Ignite Medical Resort Crown Point Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Crown Point, Indiana.
- Location
- 1555 S Main Street, Crown Point, Indiana 46307
- CMS Provider Number
- 155835
- Inspections on file
- 34
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 37
Citation history
Health deficiencies cited at Ignite Medical Resort Crown Point Llc during CMS and state inspections, most recent first.
Dirty pans and dishes were stored on a grill, food and supply boxes were kept on the floor in the freezer, dry storage area, and hallway, and the grill had crumbs and debris on it. A Sous Chef also checked food temps using thermometers that were not sanitized between foods, wiping them on the same towel instead of using probe wipes as required by policy.
Kitchen Not Kept Clean and in Good Repair: Surveyors observed dirt and debris on the floor in front of and between the oven, grill, and fryer, along with dried food spillage and residue on the shelf under the grill and the bottom shelf of the prep table. An facility representative stated the areas needed cleaning, and the Dietary Cleaning Policy required kitchen floors to be kept free of debris and cleaned daily.
The facility failed to ensure the Activities Program was directed by a qualified professional. Record review showed the Activities Director was hired without evidence of the required Activities Director course, prior experience, or qualifying credentials, and the DON stated there was no policy related to Activity Director qualifications.
Failure to Provide Ordered Meal Choice: A resident did not receive soup that he selected on his meal ticket and requested at lunch. Staff stated there was confusion over who was supposed to make the soup, and no one prepared it, resulting in the resident being served only a salad and peaches.
A resident with COPD, asthma, and respiratory failure was observed on oxygen via nasal cannula with the flow rate set higher than the ordered 3 L. Although the resident had been on oxygen since admission, the admission MDS did not code oxygen use, and the MDS Coordinator confirmed it was not recorded on the assessment.
A resident with multiple stage IV and unstageable pressure ulcers, along with infected wounds and antibiotic treatment, did not have a comprehensive pressure ulcer care plan in place. The record lacked measurable goals, resident involvement and choice, and interventions to heal or prevent the ulcers, even though the resident was cognitively intact and the wounds were documented as present on admission.
Failure to Provide Care-Planned Activities: A resident with acute respiratory failure, morbid obesity, and moderate cognitive impairment was care-planned for leisure activities, including creative arts, music, puzzles, and trivia, but she stated nobody would take her to activities. The Activity Director said it was difficult to get her to activities, the family said she wanted to attend but could not push her wheelchair, and the activity log showed no documentation of any one-on-one or group activities for the past 30 days.
Failure to implement a fall intervention for a resident at risk for falls. A resident with HTN and type 2 DM was found on the floor next to her bed with a forehead abrasion and arm guarding, then returned from the hospital after the care plan was updated to include a floor mat next to the bed. However, staff observed the resident in bed on multiple occasions with no floor mats in place, and the DON and C Unit Manager acknowledged the mat had not been put in place after the resident returned.
Improper urinary catheter bag and tubing placement: Two residents with indwelling urinary catheters were observed with drainage bags and tubing not maintained below bladder level and, at times, touching the floor. One resident with acute kidney failure had a catheter bag hanging from a wheelchair back rest and later touching the floor, while another resident’s bag was secured above bladder level in bed and later placed on the floor under a wheelchair. The care plans for both residents directed staff to check tubing placement each shift, and a physician order for one resident directed Foley catheter placement and patency checks.
The facility failed to implement RD nutrition recommendations and failed to consistently document meal intake for two residents. One resident had documented weight loss and an RD order for liquid protein and double protein portions for wound healing that was not entered as a physician order, and observations showed trays without the recommended protein support. Another resident with hemodialysis, osteomyelitis, and a toe amputation also had significant weight loss, while meal intake records were incomplete on multiple days.
A facility failed to provide safe respiratory care for multiple residents with ordered oxygen and nebulizer treatments. One resident was observed with oxygen set below the ordered rate and had missing oxygen saturation documentation on several shifts, another resident was observed with oxygen set above the ordered rate and had no documented pre- or post-treatment respiratory assessments for daily Duoneb use, and an LPN left a resident during a breathing treatment without completing a respiratory assessment. A third resident was also observed with oxygen set below the ordered flow rate.
A resident with HF, Guillain-Barre syndrome, and AFib had a pharmacy recommendation noting sacubitril-valsartan 24/26 mg was ordered once daily even though the hospital discharge summary indicated it should be given BID. The recommendation was not clarified with the prescriber or updated in a timely manner, and the DON stated it should have been clarified when the resident was admitted from the hospital.
Infection control practices were not consistently followed for residents on EBP and during PICC line medication administration. A resident with a recent ESBL UTI and another resident with a history of ESBL and prior RSV were observed without clear precaution signage or documentation showing EBP had been implemented as indicated, and an LPN administered medication through a PICC line for a resident on EBP while wearing gloves but no gown. The DON confirmed the resident should have been on EBP and that the LPN should have worn a gown.
Failure to Attempt Non-Pharmacological Interventions Before PRN Antipsychotic Use: A resident with dementia, mood disorder, and metabolic encephalopathy received PRN quetiapine multiple times for agitation, psychotic behaviors, and psychosis related to dementia. The MAR, nurse's notes, and behavior notes contained no documentation that non-pharmacological interventions were attempted before several doses, and the DON acknowledged they should have been tried first.
Missed Scheduled Showers for Two Residents: The facility failed to ensure two residents received showers or baths as scheduled. One resident with metabolic encephalopathy and COPD was dependent for multiple ADLs and had several missed shower entries in the shower book, while another cognitively intact resident with low back pain and atrial fibrillation reported she had not had a shower since admission. The shower book was incomplete for the second resident, and the A-Unit Manager confirmed there was no documentation showing the scheduled showers were completed.
Failure to obtain ordered weights and assess skin findings: A resident with dementia, DM, and dysphagia did not have weekly weights documented as ordered. Two other residents, both receiving anticoagulants, had skin findings including a bandaged elbow with scabbed area and green discoloration underneath, and a large dark purple thigh discoloration, but the record lacked documentation of a physician order for the bandage and lacked assessment or monitoring of the skin changes. Staff were unaware of the findings, and the DON and unit manager stated one discoloration was not present on admission and may have been related to a Hoyer lift.
Failure to provide ordered pressure ulcer care for a resident with multiple stage IV and unstageable wounds. MAR/TAR documentation showed repeated missed daily wound treatments for the buttocks and thigh wounds, with no refusals recorded. The wound nurse stated the wounds had been infected, the resident had been receiving ABX, and the resident was noncompliant with offloading and wound care.
Incorrect documentation of injectable anticoagulant administration: A QMA documented Lovenox injections as given for two residents even though she stated she was not qualified to administer injections and would get a nurse to do it. The MARs showed the injections recorded under the QMA’s username, while the DON said the QMA was not administering the injectables but the documentation was incorrect.
The facility did not follow professional standards for midline catheter care for three residents, including failures to document required flushing, assessments, and medication administration. Orders for dressing changes and flushes were missing or not followed, and there was a lack of documentation regarding catheter insertion, removal, and site assessments. Missed doses of IV antibiotics were not explained, and available medications were not administered as ordered.
A resident with severe cognitive impairment and a wound infection did not receive several scheduled doses of IV antibiotics due to unavailability, and there was no documentation that the physician or POA were notified of the missed doses, as required by facility policy.
