documentation |
| LPN 15 | Licensed Practical Nurse | Observed medication cart issues and glucometer cleaning |
| LPN 12 | Licensed Practical Nurse | Observed medication cart issues |
| Nurse Manager | Completed head to toe assessment for Resident 5 | |
| Director of Nursing | DON | Provided interviews and oversight of skin integrity and respiratory care |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 79
Deficiencies: 0
Date: Nov 22, 2022
Visit Reason
This visit was for the investigation of Complaint IN00394026.
Complaint Details
Complaint IN00394026 was unsubstantiated due to lack of evidence.
Findings
The complaint IN00394026 was found to be unsubstantiated due to lack of evidence. Creekside Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the investigation.
Report Facts
Census SNF/NF: 79
Total Capacity: 79
Medicare Census: 16
Medicaid Census: 45
Other Payor Census: 18
Inspection Report
Complaint Investigation
Census: 77
Capacity: 77
Deficiencies: 0
Date: Sep 7, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00388009.
Complaint Details
Complaint IN00388009 was substantiated; however, no deficiencies related to the allegations were cited.
Findings
The complaint was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare residents: 12
Medicaid residents: 46
Other residents: 19
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