Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Creasy Springs Health Campus during CMS and state inspections, most recent first.
Failure to Assess Self-Administration of Bedside Medication: A resident had Nystatin cream stored on the bedside table, but the clinical record did not contain an interdisciplinary assessment or MD order to determine whether the resident could self-administer medications. The resident had diagnoses including DM with skin complications and rash, and staff stated bedside medication required a completed self-administration evaluation and order; the DON confirmed no such assessment was documented.
Failure to notify the physician of a resident’s significant weight gain. A resident with CHF, edema, fluid overload, CKD, depression, and DM had a daily weight order with parameters to notify the MD for gains over 2 lbs in 24 hours or 5 lbs in one week. The record showed multiple weight increases that met or exceeded the threshold, while staff interviews confirmed the process for daily weights and physician notification, and the facility stated it had no specific CHF or daily weight policy.
Missing Written Bed Hold Policy Notification: The facility failed to provide written bed hold policy information, including reserve bed payment details, to two residents or their representatives when they were sent to the hospital. One resident had pneumonia, sepsis, acute respiratory failure with hypoxia, COPD, and CKD stage 3, and the other had pneumonitis, influenza, dysphagia, IBS, COPD, hypertensive heart disease with HF, acute and chronic respiratory failure, and pneumonia. Records showed multiple hospital transfers and returns, but no documentation that the required written bed hold notice was given.
Inaccurate MDS coding and missing diagnosis care planning were identified for two residents. One resident's CHF diagnosis was not included on the quarterly MDS despite documented CHF and a furosemide order, and another resident's PTSD diagnosis was omitted from the record review and MDS, with no care plan in place even though staff confirmed the diagnosis and the DON stated it should have been included.
Incomplete Comprehensive Care Plans for Two Residents: The facility failed to develop and implement comprehensive person-centered care plans for 2 residents reviewed. One resident with CHF, edema, fluid overload, and hypertensive CKD had orders for furosemide and metolazone, but the care plan for CHF and multiple diuretics was not initiated until after the survey began. Another resident with dementia, depression, anxiety, and PTSD had no comprehensive care plan for PTSD, and both an LPN and the DCD confirmed the gap.
Medication administration orders and hold parameters were not followed for two residents. One resident with chronic pain and multiple serious diagnoses received less pregabalin than ordered and missed a scheduled morphine ER dose after staff administered previously prepared meds at the wrong time. Another resident with CHF, CKD, diabetes, and osteomyelitis received spironolactone despite systolic BP readings below the ordered hold parameter, and the record lacked documentation of re-checks after the low readings.
Unlabeled Enteral Feeding Bags: A resident with a gastrostomy and multiple respiratory and swallowing diagnoses had two enteral feeding bags hanging on a pump that was turned off and not connected to the resident; one contained a clear liquid and the other a tan liquid, and neither bag was labeled with the product name, date, or time. RN and DON interviews confirmed the bags should have been labeled, and the facility policy stated TF recommendations should include the product.
Unsafe Administration of Medications Prepared by Another Nurse: A resident with chronic pain and multiple complex diagnoses, including spinal cord injury, paraplegia, CHF, CKD, and dementia, had a medication administration error involving morphine and other scheduled meds. Nursing staff administered meds prepared by a previous shift nurse, despite facility guidance that the person who prepares the dose must be the person who administers it, and the resident then missed a scheduled morphine dose.
A resident with a gastrostomy tube was identified for EBP during high-contact care, but PPE was not placed outside or inside the room and an EBP sign was not displayed when observed. Later, an EBP sign was taped to the door, and an RN administered meds via the gastrostomy tube wearing only gloves and no other PPE. Staff interviews and the facility policy confirmed that gowns and gloves were required for this care.
A resident with R-sided weakness after a CVA could not reach her call light while seated at the bathroom sink in her wheelchair because it was positioned on her right side and out of reach. Staff left her alone after positioning her for personal hygiene, even though her care plan directed that the call light remain within reach and facility staff stated residents should always be able to reach it.
A resident was administered multiple medications in error after admission due to a failure in the medication transcription and verification process. An LPN transcribed the wrong medication orders, and the required second nurse check was not performed, resulting in the resident receiving 23 doses of 11 different medications not prescribed for him over several days. The error was discovered only after a review of records, despite concerns raised by the resident's family.