Two residents requiring assistance with ADLs were not provided timely incontinent care or adequate bathing after episodes of significant urinary incontinence. Both were left in saturated briefs and wet linens for extended periods, and care provided did not include full cleansing of all urine-soaked areas, despite care plans and facility policy requiring regular checks and assistance.
Two residents with midline and PICC catheters did not receive care in accordance with professional standards, including a non-sterile dressing change by an LPN and lack of documentation for required dressing changes, flushes, and site assessments. The facility's own policies for sterile technique and timely interventions were not followed.
A resident with osteomyelitis and dementia did not receive scheduled IV antibiotic doses as ordered because the medication was not available from the pharmacy. Despite repeated notifications and reliance on the Emergency Drug Kit for initial doses, subsequent doses were missed due to delayed pharmacy delivery, contrary to the facility's daily delivery policy.
A resident with a Stage IV pressure ulcer and multiple diagnoses did not receive physician-ordered pre-albumin and CBC lab tests. The tests were ordered and sent to the lab, but were not completed, and no results or documentation were found in the medical record. The lab was unable to provide a reason for the missed testing.
Staff did not consistently use required PPE when providing high-contact care to two residents on Enhanced Barrier Precautions. In both cases, staff initially wore only gloves instead of both gowns and gloves as required by facility policy and care plans for residents with wounds or invasive lines. Proper PPE was only used after staff were reminded or noticed signage indicating EBP requirements.
A resident was found with medication at their bedside without the necessary physician's orders and assessments for self-administration. The facility's policy requires such orders and assessments, which were not present, leading to a deficiency in medication management.
A resident with acute medical conditions was transferred to the hospital without the required State-approved transfer form. The facility's policy to inform the resident and responsible party and prepare a transfer form was not followed, as confirmed by interviews with the DON and Administrator.
A facility failed to provide a resident and their Responsible Party with the bed-hold policy upon hospital transfer. The resident, who was cognitively intact, was transferred due to acute respiratory issues, but there was no documentation of the policy being communicated at the time of transfer. The facility's practice was to provide this information only at admission, not during each transfer.
A resident with a history of UTIs and other medical conditions was observed with her Foley catheter collection bag lying on the floor on two occasions. The A Unit Manager confirmed that staff should have placed the bag in a bath basin to prevent it from touching the floor. The resident's care plan included monitoring for UTIs, and she was receiving an antibiotic for sepsis.
A facility failed to follow up on dietary recommendations for a resident with a feeding tube. The RD suggested holding tube feedings and adding oral supplements, but there was no documentation that the NP was informed or that orders were updated. The resident's meal tray lacked the recommended supplements, and the A Unit Manager did not ensure the recommendations were implemented, contrary to facility policy.
A resident with a gastrostomy was observed receiving incorrect tube feeding flow rates, deviating from the physician's order of 65 ml/hr. The resident, with severe cognitive impairment and dependence on renal dialysis, was found with flow rates of 75 ml/hr and 45 ml/hr on different occasions. The error was confirmed by the C Unit Manager.
A facility failed to maintain a PICC for a resident by not changing the dressing as ordered. The resident, with diagnoses including dementia and asthma, was observed with a PICC dressing dated over two weeks old, despite a physician's order to change it weekly. An RN confirmed the dressing had not been changed since admission.
A facility failed to ensure proper infection control measures in an isolation room for a resident under contact and droplet precautions. An LPN was observed in the resident's room wearing only personal glasses and a surgical mask, without the required N95 mask, goggles or face shield, gown, or gloves. The resident had tested positive for coronavirus OC 43, necessitating strict isolation measures, which were not followed by the LPN.
A facility failed to administer medications as ordered for a resident undergoing dialysis, did not hold medication for another resident with low blood pressure, and inadequately monitored and treated a third resident's abdominal hernia and leg swelling. These deficiencies involved missed doses of critical medications, improper administration of hydralazine, and lack of care planning for lymphedema and hernia management.
A facility failed to provide timely access to medical records for three residents, resulting in a deficiency. A resident's POA requested records through a law firm, but only partial records were provided, and follow-up communications were ignored. Two other residents experienced delays in receiving their records, which were sent two weeks after the request, contrary to the facility's policy requiring records to be provided with two working days' notice.
A resident with a history of cancer and cognitive impairment alleged rough care by staff, but the facility failed to report this to the Administrator and IDOH within the required timeframe. The allegation was initially reported to the DON, who was on vacation, and the Administrator was not informed until later, resulting in a delay in reporting to the IDOH.
A facility failed to follow standard care practices during a g-tube medication administration. An LPN administered medications and a protein supplement through a resident's g-tube without confirming its placement. The LPN was unsure of the facility's policy for checking g-tube placement, which required confirmation by drawing back on the syringe for gastric content.
The facility inaccurately posted Nurse Staffing Information by including administrative nursing staff who did not provide direct resident care. Observations revealed discrepancies between the actual number of nurses and CNAs working and the posted staffing information. The ADON confirmed that administrative staff hours were included in the postings, contrary to CMS requirements.
The facility failed to maintain a sanitary kitchen, with issues including unlabeled and undated food, a build-up of ice in the freezer, and spills in the refrigerator and dry storage room. Cook 1 acknowledged the labeling issue and recent spills.
A resident with Diabetes Mellitus and a foot ulcer was observed with a soiled dressing on a skin tear, but there was no documentation or treatment order in place. The responsible nurse forgot to document the wound, and an LPN was unaware of the incident.
The facility failed to obtain a Physician's Order for a urinary catheter, complete catheter care, and record urinary output for a resident with type 2 diabetes, anemia, and dementia. Despite the resident having a urinary catheter since admission, there were no orders or documentation for catheter care or urine output, even though the resident was being treated for a UTI. The Director of Nursing confirmed the absence of necessary orders and documentation.
The facility failed to provide correct respiratory treatment for two residents. One resident received oxygen without a Physician's Order, and another had an incorrect oxygen flow rate despite having a PRN order for a different rate.
Kitchen sanitation and thermometer sanitation failures
Penalty
Summary
The facility failed to ensure food was stored and served under sanitary conditions in the main kitchen. During the kitchen sanitation tour, the grill was observed with an accumulation of crumbs and debris, and a stack of dirty pans and dishes was sitting on top of the flat-top grill. Multiple boxes of food were stored on the floor in the walk-in freezer, with some boxes open and tipped over. Multiple boxes of food and non-food items were also stored on the floor in the dry storage area, and boxes of cups and straws were stored on the floor in the hallway outside the kitchen. The kitchen staff member interviewed at the time stated all of the items were in need of cleaning and should not have been on the floor, and that they had been there for a few days without being put away. The facility also failed to sanitize food thermometers between uses during lunch temperature checks. The Sous Chef was observed using two thermometers from a basin of ice water, wiping each thermometer off on the same blue towel before checking hamburger and stuffing temperatures, and continuing to wipe them off on the towel between foods. He stated probe wipes should have been used to clean the thermometer between each food temperature, but they did not have any at the time. The Administrator was later informed of the kitchen sanitation concerns, and the facility policy required food temperatures to be taken with a clean, rinsed, sanitized, air-dried metal stem thermometer and to immediately wipe and sanitize it after use.
