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 Creekside Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with delusional disorder and anxiety was prescribed and routinely received risperidone twice daily, as documented in physician orders and MARs during the seven-day look-back period for an annual MDS assessment. However, the MDS medication section was coded to show that no antipsychotic medications were received. The MDS Coordinator later acknowledged this was an error, resulting in inaccurate assessment documentation contrary to CMS RAI requirements.
Failure to Follow PPE, Hand Hygiene, and Catheter Bag Positioning Requirements: A resident on Contact Isolation Precautions was assisted by an RD who entered the room without gown or gloves. For another resident on EBP, an RT performed trach care without a gown, and an LPN changed gloves during catheter care without HH between glove changes. For a third resident with an indwelling catheter, the drainage bag was repeatedly observed resting on the floor or fall mat despite policy stating it should not touch the floor.
Dignity and Call Light Response Failures: Staff turned off call lights and did not return to provide requested care for multiple residents, despite repeated concerns raised in resident council meetings and by a resident who reported the same issue. In a separate event, a CNA assisted a cognitively impaired resident with eating while reading content on a personal cell phone, despite the resident being dependent on staff for feeding assistance.
A facility failed to follow ordered care for several residents. A resident with quadriplegia developed moisture-associated skin damage on the buttocks without timely physician notification, another resident’s fall precautions were not implemented as ordered, and a resident on Metoprolol received doses without documented HR checks and despite out-of-parameter DBP readings. The facility also did not address visible ear wax buildup for one resident and did not obtain ordered weights or notify the provider for another resident with weight-gain parameters tied to furosemide.
Failure to provide ordered heel boots and timely podiatry follow-up: A resident with cerebral palsy, seizure disorder, and aphasia was ordered to wear Prevalon boots every shift, but was observed in bed without the boots and with long, jagged toenails. An LPN noted the toenails needed clipping and could not find any boots in the room, while podiatry follow-up was overdue despite a prior note calling for routine at-risk foot care follow-up in 2 to 3 months.
A resident with hand contractures was observed with his left hand contracted and no splint or palm protector in place, despite an FMP directing staff to encourage use of a left-hand palm protector for 4 to 8 hours a day. Staff could not locate the device, and an LPN stated she was unaware of any order or use of a palm protector for the resident. The TM confirmed the resident’s FMP called for bilateral hand splints to help maintain skin hygiene and integrity and prevent further contractures.
A resident with dementia and recent weight loss was found to have ordered nutritional supplements delayed. The resident's discharge diet included Ensure, and a nutrition assessment identified malnutrition and recommended Magic Cup with lunch and dinner, but both supplements were not started until later due to an oversight by the facility.
Staff failed to treat a resident with dignity and respect by entering the room without knocking and speaking in a disrespectful manner regarding pain medication administration. The resident, who was moderately cognitively impaired and experiencing severe depression, expressed distress over these interactions, and staff interviews confirmed the facility's expectations for respectful communication and privacy.
A resident with dementia and rheumatoid arthritis experienced changes in muscle relaxant medications, including the restart and dosage increase of Baclofen, without timely notification to the resident's representative as required by facility policy. The lack of notification was confirmed through record review and staff interviews, and the resident was later hospitalized for acute encephalopathy and polypharmacy related to the medication changes.
A resident with multiple sclerosis and hypertension was transferred to a hospital without a physician's order or proper documentation, such as an SBAR form, to indicate the reason for transfer. Staff interviews revealed confusion about the rationale for the transfer, and the receiving hospital had to contact the facility for clarification. The facility did not issue a formal 30-day discharge notice, and there was inadequate communication and documentation as required by facility policy.
A facility failed to develop a baseline care plan within 48 hours for a resident admitted with a stage 2 pressure ulcer and severe cognitive impairment. Despite assessments and care orders being in place, no baseline care plan was created for the resident's skin concerns. Interviews revealed that the responsibility for care plans lay with the MDS staff and Wound Nurse, and the issue had been identified in the facility's QAPI process.
A resident with severe cognitive impairment and a stage 2 pressure ulcer was admitted to the facility without a comprehensive care plan addressing skin concerns. Despite assessments and care orders being in place, the facility failed to create a care plan, as revealed in interviews with the Wound Nurse and DON. This issue was previously identified and included in the facility's QAPI process, but a gap in care planning procedures remained.