A resident with dementia and Alzheimer's disease, who was not identified as exit-seeking, was allowed to leave a secured unit unsupervised after a CNA mistook the individual for a visitor and opened a secured door. The resident was later found walking outside by another staff member and returned to the facility. The facility was unaware of the elopement until notified by the staff member who found the resident.
A facility failed to maintain a resident's dignity during meal service when a CNA stood while assisting a resident with feeding, contrary to facility policy. The resident, with multiple diagnoses including Alzheimer's and dementia, had a care plan addressing significant weight loss. Staff interviews confirmed that standing while feeding could intimidate residents, and the facility's guidelines emphasized the importance of promoting dignity during dining.
The facility failed to promptly implement DNR orders for two residents, despite their advance directive wishes. One resident had a signed advance directive and POST form indicating DNR, but a physician's order initially indicated full code status. Similarly, another resident's DNR status was delayed in being reflected in a physician's order. The facility's policy required review of advance directives at admission, but there were delays in updating physician orders to match residents' wishes.
A facility failed to update a resident's PASARR Level I to reflect current mental health diagnoses and medications, despite physician's orders for antidepressant and anxiety medications. The Social Service Director confirmed the oversight, which was inconsistent with the facility's policy requiring updates for severe mental illness or psychiatric medication regimens.
A resident with hypertension and chronic kidney disease received lisinopril despite physician orders to hold the medication if systolic blood pressure was below 110. The MAR showed multiple instances of administration with blood pressure readings below this threshold. Facility policies require reviewing orders and vital signs before medication administration, but these were not followed.
The facility failed to obtain a physician's order for oxygen administration for two residents, leading to a deficiency in respiratory care. One resident with pulmonary fibrosis and another with multiple health issues were both placed on oxygen without timely physician orders, contrary to facility policy.
A resident with pneumonia and impaired kidney function received double doses of Augmentin due to the facility's failure to discontinue an initial order when a new one was issued. The resident, with a GFR of 24, was administered both 500 mg and 875 mg doses from 1/27/25 to 2/2/25. The facility's MAR did not automatically update with the pharmacy's system, requiring manual discontinuation of the previous order, which was not done.
The facility failed to manage medications properly, with a compromised lorazepam card found on the 200-hall cart and an unopened insulin pen improperly stored on the 300-hall cart. Additionally, drinking cups were stored under the sink in the 200-medication room, violating facility policy.
Two residents in a LTC facility received incorrect meal consistencies due to failures in implementing hospital discharge diet orders. One resident with dysphagia was served a regular meal instead of a mechanical soft diet, while another with multiple health issues received a regular diet instead of a soft and bite-sized consistency. Staff interviews revealed communication lapses and reliance on electronic systems for diet updates, leading to these deficiencies.
A facility failed to follow infection control protocols when a QMA handled a pain pill without gloves for a resident with multiple health conditions. The QMA picked the pill from a cup with bare hands and placed it in the resident's mouth after it fell on his shirt, contrary to the facility's policy requiring gloves for handling medications.
A resident with chronic kidney disease received duplicate doses of Augmentin due to a failure in the facility's antibiotic stewardship program. The resident was prescribed two different dosages without discontinuing the initial order, leading to inappropriate medication administration. The oversight was not identified by the clinical team or the pharmacy, despite daily reviews of new antibiotic orders.
A resident with multiple health conditions did not receive an influenza vaccination in a timely manner despite signing a consent form. The facility's process involved educating the resident and ordering the vaccine, but the administration was delayed, deviating from the policy that residents receive immunizations per their request.
A resident with multiple health conditions signed a consent form for a COVID-19 vaccine, but the facility failed to administer the vaccine in a timely manner, resulting in a delay of several months. The facility's policy required timely vaccination upon consent, but the process of batching vaccines led to a significant delay.
