IGNITE MEDICAL RESORT CROWN POINT LLC

1555 S MAIN STREET, CROWN POINT, IN 46307 (219) 323-8700
For profit - Corporation 70 Beds IGNITE MEDICAL RESORTS Data: November 2025
Trust Grade
45/100
#356 of 505 in IN
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Last Inspection: January 2025

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Ignite Medical Resort Crown Point LLC has a Trust Grade of D, indicating below-average quality with several concerns. It ranks #356 out of 505 facilities in Indiana, placing it in the bottom half, and #5 out of 20 in Lake County, meaning only four local options are worse. Unfortunately, the facility is worsening, with issues increasing from 10 in 2024 to 16 in 2025. Staffing is a significant concern, rated only 1 out of 5 stars with a high turnover rate of 58%, which is above the state average. While there have been no fines, the facility has less RN coverage than 94% of Indiana facilities, which is troubling as RNs are crucial for catching potential problems. Specific incidents of concern include unsanitary conditions in the kitchen, such as unlabeled and undated food, and spilled substances that could affect all residents. Additionally, it was noted that some residents who need help with daily activities did not receive adequate bathing assistance, missing scheduled showers. Lastly, the facility has failed to manage midline catheters properly, which are critical for residents receiving IV treatments, raising serious care quality concerns. Overall, while there are some strengths, particularly the absence of fines and high quality measures, the facility has significant weaknesses that families should consider carefully.

Trust Score
D
45/100
In Indiana
#356/505
Bottom 30%
Safety Record
Low Risk
No red flags
Inspections
Getting Worse
10 → 16 violations
Staff Stability
⚠ Watch
58% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties
✓ Good
No fines on record. Clean compliance history, better than most Indiana facilities.
Skilled Nurses
⚠ Watch
Each resident gets only 22 minutes of Registered Nurse (RN) attention daily — below average for Indiana. Fewer RN minutes means fewer trained eyes watching for problems.
Violations
⚠ Watch
32 deficiencies on record. Higher than average. Multiple issues found across inspections.
★★☆☆☆
2.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 10 issues
2025: 16 issues

The Good

  • 5-Star Quality Measures · Strong clinical quality outcomes
  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record

Facility shows strength in quality measures, fire safety.

The Bad

2-Star Overall Rating

Below Indiana average (3.1)

Below average - review inspection findings carefully

Staff Turnover: 58%

12pts above Indiana avg (46%)

Frequent staff changes - ask about care continuity

Chain: IGNITE MEDICAL RESORTS

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is elevated (58%)

10 points above Indiana average of 48%

The Ugly 32 deficiencies on record

Sept 2025 1 deficiency
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0694 (Tag F0694)

Could have caused harm · This affected 1 resident

Based on observation, record review and interview, the facility failed to care for a midline catheter (inserted into a vein in the upper arm for intravenous [IV] treatments) in accordance with profess...

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Based on observation, record review and interview, the facility failed to care for a midline catheter (inserted into a vein in the upper arm for intravenous [IV] treatments) in accordance with professional standards of practice related to flushing orders and flushing of the catheter, medications administered as ordered, documentation of the insertion and discontinuation of the catheter, assessments of the catheter line with dressing changes and after discontinuing the catheter, for 3 of 3 residents reviewed for midline/PICC (peripherally inserted central catheter) care. (Residents B, C, and F)Findings include:1. Resident B's closed record was reviewed on 9/8/25 at 9:56 a.m. The diagnoses included, but were not limited to, urinary tract infection and bladder cancer. A Care Plan, dated 6/2/25, indicated IV medication was being administered. The interventions included, the dressing for the site was to be changed daily and the observations of the site were to be recorded and the IV line was to be flushed per the Physician's Orders.A Physician's Order, dated 6/2/25, indicated the dressing on the midline was to be changed every seven days for midline maintenance per the midline maintenance protocol.The Medication Administration Record (MAR), dated 6/2025, had initials as completed on June 2, 10, 26, and 24, 2025. There was no assessment of site and length of the IV line documented.A Physician's Order, dated 6/2/25, indicated piperacillin-tazobactam (antibiotic) 3-0.375 grams was to be administered per the IV in 100 milliliters (ml) of normal saline every eight hoursThe Medication Administration Record (MAR), dated 6/2025, indicated the last dose of the antibiotic had been administered on 6/10/25 at 2:00 p.m. A Physician's Order, dated 6/2/25 and discontinued on 6/30/25, indicated a normal saline flush solution, 10 mls was to be used to flush the midline before and after the medication was infused. The MAR, dated 6/2025, indicated the flush was scheduled as needed and had not been administered from 6/2/25 to 6/30/25.A Nurse Practitioner's (NP) Progress Note, dated 6/3/25 at 2:37 p.m., indicated the IV antibiotic was to be discontinued on 6/9/25. An admission Minimum Data Set (MDS) assessment, dated 6/7/25, indicated a moderately impaired cognitive status, and indwelling urinary catheter was present, had a urinary tract infection in the last 30 days, and an IV was present.There was no documentation on the MAR or the Nurses' Progress Notes that indicated the IV line had been flushed before and after the medication and after the IV antibiotics had been discontinued.A Nurse's Progress Note, dated 6/25/25 at 7:07 p.m., indicated the midline in the right upper arm had been removed per the NP orders. There was no bleeding or signs of infection. The resident had tolerated the procedure well.There was documentation in the Nurse's Progress Note that indicated the length of the IV line and the condition of the tip of the catheter.During an interview on 9/8/25 at 12:05 p.m., the Director of Nursing (DON), indicated the midlines/PICC lines were usually discontinued when it was determined there would be no further treatment. When the line was no longer in use, it was to be flushed with 10 ml normal saline twice a day.During an interview on 9/8/25 at 1:25 p.m., the DON indicated she was trying to find the flush orders for before and after the antibiotic was administered and assumed it had been done per the as needed order when the medication had been administered. She acknowledged there was no assessment of the length of the line and the tip condition with dressing changes and when the line had been discontinued. 2. During an observation on 9/8/25 at 8:25 a.m., Resident C was lying in bed and had an IV line in her upper left arm. The dressing that covered the insertion site had a date of 9/5/25.Resident C's record was reviewed on 9/8/25 at 1:37 p.m. The diagnoses included, but were not limited to urinary tract infection.A Physician's Order, dated 9/4/25, indicated meropenem (antibiotic) one gram was to be administered per the IV every 12 hours for seven days due to a urinary tract infection.A Physician's order, dated 9/5/25, indicated a midline IV was to be inserted for the antibiotic treatment.The MAR, dated 9/2025, indicated the meropenem had not been administered as ordered on 9/5/25 at 9:00 a.m., 9/6/25 at 9:00 p.m. and 9/7/25 at 9:00 p.m.There were no Physician's Orders for the weekly dressing change, assessment of the site, or the normal saline flushes before and after the antibiotic until 9/8/25 at 8:53 a.m.An NP Progress Note, dated 9/4/25 at 3:25 p.m., indicated, a urinary tract infection was present secondary to the urinary catheter. Cipro (antibiotic) had been initiated for seven days, pending the final sensitivity report.A MAR Note, dated 9/5/25 at 9:00 a.m., indicated the meropenem had not arrived from the pharmacy and had not been administered.An NP Progress Note, dated 9/5/25 at 4:21 p.m. and written on 9/6/25 at 12:22 p.m., indicated meropenem per IV had been ordered due to the sensitivity indicating the organism was resistant to the Cipro. A heperin lock (IV insertion) had been placed in the antecubital for IV access and a midline catheter had been ordered.A MAR Note, dated 9/6/25 at 8:57 p.m., indicated the meropenem had not been administered. No reason was documented.A MAR Note, dated 9/7/25 at 10:07 p.m., indicated the meropenem had not been administered. No reason was documented.There was no documentation who had inserted the heparin lock and when the midline had been inserted.During an interview on 9/8/25 at 2:22 p.m., the DON indicated the NP had inserted the heparin lock. There was no documentation who had placed the heparin lock and no documentation when the midline had been administered.During an interview on 9/8/25 at 3:19 p.m., the DON indicated the nurses had attempted to place the heparin lock and were unable to place, so the NP had placed the lock. The meropenem had not arrived from the pharmacy. The facility did have the medication available in the EDK 9emergency frug kit). The nurse had not looked in the EDK for the medication. The physician had not been notified. The flush orders and care of the mid-line had not been written at the time of the insertion. The first dose of the meropenem had been administered through the heparin lock on 9/5/25 at 10:00 a.m.3. Resident F's record was reviewed on 9/8/25 at 3:03 p.m. The diagnoses included, but were not limited to, rhabdomyolysis and peripheral vascular disease.A Care Plan, dated 5/20/25 and revised on 8/11/25, indicated IV medication was being received. The interventions included, the dressing would be changed weekly and the observation of the IV site was to be recorded. The IV would be flushed as ordered.A Physician's Order, dated 7/23/25 and discontinued on 8/13/25, indicated the IV midline dressing change was to be completed every seven days per midline protocol.A Physician's Order, dated 7/23/25 and discontinued on 8/13/25, indicated a flush of normal saline, 10 ml was to be completed before and after the IV medication was given.A Physician's Order, dated 7/23/25 and discontinued on 8/6/25, indicated meropenem one gram was to be administered every 8 hours for a urinary tract infection for 14 days. (42 doses)The MAR, dated 7/2025, indicated the meropenem had not been administered on 7/23/25 at 10:00 p.m. and 7/24/25 at 6:00 a.m. and was marked as refused.A Physician's Order, dated 7/23/24, indicated daptomycin (antibiotic) 476 milligrams as to be administered every 24 hours for 14 day, for the urinary tract infection.The MAR, dated 7/2025, indicated the daptomycin dose on 7/24/25 had not been given at 11:22 a.m.The MAR's, dated 7/2025 and 8/2025, indicated the dressing change had been completed on 7/26/25, 8/2/25, 8/10/25, 8/16/25, and 8/24/25. There was no documentation of the mid-line's length.A Physician's Order, dated 8/14/25, indicated the midline IV was to be discontinued.There was no documentation the mid-line had been discontinued, the length of the line or the status of the line's tip.During an interview on 9/9/25 at 10 a.m., the DON indicated the full dosages of the antibiotics were not administered and there was no documentation of the mid-line being discontinued and the assessment of the site and line had not been completed.The facility's central line care policy, dated 12/2024 and received from the DON as current, indicated general instructions after insertion of all PICC line treatments and dressings required a physician's order. A physician's order was required for flushing the line prior to and post administration of the medication, maintenance of the lines and routine line care. The removal of the line was to be documented in the record. The measurement of the line will be obtained by measuring the entire length of the line and was to be recorded. The measurement was to be compared to the insertion measurement. Assessment of the insertion site was to be completed every shift for seventy-two hours.This citation relates to Intake 1839939.3.1-47(a)(2)
May 2025 6 deficiencies
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to notify a resident's physician and responsible party that a medication was unavailable for 1 of 9 residents reviewed for physician/responsib...

