Indian Creek Healthcare Center

In the surveyor’s words

From the most serious findings on record at Indian Creek Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF744Mar 1, 2023

  Based on interview and record review, the facility failed to provide appropriate dementia care, related to behaviors, for a resident (Resident B) which resulted in a fractured right wrist and a left black eye for 1 of 3 residents reviewed for dementia care. Findings include: The clinical record for Resident B was reviewed on 2/28/23 at 11:35 a.m. The diagnoses included, but were not limited to, dementia with behavioral disturbance, anxiety and affective mood disorder. The admission evaluation report, dated 2/23/23 at 3:00 p.m., indicated the resident had a non-pressure area which consisted of diffuse punctured areas to the bottom of the right foot. She was a risk for falls with interventions to keep the room well-lit and free of clutter. […]

• No harm, potential for more than minimal, widespreadF881Feb 20, 2023

  Based on record review and interview the facility failed to ensure an infection prevention and control program related to the tracking and monitoring of infections and antibiotics was followed related to organisms and prescribing of antibiotics for UTIs. This deficient practice had the potential to affect 125 of 125 residents that reside in the facility. Findings include: The review of the Antibiotic Stewardship tracking log indicated the following information on residents with UTIs: In July 2022 there were 17 UTIs (urinary tract infections) on the tracking log, which included the number of cases of organizms identified: 2 Providencia Stuartii 3 Escherichia Coli 1 Escherichia Coli ESBL (Extended-Spectrum Beta-Lactamase) 1 Pneumoniae E. […]

• No harm, potential for more than minimal, patternF842Jul 19, 2026

  Based on observation, interview and record review, the facility failed to ensure administered narcotic medications were documented on the controlled substance medication administration record for 6 of 6 residents reviewed for resident medical records. (Resident B, C, D, E, F and G) Findings include:1. The clinical record for Resident B was reviewed on 7/19/26 at 10:49 a.m. The resident's diagnoses included, but were not limited to, anxiety (the bodies natural response to stress) and malignant neoplasm of the tonsil (a type of head and neck cancer).The physician's order, dated 7/10/26, indicated the resident was to receive Clonazepam (medication for anxiety) 0.5 mg (milligrams) in the morning and evening for anxiety.The physician's order, dated 6/30/26, indicated the resident was to receive… […]

• No harm, potential for more than minimal, patternF623Jan 23, 2024

  Based on record review and interview, the facility failed to ensure 5 of 5 residents or responsible parties were provided written notice of Transfer/Discharge upon transfer to an acute care facility. (Residents 101, 26, 122, 83, and 103) Findings include: 1. The record for Resident 101 was reviewed on 1/17/24 at 2:05 p.m. The diagnosis included, but was not limited to, absence of parts of the digestive tract. The Annual MDS (Minimum Data Set) assessment, dated 1/5/24, indicated the resident was severely cognitively impaired. The nurse's note, dated 12/21/23 at 11:08 a.m., indicated the resident was lethargic with a temperature of 101.1 degrees Fahrenheit. Tylenol was given. […]

• No harm, potential for more than minimal, patternF625Jan 23, 2024

  Based on record review and interview, the facility failed to ensure 5 of 5 residents or responsible parties were provided written notice of and signed the facility's bed hold policy upon transfer to an acute care facility. (Residents 101, 26, 122, 83, and 103) Findings include: 1. The nurse's note, dated 12/21/23 at 11:08 a.m., indicated Resident 101 was lethargic with a temperature of 101.1 degrees Fahrenheit. Tylenol was given. The CMP (Comprehensive Metabolic Panel) liver enzymes were elevated, and the urine was bright orange with a strong noticeable odor. The NP (Nurse Practitioner) gave an order to transfer the resident to the ED (Emergency Department) at a local hospital. The resident's family was notified. […]