Failure to Assess Self-Administration of Bedside Medication
Penalty
Summary
The facility failed to ensure that a resident was assessed to self-administer medications for 1 of 1 resident randomly reviewed for self-medication administration. During an observation, a clear plastic bag labeled with prescription information containing Nystatin cream was found on the resident’s bedside table. The resident stated the cream was for a sore area, and the Executive Director later removed the medication from the room and stated he would need to determine whether an evaluation had been completed for self-administration. The resident’s clinical record included diagnoses of type 2 diabetes mellitus with skin complications, rash, and nonspecific skin eruptions, and a physician’s order directed Nystatin ointment to be applied topically to areas of rash twice daily. The record also showed a care plan for moisture associated skin damage to the left buttock with treatment as ordered, but it did not contain an assessment or physician’s order completed by the interdisciplinary team to determine whether the resident could self-administer medications. Staff interviews indicated that medication cream should be stored in the treatment cart unless a resident had a completed evaluation and doctor’s order to self-administer, and the DON stated that if a resident had medication at the bedside, a self-administration observation or evaluation should have been completed. The facility policy stated that the interdisciplinary team verifies a resident’s ability to self-administer medications through a skill assessment and, if appropriate, conducts a further assessment of bedside medication storage.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to ensure the physician was notified of Resident 9’s weight gains according to the ordered parameters. Resident 9 had diagnoses including congestive heart failure (CHF), edema, fluid overload, hypertensive chronic kidney disease, depression, and diabetes mellitus. A physician’s order dated 12/10/25 and discontinued on 1/5/26 directed staff to notify the physician of a weight gain greater than 2 pounds in 24 hours or 5 pounds in one week, and to weigh the resident daily right after getting up, after voiding, still in bedclothes, and before breakfast. Review of the daily weights showed multiple documented weight increases that met or exceeded the notification threshold, including increases of 3.2 pounds, 15.6 pounds, 15.2 pounds, 13 pounds, 4 pounds, 15.2 pounds, 9 pounds, and 10 pounds on various dates. During interviews, QMA 10 stated she would notify the nurse when a resident required a daily weight and the nurse would notify the physician. RN 5 stated daily weights were to be completed at approximately the same time each morning, with no shoes or heavy clothing, no portable oxygen concentrators on the back of wheelchairs, in the same wheelchair, and with an empty bladder. The DON stated residents with daily weight orders had parameters to follow and the nurse would call the physician if the resident had a weight gain of 2 pounds in 2 days and 5 pounds in one week. Clinical Support Nurse 4 stated the facility did not have a policy related to CHF or daily weights and followed state regulations.
Missing Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to ensure that the resident or the resident's representative were given written notification of the facility bed hold policy, including the reserve bed payment, for two residents who were hospitalized. Resident 11 had diagnoses including pneumonia, sepsis, acute respiratory failure with hypoxia, COPD, and chronic kidney disease stage 3. The record showed the resident was sent to the emergency room for respiratory distress and later returned after a hospital stay for pneumonia; the resident was again sent to the emergency room for chest pain and later returned after a hospital stay for pneumonia and hyperkalemia. The clinical record did not contain documentation that written bed hold policy information was provided for either hospitalization. Resident 3 had diagnoses including pneumonitis due to inhalation of food and vomit, influenza with other respiratory manifestations, dysphagia, IBS, COPD, hypertensive heart disease with heart failure, acute and chronic respiratory failure, and pneumonia. The record showed the resident was sent to the emergency room for shortness of breath and difficulty breathing, returned from a hospital stay, and was later sent again for cough, chest pressure, and fever. The clinical record did not contain documentation that the resident or the resident's representative were given written information about the facility bed hold policy, including the reserve bed payment. Staff interviews indicated the bed hold policy should be given when a resident is sent to the hospital, and the Administrator stated it should be completed, signed, and given to the resident or representative.
Inaccurate MDS Coding and Missing Diagnosis Care Planning
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were coded accurately for 2 of 2 residents reviewed for MDS accuracy. For one resident, the clinical record showed diagnoses including congestive heart failure, edema, fluid overload, and hypertensive chronic kidney disease, and a physician's order dated 12/10/25 directed furosemide 80 mg twice daily. During interview, the MDS Coordinator stated the congestive heart failure diagnosis was not included in the resident's quarterly MDS assessment completed on 12/12/25. For the second resident, the clinical record listed diagnoses including dementia, depression, anxiety, and post-traumatic stress disorder, but the diagnosis list did not include post-traumatic stress disorder. The MDS assessment also did not indicate post-traumatic stress disorder, and no care plan was found related to that diagnosis. Staff interviews confirmed the resident had post-traumatic stress disorder related to being in a war, that the diagnosis should have been included on the MDS, and that a care plan should have been in place. The DON also stated the resident was admitted with post-traumatic stress disorder.