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Based on record review and interview, the facility failed to notify a resident's physician and responsible party that a medication was unavailable for 1 of 9 residents reviewed for physician/responsible party notification. (Resident D) Finding includes: Resident D's record was reviewed on 5/1/25 at 10:00 a.m. The diagnoses included, but were not limited to, osteomyelitis left ankle/foot and dementia. A Social Service assessment, dated 4/30/25, indicated a severe cognitive impairment A family member was designated as the legal Power of Attorney (POA). A Physician's Order, dated 4/29/25 at 6:00 p.m., indicated IV (intravenous) ampicillin-sulbactam (antibiotic) 3 grams (gm) was to be administered every six hours due to a wound infection. The Medication Administration Record (MAR), dated 4/2025, indicated the antibiotic had not been available and was not given on 4/30/25 at 12:00 p.m. and 6:00 p.m. The MAR, dated 5/2025, indicated the antibiotic had not been available and was not given on 5/1/25 at 12:00 a.m. and 6:00 a.m. Cross reference F755. There was no documentation to indicate the resident's physician and POA had been notified of the missed antibiotic doses. During an interview on 5/1/25 at 10:56 a.m., the Director of Nursing indicated the POA and the Physician should have been notified of the missed doses of the antibiotic A facility policy for physician notification, dated 10/2024 and received from the Director of Nursing as current, indicated the physician or nurse practitioner would be notified if it was deemed necessary or appropriate in the best interest of the resident. The communication with the responsible party as well as the physician was to be documented in the medical record. This citation relates to Complaint IN00457153. 3.1-5(a)(3)
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interview, the facility failed to provide incontinent care in a timely manner and failed to ensure Resident D was bathed after a large amount of urinary incont...

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Based on observation, record review, and interview, the facility failed to provide incontinent care in a timely manner and failed to ensure Resident D was bathed after a large amount of urinary incontinence for 2 of 3 residents reviewed for activities of daily living (ADL's). (Residents D and E) Findings include: 1. During an observation on 4/29/25 from 9:07 a.m. through 9:32 a.m., Resident D was lying in bed with the head of the bed elevated. There was a yellow tinged color on the edge of the incontinence pad that was under the resident. LPN 3 and CNA 2 entered the room. CNA 2 indicated she came in to work at 6 a.m. and she had not checked the resident for urinary incontinence since she started work that morning. CNA 2 indicated the gown was wet with urine and there were two incontinence pads under the resident that were saturated with urine. The sheet under the incontinence pads was soaked with urine as well and there was a drying ring of urine on the bottom sheet of the bed. The top sheet and covers were also wet. CNA 2 indicated the gown and incontinence brief were saturated with urine. The resident's gown was removed and the bed linens were changed. The resident's peri area and buttocks area was cleansed with wipes. The other areas soaked by urine, the abdomen, back, arms and legs, were not washed. A clean brief was applied and the resident was dressed without the other areas of the body being cleansed. Resident D's record was reviewed on 5/1/25 at 10:00 a.m. The diagnoses included, but were not limited to, osteomyelitis left ankle/foot and dementia. An admission Nursing Assessment, dated 4/29/25 at 1:30 p.m., indicated an open wound on the right heel, urine and bowel incontinence, assistance was required for ADL's, and a PICC (peripherally inserted central catheter) line was present. A Care Plan, dated 4/29/25, indicated assistance was required for ADL's. The intervention included maximum assistance would be required for bathing and toileting. The resident was incontinent and would be checked for incontinency every 2-3 hours. A Social Service assessment, dated 4/30/25, indicated a severe cognitive impairment. 2. During an observation on 4/30/25 at 8:30 a.m., there was an odor of urine outside Resident E's room and inside the room. Resident E was lying in bed with her eyes closed. CNA 5 entered the room with a covered breakfast tray. CNA 5 donned gloves and stated the bed covers were damp and the resident's clothing was wet. There was a large ring of urine on the incontinence pad under the resident with drying urine on the edges. The incontinence brief was saturated with urine. CNA 5 indicated she had not checked the resident for incontinence since she started work at 6:00 a.m. and it had been a while since the resident had been checked for incontinence. She then completed incontinence care with the wet wipes at the bedside and placed a new incontinence brief on the resident. The clothing was changed after the skin was washed with the wipes. Resident E's record was reviewed on 5/1/25 at 11:12 a.m. The diagnoses included, but were not limited to dementia. A Care Plan, dated 4/24/25, indicated assistance was required with ADL's. The interventions included moderate assistance would be provided for toileting and bathing. The resident would be checked for incontinence every 2-3 hours. During an interview on 4/30/25 at 10:17 a.m., the Director of Nursing indicated the residents should have been checked for incontinence and changed prior to the observation and they should have been showered or bathed due to the large amount of urine incontinence. During an interview on 5/1/25 at 8:39 a.m., LPN 4 indicated the night shift CNA's start their last rounds at 4:00-4:30 a.m. A facility incontinence care policy, dated 11/2024 and received from the Director of Nursing as current, indicated incontinent residents were changed every two hours and more frequently if needed. This citation relates to Complaint IN00457153. 3.1-38(a)(3)
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0694 (Tag F0694)

Could have caused harm · This affected 1 resident

Based on observation, record review and interview, the facility failed to care for a midline catheter (inserted into a vein in the upper arm for intravenous [IV] treatments) in accordance with profess...

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Based on observation, record review and interview, the facility failed to care for a midline catheter (inserted into a vein in the upper arm for intravenous [IV] treatments) in accordance with professional standards of practice related to a non-sterile dressing change and a lack of dressing changes to the site, assessments of the site, and flushes of the catheter for 2 random PICC line observations. (Residents D and J) Findings include: 1. During an observation on 4/29/25 at 9:46 a.m., Resident D was lying in bed with the head of the bed elevated. There was a PICC line in the left upper extremity. LPN 3 indicated there was blood on the PICC line dressing and the dressing needed to be changed. A sterile dressing kit was placed on the resident's bed and opened up. LPN 3 applied sterile gloves after using the alcohol based hand rub. She then lifted the resident's left arm up with the sterile gloves on and placed a sterile pad under the arm. She then put a face mask on herself and touched the top of her ears and hair with the sterile gloves. The soiled PICC line dressing was removed and the insertion area was cleansed with the alcohol cleaning utensil in the kit. She then removed the gloves and applied a second pair of sterile gloves without cleansing her hands. While the sterile gloves were applied, she touched the fingers of the right hand glove with her ungloved fingers of the left hand. She then applied the left sterile glove. She touched the underside of the kit wrap and moved the kit in the bed, then touched the resident's arm for positioning and placed a new dressing on the PICC line insertion site. Resident D's record was reviewed on 5/1/25 at 10:00 a.m. The diagnoses included, but were not limited to, osteomyelitis left ankle/foot and dementia. An admission Nursing Assessment, dated 4/29/25 at 1:30 p.m., indicated an open wound on the right heel, urine and bowel incontinence, assistance was required for ADL's, and a PICC (peripherally inserted central catheter) line was present. A Care Plan, dated 4/29/25, indicated an IV was present. The interventions indicated the dressing would be changed every week. During an interview on 4/30/25 at 10:17 a.m., the Director of Nursing indicated PICC line dressing changes were to be completed using a sterile dressing change process. 2. During an observation on 5/1/25 at 1:45 p.m., Resident J was sitting in a wheelchair in his room. There was a PICC line inserted into the right upper arm with date of 4/26/25 written on the dressing site. Resident J's record was reviewed on 5/1/25 at 1:10 p.m. The diagnoses included, but were not limited to, diabetes mellitus. The admission date was 4/2/25. A Physician's Order, dated 4/16/25, indicated a midline IV catheter was to be placed for IV antibiotic administration. A Nurse's Progress Note, dated 4/16/25 at 4:58 p.m., indicated a nurse from the IV insertion company was at the facility and a midline catheter was placed in the right arm. A Professional Nursing Service Note, dated 4/16/25, indicated a midline IV had been inserted. The nursing care indicated to flush the line with 10 cc's (cubic centimeters) of normal saline before and and right after all infusions per facility protocols. The dressing was to be changed within 24 hours of insertion, then weekly and as needed for soiling and looseness. A Care Plan, dated 4/17/25, indicated the resident was receiving an antibiotic through an IV. The interventions included the dressing over the IV would be observed every shift, the dressing would be changed weekly and flushed per the physician's orders. The IV insertion site was to be monitored for infection and other concerns. The Physician's antibiotic orders included the following: 4/16/25 to 4/21/25 - vancomycin, 1 gm (gram) daily for knee infection. 4/18/25 to 4/21/25 - meropenem - 1 gm every 12 hours 4/22/25 - ampicillin 2 gm to be given every 8 hours for a left knee infection. There were no orders to flush and monitor the midline IV or for the dressing changes written as a Physician's Order. There was no documentation that indicated the dressing had been changed 24 hours after the insertion or the midline had been flushed before and after the medication. There was no documentation the midline had been assessed for placement and signs and symptoms of infection. During an interview on 5/1/25 at 2:03 p.m., the Director of Nursing indicated there was an order for the midline, but there were no orders for the flush, dressing change, or the care of the midline. A PICC line/midline policy, dated 11/2024 and received from the Director of Nursing as current, indicated the treatments and dressing required a physician's order. The dressing was to be changes 24 hours after insertion and then at least weekly or any time the dressing became moist, loosened, or soiled. The PICC line must remain sterile. 3.1-47(a)(2)
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to ensure a resident was provided with an intravenous (IV) antibiotic in a timely manner by the contracted pharmacy, related to the antibiotic...