Kitchen Not Kept Clean and in Good Repair
Penalty
Summary
The facility failed to keep the Main Kitchen clean and in good repair. During the kitchen sanitation tour, surveyors observed an accumulation of dirt and debris on the floor in front of the oven and between the oven, grill, and fryer. They also observed dried food spillage, dirt, and debris on the shelf underneath the grill, along with an accumulation of dried white and pink substance on the bottom shelf of the prep table. During interview, the facility representative stated that all of the observed areas were in need of cleaning. The facility’s Dietary Cleaning Policy stated that kitchen floors should be kept free of debris, staff should use a “clean as you go” technique, and kitchen walls and floors are to be cleaned daily.
Activities Program Not Directed by Qualified Professional
Penalty
Summary
The facility failed to ensure the Activities Program was directed by a qualified professional who met the required training and certification standards before assuming the role of Activities Director. Record review showed the Activities Director was hired on 10/20/25 and had a certificate dated 12/31/25 for Hospitality Management Studies, but there was no indication she had completed the Activities Director course. During an interview on 4/1/26 at 11:25 a.m., the Activities Director stated she had a certificate in hotel hospitality, had not completed the Activity Director course, was not aware it was necessary, did not have 2 years of prior experience, and was not a therapeutic recreation specialist or an activities professional. During an interview on 4/2/26 at 8:50 a.m., the DON stated she did not have a policy related to the Activity Director or qualifications.
Failure to Provide Ordered Meal Choice
Penalty
Summary
The facility failed to honor a resident's food preferences for 1 of 2 residents reviewed for food choices, involving Resident 104. On 3/29/26 at 1:51 p.m., the resident was observed sitting in his room with his daughter and stated he wanted soup for lunch, but was told none was available. His daughter said she had to go to his Assisted Living apartment to get a can of soup for him to eat for lunch, and both indicated he did not always receive what he ordered from the menu. Record review showed Resident 104 was admitted to the facility on [DATE]. During an interview on 4/1/26 at 9:08 a.m., the A Unit Manager stated the resident's daughter filled out his meal tickets for the week and the kitchen had his meal tickets. The lunch meal ticket for 4/1/26 showed the resident chose soup of the day, a small salad with French dressing, and chilled peaches. Later that day at 1:42 p.m., the resident was observed eating lunch with a salad and chilled peaches, but no soup. The resident again stated he wanted soup but did not receive any. The Sous Chef stated he did not make any soup that day and one of the cooks was supposed to make it. [NAME] 1 stated [NAME] 2 was supposed to make the soup and she was unsure why she did not. The Administrator later stated there was confusion over who was supposed to make the soup, so no one made it.
MDS Assessment Did Not Accurately Code Oxygen Use
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) comprehensive assessment was accurately completed for oxygen use for one resident. The resident was observed lying in bed with oxygen via nasal cannula attached to a concentrator, and the flow rate was set at 4 liters, while the resident stated she had been on 3 liters of oxygen since admission and did not know why it was set at 4 liters. Record review showed diagnoses including chronic obstructive pulmonary disease, asthma, and respiratory failure, and a physician's order directed oxygen at 3 liters every shift. The admission MDS assessment identified the resident as cognitively intact, but it did not indicate that the resident received oxygen on admission or as a resident. During interview, the MDS Coordinator stated the resident had been on oxygen since admission and it was not coded on the assessment.
Failure to Implement Pressure Ulcer Care Plan
Penalty
Summary
The facility failed to ensure a care plan was implemented for pressure ulcers for one resident reviewed for pressure ulcers. Resident F stated she was receiving treatment for multiple pressure ulcers that were causing a lot of pain and that she had received antibiotics for an infection in the wounds. During wound care observation, the Wound Nurse indicated the resident’s wounds had been infected, that she had been receiving antibiotics for wound infections, and that the resident was noncompliant with offloading and wound care. Record review showed Resident F was cognitively intact and had two stage IV pressure ulcers, two unstageable pressure ulcers, and two venous/arterial ulcers, with antibiotic treatment also documented. Wound rounds documented a stage IV pressure ulcer to the right buttocks measuring 9.0 cm by 17.0 cm by 2.0 cm, an unstageable pressure ulcer on the left lateral posterior thigh measuring 9.5 cm by 5.0 cm, and a stage IV pressure ulcer to the left buttocks measuring 6.5 cm by 18.0 cm by 2.0 cm; these pressure ulcers were present on admission. The comprehensive care plan lacked a pressure ulcer care plan identifying needs, measurable goals, resident involvement and choice, and interventions to heal or prevent pressure ulcers. The DON stated there was a skin impairment care plan, but no care plan related to the pressure ulcers.
Failure to Provide Care-Planned Activities
Penalty
Summary
The facility failed to ensure activities were provided to a dependent resident as care-planned for 1 of 1 resident reviewed for activities. Resident 51 was observed in bed and stated she liked to go to activities, but nobody would take her to them. Her record showed diagnoses including acute respiratory failure and morbid obesity, and the admission MDS indicated moderate cognitive impairment and a need for substantial maximum assistance for transfers. The Leisure Preferences Care Plan, dated 2/12/26, stated she would participate in leisure activities as desired, with interventions including creative arts, music, puzzles and trivia, and music. The Activity Director stated it was difficult to get the resident to activities and noted the resident liked to come to Friday dinner and a movie with her family. The resident’s family member stated she would like to go to activities, but no one would take her and she was unable to push the wheelchair. Review of the resident’s electronic activity log for the past 30 days showed no documentation of any one-on-one or group activities. The Activity Director later acknowledged there were no activities documented in the resident’s record for the past 30 days and stated staff could take her to the activities.
Failure to Implement Ordered Fall Mat for Resident at Risk for Falls
Penalty
Summary
The facility failed to ensure safety was maintained related to fall interventions not being in place for one of four residents reviewed for accidents, Resident 79. Resident 79 had diagnoses including hypertension and type 2 diabetes mellitus, was admitted to the facility on [DATE], was discharged to the hospital on 3/16/26, and returned on 3/28/26. The admission MDS assessment was still in progress. The baseline care plan, initiated on 3/8/26, identified the resident as at risk for falls. After Resident 79 was found on the floor next to her bed on 3/16/26 with an abrasion to her left forehead and guarding her right arm, she was sent to the emergency room for evaluation. An IDT meeting note documented that a mat on the floor would be implemented upon her return, and the falls care plan was updated to include a floor mat next to the bed. However, on 3/29/26, 3/30/26, and 3/31/26, the resident was observed lying in bed with no floor mats in place on either side of the bed. During interview, the DON was made aware the fall mat was not in place, and the C Unit Manager stated the resident had returned from the hospital and the floor mat was not put in place upon her return.
Improper urinary catheter bag and tubing placement
Penalty
Summary
The facility failed to ensure indwelling urinary catheter bags and tubing were positioned below the level of the bladder and kept off the floor for 2 of 3 residents reviewed for catheters. Resident 115, whose diagnoses included acute kidney failure, had a urinary catheter noted in the care plan with an intervention to check tubing placement each shift. On 3/29/26, Resident 115 was observed in a wheelchair with the catheter bag hanging from the back rest, not below bladder level, and later the same day the bag was again observed hanging from the wheelchair back rest. On 3/31/26, the catheter bag was observed hanging from the bottom of the wheelchair with the bag touching the floor. Resident F also had a urinary catheter documented in the care plan, with interventions to check tubing placement each shift, and a physician’s order to check placement and patency of the Foley catheter. On 3/31/26, Resident F was observed lying in bed with the catheter bag secured to the footboard above bladder level. On 4/1/26, Resident F was observed sitting in a wheelchair eating lunch with the catheter bag on the floor underneath the wheelchair and the tubing touching the floor. The DON was informed of the observations, and the facility policy titled Urinary Indwelling Catheter Management stated the catheter should be secured to facilitate urine flow, prevent kinking, and be positioned below the level of the bladder.