A resident with hemiplegia and muscle weakness fell twice due to inadequate assistance during transfers, resulting in a head injury and a fractured arm. Another resident was transferred without a gait belt, and a third resident with cerebral palsy fell from bed during care, highlighting failures in following care plans and safety protocols.
The facility failed to maintain resident dignity and respect, as residents reported staff rudeness, lack of compassion, and inappropriate comments. Staff were loud during sleeping hours and often ignored call lights. Specific incidents included a CNA instructing a resident to have a bowel movement in bed and neglect of incontinent care. Most affected residents were cognitively intact, validating their complaints.
The facility failed to conduct quarterly care plan meetings for two residents, one with depression and hypertension, and another with multiple diagnoses including hypertension and diabetes. Both residents were cognitively intact but were not aware of or invited to regular care plan meetings. The Social Service Director cited excessive workload as a reason for the missed meetings, despite the facility's policy supporting resident participation in care planning.
A resident with hemiplegia did not receive routine oral care and timely incontinence care as per their care plan. The resident reported that staff did not assist with brushing teeth and instructed them to use their brief for bowel movements. Observations confirmed inadequate oral hygiene and delayed brief changes, with staff failing to properly cleanse and dry the resident during incontinence care. Interviews revealed inconsistencies in care provision, with staff indicating that oral care should have been done by the night shift and residents should be changed every two hours.
A facility failed to conduct required pre and post dialysis assessments for a resident with end stage renal disease. Despite a care plan outlining the need for monitoring side effects of dialysis, assessments were missing for several dates. The DON confirmed the absence of these assessments, which are mandated by the facility's policy to ensure resident safety.
Failure to Accurately Code Antipsychotic Use on MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to accurately document a resident’s antipsychotic medication use on an annual Minimum Data Set (MDS) assessment. Resident D had diagnoses including delusional disorder and anxiety. Physician orders revised in early September indicated the resident was prescribed risperidone 0.25 mg twice daily for delusional disorder. Medication Administration Records for January and February showed the resident routinely received risperidone twice daily during the seven-day look-back period for the annual MDS assessment dated early February. Despite this documented and administered antipsychotic therapy, the MDS assessment’s medication section indicated that the resident had not received any antipsychotic medications during the look-back period. During an interview, the MDS Coordinator, who had over one year of experience at the facility and over five years of MDS experience, acknowledged that the medication section of the MDS contained an error. The CMS RAI User’s Manual requires that the MDS identify, by pharmacological category, any medication received in the last seven days, but this requirement was not met for Resident D’s antipsychotic medication use.
Failure to Follow PPE, Hand Hygiene, and Catheter Bag Positioning Requirements
Penalty
Summary
The facility failed to ensure staff used required PPE before entering a room for a resident on Contact Isolation Precautions. Resident 22’s room had a sign on the door frame indicating Contact Isolation Precautions, and an isolation cart with gowns and gloves was outside the room. A registered dietician was observed standing at the resident’s bedside assisting her to drink from a straw without wearing an isolation gown or gloves. During interview, the RD stated she had not seen the precaution sign before entering and acknowledged she should have donned PPE before entering the room. The facility also failed to ensure enhanced barrier precautions and hand hygiene practices were followed during care for a resident with a tracheostomy, suprapubic catheter, and wounds. Resident 1’s care plan required enhanced barrier precautions. A respiratory therapist was observed performing tracheostomy care after performing hand hygiene and donning sterile gloves, but without donning an isolation gown. The therapist stated she should have worn a gown because the resident was on enhanced barrier precautions. During catheter care for the same resident, an LPN was observed removing and replacing gloves multiple times without performing hand hygiene between glove changes, despite performing catheter site care and dressing changes. The facility also failed to ensure correct positioning of an indwelling catheter drainage bag for Resident 80. Her care plan included teaching on proper positioning of the drainage bag. On multiple observations, the catheter bag was hanging from the side of the bed and resting on the floor or on the fall mat while the bed was in a low position. The resident’s family member stated the bag was always resting on the floor or fall mat when visiting. The hospice RN stated the catheter bag should not touch the floor and that he repositioned the bed and bag when he found it on the floor. The facility’s catheter care policy stated tubing and the catheter bag should not touch the floor.