Incomplete Comprehensive Care Plans for Two Residents
Penalty
Summary
The facility failed to ensure comprehensive person-centered care plans were developed and implemented for 2 of 2 residents reviewed for care plans. One resident had diagnoses including congestive heart failure, edema, fluid overload, and hypertensive chronic kidney disease, and had physician orders for furosemide 80 mg twice daily and metolazone 5 mg daily. A comprehensive person-centered care plan related to congestive heart failure and the use of multiple diuretic medications was not initiated until after the start of the survey. The other resident had diagnoses including dementia, depression, anxiety, and PTSD. The clinical record contained a social history observation stating the resident had no traumatic history, but the record did not contain a comprehensive person-centered care plan related to PTSD. During interviews, an LPN stated the resident had PTSD related to being in a war and did not have a care plan in place for it, and the Dementia Care Director also confirmed the resident had PTSD and did not have a care plan. The facility policy stated comprehensive care plans are to be developed within 7 days of the admission comprehensive assessment and remain accurate and current.
Medication Administration and Hold Parameters Not Followed
Penalty
Summary
The facility failed to ensure medications were administered as ordered for a resident with right distal femur fracture, paraplegia, spinal cord injury, CHF, edema, fluid overload, hypertensive chronic kidney disease, depression, dementia, and chronic pain. The resident had a care plan directing staff to administer medications and opioids as ordered. A physician order directed pregabalin 50 mg, 2 capsules three times daily, but the controlled drug record showed the resident received only 1 capsule on two documented administrations instead of the ordered 2 capsules each time. The facility also failed to follow medication timing and administration parameters for morphine sulfate ER 15 mg every 8 hours. After the resident refused evening medications, the overnight nurse administered the previously prepared medications at 12:30 a.m., which resulted in the resident missing the morning morphine dose and not receiving another dose until 1:15 p.m. Staff interviews confirmed the missed dose and that the resident could have been in pain before the next scheduled dose. For another resident with CHF, osteomyelitis of the left ankle and foot, diabetes mellitus, and chronic kidney disease, a physician order directed spironolactone 12.5 mg daily and to hold it if systolic BP was less than 105. The medication was given on multiple occasions when systolic BP readings were below the hold parameter, and the record did not contain documentation that the low blood pressures were re-checked after administration until the next dose.
Unlabeled Enteral Feeding Bags
Penalty
Summary
The facility failed to ensure an enteral feeding bag was labeled with the product name, date, and time for 1 of 1 resident reviewed for enteral feeding. During an observation on 2/4/26 at 12:22 p.m., Resident 3 had two clear bags hanging on a feeding pump that was turned off and not connected to the resident. One bag was half full of a clear liquid and the other was half full of a tan colored liquid, and neither bag had a label with the date, time, or substance. Resident 3’s record showed diagnoses including pneumonitis due to inhalation of food and vomit, influenza, dysphagia, gastrostomy status, irritable bowel syndrome, COPD, hypertensive heart disease with heart failure, acute and chronic respiratory failure, and pneumonia. Orders directed enteral feeding formula [NAME] Farms 1.4 at 60 ml/hour for 14 hours overnight, free water flushes every 4 hours, and changing the enteral feeding bag every day. Staff interviews confirmed the bags should have been labeled with the date, time, and name of the substance in the bag, and the facility policy titled Tube Feedings stated TF recommendations should include product.
Unsafe Administration of Medications Prepared by Another Nurse
Penalty
Summary
The facility failed to ensure nursing staff administered medications in a safe and competent manner for Resident 64, who had diagnoses including right distal femur fracture, depression, paraplegia, spinal cord injury, CHF, edema, fluid overload, hypertensive chronic kidney disease, and dementia. The resident’s care plan, dated 9/16/25, identified chronic pain and directed staff to administer medications and opioids as ordered. A nursing progress note dated 10/11/25 at 6:29 a.m. stated the resident refused evening medications, and RN 8 offered the resident medication prepared by the evening shift nurse at 12:30 a.m.; the resident said he would take the medication prepared by the previous nurse. The morning morphine dose was not given because it was too close to the prior dose. The controlled drug record showed morphine 15 mg was signed out for the 9:00 p.m. dose, but there was no documentation that the resident had refused that dose. The midnight shift nurse administered the evening medications prepared by the previously scheduled nurse at 12:30 a.m., and the resident then missed his morning morphine dose, with the next dose not given until 1:15 p.m. on 10/12/25. Interviews with Clinical Support Nurse 3 and RN 3 indicated that medications prepared by another nurse should not have been administered and should have been destroyed, and that nurses should only administer medication they prepared.
