Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 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.
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 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.
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 809 citations issued within 25 miles in the last 12 months — including the 8 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 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 | — | 4 | 0 |
| Miller's Merry Manor | 4.2 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Creekside Health And Rehabilitation Center.
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 August 2026) and official state health department websites.