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Based on record review and interview, the facility failed to ensure a resident was provided with an intravenous (IV) antibiotic in a timely manner by the contracted pharmacy, related to the antibiotic not being available to be administered as ordered by the physician for 1 of 3 residents reviewed for antibiotic medications. (Resident D) Finding includes: Resident D's record was reviewed on 5/1/25 at 10:00 a.m. The diagnoses included, but were not limited to, osteomyelitis left ankle/foot and dementia. A Care Plan, dated 4/29/25, indicated an IV antibiotic was ordered by the physician for a wound infection. The goal indicated there would be no complications related to the IV therapy. A Physician's Order, dated 4/29/25 at 6:00 p.m., indicated an IV of ampicillin-sulbactam (antibiotic) 3 grams (gm) was to be administered every six hours due to a wound infection. The Medication Administration Record (MAR), dated 4/2025, indicated the IV antibiotic was given on 4/29/25 at 6:00 p.m., 4/30/25 at 12:00 a.m. and 6:00 a.m. The MAR indicated the medication had not been available and was not given on 4/30/25 at 12:00 p.m. and 6:00 p.m. The MAR, dated 5/2025, indicated the antibiotic had not been available and was not given on 5/1/25 at 12:00 a.m. and 6:00 a.m. A Medication Administration Progress Note, dated 4/30/25 at 11:37 a.m., indicated the antibiotic was not available in the Emergency Drug Kit (EDK). The pharmacy was notified and they expected the antibiotic to be delivered by 1 p.m. on 4/30/25. A Medication Administration Progress Note, dated 4/30/25 at 5:05 p.m., indicated the antibiotic was not available and the pharmacy was notified again and was ordered to bring the antibiotic as soon as possible. A Medication Administration Progress Note, dated 5/1/25 at 4:07 a.m., indicated the antibiotic was not administered and was on order. During an interview on 5/1/25 at 10:56 a.m., the Director of Nursing indicated the first three doses of the antibiotic were taken from the IV EDK (emergency drug kit). The pharmacy had been notified and would be delivering the antibiotic. A facility pharmacy delivery policy, dated 1/2023 and received from the Director of Nursing as current, indicated the pharmacy will have a daily delivery of medications and supplies. This citation relates to Complaint IN00457153. 3.1-25(a)
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0772 (Tag F0772)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to ensure a resident received laboratory services as ordered by the physician for 1 of 3 residents reviewed for laboratory services. (Resident...

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Based on record review and interview, the facility failed to ensure a resident received laboratory services as ordered by the physician for 1 of 3 residents reviewed for laboratory services. (Resident B) Finding includes: Resident B's record was reviewed on 4/30/25 at 2:12 p.m. The diagnoses included, but were not limited to, stroke and dementia. A Wound Physician Progress Note, dated 4/18/25, indicated a Stage IV (full thickness skin loss with extensive destruction) pressure ulcer was present on the coccyx. An order for a pre-albumin and a complete blood count (CBC) was received. The pre-albumin and complete blood count results were not in the medical record and there was no documentation the laboratory testing had been completed. During an interview on 4/30/25 at 4:42 p.m., Wound Nurse 1 indicated the laboratory testing had been ordered and sent to the lab. The pre-albumin and the CBC were not completed by the lab. It was scheduled to be completed on 4/20/25. The lab was notified and they indicated the testing had not been completed and were unable to provide a reason why the testing had not been done. This citation relates to Complaint IN00457153. 3.1-49(e)
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by a staff members (LPN 3, CNA 2, CNA 6, and CNA 7) when providin...

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Based on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by a staff members (LPN 3, CNA 2, CNA 6, and CNA 7) when providing care to a residents (Residents D and J) who were in Enhanced Barrier Precautions (EBP) for two random observations for infection control. Findings include: 1. During an observation on 4/29/25 from 9:07 a.m. through 9:32 a.m., Resident D was lying in bed with the head of the bed elevated. There was a peripherally inserted central catheter (PICC) inserted in the left upper arm and a wound dressing on the right heel. The resident had been incontinent of urine and LPN 3 and CNA 2 had gloves on and were starting to complete incontinence care and were stopped. LPN 3 indicated she was unsure if the resident required EBP and indicated there was no sign on the door that indicated he required EBP and EBP was not needed. LPN 3 then indicated the resident had a wound and EBP would be needed. CNA 2 and LPN 3 then donned a gown and changed gloves and began incontinence care. Resident D's record was reviewed on 5/1/25 at 10:00 a.m. The diagnoses included, but were not limited to, osteomyelitis left ankle/foot and dementia. An admission Nursing Assessment, dated 4/29/25 at 1:30 p.m., indicated an open wound on the right heel, urine and bowel incontinence, assistance was required for ADL's, and a PICC line was present. A Care Plan, dated 4/29/25, indicated EBP was required due to the PICC line and gowns and gloves were to be worn during high contact care activities. 2. During an observation on 4/30/25 at 10:50 a.m., there was a sign on the outside door frame that indicated the resident required EBP. Resident J was lying in bed. There was a PICC line observed in the right upper arm. CNA 6 and CNA 7 were in the room and indicated they were giving a bed bath and getting ready to wash the resident's back. There was a wash basin with soapy water and washcloths sitting on the night stand. CNA 6 and CNA 7 had gloves on. CNA 6 indicated EBP was not required and only gloves were required with care. CNA 7 then read the sign on the door frame and both CNA's then place gowns on over their uniforms. Resident J's record was reviewed on 5/1/25 at 1:10 p.m. The diagnoses included, but were not limited to, diabetes mellitus. The admission date was 4/2/25. A Care Plan, dated 4/2/25, indicated EBP was required. The interventions included gowns and gloves would be used when providing high contact resident care. A Physician's Order, dated 4/16/25, indicated a midline IV catheter was to be placed for IV antibiotic administration. A facility EBP policy, dated 3/2024 and identified as current by the [NAME] President of Operations, indicated staff were to don a gown and gloves during high-contact resident care. EBP PPE was to be used for residents with wounds. 3.1-18(b)
Jan 2025 9 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interview, the facility failed to ensure residents had Physician's Orders for medications and an assessment to self-administer their own medications for 1 of 1...

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Based on observation, record review, and interview, the facility failed to ensure residents had Physician's Orders for medications and an assessment to self-administer their own medications for 1 of 1 resident reviewed for self-administration of medication. (Resident 40) Finding includes: During a random observation on 1/6/25 at 10:52 a.m., there was a medication tablet in a clear medication cup on Resident 40's bedside table. At the time, Resident 40 indicated the medication was an extra strength Tylenol and the nurse always left her medications at the bedside for her to take before she went to therapy. Resident 40's record was reviewed on 1/7/25 at 3:07 p.m. Diagnoses included, but were not limited to, acute kidney failure, pressure ulcer of the sacral region, and acute respiratory failure. The Quarterly Minimum Data Set (MDS) assessment, dated 12/31/24, indicated the resident was cognitively intact for daily decision making. A Care Plan, revised on 1/6/25, indicated the resident had an order for self-administration of all medications and may keep at bedside. An intervention, dated 10/3/24, indicated to assess resident's ability to safely self-administer medications specified on admission/re-admission, quarterly, with change in medication orders, and with significant changes in condition. A Physician's Order, dated 12/30/24, indicated acetaminophen (Tylenol) oral tablet 500 milligram, give 2 tablets by mouth every 6 hours as needed for pain. There were no self-administration assessments or physician's orders for the self-administration of Tylenol. During an interview on 1/6/25 at 11:42 a.m., LPN 2 indicated she had left Resident 40's medications at the bedside during the morning medication pass as the resident was allowed to self-administer all medications. During a follow up interview on 1/6/25 at 2:22 p.m., LPN 2 indicated the most recent self-administration of medications assessment did not have all of the resident's medications listed and she did not have an order to self-administer all medications. During an interview on 1/6/25 at 2:44 p.m., the Director of Nursing indicated the order for self-administration of all medications must have been dropped off when she had gone out to the hospital. A policy titled, Self Administration of Medications and Treatments indicated .1. Self administration of medications and treatments is determined by physician order after determining that the resident is able to self administer .Procedure 1. If it is determined by a member of the interdisciplinary team, or if the resident requests to self administer, it is documented in the chart and the physician is called for an order to self administer medications, and keep the medications at the bedside. 2. Assessment of the ability to self-administer medications will be done by nursing using the tool Assessment for Self-Administration of Medications .7. A care plan is made for the resident who self administers medications, and documentation should be present in the nursing notes of teaching related to self administration of the medications or treatments. 3.1-11(a)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to ensure a resident and/or their Responsible Party were notified in writing related to a transfer to the hospital for 1 of 4 residents review...

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Based on record review and interview, the facility failed to ensure a resident and/or their Responsible Party were notified in writing related to a transfer to the hospital for 1 of 4 residents reviewed for hospitalization. (Resident 40) Finding includes: Resident 40's record was reviewed on 1/7/25 at 3:07 p.m. Diagnoses included, but were not limited to, acute kidney failure, pressure ulcer of the sacral region, and acute respiratory failure. The Quarterly Minimum Data Set (MDS) assessment, dated 12/31/24, indicated the resident was cognitively intact for daily decision making. A Progress Note, dated 12/21/2024 at 7:39 a.m., indicated the resident was asleep in bed with the head of bed elevated. The resident was observed to have tremors. The resident woke up when stimulated. She was using accessory muscles while breathing, lips slightly blue, and having difficulty breathing while speaking. The resident denied shortness of breath when asked. Oxygen was applied via nasal cannula and she was sent to the hospital for a medical evaluation via 911. The resident left awake, alert and oriented, verbally responsive, and with a rebreather mask. The resident left on a stretcher accompanied via 2 attendants. The physician, emergency contact, and supervisor were made aware. There was no documentation to indicate the State approved transfer form was completed and sent with the resident. During an interview on 1/10/25 at 10:57 a.m., the Director of Nursing indicated the resident signed/received a bed hold policy and transfer form at the time of admission. An updated form was not provided. During an interview on 1/13/25 at 12:11 p.m., the Administrator indicated all resident's received a bed hold and transfer form at the time of admission and the facility did not send it out each time of transfer from the facility. A policy titled, Discharges indicated .Hospital Transfer .4. Inform the resident and resident's responsible party of the transfer. 5. Prepare transfer form with a face sheet and medication list . 3.1-12(a)(6)(A)(ii) 3.1-12(a)(6)(A)(iii)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to ensure a resident and/or their Responsible Party were sent the facility's bed-hold and reserve bed payment policy before and upon transfer ...