Failure to Follow Enhanced Barrier Precautions for Resident With Feeding Tube
Penalty
Summary
The facility failed to ensure enhanced barrier precautions (EBP) infection control practices were implemented and followed for a resident with a gastrostomy tube. The resident’s clinical record showed diagnoses including gastrostomy status and irritable bowel syndrome. A care plan dated 12/12/25 stated the resident required EBP during high-contact care because of the feeding tube, with interventions including use of a gown and gloves according to the facility’s EBP policy. A physician’s order dated 1/7/26 also directed EBP due to the gastrostomy tube. During observation, no PPE was placed outside or inside the resident’s room and no EBP sign was displayed inside or outside the room or on the door. An EBP sign was later observed taped to the exterior side of the door. The Administrator stated he did not tape the sign outside the room and that a CNA did, and he acknowledged the signs should have been placed on the doors prior. During another observation, an RN administered medications through the resident’s gastrostomy tube wearing only gloves and no other PPE. Interviews with the Clinical Support Nurse, a QMA, the RN, and the DON indicated PPE should be worn and an EBP sign should be displayed at the room entrance when providing care or administering medications through a gastrostomy tube. The facility policy titled Enhanced Barrier Precautions Standard Operating Procedure stated EBP applies to residents with feeding tubes and that staff shall wear gloves and gowns during high-contact care activities.
Call Light Not Accessible at Bathroom Sink
Penalty
Summary
The facility failed to ensure a call light was accessible to a resident while she was sitting at the bathroom sink in her wheelchair. Resident 4 stated that staff positioned her at the sink to complete personal hygiene and then left the room, but she could not reach her call light from that position because it was on her right side and out of reach. Her right arm was weakened from a stroke, and she was unable to maneuver her wheelchair away from the sink to reach the call light. Resident 4’s clinical record showed diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, muscle wasting and atrophy, lack of coordination, and weakness. Her care plan identified her as at risk for falling related to weakness, incontinence, and medications and included keeping the call light within reach. The Clinical Support Nurse stated the call light should always be in reach of residents, the Administrator stated the bathroom call light was too short to reach the resident while she was at the sink, and CNA 2 stated a resident should not be left alone if they could not reach the call light. The facility policy also stated the call light should be in reach of the resident and returned to within reach after the requested service has been provided.
Medication Transcription Error on Admission Leads to Multiple Medication Errors
Penalty
Summary
The facility failed to ensure that medications were transcribed correctly upon admission for a resident, resulting in significant medication errors. Upon admission, a staff member transcribed medication orders for the resident, but the orders entered into the resident's record were actually those intended for another resident. This error was not identified because the required second nurse check, as outlined in facility policy, was not completed. As a result, the resident received multiple medications that were not prescribed for him over several days. The resident's family member noticed that a staff member attempted to administer unfamiliar medications and raised concerns with the staff. Despite this, the resident continued to receive incorrect medications for several days. The clinical record review confirmed that 11 medications not ordered by the transferring hospital were administered in error, with a total of 23 incorrect doses given over four days. The medications included drugs for Alzheimer's disease, overactive bladder, anxiety, high blood pressure, diarrhea, stomach acid, potassium supplementation, pain, depression, nausea, and constipation. The facility's own policies required that all new admission orders be double-checked by a second nurse and that the five rights of medication administration be followed. However, these procedures were not followed in this case, leading to the administration of multiple incorrect medications. The error was only discovered after several days when a review of the records was conducted, confirming that the resident had received medications intended for another individual.