Dignity and Call Light Response Failures
Penalty
Summary
The facility failed to maintain residents’ dignity and respect resident rights when staff turned off call lights and did not return to provide the requested services for multiple residents, including Residents C, D, E, F, G, H, J, K, L, M, N, P, Q, R, S, T, and V. Resident council minutes dated November 20, 2025, documented that staff were turning off call lights without providing the requested assistance. During a resident council meeting, attendees reported that call light response remained a problem and had been raised in prior meetings without being addressed. Resident V also stated that staff would turn off the call light, say they would be back, and then not return. The facility also failed to maintain dignity during mealtime assistance for Resident ZZ. Resident ZZ had a history of stroke, was cognitively impaired, had impairment of both upper extremities, and was dependent on staff for eating assistance. During an observation in the dining room, CNA 1 was assisting Resident ZZ with lunch while sitting beside her and reading content on a personal cell phone at the same time. The DON, Executive Director, and Nurse Consultant stated that cell phones should not be used while assisting a resident with a meal and that staff should not turn off call lights without providing care or fail to return after knowing care was needed.
Failure to follow ordered care for skin, falls, medication parameters, ear care, and weights
Penalty
Summary
The facility failed to timely address a resident’s skin condition for a resident with quadriplegia who was frequently incontinent of urine and dependent for toilet hygiene. A skin sweep and risk assessment identified an open area on the left gluteal area that was moisture associated skin damage, but the record did not show physician notification or a new treatment order on that date. The wound was later documented as a new in-house acquired incontinence-associated dermatitis wound with measurements of 2.35 cm by 5.9 cm by 0.1 cm. The resident stated he had an open area on his buttocks, staff were caring for the wound, and he did not feel he was getting changes as often as he needed. The facility also failed to ensure fall interventions were implemented for a resident at risk for falls related to a history of falls, ataxia, and orthostatic hypotension. The care plan included interventions such as removing pedals from the wheelchair and using a soft touch call light. However, the resident was observed multiple times with his feet on the wheelchair pedals, and a push-button call light was present on the bed instead of the soft touch call light. The DON stated the resident had been moved closer to the nurses’ station and the soft touch call light had not been moved with him, and that he had started using foot pedals after a fractured ankle in late January 2026. The facility failed to obtain a resident’s heart rate and follow medication hold parameters for Metoprolol. The resident’s care plan and physician’s order required holding the medication for SBP below 110, DBP below 60, or HR below 60. The MAR documented blood pressures but did not document heart rates for several medication administrations, and the resident received Metoprolol on multiple dates when the DBP was below 60. The DON stated the order had been entered into the electronic health record with blood pressure parameters but not the resident’s heart rates. Additional failures included not addressing a resident’s ear wax buildup and not ensuring weights were obtained and provider notification occurred for a resident receiving furosemide for weight gain and edema. One resident was observed with a large amount of wax in both ears, including thick darker wax at the start of the ear canal and a ball of dry wax hanging in the left ear. Another resident had documented weight gains over the ordered notification thresholds, but the record did not show the physician was notified or that PRN furosemide was administered as ordered. The DON also stated weights for several dates could not be provided and there was no documentation that the provider had been notified when weights were within the ordered parameters.
Failure to Provide Ordered Heel Boots and Timely Podiatry Follow-Up
Penalty
Summary
The facility failed to ensure Resident V was provided with heel protective boots as ordered and failed to ensure timely follow-up with podiatry services. Resident V had diagnoses including cerebral palsy, seizure disorder, and aphasia, and required total staff assistance with activities of daily living. A physician’s order dated 3/24/20 directed that Prevalon boots be on every shift for preventive measures, and the February 2026 TAR indicated the boots were documented as in place every day and every shift. However, during observation on 2/10/26, Resident V was found lying in bed with bare feet and no Prevalon boots present. The Housekeeping Supervisor/CNA and an LPN both observed that the resident’s toenails were long and needed to be clipped, and the LPN could not locate any boots in the resident’s room. The resident’s podiatry note dated 10/6/25 indicated he met qualifications for routine or at-risk foot care and stated follow-up in 2 to 3 months, but no subsequent podiatry consultation notes were available. The Social Services Director stated staff had to notify them when a resident needed podiatry so the resident could be placed on the podiatry list, and no one had informed them that Resident V needed podiatry services. The family member also reported an ongoing issue with the facility not trimming Resident V’s toenails. The facility policy stated employees should refer identified foot care needs to the social worker or designee, who would assist with appointments and transportation.
