Creasy Springs Health Campus: Elopement Safety Failure - IN
The complaint-driven inspection, conducted on September 9, 2025, resulted in a citation under F0689, which covers the obligation to protect residents from accidents and preventable harm. Inspectors determined that the facility had not completed adequate assessments related to elopement and exit-seeking behaviors for affected residents. The violation was classified as causing minimal harm or potential for actual harm, with few residents affected.
Elopement, in nursing home terms, means a resident leaving or attempting to leave a facility unsupervised and undetected. For residents with dementia or other cognitive impairments, it carries serious risks. A person who slips out a door unnoticed can become disoriented, exposed to traffic, or lost entirely before staff realize they are gone.
The inspection report does not describe a specific incident in detail, but the citation connects to a complaint intake, meaning someone reported a concern to regulators that triggered the investigation. What inspectors found when they arrived was a gap in the facility's own system: the assessments that should have identified which residents were at risk of trying to leave, and the care plans that should have guided staff response, had not been properly completed.
The facility's own written policy, titled "Guideline of Elopement/Missing Resident," revised as recently as December 17, 2024, stated plainly that it is the responsibility of all personnel to report any residents attempting to leave the premises or suspected of being missing to the charge nurse as soon as possible. That policy existed on paper. The assessments that would have told staff who to watch for, and how, had not kept pace with it.
The executive director provided the policy to inspectors on September 8, 2025, the day before the inspection concluded.
By the time inspectors documented the citation, the facility said it had already moved to fix the problem. According to the report, the deficient practice was corrected by August 25, 2025, before the inspection itself was completed. The facility conducted a thorough investigation, performed door checks, updated elopement assessments and care plans, and re-educated all staff on elopement procedures. Ongoing elopement drills and audits were put in place. The nursing assistant identified in the complaint, listed in the report as CNA 2, was suspended and disciplined.
The timeline is worth pausing on. The complaint that triggered this inspection was filed before the facility finished its internal corrections. That sequence, a concern raised by someone outside the facility prompting a process that the facility then scrambled to complete, is a familiar pattern in nursing home oversight. The policy was updated in December. The assessments were not current. A complaint arrived. Then the corrections followed.
What the report does not say is who filed the complaint, what specifically they witnessed, or whether any resident came close to leaving the building unsupervised before the problem was caught. The citation covers few residents, and the harm level is listed as minimal or potential. But the distance between "potential" harm and actual harm in an elopement situation can be measured in minutes and unlocked doors.
Facilities with memory care residents or those with a history of exit-seeking behavior are required to know, resident by resident, who poses a risk and what protections are in place. An assessment is not a formality. It is the document that tells a night-shift aide, who may never have met a particular resident, that this person has tried to leave before, that they become agitated near exits, that they need a specific response. Without it, staff are working without the information they need.
CNA 2, whose name is not included in the inspection report, bore the disciplinary consequence here. Whether the lapse in assessments reflected a broader staffing or supervision failure, or how long the gap existed before the complaint was filed, the report does not say.
Creasy Springs Health Campus operates in Lafayette, a city of roughly 70,000 in north-central Indiana. The September inspection was a complaint investigation, not a routine survey, meaning regulators came specifically because someone raised an alarm.
The drills are now ongoing. The care plans have been updated. The door checks were completed. What remains unresolved in the public record is the period before August 25, when the assessments were incomplete and the staff had not yet been retrained, and what, if anything, happened to residents during that time.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Creasy Springs Health Campus from 2025-09-09 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
CREASY SPRINGS HEALTH CAMPUS in LAFAYETTE, IN was cited for violations during a health inspection on September 9, 2025.
Inspectors determined that the facility had not completed adequate assessments related to elopement and exit-seeking behaviors for affected residents.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.