Resident with Dementia Allowed to Exit Secured Unit Unsupervised
Penalty
Summary
A resident with dementia and Alzheimer's disease, newly admitted to the secured locked unit, was able to leave the facility unsupervised. The resident was not identified as exit-seeking and had no history of elopement according to the admission assessment. On the day of the incident, a CNA responded to a door alarm and, after interacting with the resident who requested to go outside, allowed the resident to exit through a secured door by entering the code. The CNA mistook the resident for a visitor and did not provide supervision as the resident left the building. The resident was later observed by another staff member walking on a sidewalk away from the facility and was subsequently escorted back. The facility was unaware of the resident's elopement until notified by the staff member who found the resident. Documentation confirmed that the door alarm functioned as intended, but staff failed to follow elopement prevention protocols, resulting in the resident being unsupervised outside the facility for a period of time.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity during meal service. During an observation, a Certified Nursing Assistant (CNA) was seen standing while assisting a resident with feeding in the dining room. The CNA remained standing for the entirety of the meal, which is against the facility's policy that requires staff to sit at eye level with residents while assisting them with eating. This action was observed despite the facility's guidelines emphasizing the importance of promoting resident independence and dignity during dining. The resident involved had a clinical record indicating diagnoses such as Alzheimer's, hypertensive, anxiety disorder, tachycardia, dementia, and acute kidney failure. The care plan for the resident, who had experienced significant weight loss, included interventions like offering encouragement and assistance with eating. Interviews with staff revealed that standing while feeding residents could make them feel intimidated, and it was acknowledged by the CNA involved that this practice was not appropriate. The facility's documents and policies clearly outlined the expectation for staff to treat residents with dignity and respect, including during meal times.
Failure to Implement DNR Orders Promptly
Penalty
Summary
The facility failed to promptly implement a do not resuscitate (DNR) order for two residents, despite their advance directive wishes. Resident 152 had a signed Indiana advance directive form and a Physician Orders for Scope of Treatment (POST) form indicating a DNR status, yet a physician's order dated 1/23/25 indicated full code status. It was not until 1/24/25 that a physician's order reflected the resident's DNR status. The Legacy Director confirmed that the facility's process involved meeting with residents and their representatives to discuss code status, ensuring paperwork was signed, and updating the electronic medical record. However, there was a delay in aligning the physician's order with the resident's advance directive. Similarly, Resident 160 had a signed State of Indiana Out of Hospital Do Not Resuscitate Declaration and Order on 1/9/25, but a physician's order on 1/7/25 indicated full code status. The resident's DNR status was not reflected in a physician's order until 1/17/25. The facility's policy required that advance directives be reviewed at admission and that nursing staff obtain an order from the attending physician for the desired code status. Despite this policy, there was a delay in updating the physician's order to match the resident's advance directive, as confirmed by interviews with facility staff.
Failure to Update PASARR for Resident's Mental Health Diagnoses and Medications
Penalty
Summary
The facility failed to ensure a revised Preadmission Screen and Resident Review (PASARR) Level I was submitted to reflect a resident's current diagnoses and medications. The clinical record for a resident was reviewed, revealing diagnoses of anxiety, depression, and adjustment disorder with mixed anxiety and depressed mood. However, the PASARR Level I, dated 1/7/25, indicated no known or suspected mental health diagnoses and no mental health medications being prescribed. This was inconsistent with the physician's orders dated 1/6/25 and 1/7/25, which included prescriptions for trazodone, sertraline, and buspirone, all medications related to mental health conditions. During an interview, the Social Service Director acknowledged that a new Level I PASARR was not completed to reflect the resident's mental health diagnoses and medications. The facility's policy, as provided by the Director of Nursing, indicated that certain conditions, such as severe mental illness or a psychiatric diagnosis and medication regimen, would trigger a Level II PASARR. The failure to update the PASARR to include the resident's mental health diagnoses and medications represents a deficiency in the facility's compliance with the PASARR requirements.
Failure to Hold Medication as Ordered for Blood Pressure Parameters
Penalty
Summary
The facility failed to adhere to physician's orders regarding the administration of lisinopril for a resident with essential primary hypertension, hypertensive chronic kidney disease, and type 2 diabetes mellitus. The physician's order specified that lisinopril should be held if the resident's systolic blood pressure was less than 110. However, the Medication Administration Records (MAR) from July to October 2024 indicated that lisinopril was administered multiple times when the resident's systolic blood pressure was below the specified threshold, with readings as low as 97. An interview with a nurse confirmed that medications should be held if a resident's blood pressure is outside the hold parameters, and such instances should be documented on the MAR. The facility's policies on medication administration, which were reviewed and confirmed by the Director of Nursing and a Clinical Support nurse, emphasize the importance of reviewing and confirming medication orders and checking vital signs before administering medications. Despite these guidelines, the facility did not comply with the physician's order, leading to the administration of unnecessary medication to the resident.
