Cedar Creek Health Campus

In the surveyor’s words

From the most serious findings on record at Cedar Creek Health Campus, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 5, 2024

  Based on record review and interview, the facility failed to ensure adequate supervision was provided to a cognitively impaired resident with a history of exit seeking and failed to ensure an alarmed door was effectively secured to prevent elopement for 1 of 6 residents reviewed for elopement risk. (Resident M) This deficient practice resulted in Resident M exiting the facility and being picked up by a stranger who activated 911. The immediate jeopardy began on 5/25/24 when a cognitively impaired male resident, with a history of exit seeking and a Wanderguard (door alarm bracelet used to monitor residents who wander) in place, exited the facility without staff knowledge and ambulated 0.3 miles away from the facility. […]

• No harm, potential for more than minimal, widespreadF812May 22, 2023

  Based on observation and interview, the facility failed to ensure food was stored and distributed in a sanitary manner related to an uncovered ice bowl in the main dining room. This had the potential to affect all 52 residents in the facility who received beverages with ice from the main dining room. Finding includes: On 5/16/23 at 3:05 p.m., the ice machine in the main dining room was observed. There was a note taped to the ice dispenser that indicated to use the ice in the bowl on the counter. Observed on the counter was an uncovered stainless steel bowl of ice with the ice scoop laying directly on top of the ice. Staff and residents were scooping ice into glasses. […]

• No harm, potential for more than minimal, patternF809Jan 21, 2025

  Based on observation, record review, and interview, the facility failed to ensure meals were served with no more than 14 hours between an evening meal and breakfast the following day for 1 of 2 meals observed. This had the potential to affect all 11 residents that ate in the VIP Dining Room. Finding includes: During a tour of the kitchen on 1/21/25 at 8:21 a.m., the Director of Food Services (DFS) indicated breakfast was served from 7:00 a.m. to 9:00 a.m. and was open dining. There were breakfast trays being served to the Main Dining Room at the time. During an observation of the breakfast meal service on 1/21/25 at 9:27 a.m., Assistant Director of Food Services (ADFS) delivered meal trays to resident's rooms. […]

• No harm, potential for more than minimal, isolatedF609Aug 13, 2026

  Based on interview and record review, the facility failed to ensure an allegation of abuse/misappropriation was reported to the Indiana Department of Health (IDOH) and other proper authorities related to an allegation of drug diversion by facility staff for 1 of 1 misappropriation allegation reviewed. (RN 1)Finding includes:A facility investigation of an allegation of drug diversion, dated 7/12/26 and received from the Executive Director (ED), was reviewed on 8/12/26 at 10:00 a.m. The initial statement indicated RN 2 had made an allegation RN 1 was taking controlled narcotics from the facility residents. […]

• No harm, potential for more than minimal, isolatedF641May 18, 2026

  Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) comprehensive assessment was accurately completed related to insulin for 1 of 16 MDS assessments reviewed. (Resident 15)Finding includes:Record review for Resident 15 was completed on 5/12/26 at 3:16 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus.The admission MDS assessment, dated 3/17/26, indicated the resident had received an insulin injection in the past seven days.The Medication Administration Record, dated 3/2026, lacked documentation of any insulin administration.The Physician's Order Summary, dated 5/2026, lacked any orders for insulin.During an interview on 5/13/26 at 3:05 p.m., the MDS Coordinator indicated the resident had not received any insulin and it had… […]