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Based on record review and interview, the facility failed to ensure a resident and/or their Responsible Party were sent the facility's bed-hold and reserve bed payment policy before and upon transfer to the hospital for 1 of 4 residents reviewed for hospitalization. (Resident 40) Finding includes: Resident 40's record was reviewed on 1/7/25 at 3:07 p.m. Diagnoses included, but were not limited to, acute kidney failure, pressure ulcer of the sacral region, and acute respiratory failure. The Quarterly Minimum Data Set (MDS) assessment, dated 12/31/24, indicated the resident was cognitively intact for daily decision making. A Progress Note, dated 12/21/2024 at 7:39 a.m., indicated the resident was asleep in bed with the head of bed elevated. The resident was observed to have tremors. The resident woke up when stimulated. She was using accessory muscles while breathing, lips slightly blue, and having difficulty breathing while speaking. The resident denied shortness of breath when asked. Oxygen was applied via nasal cannula and she was sent to the hospital for a medical evaluation via 911. The resident left awake, alert and oriented, verbally responsive, and with a rebreather mask. The resident left on a stretcher accompanied via 2 attendants. The physician, emergency contact, and supervisor were made aware. There was no documentation to indicate the facility's bed-hold policy was sent to the resident and/or their Responsible Party. During an interview on 1/10/25 at 10:57 a.m., the Director of Nursing indicated the resident signed/received a bed hold policy and transfer form at the time of admission. An updated form was not provided. During an interview on 1/13/25 at 12:11 p.m., the Administrator indicated all residents received a bed hold and transfer form at the time of admission and the facility did not send it out each time of transfer from the facility. 3.1-12(a)(25)(A)
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a resident received medications as ordered for...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a resident received medications as ordered for 1 of 1 resident reviewed for dialysis, failed to hold medications outside of ordered parameters for 1 of 1 resident reviewed for discharge, failed to assess and monitor an abdominal hernia, and lack of treatment in place for leg swelling for 1 of 3 residents reviewed for edema and skin conditions. (Residents C, B, and D) Findings include: 1. Resident C's record was reviewed on 1/7/25 at 2:08 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, dependence on renal dialysis, unspecified dementia, and gastrostomy. The admission Minimum Data Set (MDS) assessment, dated 1/2/25, indicated the resident had severe cognitive impairment, received renal dialysis and tube feedings. The resident went to renal dialysis on Monday, Wednesday and Friday mornings. The resident went to dialysis on 1/2/25 and 1/3/25 due to the holiday on Wednesday,1/1/25, that week. The January 2025 Medication Administration Record (MAR) indicated the resident did not receive his morning medications on 1/2/25, 1/3/25 and 1/8/25 because he was out of the facility. The MAR was left blank on the morning of 1/6/25. The medications that were not given included, but were not limited to, doxycycline (an antibiotic), carvedilol (hypertension medication), and eopetin alfa injection (for anemia). During an interview on 1/8/25 at 2:25 p.m. with the C Unit Manager, she indicated if medications were scheduled during dialysis time, they should be rescheduled. The resident's missed medications were concerning and she would have them rescheduled. 2. Resident B's record was reviewed on 1/8/25 at 9:37 a.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, high blood pressure, and chronic kidney disease. The Discharge Minimum Data Set assessment, dated 12/16/24, indicated the resident was cognitively intact for daily decision making. The December 2024 Physician's Order Summary indicated hydralazine oral tablet 50 milligrams, 1 tablet every 8 hours, and hold for systolic blood pressure less than 130. The December 2024 Medication Administration Record indicated the resident received hydralazine on the following dates and times with a blood pressure less than 130: - 12/7/24 at 2:30 p.m. with a blood pressure of 127/74 - 12/14/24 at 10:00 p.m. with a blood pressure of 117/59 - 12/15/24 at 6:00 a.m. with a blood pressure of 120/60 - 12/16/24 at 6:00 a.m. with a blood pressure of 128/66 During an interview on 1/10/25 at 12:40 p.m., the Nurse Consultant had no further information to provide. 3. During an observation and interview on 1/7/25 at 9:35 a.m., Resident D indicated she had a large hernia that was causing discomfort and she was having a hard time eating because of it. She had a brace that she wore before in the hospital to help with the pain that she had while coughing. The resident also indicated she had edema to both of her lower legs and was supposed to have some type of wrap to them, however the facility staff were not doing that daily. The resident's legs were observed elevated on a pillow and there was a bandage on the left lower leg. There were no wraps on either leg and her legs were swollen. During an observation on 1/8/25 at 10:47 a.m., Resident D indicated her legs had no wraps on them at the time and they had never wrapped them the previous day. Her legs were elevated on a pillow. Resident D's record was reviewed on 1/8/25 at 11:55 a.m. She re-admitted to the facility on [DATE]. Diagnosis included, but were not limited to, lymphedema and heart failure. The Discharge Minimum Data Set (MDS) assessment, dated 4/15/24, indicated the resident was cognitively intact for daily decision making. The admission Minimum Data Set (MDS) assessment, dated 1/9/25, was still in progress. The January 2025 Physician's Order Summary indicated to off load heels as tolerated every shift and give furosemide tablet (diuretic medication) 40 milligrams twice daily for fluid retention. The current Care Plan indicated the resident was at risk for alteration in skin integrity related to incontinence, head of bed elevation, and history of heart failure, lymphedema, osteoarthritis, diabetes mellitus, gastroesophageal reflux disease, and high blood pressure. Interventions included, but were not limited to, ensure the heels are elevated while in bed and monitor skin when providing cares. A Nurses' Note, dated 1/2/25 at 5:43 p.m., indicated the resident arrived to the facility and was alert and oriented and able to answer questions appropriately. She had 4+ pitting edema to the bilateral lower extremities, which were both wrapped at the time for her lymphedema. Her abdomen was soft and nontender with active bowel sounds. A Skin/Wound Note, dated 1/3/25 at 1:03 p.m., indicated the resident was admitted to the facility for therapy services. She had lymphedema to bilateral lower extremities. Ammonium lactate was ordered and applied. She had a history of lymphedema and a diagphramatic hernia. A Physician Progress Note, dated 1/3/25 at 8:05 p.m., indicated the resident was observed in bed. She had bilateral lower extremities noted with chronic lymphedema and wrapped in ace wraps. She was on diuretic medication for the edema. The record lacked a care plan related to an abdominal hernia, an assessment or monitoring in place for the abdominal hernia, and orders for ace wraps to the bilateral lower extremities. During an interview on 1/9/25 at 2:05 p.m., the A Unit Manager indicated there was now an order for ace wraps for the bilateral lower extremities. The resident had a hernia that was inoperable. She was sent to the surgeon during a previous stay at the facility. The A Unit Manager was unable to locate an assessment for the hernia. During an interview on 1/9/25 at 2:15 p.m., the Director of Nursing (DON) indicated the staff would not document on the hernia unless she was having pain or telling staff she was having problems with it. The DON did not provide any further documentation regarding the hernia. During a follow up interview on 1/10/25 at 11:04 a.m., the DON provided documentation that the resident's hernia was addressed during her last stay in April and her Physician could not do any surgery for it. She was unable to provide an assessment of the hernia. She indicated the resident was currently on diuretics for edema, and wraps were now being added to the care plan. This citation relates to Complaint IN00449507. 3.1-37(a)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an indwelling Foley (urinary) catheter collect...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an indwelling Foley (urinary) catheter collection bag for a resident with a history of infection was kept off the floor for 1 of 1 resident reviewed for urinary catheters. (Resident 160) Finding includes: On 1/7/25 at 1:40 p.m., Resident 160 was observed sitting in a wheelchair at the nurses' station. The resident was talking on the phone and her catheter collection bag was lying on the floor underneath her wheelchair. On 1/9/24 at 9:16 a.m., Resident 160 was observed sitting in a recliner in her room. The resident's catheter collection bag was touching the floor in front of the recliner. During an interview on 1/19/24 at 9:19 a.m., the A Unit Manager indicated staff should have put the resident's catheter bag into a bath basin so it would not be touching the floor. Record review for Resident 160 was completed on 1/9/24 at 9:36 a.m. Diagnoses included, but were not limited to, anxiety, cerebral palsy, chronic kidney disease, hypertension, and urinary tract infection (UTI). The resident was admitted to the facility on [DATE]. A Care Plan, dated 1/6/25, indicated the resident had a urinary catheter. An intervention included to monitor and report signs or symptoms of a UTI. The January 2025 Physician's Order Summary indicated an order for Firvanq (antibiotic) 50 mg (milligrams)/ml (milliliters) solution. Give 2.5 ml by mouth one time a day for Sepsis (serious condition in which the body responds improperly to an infection). A facility policy titled, Perineal Care, and received as current from the Director of Nursing on 1/9/25, indicated, .7. Ensure Foley catheter is positioned correctly and secured . 3.1-41(a)(2)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure timely follow up on dietary recommendations fo...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure timely follow up on dietary recommendations for a resident with a feeding tube was completed for 1 of 3 residents reviewed for nutrition. (Resident 46) Finding includes: Record review for Resident 46 was completed on 1/9/25 at 11:45 a.m. Diagnoses included, but were not limited to, stroke, hypertension, and intellectual disabilities. The resident was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment, dated 12/19/24, indicated the resident was moderately cognitively impaired. The resident had a feeding tube. A Care Plan, dated 12/12/24 and revised 1/6/25, indicated the resident had the potential for alteration in nutrition and hydration related to a feeding tube. An intervention included the Registered Dietician was to evaluate and make diet change recommendations when necessary. A Registered Dietician (RD) note, dated 1/7/25 at 3:52 p.m., indicated the resident's weight was slowly increasing and staff were reporting a fair intake at most meals. A recommendation was made to place the tube feedings on hold and add supplements by mouth to ensure adequate intake. Add Med Pass (nutritional supplement drink) 120 ml (milliliters) every 6 hours and give a Magic Cup (fortified nutrition dessert cup) with all meals. A Nurse Practitioner's (NP) note, dated 1/8/25 at 2:18 p.m., indicated the resident received bolus feedings every 6 hours when the resident did not eat more than 50%. The January 2025 Physician's Order Summary indicated orders for the following: - regular diet with mechanical soft texture; give feeding when the resident ate less than 50% of their meal - after meals bolus (way to send formula through a feeding tube using a syringe), feed Jevity (fortified therapeutic nutrition) 1.2. Hold the feeding if the resident ate more than 50% of each meal. There was a lack of documentation to indicate the NP was notified of the RD's recommendations of the Med Pass and Magic Cup. There were no progress notes or Physician's Orders indicating the recommendations were addressed. There were no physician's orders for the Med Pass or the Magic Cup. On 1/10/25 at 12:31 p.m., resident was sitting in a wheelchair in her room. The resident was brought her lunch tray. There was no Magic Cup observed on the tray. The resident's meal ticket did not have a Magic Cup listed. During an interview on 1/10/25 at 2:16 p.m., the A Unit Manager indicated the nursing staff was responsible to follow up with the RD's recommendations. She was unsure about the RD's recommendations for the resident and she would have to check on it. During an interview on 1/10/25 at 3:08 p.m., the A Unit Manager indicated she received the RD's recommendations on 1/8/25 and sent them to the Physician's office. The NP saw the resident on 1/8/25, but she was unsure if that was before or after she sent the recommendations to the office. She did not address the recommendations in person with the NP that day or after and the office had not responded to her about the recommendation. The A Unit Manager followed back up on the recommendation with the Physician's office on 1/10/25, and they put an order in for the Med Pass and Magic Cup. She indicated she had not followed back up on the recommendations until it was brought to her attention. A facility policy titled, Dietary Referrals and received as current from the Director of Nursing on 1/10/25, indicated, .1. If there is a referral from dietician consult, the nurse is to inform the physician of the recommendation .3. Documentation will be present in resident records . 3.1-46(a)(1) 3.1-46(a)(2)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a resident with a gastrostomy (surgical insert...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a resident with a gastrostomy (surgical insertion of a feeding tube) received the appropriate treatment related to incorrect flow rate for the tube feeding for 1 of 1 resident reviewed for tube feedings. (Resident C) Finding includes: On 1/8/25 at 2:20 p.m., Resident C was observed lying in his bed. His tube feeding was on and flowing at 75 milliliters per hour (ml/hr). On 1/9/25 at 9:18 a.m. and 11:20 a.m., the resident was in bed and his tube feeding was on and flowing at 45 ml/hr. The resident's record was reviewed on 1/7/25 at 2:08 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, dependence on renal dialysis, unspecified dementia and gastrostomy. The admission Minimum Data Set (MDS) assessment, dated 1/2/25, indicated the resident had severe cognitive impairment, received renal dialysis, and tube feedings. A Physician's Order, dated 1/7/25, indicated the resident was to receive Nepro with Carb Steady via tube feeding at 65 ml/hr for 24 hours daily. During an interview on 1/9/25 at 11:20 a.m., the C Unit Manager indicated the tube feeding should be 65 ml/hr and she would correct it. 3.1-44(a)(2)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0694 (Tag F0694)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a peripheral inserted central catheter (PICC) ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a peripheral inserted central catheter (PICC) was maintained related to the dressing not being changed as ordered for 1 of 3 residents reviewed for non-pressure skin conditions. (Resident 116) Finding includes: On 1/6/25 at 1:37 p.m., Resident 116 was observed in his bed. He had a PICC inserted in his right upper arm with a dressing dated 12/23/24. The resident's record was reviewed on 1/6/25 at 3:00 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to unspecified dementia, asthma, and gout. The admission Minimum Data Set (MDS) assessment, dated 12/30/24, indicated the resident had moderate cognitive impairment, was dependent on staff for transfers, and did not have IV access. A Physician's Order, dated 12/25/24, indicated to change the PICC dressing every seven days on Saturday. The January 2025 Medication Administration Record indicated the dressing had been changed on 1/4/25. During an interview with RN 4 on 1/6/25 at 1:51 p.m., she indicated the dressing was dated 12/23/24 and had not been changed since admission. 3.1-47(a)(2)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interview, the facility failed to ensure infection control measures were in place and maintained related to improper protective personal equipment (PPE) worn i...