Failure to Implement RD Nutrition Recommendations and Document Meal Intake
Penalty
Summary
The facility failed to follow up on and implement RD recommendations for a resident with documented weight loss and for another resident receiving nutrition support for wound healing. For Resident F, the record showed a weight of 186 lbs on 3/15/26, 156 lbs on 3/20/26, and 159 lbs on 3/29/26, reflecting a 14.52% loss from 3/15/26 to 3/29/26. The care plan identified potential alterations in nutrition and hydration and included monitoring weight changes and following facility protocol for significant weight loss. An RD evaluation on 2/27/26 recommended liquid protein 30 mL twice daily and double portions of protein foods at all meals for wound healing, but there were no physician orders entered for those recommendations. Observations on 3/31/26 and 4/1/26 showed lunch trays without double protein portions or a health shake, and the Amount Eaten documentation had multiple dates with no meal entries or only one entry for the day. For Resident C, the record showed a weight of 250 lbs on 2/13/26 and 218 lbs on 3/29/26, a 12.8% loss. The RD evaluation on 3/13/26 noted the resident required hemodialysis, had a history of osteomyelitis and a left great toe amputation with complications, and was receiving two Nepro supplements daily; the RD recommended decreasing to one Nepro daily with 30 mL of liquid protein for wound healing. The Amount Eaten Point of Care documentation also showed multiple dates with no meal entries and several dates with only one documented meal entry. The DON stated each meal should have been documented, and the facility reported the scales had recently been recalibrated because errors were being found with resident weights.
Incorrect Oxygen Flow and Missing Respiratory Assessments
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for residents who had physician-ordered oxygen therapy. Resident 51, who had diagnoses including acute respiratory failure with hypoxia, pleural effusion, and pneumonia, was observed with oxygen flowing at 1 lpm even though the physician ordered 2 lpm every shift. The resident’s oxygen saturation monitoring log was also missing entries on multiple dates over a two-week period, despite an order to monitor oxygen saturation every shift. During an interview, the A Unit Manager confirmed the oxygen was set below the ordered rate and noted there were no new orders or documentation showing it had been changed. Resident M, who had COPD, asthma, and respiratory failure, was observed with oxygen set at 4 liters even though the physician ordered 3 liters every shift. The resident stated she had been on 3 liters since admission and did not know why it was set at 4 liters. The record review showed the resident received ipratropium-albuterol inhalation treatments every day, but the MARs did not include a respiratory assessment section with each administration, and there was no documentation showing respiratory assessments were completed before or after the treatments. The DON stated the nurses should have been completing and documenting respiratory assessments prior to and after inhalation medication treatments. During medication administration, an LPN prepared a Duoneb treatment for Resident 51, applied the mask, and left the room without completing a respiratory assessment or staying with the resident during the treatment. The nurse stated she did not complete respiratory assessments before administering inhalation medication and routinely left residents’ rooms during breathing treatments, returning later to check whether the treatment was finished. The DON stated nurses should be doing respiratory assessments before breathing treatments and staying in the resident’s room during the treatments. Resident C was also observed with oxygen set at 2 lpm even though the physician ordered continuous oxygen at 4 lpm every shift.
Delayed Clarification of Pharmacy Recommendation
Penalty
Summary
The facility failed to timely address a pharmacy recommendation for Resident L, whose diagnoses included heart failure, Guillain-Barre syndrome, and atrial fibrillation. A Consultant Pharmacist Recommendations to Nursing form dated 3/20/26 indicated that the resident’s sacubitril-valsartan 24/26 mg order was written for once daily, while the hospital discharge summary showed the medication was to be given twice daily, and the pharmacist requested clarification with the prescriber and an update. Record review showed no documentation that the recommendation was clarified with the prescriber and updated until 3/31/26. During interview, the DON stated the pharmacy recommendation had not been completed until 3/31/26 and that the medication should have been clarified with the physician when the resident was admitted from the hospital.
Infection Control Practices Not Followed for EBP and PICC Medication Administration
Penalty
Summary
The facility failed to ensure infection control practices were in place and implemented for residents on Enhanced Barrier Precautions (EBP) and during PICC line medication administration. Resident L was observed in bed with no signs on the doorway or in the room indicating infection control precautions. Record review showed diagnoses including Guillain-Barre syndrome and a urinary tract infection in the past 30 days, with a physician progress note documenting a UTI with MDRO/ESBL production and antibiotic treatment continued through 3/20/26. There was no documentation showing the resident had been placed on infection control precautions for the ESBL infection, and the DON stated the resident should have had EBP in place because of the history of ESBL in the urine. Resident 104 was observed in the room without signs indicating precautions, and later had a door sign for droplet precautions. Record review showed the resident had been asymptomatic related to prior RSV and was to be removed from strict isolation and entered into EBP isolation because of a history of ESBL in the urine, but there was no documentation that precautions had been in place before the later change. During a medication administration for Resident E, an LPN prepared and administered an antibiotic through the resident’s PICC line while the room had an EBP sign posted, but the nurse wore gloves only and did not put on a gown. The nurse stated she was unsure whether a gown was required, and the DON stated the nurse should have worn a gown. The EBP policy for MDROs was not provided.
Failure to Attempt Non-Pharmacological Interventions Before PRN Antipsychotic Use
Penalty
Summary
The facility failed to ensure non-pharmacological interventions were attempted before administering PRN antipsychotic medication to Resident G, who was admitted with diagnoses including dementia, mood disorder, and metabolic encephalopathy. The admission MDS dated 2/24/26 indicated severe cognitive impairment and use of antipsychotic medications. Resident G had physician orders for quetiapine fumarate 12.5 mg every eight hours as needed, first for agitation, then for psychotic behaviors, and later for psychosis related to dementia with psychotic disturbance. The February and March 2026 MAR showed the resident received quetiapine nine times between 2/26/26 and 3/1/26. The record contained no documentation in the MAR, nurse's notes, or behavior narrative notes that non-pharmacological interventions were attempted before giving the medication on 2/19, 2/24, 2/26, 3/1, or 3/7/26. The facility policy stated that alternative non-pharmacologic interventions for psychiatric disorders and problem behaviors related to dementia would be attempted prior to and during administration of antipsychotic medications. During interview, the DON stated non-pharmacologic interventions should have been attempted before giving the medication.
Missed Scheduled Showers for Two Residents
Penalty
Summary
The facility failed to ensure dependent residents received showers or baths as scheduled for 2 of 2 residents reviewed for ADL care. Resident H was observed in bed with uncombed hair and was unshaven; he was unable to communicate whether he had recently had a shower or whether he preferred to be clean shaven. His record showed diagnoses including metabolic encephalopathy and COPD, and the admission MDS indicated he was rarely or never understood and was dependent for toileting, bed mobility, and transfers. His ADL care plan identified self-care deficits, performance deficits, and limitations in physical mobility, with interventions including partial to moderate assistance with tub and/or shower transfers. The shower book showed Resident H was scheduled for showers or bed baths on Tuesday and Friday during the day shift, but there were no showers or baths documented on multiple scheduled dates. The A-Unit Manager stated there was no additional documentation that the scheduled showers had been completed. Resident J was observed lying in bed and stated she had not had a shower since she had been in the facility. Her record showed diagnoses including low back pain and atrial fibrillation, and the admission MDS indicated she was cognitively intact and required partial to moderate assistance for showering and toileting. The shower book did not have a page for Resident J, and the resident who previously occupied her room was still listed in the shower book; the A-Unit Manager stated there were no shower sheets for her and said she would ensure she was showered that day.