Failure to Provide Palm Protector per Functional Maintenance Program
Penalty
Summary
The facility failed to provide Resident V’s palm protector as directed by his functional maintenance program for limited ROM and contractures. Resident V’s record showed diagnoses including contractures, and an observation found him sitting in his wheelchair with his left hand contracted and no splint, carrot, or palm protector in place. There were no physician’s orders for a splint, carrot, or palm protector for his left hand, even though the ADL care plan directed staff to encourage use of a left-hand palm protector for 4 to 8 hours a day and to wash, dry, and stretch his hands before applying hand splints. During follow-up observations, Resident V was again found without a left-hand palm protector while lying in bed. The HS/CNA stated she had seen a palm protector at one time, but it was not in place during the observation. An LPN who had worked the hall full time since November 2025 stated she did not know anything about the resident using a palm protector or having an order for it and had never seen him with one; she also could not locate a palm protector in the resident’s drawers or closets. The Therapy Manager confirmed the resident had a functional maintenance plan created when therapy ended in February 2024, which identified contractures to both hands and recommended encouraging wear of bilateral hand splints for up to 4 to 8 hours.
Delayed Start of Ordered Nutritional Supplements
Penalty
Summary
Provide enough food and fluids to maintain a resident's health was not met for Resident 25 when ordered nutritional supplements were not started in a timely manner. The resident had a diagnosis that included dementia, and the clinical record showed recent weight changes, including a drop from 150 pounds on 1/26/26 to 142.8 pounds on 2/01/26 and 142.4 pounds on 2/02/26. The resident's family member reported that she had not been eating very well lately and had lost weight. The nutrition care plan revised on 1/13/26 directed that the resident receive her diet as ordered, and the hospital discharge instructions indicated a regular diet with Ensure supplements. The 1/13/26 nutrition assessment identified the resident as malnourished due to decreased appetite/intakes, recent weight loss, reduced mobility, recent acute illness, and dementia, and recommended Magic Cup with lunch and dinner. The facility physician's orders and MAR showed that both the Ensure and Magic Cup supplements did not begin until 2/05/26. The ADON stated that the supplements not starting until 2/5/26 was an oversight.
Failure to Honor Resident Dignity and Respect
Penalty
Summary
A deficiency was identified when staff failed to treat a resident with dignity and respect. The resident, who had diagnoses including depression and right knee pain, was assessed as moderately cognitively impaired with severe depression. On multiple occasions, staff entered the resident's room without knocking, despite the resident expressing that this behavior bothered him. During one observation, a CNA entered the room without knocking to check on the resident, who later confirmed that staff frequently entered without knocking and that it was upsetting to him. Additionally, a QMA interacted with the resident in a manner that was not respectful. When the resident inquired about his pain medications, the QMA responded in a sharp tone, questioned his understanding of his medication schedule, and threatened to record a refusal and discard his medication if he did not take it immediately. The resident became tearful and reported that staff often spoke to him disrespectfully, making him feel as though there was something wrong with him. Interviews with staff and facility leadership confirmed that the expectation was for staff to knock before entering and to treat residents with dignity and respect.
Failure to Notify Resident Representative of Medication Changes
Penalty
Summary
The facility failed to timely notify a resident's representative of medication changes for a resident diagnosed with dementia and rheumatoid arthritis. The resident, who was cognitively intact according to a recent assessment, experienced increased confusion and lethargy after taking Baclofen, leading to the discontinuation of several medications, including Baclofen. Later, due to ongoing muscle spasms and pain, Baclofen was restarted and its dosage was subsequently increased. However, there was no documentation in the clinical record that the resident's representative was notified of either the restart or the dosage increase, despite special instructions in the resident's profile to notify the family of any medication changes. Nursing notes indicated that the resident became confused and semi-conscious, prompting notification of the physician, DON, and family, and a subsequent reduction in Baclofen dosage. The resident's daughter later requested transfer to the ER after observing slurred speech, and the resident was admitted to the hospital for polypharmacy, acute encephalopathy, and hypertensive urgency, with hospital records linking the altered mental status to increased Baclofen dosing. Interviews confirmed that the family had not been notified of the medication changes, and staff expressed uncertainty about who was responsible for family notification. The facility's policy required prompt notification of the resident's representative for changes in treatment, including new or discontinued medications.