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Based on observation, record review, and interview, the facility failed to ensure infection control measures were in place and maintained related to improper protective personal equipment (PPE) worn in an isolation room for 1 of 1 resident reviewed for respiratory care. (Resident 125) Finding includes: On 1/7/25 at 10:35 a.m., Resident 125 was observed in her room. There were isolation signs on the resident's door that indicated she was on contact and droplet precautions. Another sign indicated the room was a Red Zone, and PPE required to enter was an N95 or approved KN95 respiratory mask, goggles or a faceshield, gown and gloves. There was a PPE bin outside the resident's room. On 1/8/25 at 9:32 a.m., LPN 1 was observed in the resident's room speaking with a family member. The nurse had her personal glasses on and was wearing a surgical mask. She was not wearing an N95 mask, goggles or a faceshield, gown or gloves. LPN 1 exited the room at 9:40 a.m. During an interview at that time, the LPN indicated the resident was on isolation because she was immunocompromised, she was not aware the resident had coronovirus. Resident 125's record was reviewed on 1/10/25 at 9:00 a.m. Diagnoses included, but were not limited to, heart failure, acute and chronic respiratory failure, and hypothyroidism. The admission Minimum Data Set assessment, dated 1/1/25, indicated the resident was cognitively intact, required supervision for transfers, toileting and bed mobility, and used oxygen. A Medication Administration Note, dated 1/1/25, indicated the resident had a persistent cough and chronic obstructive pulmonary disease and the on call Physician had ordered a respiratory panel (test for respiratory pathogens) to be done. A Health Status Note, dated 1/3/25, indicated the resident had tested positive for coronovirus and would be placed on strict droplet isolation. A Physician's Order, dated 1/4/25, indicated strict transmission based contact/droplet isolation precautions and all services to be provided in private room. A Physician Progress Note, dated 1/8/25, indicated the resident had tested negative for COVID-19. However the respiratory panel detected Coronovirus OC 43, .while this is not COVID-19, COVID-19 and this virus are both coronoviruses, and are transmitted via respiratory excretion. For this reason, the patient was kept in isolation for 10 days to avoid the risk of spreading this virus to staff and patients. The document, Infection Control Policy, reviewed 11/2024, indicated, .Droplet Precautions will be used for residents known or suspected to be infected with microorganisms transmitted by droplets that can be generated by the resident during coughing, sneezing, talking or during cough-inducing procedures .don a mask prior to entering the room . and, .Contact Precautions will be used for specified resident known or suspected to be infected with microorganisms that can be transmitted by direct contact .or indirect contact (touching) with environmental surfaces or resident care items in the resident's environment . [NAME] gloves and gown when entering the room. 3.1-18(a)(2)
Dec 2024 1 deficiency
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0573 (Tag F0573)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide residents' medical records to the resident/ Power of Attorn...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide residents' medical records to the resident/ Power of Attorney (POA) in a timely manner after a request was made for 3 of 3 residents reviewed for medical record requests. (Residents B, C, and D) Finding includes: 1. Resident B's closed record was reviewed on 12/5/24 at 9:04 a.m. The diagnoses included, but were not limited to, fractured left femur. Resident B was discharged from the facility on 7/3/24. A Power of Attorney (POA) form and Healthcare Representative (HCR) form, both dated 6/26/18, indicated the resident's husband was appointed POA and HCR. In the absence of the resident's husband, the resident's daughter was the successor. During an interview with resident's POA on 12/5/24 at 9:38 a.m., she indicated the resident's condition had deteriorated and a signed release of information approval had been given to a law firm. The firm had received part of the medical record, though there were several duplicates in the file received and the full record had not been received as requested. The law firm had been attempting to notify the facility for the rest of the medical records and had no return communication from the facility. During an interview on 12/5/24 at 10:15 a.m., the Administrator indicated the only request he had been aware of was a request for the billing records, and those had been sent. He indicated the facility had received a letter from the law firm on either 11/29/24 or 12/2/24, that had been dated 11/7/24. The letter indicated the law firm had received part of the medical record and requested the rest of the record to be sent. He indicated the facility Medical Records Coordinator (MRC) had left the position and the position had just been filled by another person. All requests were to be forwarded to the Corporate MRC for approval, then were to be sent as requested. During a telephone interview on 12/5/24 at 10:20 a.m., the former MRC indicated she did not remember if a request had been made for the medical record. If she had received a request, the request would have been forwarded to the Administrator, Director of Nursing, and the Corporate MRC. The record would not have been sent until the Corporate MRC approved the request. On 12/5/24 at 10:25 a.m., the Administrator provided the medical record request and grievance letter received from the law firm. The title page indicated the letter had been faxed to the facility on [DATE]. The Administrator indicated he had just received the letter. The current MRC indicated the letter had been placed in her facility mailbox and she received the letter either on 11/29/24 or 12/2/24. She was unsure who had placed the letter in her mailbox. She indicated the letter had not been faxed to her fax machine. The letter faxed to the facility was dated 11/7/24, and the timeline documented indicated the first request for the medical record was on 8/28/24. They had received 106 pages on 8/29/24, which was triple copies of the same 36 pages. The former MRC was contacted on 8/30/24 and informed the full record had not been received and the records received were triple copies. On 9/9/24, the former MRC had messaged the law firm and indicated the resident had been at the facility for a short time so there was not a lot of information in the record. An email had been sent to the former MRC on 11/7/24 and the email was returned undeliverable. Several attempts were made to contact the facility by telephone, and the calls were not answered. During an interview on 12/5/24 at 10:55 a.m., the current MRC indicated she had received the letter on 11/24/24 and forwarded the request/grievance to the Corporate MRC. During an interview on 12/5/24 at 10:58 a.m., the Corporate MRC indicated when a request was made for a medical record, it was forwarded to her and she would then give the approval to send the requested record. She had not received a request for Resident B's full medical record. She had only received the request for the billing record and it had been sent. The full medical record would be sent to the law firm today (12/5/24). During an interview on 12/5/24 at 11:04 a.m., the Administrator indicated the requested medical record had not been provided timely. 2. Resident C's record was reviewed on 12/5/24 at 11:26 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease. The resident requested a copy of the complete medical record on 10/11/24. A Progress Note, dated 10/25/24, indicated the medical record had been sent through secure email. 3. Resident D's record was reviewed on 12/5/24 at 11:31 am The diagnoses included, but were not limited to, dislocation of left shoulder. The resident requested a copy of the complete medical record from 8/4/24 through 10/7/24 on 10/11/24. A Progress Note, dated 10/25/24, indicated the medical record had been sent to the resident. A medical records policy and procedure, dated 5/2023 and received as current from the Administrator, indicated the resident/representatives will have the ability to review, inspect and/or obtain a copy of his/her protected health information in the health record. A copy of the record or any portions of the record would be provided upon request and two working days advance notice to the facility. This citation relates to Complaint IN00447084. 3.1-4(b)(2)
Jul 2024 3 deficiencies
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure an allegation of abuse was reported to the Administrator and the Indiana Department of Health (IDOH) immediately or within the 2 hou...