Failure to obtain ordered weights and assess skin findings
Penalty
Summary
The facility failed to ensure weekly weights were obtained as ordered for a resident with dementia, diabetes mellitus, and dysphagia. The resident’s nutritional care plan directed staff to obtain and document weights per physician order and facility protocol, and a physician’s order required a weekly weight every Sunday. The record showed weights documented on only 2/17/26 and 3/19/26, with no weight documented for 30 days despite the order for weekly weights. The resident’s MDS indicated severe cognitive impairment and the need for supervision or touch assistance for eating. The facility also failed to ensure a physician’s order was in place for a bandage and failed to assess and monitor a skin area for a resident with atrial fibrillation, diabetes mellitus, and end stage renal disease who received anticoagulant medication. The resident was observed with an undated white bandage on the left inner elbow and a thick black scabbed area on the left forearm. On a later observation, the resident removed the bandage and the skin underneath was observed with a green discoloration. The record lacked documentation showing a physician’s order for the bandage or that the scabbed area was assessed or monitored. A third resident with Guillain-Barre syndrome, atrial fibrillation, and diabetes mellitus was observed with a large dark purple discoloration on the right upper inner thigh extending from the groin area to the middle of the upper leg. The resident was receiving anticoagulant medication and was dependent on staff for toileting, hygiene, and transfers. The record lacked documentation showing the discoloration was assessed or monitored. Staff interviews indicated they were unaware of the skin findings, while the DON and unit manager stated the discoloration was not present on admission and may have come from use of the Hoyer lift.
Failure to Provide Ordered Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure pressure ulcer care was provided as ordered for one resident with multiple wounds. The resident was cognitively intact and had two stage IV pressure ulcers, two unstageable pressure ulcers, and two venous/arterial ulcers on admission, along with a diagnosis of local infection of skin and subcutaneous tissue and antibiotic treatment. The resident reported receiving treatment for multiple pressure ulcers that were causing a lot of pain and said she had received antibiotics for an infection in the wounds. Record review showed multiple wound care orders for the left buttocks/ischium, right buttocks/ischium, and left lateral posterior thigh, with daily dressing changes ordered. The March 2026 MAR/TAR did not show the wound care as completed on several dates for each wound, and there were no refusals documented in the medical record. During observation, the wound nurse stated the wounds had been infected and the resident had been receiving antibiotics for wound infections, and also stated the resident was noncompliant with offloading and wound care and that weekend nurses were supposed to provide the wound care.
Incorrect Documentation of Injectable Anticoagulant Administration
Penalty
Summary
The facility failed to ensure clinical records were complete and accurately documented when a Qualified Medication Aide documented administration of injectable anticoagulant medication for two residents. Resident B’s record showed a physician’s order for Lovenox 40 mg/0.4 mL injection once daily for blood clot prevention, and the January and February 2026 MAR showed QMA 1 marked the injections as administered on multiple dates. Resident D’s record also showed a physician’s order for Lovenox 40 mg/0.4 mL injection once daily, and the January and February 2026 MAR showed QMA 1 marked the injections as administered on multiple dates. Both residents’ discharge MDS assessments indicated they were cognitively intact and received anticoagulant medications while residents. During a telephone interview, QMA 1 stated she was not qualified to administer injections or IV medications and would get a nurse to give injectable medications when needed. She explained that she had two MARs open on her computer, one under her username and one under a nurse’s username, and that when nurses administered the medication they sometimes opened the wrong window and the administration was falsely documented under QMA 1’s username. The DON stated she did not believe the QMA was administering the injectables, but that the documentation was incorrect.
Failure to Follow Midline Catheter Care Standards and Documentation
Penalty
Summary
The facility failed to provide care for midline catheters in accordance with professional standards for three residents who required intravenous (IV) treatments. For one resident with a history of urinary tract infection and bladder cancer, there was a lack of documentation regarding the flushing of the midline catheter before and after medication administration, as well as after discontinuation of IV antibiotics. The medication administration record (MAR) did not show that flushes were performed as ordered, and there was no assessment or documentation of the IV line’s length or the condition of the catheter tip during dressing changes or after removal. The Director of Nursing (DON) acknowledged the absence of required documentation and orders related to flushing and assessments. Another resident with a urinary tract infection had a midline IV inserted for antibiotic treatment, but there were no physician’s orders for weekly dressing changes, site assessments, or normal saline flushes at the time of insertion. The MAR indicated that several doses of the prescribed antibiotic were not administered, and there was no documentation explaining the missed doses. Additionally, there was no record of who inserted the heparin lock or when the midline was placed. The DON confirmed that the medication was available in the emergency drug kit but was not used, and the physician was not notified about the missed doses. A third resident with rhabdomyolysis and peripheral vascular disease also experienced deficiencies in midline care. The MAR showed missed doses of prescribed antibiotics, and there was no documentation of the midline’s length or its discontinuation, nor was there an assessment of the site and line after removal. The facility’s central line care policy required physician orders for all treatments, documentation of line removal, and measurement of the line, but these standards were not met for the residents reviewed.
Failure to Notify Physician and POA of Missed Antibiotic Doses
Penalty
Summary
A resident with diagnoses including osteomyelitis of the left ankle/foot and dementia, and who had a family member designated as Power of Attorney (POA), was prescribed IV ampicillin-sulbactam every six hours for a wound infection. The Medication Administration Record (MAR) showed that the antibiotic was unavailable and not administered at four scheduled times over two days. There was no documentation indicating that the resident's physician or POA had been notified about the missed doses. During an interview, the Director of Nursing confirmed that both the physician and POA should have been notified of the missed medication. Facility policy required that such notifications be made and documented in the medical record, but this was not done.
Failure to Provide Timely and Adequate Incontinent Care and Bathing
Penalty
Summary
The facility failed to provide timely and adequate incontinent care and bathing for two residents who required assistance with activities of daily living (ADLs). In one instance, a resident with dementia, osteomyelitis, and a PICC line was observed lying in bed with saturated incontinence pads, wet linens, and a wet gown. The resident had not been checked for urinary incontinence since the CNA's shift began at 6 a.m. The resident's peri and buttocks areas were cleansed, but other urine-soaked areas such as the abdomen, back, arms, and legs were not washed before the resident was dressed in clean clothing and linens. The care plan indicated the resident required maximum assistance for bathing and toileting and should be checked for incontinence every 2-3 hours. Another resident with dementia was found in a room with a strong urine odor, lying in bed with damp covers, wet clothing, and a saturated incontinence brief. The incontinence pad under the resident had a large ring of drying urine. The CNA had not checked the resident for incontinence since starting work at 6 a.m. and indicated it had been a while since the resident was last checked. The resident received incontinence care with wipes and was changed into clean clothing, but the care plan required moderate assistance with toileting and bathing and checks for incontinence every 2-3 hours. Facility policy stated that incontinent residents should be changed every two hours and more frequently if needed.