Failure to Document and Communicate Resident Transfer to Hospital
Penalty
Summary
The facility failed to properly document the reason for transferring a resident to a local hospital and did not ensure appropriate communication with the receiving health facility. The clinical record for the resident, who had diagnoses including multiple sclerosis and hypertension, did not contain a physician's order for the hospital transfer, nor did it include a Situation, Background, Assessment, and Recommendation (SBAR) form to indicate the change in condition that prompted the transfer. Nursing notes indicated the resident was sent to the emergency room due to a decline in condition, but staff interviews revealed uncertainty about the specific reason for the transfer and a lack of documentation regarding what information was sent with the resident. The resident's care plan had been focused on discharge home with her spouse, and she had recently been referred to hospice services following a decline in her condition and the end of Medicare Part A coverage. Interviews with staff and the resident's family member revealed that discussions about an outstanding balance and the possibility of inpatient hospice occurred, but no formal 30-day discharge notice was issued. The family was informed that if payment was not received by midnight, the resident would be discharged to an inpatient hospice program, yet there was confusion among staff about the process and rationale for the late-night transfer to the hospital. Further, the receiving hospital contacted the facility to clarify the reason for the transfer, indicating a lack of clear communication. The facility's own policy required a physician's order for emergency transfers and documentation of assessment findings, which were not present in this case. The resident returned from the hospital without new orders, and staff interviews confirmed that standard procedures for documenting and communicating transfers were not followed.
Failure to Develop Baseline Care Plan for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident with a stage 2 pressure ulcer. The resident, who had severe cognitive impairment and multiple diagnoses including metabolic encephalopathy and atherosclerotic heart disease, was admitted with a pressure ulcer to the coccyx. Despite the nursing staff obtaining an assessment of the wound, notifying the doctor and family, and having care orders in place, there was no baseline care plan developed for the resident's skin concerns or pressure ulcers. Interviews with the Wound Nurse and the Director of Nursing revealed that the responsibility for developing care plans for skin-related issues lay with the MDS staff and the Wound Nurse. The Director of Nursing acknowledged an ongoing issue with baseline care plans not being routinely conducted by floor nurses, which had been identified and addressed in the facility's Quality Assurance and Performance Improvement (QAPI) process. Despite previous in-service educational offerings on admission assessment and care plans, the deficiency persisted, as evidenced by the absence of a baseline care plan for the resident in question.
Failure to Develop Comprehensive Care Plan for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with a stage 2 pressure ulcer. The resident, who had severe cognitive impairment and multiple diagnoses including metabolic encephalopathy and atherosclerotic heart disease, was admitted with a pressure ulcer to the coccyx. Despite having conducted an assessment of the wound, notifying the doctor and family, and having care orders in place, the facility did not create a care plan addressing the resident's skin concerns or pressure ulcers. Interviews with the Wound Nurse and the Director of Nursing revealed that the responsibility for developing care plans for skin-related issues lay with the Wound Nurse and MDS staff. The Director of Nursing acknowledged an ongoing issue with care plans not being routinely conducted by floor nurses, which had been identified and included in the facility's Quality Assurance and Performance Improvement process. Despite previous in-service educational offerings on admission assessment and care plans, the facility did not have a baseline care plan for the resident, highlighting a gap in the implementation of care planning procedures.