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Based on interview and record review, the facility failed to ensure an allegation of abuse was reported to the Administrator and the Indiana Department of Health (IDOH) immediately or within the 2 hour time period for 1 of 3 residents reviewed for abuse. (Resident E) Finding includes: During an interview on 7/15/24 at 4:35 a.m., LPN 1 indicated a few weeks ago, Resident E had made the allegation the staff were rough with her during care. She was unable to give the names of the staff. LPN 1 immediately reported the allegation to the Director of Nursing (DON) and the DON indicated she would follow up on the allegation. During an interview on 7/15/24, the Administrator indicated he was not notified of the allegation of the staff being rough during care by Resident E. There was no reported incident to the IDOH about the allegation. During an interview on 7/16/24 at 9:45 a.m., the Administrator indicated he had spoken to the DON, who was on vacation, and the DON indicated LPN 1 had reported the allegation to her. The DON had interviewed the resident she had not voiced an allegation about rough care during the interview. The Administrator indicated as soon as he had been aware of the allegation on 7/15/24, he immediately reported it to the IDOH. Resident E's record was reviewed on 7/16/24 at 11:03 a.m. The diagnoses included, but were not limited to malignant cancer of the breast and uterus. An admission Minimum Data Set assessment, dated 6/25/24, indicated a moderately impaired cognitive status and required supervision for bed mobility and upper body dressing, moderate assistance with lower body dressing, hygiene, and transfers, and maximum assistance for toileting and bathing. There was no documentation in the Nurses' Progress notes from 6/18/24 through 7/14/24 that indicated an allegation of rough care was voiced by the resident. A facility abuse policy, dated 3/2024 and received as current from the Administrator, indicated an allegation of abuse was to be immediately reported to the Administrator. If the Administrator was not present, the allegation was to be reported to their immediate supervisor and/or the facility DON. The Administrator or designee were to report the allegation to the IDOH immediately, within two hours if actual harm was suspected and 24 hours for all other alleged allegations. This citation relates to Complaints IN00436496 and IN00437883. 3.1-28(c)
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interview, the facility failed to ensure standard practice of care was followed during an observation of a gastrostomy (g-tube) (feeding tube) medication admin...

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Based on observation, record review, and interview, the facility failed to ensure standard practice of care was followed during an observation of a gastrostomy (g-tube) (feeding tube) medication administration, related to the placement of the g-tube not being confirmed prior to the administration of the medications, for 1 of 1 resident observed and reviewed for g-tube care. (Resident F) Finding includes: During a medication administration observation on 7/15/24 at 8:28 a.m., LPN 2 entered Resident F's room with 11 medication cups containing one crushed medication in each cup, a glass with apple juice which contained a medication that required apple juice for administration, and 30 ml (milliliters) of a protein supplement. The medications were placed on the over bed table. LPN 2 mixed the medications with 5 mls of water in each cup, flushed the g-tube with 60 ml of water, then administered the protein supplement and the medications separately through the resident's g-tube. LPN 2 did not confirm the placement of the g-tube prior to the administration of the medications. During an interview on 7/15/24 at 8:28 a.m., LPN 2 indicated she was unsure how to confirm placement of the g-tube at the facility. She indicated she worked in other facilities and was not sure of this facility's policy for how to check for placement. A facility medication administration via a g-tube policy, dated 3/2023 and received as current from the Assistant Director of Nursing, indicated medications were to be given separately through the g-tube. The placement of the tube was to be confirmed prior to the administration of the medications by gently drawing back on the piston of the syringe for gastric content, which would indicate the g-tube was patent and in the stomach. 3.1-44(a)(2)
MINOR (C) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Minor Issue - procedural, no safety impact

Staffing Information (Tag F0732)

Minor procedural issue · This affected most or all residents

Based on observation, record review, and interview, the facility failed to ensure the posted Nurse Staffing Information included only the staff who were providing direct resident care, related to Nurs...

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Based on observation, record review, and interview, the facility failed to ensure the posted Nurse Staffing Information included only the staff who were providing direct resident care, related to Nursing Administration hours included on the postings. This had the potential to affect all residents who resided in the facility during May, June, and July, 2024. Finding includes: During an observation on 7/15/24 at 4:30 a.m., there were two nurses, one QMA, and three CNAs working the evening/night shift. LPN 1 indicated the staff work 12 hours shifts. During an observation on 7/15/24 at 8 a.m., there were four nurses and six CNAs working the day/evening shift. Nursing schedules and posted nursing hours, dated 5/19/24 through 6/9/24 and 7/1/24 through 7/14/24 were reviewed on 7/16/24 at 12:00 p.m. The scheduled hours for the nurses did not match the posted hours when compared for each day. The nurses' hours were higher on the Nurse Staffing Information than the observations of the nurses in the facility who provided direct resident care. During an interview on 7/16/24 at 1:04 p.m., the Assistant Director of Nursing (ADON) indicated the Nurse Staffing Information included all the Administrative Nursing staff, which included, but was not limited to, the Director of Nursing, the ADON, and the Minimum Data Set (MDS) assessment Nurse. She indicated the Administrative Nursing staff did not provide continual direct resident care. The Corporate Regional [NAME] President indicated the nursing hours reported for the CMS Staffing Data Report were only nurses who provided direct resident care and the Administrative Nursing staff hours were not reported for the Data Report. This citation is related to Complaint IN00436496.
Apr 2024 4 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interview, the facility failed to ensure residents received the necessary care and treatment related to lack of assessment and treatment order for a skin tear,...

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Based on observation, record review, and interview, the facility failed to ensure residents received the necessary care and treatment related to lack of assessment and treatment order for a skin tear, for 1 of 1 residents reviewed for non-pressure skin conditions. (Resident 31) Finding includes: On 4/1/24 at 2:23 p.m., Resident 31 was observed seated in his room. He had a dressing on his right elbow that was coming loose and was soiled with blood. He indicated he had bumped his elbow that morning and got a skin tear. Resident 31's record was reviewed on 4/2/24 at 9:28 a.m. Diagnoses included, but were not limited to, Diabetes Mellitus and a foot ulcer. The admission Minimum Data Set assessment, dated 2/22/24, indicated the resident required extensive staff assistance for transfers and toileting. He was cognitively intact. The record lacked documentation or assessment of the skin tear on his right elbow. The record lacked a Physician's Order for treatment of the skin tear. During an interview on 4/2/24 at 9:35 a.m., LPN 4 indicated she was unaware of what had happened to the resident's elbow. During an interview on 4/2/24 at 10:44 a.m., the Unit Manager indicated she had spoken to the nurse who was taking care of the resident the previous day. The nurse indicated she had forgotten to document the wound, but had notified the Wound Nurse, and there was not a treatment order in place. 3.1-37(a)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a Physician's Order was obtained for a urinary...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a Physician's Order was obtained for a urinary catheter, catheter care was completed, and urinary output was recorded for 1 of 3 residents reviewed for urinary catheters. (Resident 105) Finding includes: On 4/1/24 at 10:44 a.m., Resident 105 was observed in his room with a urinary catheter bag in place. On 4/3/24 at 1:30 p.m., Resident 105 was observed seated in his wheelchair in his room. He had a catheter bag in place. The record for Resident 105 was reviewed on 4/4/24 at 9:51 a.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, anemia, and dementia. The resident was admitted to the facility on [DATE]. A Care Plan, dated 3/28/24, indicated the resident had a urinary catheter. The admission Nursing Evaluation, dated 3/28/24, indicated the resident had a 16f (french, catheter size) indwelling catheter. The admission Progress Note from the Nurse Practitioner, dated 3/29/24 6:04 p.m., indicated the resident had a chronic foley catheter, last changed on 3/20/24. He had a follow up appointment with urology on 4/11/24 for a catheter exchange. The Physician's Order Summary, dated 4/2024, lacked any orders for the urinary catheter, catheter care, or to record urine output. An order, dated 4/2/24, indicated to give ceftriaxone (an antibiotic) 1 gram every 24 hours intravenously for 5 days for a urinary tract infection (UTI). The Medication Administration Records (MAR) and Treatment Administration Records (TAR), dated 3/2024 and 4/2024, lacked any documentation of catheter care or urine output. The resident was currently receiving an antibiotic treatment for a UTI. The Bladder Continence Task documentation, dated 3/2024 and 4/2024, indicated the urine output had only been documented one time since the resident's admission to the facility: 3/31/24 at 5:59 a.m. - 1800 cc (cubic centimeters) During an interview with the Director of Nursing (DON) on 4/4/24 at 11:34 a.m., she indicated the resident had a catheter since admission. There were no orders in the computer for the urinary catheter, catheter care, or for recording the urine output. 3.1-41(a)(2)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

2. On 4/2/24 at 9:22 a.m., Resident 3 was lying in bed. The resident was wearing oxygen via a nasal cannula with a flow rate at 2.5 liters. On 4/2/24 at 12:52 p.m., Resident 3 was lying in bed. The re...

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2. On 4/2/24 at 9:22 a.m., Resident 3 was lying in bed. The resident was wearing oxygen via a nasal cannula with a flow rate at 2.5 liters. On 4/2/24 at 12:52 p.m., Resident 3 was lying in bed. The resident was wearing oxygen via a nasal cannula with a flow rate at 2.5 liters. On 4/3/24 at 10:00 a.m., Resident 3 was lying in bed. The resident was wearing oxygen via a nasal cannula with a flow rate at 2.5 liters. Record review for Resident 3 was completed on 4/2/24 at 1:12 p.m. Diagnoses included, but were not limited to, depression, chronic obstructive pulmonary disease (COPD) and asthma. The Annual Minimum Data Set (MDS) assessment, dated 3/15/24, indicated the resident was cognitively intact. The resident required assistance with ADLs (activities of daily living). The resident did not have oxygen therapy. A Care Plan, dated 4/1/23 and revised 3/31/24, indicated the resident had oxygen therapy at 3 liters via nasal cannula PRN (when necessary) related to COPD. An intervention included to administer oxygen per physicians orders. The April 2024 Physician's Order Summary indicated and order for Oxygen at 3 liters per nasal cannula every shift PRN. During an interview on 4/3/24 at 10:55 a.m., the Director of Nursing indicated the resident's oxygen was a PRN order. The staff should have set the flow rate at 3 liters when the resident required the oxygen. 3.1-47(a)(6) Based on observation, record review, and interview, the facility failed to ensure residents received the correct and necessary respiratory treatment, related to no Physician's Order for oxygen and incorrect oxygen flow rate, for 2 of 4 residents reviewed for respiratory care. (Residents 258 and 3) Findings include: 1. On 4/1/24 at 11:05 a.m., Resident 258 was observed lying in bed. He had a nasal cannula in place with oxygen flowing at 2.5 liters per minute. Resident 258's record was reviewed on 4/3/24 at 9:05 a.m. Diagnoses included, but were not limited to, acute kidney failure, Diabetes Mellitus and congestive heart failure. There was no Physician's Order for the oxygen. An admission Nursing Evaluation, dated 3/21/24, indicated the resident's oxygen saturation was 94% on oxygen via nasal cannula. During an interview on 4/3/24 at 2:45 p.m., the Unit Manager indicated there was no Physician's Order for the oxygen.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on observation and interview, the facility failed to ensure there was a sanitary kitchen, related to undated and/ or unlabeled food, a build up on ice in the freezer, and a spilled substance and...