Failure to Maintain Sterile Technique and Documentation for IV Catheter Care
Penalty
Summary
The facility failed to provide safe and appropriate care for midline and PICC catheters in accordance with professional standards of practice for two residents. For one resident with a PICC line in the left upper extremity, an LPN performed a dressing change using a process that was not fully sterile. The LPN touched non-sterile surfaces, such as her own hair and the resident's arm, while wearing sterile gloves, and did not cleanse her hands between glove changes. The resident's care plan indicated weekly dressing changes, but the observed process did not maintain sterility as required. For another resident with a midline IV catheter, there was no documentation of required dressing changes within 24 hours of insertion, nor evidence of regular flushing or assessment of the catheter site for infection or placement. The care plan called for weekly dressing changes and regular site monitoring, but there were no physician's orders for these interventions, and no documentation that they were performed. The facility's own policy required physician orders for treatments and dressing changes, as well as sterile technique and timely dressing changes, but these standards were not met for the residents involved.
Failure to Provide Timely IV Antibiotic Due to Pharmacy Delay
Penalty
Summary
The facility failed to provide a resident with an intravenous (IV) antibiotic in a timely manner as ordered by the physician. The resident, who had diagnoses including osteomyelitis of the left ankle/foot and dementia, was prescribed IV ampicillin-sulbactam every six hours for a wound infection. According to the Medication Administration Record (MAR), the first three doses were administered as ordered, but subsequent doses were missed because the medication was not available. Documentation showed that the antibiotic was not present in the Emergency Drug Kit (EDK), and the pharmacy was notified multiple times regarding the need for delivery. Despite repeated notifications to the pharmacy, the antibiotic was not delivered in time to prevent missed doses on several occasions. Progress notes indicated ongoing communication with the pharmacy and continued unavailability of the medication, resulting in the resident not receiving the prescribed antibiotic at the scheduled times. The facility's pharmacy delivery policy stated that medications and supplies would be delivered daily, but this was not adhered to in this instance, leading to the deficiency.
Failure to Complete Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that a resident received laboratory services as ordered by the physician. A resident with a history of stroke and dementia had a Stage IV pressure ulcer on the coccyx, and a physician ordered pre-albumin and complete blood count (CBC) laboratory tests. Review of the medical record showed that the results of these tests were not present, and there was no documentation that the laboratory testing had been completed. During an interview, the wound nurse confirmed that the tests had been ordered and sent to the lab, but the lab did not complete the tests as scheduled and could not provide a reason for the failure.
Failure to Ensure Proper PPE Use During Enhanced Barrier Precautions
Penalty
Summary
Staff failed to use correct Personal Protective Equipment (PPE) when providing care to residents on Enhanced Barrier Precautions (EBP) during two separate observations. In the first instance, a resident with a PICC line, open wound, and incontinence was being cared for by an LPN and a CNA who initially wore only gloves and were unsure if EBP was required, as there was no sign on the door. After discussion, they realized EBP was needed due to the resident's wound and PICC line, and then donned gowns and changed gloves before continuing care. The resident's care plan specified that gowns and gloves were to be worn during high-contact care activities. In the second instance, two CNAs were observed providing a bed bath to a resident with a PICC line and a care plan requiring EBP. Although a sign indicating EBP was present on the door, both CNAs initially wore only gloves and believed EBP was not required. After reading the sign, they donned gowns over their uniforms. The facility's EBP policy required staff to wear gowns and gloves during high-contact care for residents with wounds or invasive lines, but this was not initially followed in either case.
Failure to Ensure Proper Orders for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident had the necessary physician's orders and assessments to self-administer medications. During an observation, a medication tablet was found on a resident's bedside table, which the resident identified as extra strength Tylenol. The resident stated that the nurse routinely left medications at the bedside for self-administration before therapy sessions. However, upon reviewing the resident's records, it was found that there were no self-administration assessments or physician's orders for the self-administration of Tylenol, despite the care plan indicating an order for self-administration of all medications. Interviews with the LPN and the Director of Nursing revealed that the most recent self-administration assessment did not include all of the resident's medications, and there was no order for self-administration of all medications. The facility's policy requires a physician's order and an assessment to determine a resident's ability to self-administer medications, which was not followed in this case. The Director of Nursing suggested that the order might have been overlooked when the resident was hospitalized, indicating a lapse in maintaining accurate and complete records for medication self-administration.
Failure to Provide Proper Notification and Documentation for Hospital Transfer
Penalty
Summary
The facility failed to ensure proper notification and documentation during the transfer of a resident to the hospital. The resident, who was cognitively intact and had diagnoses including acute kidney failure, pressure ulcer, and acute respiratory failure, was observed with tremors and difficulty breathing. Despite these symptoms, there was no documentation indicating that the State-approved transfer form was completed and sent with the resident when she was transferred to the hospital for medical evaluation. Interviews with the Director of Nursing and the Administrator revealed that while residents received a bed hold policy and transfer form at admission, the facility did not provide updated forms for each transfer. The facility's policy required informing the resident and their responsible party of the transfer and preparing a transfer form with a face sheet and medication list, which was not adhered to in this instance.
Failure to Provide Bed-Hold Policy Upon Hospital Transfer
Penalty
Summary
The facility failed to ensure that a resident and/or their Responsible Party were provided with the facility's bed-hold and reserve bed payment policy before and upon transfer to the hospital. This deficiency was identified for one of the four residents reviewed for hospitalization. The resident in question, who was cognitively intact for daily decision-making, was transferred to the hospital due to acute respiratory issues. Despite the transfer, there was no documentation indicating that the bed-hold policy was communicated to the resident or their Responsible Party at the time of the transfer. Interviews with the Director of Nursing and the Administrator revealed that the facility's practice was to provide the bed-hold policy and transfer form only at the time of admission, and not at each subsequent transfer. This oversight resulted in the resident and their Responsible Party not being informed of the bed-hold policy during the hospital transfer, which is a requirement to ensure residents and their families are aware of their rights and responsibilities regarding bed reservation during absences.
Improper Foley Catheter Care for a Resident
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling Foley catheter, as the catheter collection bag was observed lying on the floor on two separate occasions. Resident 160, who has a history of urinary tract infections and other medical conditions such as anxiety, cerebral palsy, chronic kidney disease, and hypertension, was seen with her catheter bag touching the floor while sitting in a wheelchair and a recliner. The A Unit Manager acknowledged that staff should have placed the catheter bag in a bath basin to prevent it from touching the floor. The resident's care plan included monitoring and reporting signs of a urinary tract infection, and the resident was receiving an antibiotic for sepsis as per the physician's order summary.
Failure to Implement Dietary Recommendations for Resident with Feeding Tube
Penalty
Summary
The facility failed to ensure timely follow-up on dietary recommendations for a resident with a feeding tube. Resident 46, who was moderately cognitively impaired and had a feeding tube, was observed to have a potential alteration in nutrition and hydration. The Registered Dietician (RD) recommended placing the tube feedings on hold and adding oral supplements, including Med Pass and Magic Cup, to ensure adequate intake. However, there was no documentation indicating that the Nurse Practitioner (NP) was notified of these recommendations, nor were there any progress notes or physician's orders addressing them. On observation, the resident's lunch tray did not include the recommended Magic Cup, and the meal ticket did not list it. The A Unit Manager acknowledged receiving the RD's recommendations and sending them to the physician's office but did not follow up in person with the NP or ensure the recommendations were implemented. The facility's policy required nurses to inform physicians of dietician consults and document them in resident records, which was not adhered to in this case.