Inadequate Supervision and Assistance Leads to Resident Falls and Injuries
Penalty
Summary
The facility failed to provide adequate assistance and supervision for Resident 60, who had a history of falls and required substantial assistance for transfers due to conditions such as hemiplegia and muscle weakness. On one occasion, Resident 60 fell while being transferred from the toilet to a wheelchair by a physical therapist, resulting in a head injury. Despite this incident, the resident was later transferred by a single CNA without the use of a gait belt, leading to another fall where the resident sustained a fracture of the left upper arm. Resident B, who also required assistance due to hemiplegia, was observed being transferred from a wheelchair to the toilet without the use of a gait belt, contrary to the facility's policy. This lack of adherence to safety protocols put the resident at risk, especially on days when the resident reported difficulty with transfers. Resident 1, diagnosed with cerebral palsy and requiring total assistance for bed mobility, experienced a fall when a CNA attempted to provide perineal care alone. The resident slipped from the bed, highlighting the failure to follow the care plan that required two staff members for such tasks. These incidents demonstrate a pattern of inadequate supervision and failure to adhere to established care plans, resulting in preventable accidents and injuries.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect, as evidenced by multiple complaints from residents during a council meeting and individual interviews. Residents reported that staff were rude, lacked compassion, and made inappropriate comments. During sleeping hours, staff were loud, laughing, and yelling in the hallways, disturbing residents. Additionally, staff were reported to turn off call lights without returning to provide the requested assistance, and residents felt they had no choice in dining arrangements. Specific incidents included a CNA telling a resident to have a bowel movement in bed to avoid assisting them to the toilet, and another resident experiencing neglect of incontinent care needs during the third shift. Residents also reported that staff had poor attitudes and were unhelpful, particularly during shift changes when the noise level was likened to a party. These issues were corroborated by the residents' clinical records, which indicated that most of the affected residents were cognitively intact, highlighting the validity of their complaints.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to conduct care plan meetings quarterly for two residents, Resident 63 and Resident 95, as required. Resident 63, who has diagnoses including depression and hypertension, was found to have had his last care plan meeting on 11/19/24, with no meetings held between 2/14/24 and 11/19/24. Despite being cognitively intact, Resident 63 was unsure of when he was last invited to a care plan meeting, suggesting a lack of communication and adherence to the quarterly schedule. The Social Service Director confirmed the gap in meetings, indicating that only two meetings were held in the specified period. Similarly, Resident 95, with diagnoses including hypertension, cocaine abuse, hemiplegia, and diabetes, was not aware of what a care plan meeting was and had not been invited to one since her admission to the facility. Although a care plan meeting was documented on 04/02/2024, there was no evidence of quarterly meetings being held. The Director of Nursing provided records indicating an invitation was extended to Resident 95's daughter, but the Social Service Director admitted that meetings were not conducted timely due to an excessive workload. The facility's policy supports resident participation in care planning, but this was not effectively implemented for these residents.
Failure to Provide Adequate Oral and Incontinence Care
Penalty
Summary
The facility failed to provide routine oral care and timely incontinence care for Resident B, who was reviewed for Activities of Daily Living (ADL) care. Resident B, diagnosed with hemiplegia secondary to a cerebral vascular accident, required assistance with oral care and substantial assistance with toileting hygiene. Despite a care plan indicating the need for oral care twice daily and assistance with incontinence care, Resident B reported that staff did not help with brushing his teeth and instructed him to have a bowel movement in his brief instead of assisting him to the toilet. Observations confirmed that Resident B had visible white debris on his teeth, indicating a lack of oral care. Additionally, Resident B's incontinence care was inadequate. He reported that his brief was not changed overnight, and observations showed that his brief was heavily saturated with urine. During an observed care session, CNA 2 did not properly cleanse or dry Resident B's genitalia before applying a new brief, contrary to the facility's perineal care policy. Interviews with staff revealed inconsistencies in the provision of care, with CNA 2 indicating that night shift should have performed oral care, and CNA 3 stating that residents are changed every two hours, which was not adhered to in Resident B's case.
Failure to Conduct Pre and Post Dialysis Assessments
Penalty
Summary
The facility failed to conduct pre and post dialysis assessments for a resident with end stage renal disease, identified as Resident 43, who required dialysis services. The resident's clinical record indicated a diagnosis of end stage renal disease, necessitating dialysis treatment. A care plan dated October 25, 2024, outlined the need for monitoring for side effects of dialysis, such as changes in consciousness, cramping, fatigue, headaches, itching, and bleeding. Despite these requirements, the facility did not have documented pre and post dialysis assessments for several dates in November and December 2024, and January 2025. The Director of Nursing confirmed the absence of these assessments during an interview on January 14, 2025, acknowledging that the staff should have conducted these evaluations. The facility's dialysis policy mandates pre and post dialysis assessments to monitor the health and safety of residents receiving dialysis. These assessments include checking the level of consciousness, vital signs, and other health indicators, with any abnormalities to be communicated to the dialysis center or physician. The lack of documentation for these assessments indicates a failure to adhere to the facility's policy and ensure appropriate monitoring of the resident's condition before and after dialysis sessions.
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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.
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Nursing homes near Indianapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| American Village | 1.1 mi | ★★★★★ | 21 | 0 |
| Tranquility Nursing And Rehab | 2.4 mi | — | 0 | 0 |
| Community Nursing And Rehabilitation Center | 4.1 mi | ★★★★★ | 17 | 0 |
| North Capitol Nursing & Rehabilitation Center | 4.2 mi | ★★★★★ | 5 | 0 |
| Miller's Merry Manor | 4.2 mi | ★★★★★ | 0 | 0 |
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