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Based on observation and interview, the facility failed to ensure there was a sanitary kitchen, related to undated and/ or unlabeled food, a build up on ice in the freezer, and a spilled substance and food on the floors in a refrigerator and dry storage room. This had the potential to affect all 68 residents who received meals prepared in the kitchen. Findings include: On 4/1/24 at 8:45 a.m., during the initial kitchen tour with [NAME] 1, the following was observed: a. In the walk in refrigerator, there were boxes of soda and pies sitting directly on the floor. b. In the walk in refrigerator, there was a package of raw meat, gravy in a plastic container, and mashed potatoes that were unlabeled and undated. c. There was a raw potato and a pink substance spilled on the refrigerator floor. d. In the freezer, there was a heavy build up of ice on the ceiling and on two boxes of food. e. In the dry storage room, there was a large amount of dry oatmeal spilled on the shelves and floor. During an interview with [NAME] 1 at the time of observation, she indicated the items should be labeled and dated. She indicated the spills just happened recently and the staff was busy preparing breakfast. 3.1-21(i)(3)
Feb 2024 2 deficiencies
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

3. The record for Resident G was reviewed on 2/14/24 at 8:44 a.m. Diagnoses included, but were not limited to dementia, hypertension, and chronic kidney disease. The admission Minimum Data Set (MDS) ...

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3. The record for Resident G was reviewed on 2/14/24 at 8:44 a.m. Diagnoses included, but were not limited to dementia, hypertension, and chronic kidney disease. The admission Minimum Data Set (MDS) assessment, dated 1/28/24, indicated the resident was cognitively impaired and required partial to moderate assistance with eating. A current care plan indicated the resident had an ADL self-care deficit and was dependent on staff for assistance with eating. The food consumption task documentation, dated 1/21/24 through 2/14/24, indicated there were no meal consumption's documented for the following days and meals: 1/22/24 breakfast, lunch, and dinner 1/23/24 breakfast, and dinner 1/24/24 breakfast, lunch, and dinner 1/25/24 dinner 1/26/24 breakfast, lunch, and dinner 1/27/24 lunch and dinner 1/28/24 lunch 1/29/24 breakfast and lunch 1/30/24 breakfast and dinner 1/31/24 breakfast and dinner 2/1/24 lunch 2/2/24 breakfast and dinner 2/3/24 breakfast and dinner 2/4/24 breakfast and dinner 2/5/24 dinner 2/6/24 dinner 2/7/24 breakfast, lunch, and dinner 2/8/24 dinner 2/9/24 dinner 2/10/24 breakfast and dinner 2/11/24 dinner 2/12/24 breakfast, lunch, and dinner 2/13/24 breakfast and dinner During an interview with the Director of Nursing (DON), on 2/14/24 at 1:45 p.m., she indicated the facility had just switched to twelve hours shifts on February 1st, and the meal consumption charting was something they needed to work out. This citation relates to Complaints IN00426084 and IN00428145. 3.1-50(a)(1) 3.1-50(a)(2) Based on record review and interview, the facility failed to ensure a resident's record was complete and accurate, related to documentation of dietary intakes, for 3 of 3 residents reviewed for dietary intakes. (Residents D, F, and G) Findings include: 1) Resident D's closed record was reviewed on 2/14/24 at 9:06 a.m. The diagnoses included, but were not limited to, chronic lymphocytic leukemia and cognitive communication deficit. An Admission/5-Day Minimum Data Set (MDS) assessment, dated 1/26/24, indicated a severely impaired cognitive status, no behaviors, and moderate assistance was required for dietary intake. A Care Plan, dated 1/22/24 and revised on 1/29/24, indicated she was a risk for malnutrition. The interventions included she would be assisted with eating her meals. The food consumption task documentation, dated 1/21/24 through 2/12/24, indicated there were no meal consumption's documented for the following days and meals: 1/21/24 supper 1/22/24 lunch and supper 1/23/24 lunch and supper 1/24/24 lunch and supper 1/25/24 lunch and supper 1/26/24 breakfast, lunch, and supper 1/27/24 breakfast, lunch, and supper 1/28/24 lunch and supper 1/29/24 breakfast, lunch, and supper 1/30/24 breakfast, lunch, and supper 1/31/24 breakfast, lunch, and supper 2/1 - 2/11/24 breakfast, lunch, and supper 2/12/24 supper 2. Resident F's record was reviewed on 2/13/24 at 3:55 p.m. The diagnoses included, but were not limited to, pulmonary fibrosis and diabetes mellitus. An Admission/5-Day MDS assessment, dated 1/22/24, indicated a severely impaired cognitive status, no behaviors, and required maximum assistance with dietary intake. A Care Plan, dated 1/16/24, indicated assistance was needed for all ADL's (activities of daily living). The food consumption task documentation, dated 1/16/24 through 2/12/24, indicated there were no meal consumption's documented for the following days and meals: 1/16/24 supper 1/17/24 breakfast, lunch, and supper 1/18/24 breakfast and supper 1/19/24 breakfast, lunch, and supper 1/20/24 breakfast, lunch, and supper 1/21/24 supper 1/22/24 breakfast, lunch, and supper 1/23/24 supper 1/24/24 lunch and supper 1/25/24 lunch and supper 1/26/24 through 1/29/24 breakfast, lunch, and supper 1/30/24 supper 1/31/24 lunch and supper 2/8/24 and 2/9/24 breakfast, lunch, and supper 2/10/24 supper 2/11/24 breakfast, lunch, and supper 2/12/24 supper
CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

Based on record review and interview, the facility failed to ensure residents who required assistance for activities of daily living (ADL's), received bathing/showers at least twice a week, for 4 of 5...

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Based on record review and interview, the facility failed to ensure residents who required assistance for activities of daily living (ADL's), received bathing/showers at least twice a week, for 4 of 5 residents who require extensive to dependent assistance for ADL's. (Residents D, E, F, and H) Findings include 1) Resident D's closed record was reviewed on 2/14/24 at 9:06 a.m. The diagnoses included, but were not limited to, Chronic lymphocytic leukemia and cognitive communication deficit. An Admission/5-Day Minimum Data Set (MDS) assessment, dated 1/26/24, indicated a severely impaired cognitive status, no behaviors, and was dependent on staff for bathing and hygiene. A Care Plan, dated 1/22/24, indicated assistance would be provided for ADL's. The bathing schedule, indicated the resident's bathing was to be completed on Wednesdays and Saturdays on the first shift. The shower forms and tasks area of the record indicated bathing/showers were not completed on January 24, 2024 and February 10, 2024. 2) During an interview on 2/13/24 at 2:26 p.m., Resident E indicated bathing was not completed as it should be. She indicated her last bed bath was a week ago, and showers were not offered because she was unable to stand. Her bathing was scheduled for Mondays and Thursdays. Resident E's record was reviewed on 2/13/24 at 3:06 p.m. The diagnoses included, but were not limited to, diabetes mellitus. A Quarterly MDS assessment, dated 12/19/23, indicated an intact cognitive status, no behaviors, and required moderate assistance with showers. A Care Plan, dated 9/12/23, indicated assistance was required for ADL's. The bathing schedule indicated bathing was to occur on Mondays and Thursdays during the first shift. The tasks form in the record indicated bathing (type of bathing was not documented) on February 1 and 12, 2024. The shower forms, indicated no shower or bed bath had been completed on February 1, 5, 8, and 12, 2024. 3) Resident F's record was reviewed on 2/13/24 at 3:55 p.m. The diagnoses included, but were not limited to, pulmonary fibrosis and diabetes mellitus. An Admission/5-Day MDS assessment, dated 1/22/24, indicated a severely impaired cognitive status, no behaviors, and was dependent for showers. A Care Plan, dated 1/16/24, indicated assistance was needed for all ADL's. The resident was scheduled for bathing on Mondays and Thursdays during the first shift. The bathing forms indicated bathing had not occurred on January 29, 2024 and February 8, 2024. 4) During an interview on 2/13/24 at 2:03 p.m., Resident H indicated she had not received any showers at the facility due to a pressure ulcer on her buttocks. She seldom received bed baths, and has had one bed bath in the past three weeks. Resident H record was reviewed on 2/14/24 at 11:36 a.m., The diagnoses included, but were not limited to, stage 4 (deep pressure wound/ulcer) of the sacral region. An Admission/5-Day MDS assessment, dated 12/25/23, indicated an intact cognitive status, no behaviors, and was dependent for showers. A Care Plan, dated 12/18/23, indicated assistance was required for all ADL's. The bathing schedule for January, 2024, indicated bathing was to be completed on Mondays and Thursdays on day shift. Bathing was not completed on January 11 and 15, 2024. The bathing schedule for February, 2024, indicated bathing was to be completed on Wednesdays and Saturdays on the first shift. Bathing had not been completed on February 7 and 10, 2024. During an interview on 2/14/24 at 1:45 p.m., the Director of Nursing indicated showers/bathing was to be completed at least twice a week, unless it was refused by the resident. This citation relates to Complaints IN00421580 and IN00426084. 3.1-38(a)(3) 3.1-38(b)(2)
Mar 2023 6 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interview, the facility failed to ensure residents had Physician's Orders for medications and an assessment to self-administer their own medications for 1 of 1...