Incorrect Tube Feeding Flow Rate for Resident with Gastrostomy
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy received the appropriate treatment related to the flow rate of tube feeding. The resident, who was admitted with diagnoses including dependence on renal dialysis, unspecified dementia, and gastrostomy, was observed on multiple occasions with incorrect tube feeding flow rates. On one occasion, the flow rate was set at 75 ml/hr, and on another, it was set at 45 ml/hr, both of which deviated from the physician's order of 65 ml/hr. The resident's Admission Minimum Data Set assessment indicated severe cognitive impairment and the need for tube feedings. The discrepancy in the flow rate was confirmed during an interview with the C Unit Manager, who acknowledged the error and indicated the correct rate should be 65 ml/hr.
Failure to Change PICC Dressing as Ordered
Penalty
Summary
The facility failed to maintain a peripheral inserted central catheter (PICC) for a resident, identified as Resident 116, by not changing the dressing as ordered. On January 6, 2025, Resident 116 was observed with a PICC in the right upper arm, with a dressing dated December 23, 2024. The resident's medical record indicated a physician's order from December 25, 2024, to change the PICC dressing every seven days on Saturday. However, the January 2025 Medication Administration Record showed the dressing was last changed on January 4, 2025, indicating a lapse in following the prescribed schedule. During an interview, RN 4 confirmed that the dressing had not been changed since the resident's admission, despite the order to do so weekly. Resident 116 had diagnoses including unspecified dementia, asthma, and gout, and was noted to have moderate cognitive impairment and dependency on staff for transfers.
Inadequate PPE Use in Isolation Room
Penalty
Summary
The facility failed to maintain proper infection control measures in an isolation room for a resident under contact and droplet precautions. On January 7, 2025, Resident 125 was observed in her room with isolation signs indicating the need for an N95 or approved KN95 respiratory mask, goggles or a face shield, gown, and gloves. However, on January 8, 2025, an LPN was seen in the resident's room wearing only personal glasses and a surgical mask, without the required N95 mask, goggles or face shield, gown, or gloves. The LPN was unaware that the resident had tested positive for a coronavirus, which necessitated strict isolation measures. Resident 125's medical record indicated diagnoses of heart failure, acute and chronic respiratory failure, and hypothyroidism. The resident was cognitively intact and required supervision for certain activities. A health status note from January 3, 2025, confirmed the resident tested positive for coronavirus OC 43, a virus transmitted via respiratory excretion, leading to the implementation of strict droplet isolation. Despite a negative COVID-19 test, the resident remained in isolation to prevent virus transmission. The facility's infection control policy required droplet and contact precautions, including wearing a mask, gloves, and gown when entering the room, which were not adhered to by the LPN.
Medication and Monitoring Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure that a resident received medications as ordered, particularly for a resident undergoing dialysis. Resident C, who was dependent on renal dialysis and had severe cognitive impairment, missed several doses of critical medications, including doxycycline, carvedilol, and eopetin alfa injection, on multiple occasions due to being out of the facility for dialysis. The C Unit Manager acknowledged the issue and indicated that medications should be rescheduled if they coincide with dialysis times. Resident B, who was cognitively intact and diagnosed with type 2 diabetes mellitus, high blood pressure, and chronic kidney disease, received hydralazine despite having a systolic blood pressure below the ordered threshold of 130. This occurred on several occasions, as documented in the Medication Administration Record, indicating a failure to adhere to the physician's order to hold the medication under certain conditions. Resident D, who had lymphedema and heart failure, was not properly assessed or monitored for an abdominal hernia, and there was a lack of treatment for leg swelling. The resident reported discomfort from the hernia and noted that her legs were not wrapped as required for her lymphedema. Observations confirmed the absence of wraps and the presence of swelling. The facility's records lacked a care plan for the hernia and orders for ace wraps, highlighting a gap in the resident's care management.
Delayed Provision of Medical Records to Residents
Penalty
Summary
The facility failed to provide timely access to medical records for three residents, leading to a deficiency. Resident B's medical records were requested by a law firm on behalf of the resident's Power of Attorney (POA) but were not fully provided. The facility's Administrator was unaware of the request until a letter from the law firm was received, which had been delayed in reaching the appropriate personnel. The former Medical Records Coordinator (MRC) did not recall receiving the request, and the Corporate MRC had not approved the release of the full record. The facility's process for handling medical record requests was disrupted due to a change in personnel, resulting in the law firm receiving only partial records with duplicates and no response to their follow-up communications. Residents C and D also experienced delays in receiving their requested medical records. Both residents requested their complete medical records on the same date, but the records were not sent until two weeks later. The facility's policy required that records be provided upon request with two working days' notice, which was not adhered to in these cases. The deficiency was related to a complaint, indicating a systemic issue in the facility's process for managing medical record requests.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as Resident E, to the Administrator and the Indiana Department of Health (IDOH) within the required two-hour timeframe. The incident involved Resident E alleging that staff were rough during care. This allegation was reported by an LPN to the Director of Nursing (DON), who was on vacation at the time. However, the Administrator was not informed of the allegation until a later date, and there was no documentation of the incident being reported to the IDOH until the Administrator became aware of it. Resident E, who had a medical history including malignant cancer of the breast and uterus, was assessed to have a moderately impaired cognitive status and required varying levels of assistance for daily activities. Despite the resident's allegation, there was no documentation in the Nurses' Progress notes indicating that the allegation was voiced. The facility's abuse policy mandates immediate reporting of such allegations to the Administrator and the IDOH, which was not adhered to in this case.
Failure to Confirm G-Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure standard practice of care during a gastrostomy (g-tube) medication administration for a resident. During an observation, an LPN administered medications and a protein supplement through the resident's g-tube without confirming the placement of the tube beforehand. The LPN was unsure of the facility's policy for confirming g-tube placement, despite having worked in other facilities. The facility's policy, dated March 2023, required that the placement of the g-tube be confirmed by gently drawing back on the piston of the syringe for gastric content before administering medications.
Inaccurate Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the posted Nurse Staffing Information accurately reflected only the staff providing direct resident care. During observations, it was noted that the number of nurses and CNAs working did not match the posted staffing information. Specifically, the posted hours included administrative nursing staff, such as the Director of Nursing, the Assistant Director of Nursing, and the MDS assessment nurse, who did not provide continual direct resident care. This discrepancy was confirmed during an interview with the ADON, who acknowledged that the administrative staff hours were included in the posted information, contrary to the CMS Staffing Data Report requirements, which only account for direct care providers. This issue was identified during a review of nursing schedules and posted hours for specific periods in May, June, and July 2024.
Sanitary Kitchen Deficiency
Penalty
Summary
The facility failed to maintain a sanitary kitchen, as observed during an initial kitchen tour. In the walk-in refrigerator, boxes of soda and pies were found sitting directly on the floor, and a package of raw meat, gravy in a plastic container, and mashed potatoes were unlabeled and undated. Additionally, a raw potato and a pink substance were spilled on the refrigerator floor. In the freezer, there was a heavy build-up of ice on the ceiling and on two boxes of food. The dry storage room had a large amount of dry oatmeal spilled on the shelves and floor. Cook 1 acknowledged that the items should be labeled and dated and indicated that the spills had occurred recently while staff were busy preparing breakfast.