Failure to Obtain Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to obtain a physician's order for the administration of oxygen for two residents, leading to a deficiency in respiratory care. Resident 150 was observed wearing 2 liters of oxygen via nasal cannula without a prior physician's order. The resident's clinical record indicated a history of pulmonary fibrosis, chronic obstructive pulmonary disease, and other significant health issues. Despite the resident using oxygen at night in the hospital before arriving at the facility, a physician's order for oxygen was not obtained until after the resident had already been receiving oxygen at the facility. Similarly, Resident 156 was placed on oxygen due to low O2 saturations, but a physician's order was not obtained until several days later. The resident's clinical record showed a history of hemiplegia, diabetes, heart failure, and asthma. Nursing progress notes documented the resident's oxygen use, but the order for oxygen administration was delayed. The facility's policy allowed for emergency oxygen administration as a nursing intervention, but a physician's order was required thereafter, which was not promptly obtained in these cases.
Failure to Discontinue Duplicate Antibiotic Order Leads to Double Dosing
Penalty
Summary
The facility failed to ensure the discontinuation of an order for Augmentin 500 mg when a new order for Augmentin 875 mg was received, resulting in double dosing of the antibiotic for a resident with pneumonia. The resident, who had a history of hemiplegia, type 2 diabetes, chronic kidney disease, and other conditions, was administered both doses from 1/27/25 to 2/2/25. The resident's GFR was low at 24, indicating impaired kidney function, which necessitated a lower dose of Augmentin. Despite the pharmacy's usual practice of canceling duplicate orders, the facility did not send a discontinue order for the initial dose, leading to both doses being administered. Interviews with the Assistant Director of Nursing/Infection Preventionist and a pharmacist revealed that the facility's MAR did not automatically update with the pharmacy's system, requiring manual discontinuation of the previous order. The pharmacist noted that the resident should not have received the 875 mg dose due to her impaired renal function. An LPN indicated that she would verify doctor's orders and consult with a pharmacist if she encountered duplicate medications on the MAR, although she was not involved in administering the medications during the double dosing period. A Medication Error Event progress note confirmed the occurrence of the medication error due to the duplicate order.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to properly manage and store medications, leading to several deficiencies. On the 200-hall medication cart, a compromised controlled substance card of lorazepam for a resident was found with taped slots, indicating improper handling. The lorazepam tablets had expired, and there was no current order for them in the Electronic Health Record. The Licensed Practical Nurse on duty did not notice the tape during the narcotics count, and the Assistant Director of Nursing confirmed that the pills needed to be destroyed by two nurses. Additionally, on the 300-hall medication cart, an unopened Humalog insulin pen for another resident was improperly stored outside of the refrigerator, contrary to the storage instructions. The Director of Nursing confirmed that the insulin pen should have been refrigerated until needed and should be destroyed if not stored correctly. Furthermore, in the 200-medication room, drinking cups were improperly stored under the sink, which was against facility policy. The Assistant Director of Nursing acknowledged that nothing should be stored under the sink, and the cups needed to be destroyed.
Dietary Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to accurately initiate the correct diet orders upon admission for two residents, leading to inappropriate meal consistencies being served. Resident 151, who had a history of cerebrovascular accident, Alzheimer's dementia, and dysphagia, was observed receiving a regular consistency meal instead of the prescribed mechanical soft diet. The resident's hospital discharge summary recommended a Level 5 Minced and Moist diet, but due to a series of miscommunications and errors in updating the diet orders, the resident was initially served inappropriate food items. The Speech Therapist intervened, and the meal was corrected, but not before the resident had already started eating the incorrect meal. Resident 156, who had multiple health issues including hemiplegia, diabetes, and heart failure, was also affected by incorrect diet orders. The hospital discharge summary indicated a Level 6 Soft and Bite-Sized diet, but the facility ordered a regular consistency diet instead. This oversight was compounded by the resident's ongoing health issues, including pneumonia and a productive cough, which raised concerns about potential aspiration. The facility's failure to recognize and implement the correct diet order from the hospital discharge summary contributed to the resident's risk of aspiration. Interviews with facility staff revealed systemic issues in the communication and implementation of diet orders. The Director of Dining Services noted reliance on the electronic medical record system for diet order updates, which failed to capture last-minute changes. Additionally, the Clinical Support Nurse admitted to not seeing the correct diet order on the hospital discharge summary, leading to the incorrect diet being ordered. These lapses in communication and procedure resulted in the residents receiving inappropriate meals, highlighting deficiencies in the facility's dietary management processes.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration for a resident. During an observation, a Qualified Medication Aide (QMA) was seen handling a pain pill without wearing gloves. The resident, who had multiple diagnoses including end-stage renal disease and chronic heart failure, requested only the pain pill from a cup containing multiple medications. The QMA picked the pill out with bare hands and handed it to the resident, who then dropped it onto his shirt. The QMA subsequently picked the pill up from the resident's shirt and placed it in his mouth without donning gloves. The facility's policy on oral medication administration requires staff to avoid touching medications unless wearing gloves, which was not followed in this instance.