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Based on observation, record review, and interview, the facility failed to ensure residents had Physician's Orders for medications and an assessment to self-administer their own medications for 1 of 1 residents reviewed for self-administration of medication. (Resident 160) Finding includes: During a random observation on 3/20/23 at 9:45 a.m., a basin was noted in the bathroom that held a bottle of throat spray and a bottle of Dakins solution. During a random observation on 3/21/23 at 9:29 a.m., a basin was noted in the bathroom that held a bottle of throat spray and a bottle of Dakins solution. Resident 160's record was reviewed on 3/22/23 at 1:51 p.m. Diagnoses included, but were not limited to, high blood pressure and hypothyroidism. A Physician's Order, dated 3/17/23, indicated Dakins External Solution 0.25 % (sodium hypochlorite), apply to mid abdomen topically every day shift for wound care. Cleanse with wound cleanser, pack lightly with Dakins soaked gauze, cover with abd pad and dry dressing. There were no orders for a throat spray. There were no orders for self-administration of any medications. A self-administration of medication assessment was not completed. Interview with the Director of Nursing on 3/23/23 at 2:55 p.m., indicated the resident said those were her personal belongings that came from the hospital that she wanted to keep but she had not used them since she arrived to the facility. 3.1-11(a)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interview, the facility failed to ensure oxygen was properly placed for 1 of 2 residents reviewed for respiratory services. (Resident 162) Finding includes: On...

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Based on observation, record review, and interview, the facility failed to ensure oxygen was properly placed for 1 of 2 residents reviewed for respiratory services. (Resident 162) Finding includes: On 3/20/23 at 11:27 a.m., Resident 162 was observed in bed. His nasal cannula and oxygen tubing were noted to be hanging on the bedside rail and not in use. On 3/21/23 at 9:26 a.m., Resident 162 was observed in bed. The oxygen was not in use. Resident 162's record was reviewed on 3/22/23 at 11:47 a.m. Diagnoses included, but were not limited to heart failure, chronic obstructive pulmonary disease, high blood pressure, and diabetes mellitus. A Physician's Order, dated 3/15/23, indicated oxygen at 2 liters per minute continuously. A Care Plan, dated 3/16/23, indicated the resident had oxygen therapy. Interventions included, but were not limited to, administer oxygen per physicians orders. Interview with the Director of Nursing on 3/24/23 at 8:59 a.m., indicated the respiratory therapist had instructed the resident to start weaning off of the oxygen, but there was no documentation. 3.1-47(a)(6)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a pain medication was provided for a resident ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a pain medication was provided for a resident experiencing pain for 1 of 1 residents reviewed for pain. (Resident B) Finding includes: On 3/21/23 at 9:57 a.m., Resident B was observed seated on the edge of her bed. She was rubbing her knees and grimacing, she indicated her knees and hips were hurting. On 3/23/23 at 2:26 p.m., the resident was seated in her wheelchair in her room. She indicated it hurt every time she moved in her knees and hips. The resident's record was reviewed on 3/22/23 at 2:47 p.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, dementia, heart disease and gout. A Pain Screen, dated 3/21/23, indicated the resident was having occasional pain in the past five days. A Physical Therapy Treatment Encounter Note, dated 3/18/23, indicated the patient was having increased pain in both knees requiring her to sit back in the wheelchair. A Note, dated 3/22/23, indicated she was having difficulty standing due to complaints of pain in both knees. Physician's Orders, dated 3/20/23, indicated to apply Voltaren gel (topical pain medication) 4 grams to the left knee every 6 hours as needed for pain and give Tylenol 500 milligrams every 6 hours as needed for pain. The March 2023 Medication Administration Record (MAR) indicated Voltaren gel had never been administered and Tylenol had been given one time on 3/23/23. A pain assessment was completed three times a day and marked as having no pain every time. Interview with LPN 1 on 3/23/23 at 2:45 p.m., indicated she had done the pain assessment that shift and didn't think the resident was having any pain. She indicated when the resident was moved she would complain of pain or tell them not to touch her bad leg. She indicated she had never given the resident anything for pain. This Federal tag relates to Complaint IN00393079. 3.1-37(a)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interview, the facility failed to ensure there was competent nursing staff provided for proper medication administration of an IV (intravenous) medication rela...

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Based on observation, record review, and interview, the facility failed to ensure there was competent nursing staff provided for proper medication administration of an IV (intravenous) medication related to heparin (blood thinner) flushes for a random medication administration observation. (LPN 2 and Resident 29) Finding includes: On 3/23/23 at 10:44 a.m., LPN 2 was observed passing medications to Resident 29. She prepared the ceftriaxone sodium (an antibiotic medication) 2 grams after performing hand hygiene and donning gloves. She primed new intravenous (IV) tubing, cleaned the midline access site with an alcohol swab, flushed the IV with 10 milliliters (ml) of normal saline and then attached the IV tubing containing the ceftriaxone. At 11:26 a.m., LPN 2 was observed disconnecting the IV tubing after the medication had completed infusing. She clamped the tubing, cleaned the access site with an alcohol swab, flushed the IV with 10 ml of normal saline, flushed the IV with 5 ml of heparin (an anticoagulant), cleaned the site again and applied a new cap to the access site. Resident 29's record was reviewed on 3/24/23 at 9:33 a.m. Diagnoses included, but were not limited to, pneumonia, anemia, and atrial fibrillation (irregular heart beat). A Physician's Order, dated 3/19/23, indicated IV non-valved midline, flush with 10 ml normal saline before and after medications, then flush with 3 ml heparin (10 units/ml). Interview with the Director of Nursing on 3/23/23 at 2:55 p.m., indicated the LPN should have given the ordered dose of heparin flush. 3.1-17(a)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to ensure medications were given as ordered for 1 of 5 residents reviewed for unnecessary medications. (Resident 1) Finding includes: Residen...

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Based on record review and interview, the facility failed to ensure medications were given as ordered for 1 of 5 residents reviewed for unnecessary medications. (Resident 1) Finding includes: Resident 1's record was reviewed on 3/21/23 at 2:57 p.m. Diagnoses included, but were not limited to cellulitis, high blood pressure, and coronary artery disease. The admission Minimum Data Set (MDS) assessment, dated 3/14/23, indicated the resident was cognitively intact for daily decision making. A Physician's Order, dated 3/8/23, indicated midodrine 5 milligram (mg) tablet, 1 tablet by mouth every 12 hours for hypotension. The February 2023 Medication Administration Record (MAR) indicated the midodrine medication was not administered as ordered on the following dates and times: - 2/18/23 at 9:00 p.m. with a blood pressure of 161/70 - 2/20/23 at 9:00 a.m. with a blood pressure of 146/83 - 2/21/23 at 9:00 a.m. with a blood pressure of 140/62 - 2/21/23 at 9:00 p.m. with a blood pressure of 124/55 - 2/24/23 at 9:00 a.m. with a blood pressure of 167/75 - 2/25/23 at 9:00 a.m. with a blood pressure of 132/60 - 2/26/23 at 9:00 a.m. with a blood pressure of 132/63 - 2/26/23 at 9:00 p.m. with a blood pressure of 138/69 Interview with the Director of Nursing on 3/24/23 at 8:59 a.m., indicated there were no orders received for holding the midodrine medication on those days. 3.1-48(a)(1)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented related to not cleaning a glucometer observed during medica...

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Based on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented related to not cleaning a glucometer observed during medication pass. (LPN 3) Finding includes: On 3/23/23 at 10:59 a.m., LPN 3 was observed preparing to check a resident's blood sugar. She removed a glucometer, lancet, alcohol swabs, and the test strips from the medication cart. She performed hand hygiene and donned gloves and proceeded to walk into the residents room and check her blood sugar. Once the procedure was completed, she put the lancet in the sharps container, removed her gloves, performed hand hygiene and placed the glucometer back into the medication cart. She did not clean the glucometer before or after use. Interview with LPN 3 on 3/23/23 at 11:05 a.m., indicated she washed the glucometer with an alcohol swab after every use. Interview with the Director of Nursing on 3/24/23 at 8:59 a.m., indicated the LPN should have used a sanitation wipe that was approved to clean the glucometer before and after use. A Policy titled, Blood Glucose Monitoring Machine Cleaning, and noted as current, indicated .Policy: .4. Cleanse and disinfect meter between each use. 3.1-18(b)
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

  • "Why is there high staff turnover? How do you retain staff?"
  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
  • • No fines on record. Clean compliance history, better than most Indiana facilities.
Concerns
  • • 32 deficiencies on record. Higher than average. Multiple issues found across inspections.
  • • Grade D (45/100). Below average facility with significant concerns.
  • • 58% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 45/100 indicates significant concerns. Thoroughly evaluate alternatives.

About This Facility

What is Ignite Medical Resort Crown Point Llc's CMS Rating?

CMS assigns IGNITE MEDICAL RESORT CROWN POINT LLC an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Indiana, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Ignite Medical Resort Crown Point Llc Staffed?

CMS rates IGNITE MEDICAL RESORT CROWN POINT LLC's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 58%, which is 12 percentage points above the Indiana average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 58%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Ignite Medical Resort Crown Point Llc?

State health inspectors documented 32 deficiencies at IGNITE MEDICAL RESORT CROWN POINT LLC during 2023 to 2025. These included: 31 with potential for harm and 1 minor or isolated issues.

Who Owns and Operates Ignite Medical Resort Crown Point Llc?

IGNITE MEDICAL RESORT CROWN POINT LLC is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by IGNITE MEDICAL RESORTS, a chain that manages multiple nursing homes. With 70 certified beds and approximately 64 residents (about 91% occupancy), it is a smaller facility located in CROWN POINT, Indiana.

How Does Ignite Medical Resort Crown Point Llc Compare to Other Indiana Nursing Homes?

Compared to the 100 nursing homes in Indiana, IGNITE MEDICAL RESORT CROWN POINT LLC's overall rating (2 stars) is below the state average of 3.1, staff turnover (58%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Ignite Medical Resort Crown Point Llc?

Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.

Is Ignite Medical Resort Crown Point Llc Safe?

Based on CMS inspection data, IGNITE MEDICAL RESORT CROWN POINT LLC has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Indiana. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Ignite Medical Resort Crown Point Llc Stick Around?

Staff turnover at IGNITE MEDICAL RESORT CROWN POINT LLC is high. At 58%, the facility is 12 percentage points above the Indiana average of 46%. Registered Nurse turnover is particularly concerning at 58%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Ignite Medical Resort Crown Point Llc Ever Fined?

IGNITE MEDICAL RESORT CROWN POINT LLC has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Ignite Medical Resort Crown Point Llc on Any Federal Watch List?

IGNITE MEDICAL RESORT CROWN POINT LLC is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

IGNITE MEDICAL RESORT CROWN POINT LLC

1555 S MAIN STREET, CROWN POINT, IN 46307 | (219) 323-8700

D
Trust Grade (45/100)
2.0
CMS Rating
32
Deficiencies

Strengths

  • 5-star quality

Concerns

  • 2-star rating
  • 32 deficiencies

Ask about: Staff Retention, Rn Coverage

nursinghomedata.org | Data: CMS November 2025