Failure to Document and Treat Resident's Skin Tear
Penalty
Summary
The facility failed to ensure that a resident received the necessary care and treatment for a skin tear. On 4/1/24, Resident 31 was observed with a dressing on his right elbow that was coming loose and soiled with blood. The resident indicated he had bumped his elbow that morning, resulting in a skin tear. A review of Resident 31's record on 4/2/24 revealed no documentation or assessment of the skin tear and no Physician's Order for treatment. The resident's diagnoses included Diabetes Mellitus and a foot ulcer, and he required extensive staff assistance for transfers and toileting. During interviews, an LPN was unaware of the incident, and the Unit Manager confirmed that the nurse responsible had forgotten to document the wound and there was no treatment order in place.
Failure to Obtain Physician's Order and Document Catheter Care
Penalty
Summary
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 Resident 105. The resident, who had diagnoses including type 2 diabetes mellitus, anemia, and dementia, was admitted to the facility with a urinary catheter. Despite the Care Plan and Admission Nursing Evaluation indicating the presence of a urinary catheter, the Physician's Order Summary lacked any orders for the urinary catheter, catheter care, or urine output recording. Additionally, the Medication Administration Records and Treatment Administration Records for March and April 2024 did not document any catheter care or urine output, even though the resident was receiving antibiotic treatment for a urinary tract infection (UTI). Observations on 4/1/24 and 4/3/24 confirmed the presence of the urinary catheter, and the Bladder Continence Task documentation showed that urine output had only been recorded once since the resident's admission. During an interview, the Director of Nursing acknowledged the absence of orders in the computer for the urinary catheter, catheter care, or urine output recording. This deficiency highlights the facility's failure to follow proper protocols for managing a resident with a urinary catheter, leading to inadequate care and monitoring of the resident's condition.
Failure to Ensure Correct Respiratory Treatment
Penalty
Summary
The facility failed to ensure residents received the correct and necessary respiratory treatment. Resident 258 was observed with a nasal cannula in place with oxygen flowing at 2.5 liters per minute, but there was no Physician's Order for the oxygen. The resident's record indicated diagnoses including acute kidney failure, Diabetes Mellitus, and congestive heart failure. The Unit Manager confirmed there was no Physician's Order for the oxygen during an interview. Resident 3 was observed multiple times with oxygen flowing at 2.5 liters per minute via a nasal cannula. The resident's record indicated diagnoses including depression, chronic obstructive pulmonary disease (COPD), and asthma. The Care Plan indicated the resident should have oxygen therapy at 3 liters per nasal cannula PRN, and the April 2024 Physician's Order Summary confirmed this. The Director of Nursing indicated the resident's oxygen was a PRN order and should have been set at 3 liters when required.
Latest citations in Indiana
Surveyors found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Failure to Follow Physician Orders for Insulin, Daily Weights, and BP-Related Medications
Penalty
Summary
The deficiency involves multiple failures to follow physician orders for medication administration and monitoring. For one resident with type 2 diabetes, peripheral vascular disease, and failure to thrive, a physician’s order directed use of Humalog insulin per a specific sliding scale and required physician notification if blood glucose exceeded 400. A blood sugar of 470 was recorded on one date, and the Medication Administration Record (MAR) showed that 5 units of Humalog were given, but there was no documentation in the MAR, assessment tab, or progress notes that the physician was contacted or that new insulin orders were obtained, despite the DON later stating that an additional 5 units had been ordered. Two residents with orders for daily weights did not have those weights consistently obtained or documented as ordered. One resident with heart failure, hypertension, and chronic kidney disease had a physician’s order for daily weights on dayshift, but on multiple dates in February, March, and April, the MAR/TAR and related documentation showed entries marked as “NA,” “X,” or left blank, with no recorded weights, no physician notification, and no explanation for the missing data. Another resident with hypertension, anxiety disorder, and severe protein-calorie malnutrition also had a daily weight order, yet on numerous dates in April and May, weights were marked “NA” without corresponding weights, physician notification, or explanatory documentation; one weight entry was crossed out and the re-weight was not obtained until the following day. LPNs provided differing explanations for “NA” and “X,” indicating inconsistent understanding of documentation practices. Additional deficiencies occurred in the administration of cardiac and blood pressure–related medications contrary to ordered hold parameters. One resident with hypertension had orders for amlodipine, hydralazine, and losartan potassium, each with instructions to hold the medication if systolic blood pressure (SBP) was less than 110, yet the MAR showed these medications were administered on specific dates when the SBP was below the ordered hold threshold. Another resident with hypertension and systolic and diastolic congestive heart failure had been hospitalized for severe hypotension and returned on midodrine with an order to hold the medication if SBP was greater than 110; however, the MAR showed multiple doses were given on various dates when SBP was outside the ordered hold parameter. These actions were inconsistent with the facility’s own policies requiring medications to be administered only as prescribed and weights to be accurately obtained and documented, and they formed the basis of the cited quality of care deficiency.
Informed Consent Not Documented Before Psychotropic Medication Start or Increase
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before starting or increasing psychotropic medications for 2 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with psychotic behaviors and anxiety had Rexulti 1 mg initiated for dementia with agitation, with the medication started the next day, but the Psychoactive Medication Consent and Management Agreement dated after the start lacked documentation from the resident's representative giving consent for the new psychotropic medication. Another resident with diagnoses including Alzheimer's disease, major depressive disorder, psychotic disorder, and anxiety had Vraylar increased from 1.5 mg to 3 mg for aggression, with the higher dose started the next day. The Psychoactive Medication Consent and Management Agreement was dated after the increase and documented telephone consent on that later date. The DON stated the consent form should be completed prior to initiation or increase of a new psychotropic medication, and the facility policy required informed consent to be obtained and documented before initiation or an increase in dosage, including discussion of risks, benefits, and alternatives.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to document assessments and follow medication parameters
Penalty
Summary
The facility failed to provide care according to orders and documented parameters for multiple residents. One resident with diagnoses including stroke, dementia, and osteoarthritis had an outpatient medial branch block at a surgery center, but there were no nursing progress notes documenting the procedure, the time the resident left the facility, the time the resident returned, or any assessment of the bandage or the resident’s condition on return. The Director of Nursing stated there was no documentation or assessment when the resident came back from the outpatient procedure. Another resident was observed with a dark purple bruise to the left antecubital area on multiple observations, but the record contained no documentation of that bruising. The resident’s diagnoses included anxiety disorder, major depressive disorder, diabetes, heart failure, high blood pressure, and acute kidney failure. The resident had care plan entries related to bruising and bleeding risk from anticoagulant use and bruising from needle sticks, and weekly skin observations documented no bruises. The DON stated the resident had a blood draw, but there was no documentation regarding the bruise to the left arm. Two residents had medications administered outside ordered parameters. One resident received Metoprolol Tartrate 50 mg twice daily for high blood pressure with instructions to hold if pulse was less than 60, but the MAR showed doses given when the pulse was below 60 on several occasions. Another resident on hospice care received midodrine 5 mg three times daily with instructions to hold if systolic blood pressure was greater than 110, but the MAR showed the medication was administered multiple times when systolic blood pressure exceeded that limit. In addition, a resident was observed with purple discolorations and a black scab on the left forearm, wrist, and hand, but the weekly skin assessment documented no bruising and there was no documentation that the discolorations were assessed or monitored.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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