Failure in Antibiotic Stewardship Leads to Duplicate Dosing
Penalty
Summary
The facility failed to ensure proper monitoring of antibiotic use under its antibiotic stewardship program, resulting in a resident receiving duplicate doses of the same antibiotic. Resident 156, who had a history of hemiplegia, diabetes, heart failure, and chronic kidney disease, was prescribed Augmentin for pneumonia. Initially, a dose of 500-125 mg was ordered, but a subsequent order increased the dosage to 875-125 mg without discontinuing the initial order. This led to the resident receiving both dosages concurrently, which was inappropriate given her renal function. The Assistant Director of Nursing/Infection Preventionist was unaware of the duplicate dosing and did not investigate the higher dosage. The pharmacy did not receive a discontinue order for the initial dose, resulting in both dosages appearing on the facility's Medication Administration Record. Despite daily reviews of new antibiotic orders, the clinical team failed to identify and address the duplicate dosing. The facility's policy on antibiotic stewardship was not effectively implemented, as evidenced by the lack of action to prevent the medication error that occurred.
Failure to Administer Timely Influenza Vaccination
Penalty
Summary
The facility failed to provide an influenza vaccination during the current influenza season for a resident who had requested it with a signed consent form. The resident, who had multiple health conditions including type 2 diabetes mellitus, chronic obstructive pulmonary disease, and Alzheimer's disease, signed a consent form for the influenza vaccine on January 2, 2024. However, the resident's medical record did not show any influenza vaccination administered between the date of the signed consent and the administration of the vaccine on October 4, 2024. Interviews with the Clinical Support Nurse and the Assistant Director of Nursing revealed that the facility's process involved educating the resident or family after consent was signed and then ordering the vaccine. The Assistant Director of Nursing mentioned that vaccines were occasionally batched but were typically administered within a few days to a week. Despite this process, the resident did not receive the influenza vaccine in a timely manner as per their request, which was a deviation from the facility's policy that stated residents would receive immunizations per their request.
Failure to Timely Administer COVID-19 Vaccine
Penalty
Summary
The facility failed to provide a COVID-19 vaccination to a resident who had requested it and signed a consent form. Resident 13, who had multiple health conditions including type 2 diabetes, chronic kidney disease, and Alzheimer's disease, signed a consent form for the COVID-19 vaccine on January 2, 2024. However, the resident's medical record did not show any vaccination administered between the date of consent and October 4, 2024, when the vaccine was finally given. Interviews with the Clinical Support Nurse and the Assistant Director of Nursing revealed that the facility's process involved educating the resident or family and then ordering the vaccine, which could sometimes be batched and administered within a few days to a week. Despite this procedure, there was a significant delay in administering the vaccine to Resident 13, which was not in accordance with the facility's policy that required residents to receive immunizations per their request upon signing the consent form.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 123 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lafayette
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Springs At Lafayette, The | 2.4 mi | ★★★★★ | 9 | 0 |
| St Mary Healthcare Center | 2.6 mi | ★★★★★ | 5 | 0 |
| Rosewalk Village At Lafayette | 3 mi | ★★★★★ | 2 | 0 |
| Majestic Care Of Lafayette | 3.4 mi | ★★★★★ | 16 | 0 |
| Saint Anthony Rehab And Nursing Center | 3.4 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Creasy Springs Health Campus.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.