Creasy Springs Health Campus

In the surveyor’s words

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

• Actual harm, isolatedF760Dec 20, 2023

  Based on interview and record review, the facility failed to hold insulin according to the physician ordered parameters for 1 of 1 resident reviewed for insulin administration. (Resident 29) Resident 29 had hypoglycemia which resulted in an emergency room visit and hospitalization . Finding includes: During an interview, on 12/14/23 at 10:36 a.m., RN 6 indicated Resident 29 became unresponsive, on 12/13/23 at 9:00 p.m., and was sent to the emergency room . The resident had a blood sugar of 18 (mg) milligram/(dL)deciliter (a normal fasting blood sugar level was between 70 mg/dL and 100 mg/dL). The record for Resident 29 was reviewed on 12/18/23 at 4:13 p.m. […]

• Actual harm, isolatedF684Oct 6, 2022

  Based on interview and record review, the facility failed to access and document a skin condition after a resident received a laceration to her left calf while being transferred from her wheelchair to her bed resulting in a trip to the emergency room where she received 31 stitches and subsequently developed a complicated skin infection 25 days later for 1 of 1 resident reviewed for non-pressure skin conditions. (Resident 17) Finding includes: The record for Resident 17 was reviewed on 10/04/22 at 11:05 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Incident Report, dated 09/01/2022 at 8:51 p.m., indicated Resident 17 was being assisted to bed from her wheelchair and received a laceration to her left lower extremity. […]

• No harm, potential for more than minimal, patternF657Oct 6, 2022

  Based on interview and record review, the facility failed to update care plans for advanced directives, respiratory care and antipsychotics for 5 of 17 residents reviewed for care plans. (Resident 1, 19, 11, 20 and 17) Findings include: 1. The record for Resident 1 was reviewed on 10/3/22 at 11:48 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 9/16/22, indicated the resident's advanced directives were located in the resident documents. The long term goal was to honor the resident's and the resident's representative decision regarding advanced directives. The approaches included, but were not limited to, the advanced directives would be reviewed quarterly and as needed. 2. […]

• No harm, potential for more than minimal, isolatedF554Feb 11, 2026

  Based on observation, interview and record review, the facility failed to ensure a resident was assessed to self-administer medications for 1 of 1 resident randomly reviewed for self-medication administration. (Resident 73)Findings include:During an observation, on 2/4/26 at 2:02 p.m., a clear plastic bag, labeled with prescription information containing Nystatin cream, was found on Resident 73's bedside table.The clinical record for Resident 73 was reviewed on 2/6/26 at 12:14 p.m. […]

• No harm, potential for more than minimal, isolatedF580Feb 11, 2026

  Based on interview and record review, the facility failed to ensure the physician was notified of a weight gain according to the parameters ordered for 1 of 1 resident reviewed for notification. (Resident 9)Findings include:The clinical record for Resident 9 was reviewed on 2/6/26 at 1:24 p.m. The diagnoses included, but were not limited to, 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, indicated to notify the physician of a weight gain greater than 2 pounds in 24 hours or 5 pounds in one week. […]