Ignite Medical Resort Crown Point LLC

Based on record review and interview, the facility failed to ensure pressure ulcer care was provided as ordered for 1 of 2 residents reviewed for pressure ulcers. (Resident F)Finding includes:During an interview on 3/29/26 at 12:59 p.m., Resident F indicated she was receiving treatment for multiple pressure ulcers that were causing a lot of pain and she received antibiotics for an infection in the wounds.Resident F's record was reviewed on 3/30/26 at 1:33 p.m. Diagnoses included, but were not limited to, local infection of skin and subcutaneous tissue.The admission Minimum Data Set (MDS) assessment, dated 2/25/26, indicated the resident was cognitively intact and had two stage IV pressure ulcers, two unstageable pressure ulcers, and two venous/arterial ulcers. The resident was also receiving antibiotic treatment.The Wound Round Notes, dated 3/24/26, indicated the resident had a stage IV pressure ulcer to the right buttocks measuring 9.0 cm long by 17.0 cm wide by 2.0 cm deep. She had an unstageable pressure ulcer on the left lateral posterior thigh measuring 9.5 cm long by 5.0 cm…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure safety was maintained related to fall interventions not in place for 1 of 4 residents reviewed for accidents (Resident 79)Finding includes:On 3/29/26 at 1:30 p.m., Resident 79 was observed lying in bed watching television. There were no floor mats in place on either side of the bed.On 3/30/26 at 9:17 a.m., Resident 79 was observed lying in bed. There were no floor mats in place on either side of the bed.On 3/31/26 at 11:40 a.m., Resident 79 was observed lying in bed. There were no floor mats in place on either side of the bed.Resident 79's record was reviewed on 3/31/26 at 9:34 a.m. Diagnoses included, but were not limited to, hypertension and type 2 diabetes mellitus. The resident was admitted to the facility on [DATE]. She was discharged to the hospital on 3/16/26 and returned to the facility on 3/28/26. The admission Minimum Data Set (MDS) assessment was still in progress.A Baseline Care Plan, initiated on 3/8/26, indicated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure an indwelling urinary catheter bag and tubing was placed below the level of the bladder and not on the floor for 2 of 3 residents reviewed for catheters. (Residents 115 and F)Findings include: 1. On 3/29/26 at 12:04 p.m., Resident 115 was observed seated in her wheelchair in the Main Dining Room. Her catheter bag was hanging from the back rest of her wheelchair, not below the level of the bladder. On 3/29/26 at 1:25 p.m., Resident 115 was observed seated in her wheelchair with family pushing her down the hallway towards her room. Her catheter bag was hanging from the back rest of her wheelchair, not below the level of the bladder. On 3/31/26 at 12:52 p.m., Resident 115 was observed seated in her wheelchair in the Main Dining Room. Her catheter bag was hanging from the bottom of her wheelchair with the bag touching the floor. The record for Resident 115 was reviewed on 3/30/26 at 2:46 p.m. Diagnoses included, but were not limited to, acute kidney failure. A Care Plan, updated 3/25/26, indicated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure to follow-up and implement recommendations from the Registered Dietician for a resident with documented weight loss and lack of documentation of meal intakes for 2 of 4 residents reviewed for nutrition. (Residents F and C)Findings include:1. Resident F's record was reviewed on 3/30/26 at 1:33 p.m.On 3/15/26, the resident weighed 186 pounds (lbs). On 3/20/26, the resident weighed 156 lbs. On 3/29/26, the resident weighed 159 lbs, which was a -14.52% weight loss from 3/15/26 to 3/29/26.A Care Plan, dated 2/23/26, indicated the resident had the potential for alterations in nutrition and hydration. Interventions included, but were not limited to, evaluate any weight changes, determine percentage changed and follow facility protocol for weight change, monitor/record/report to the physician any signs/symptoms of malnutrition, significant weight loss (3 lbs in 1 week, greater than 5% in a month, and greater than 10% in six months); Registered Dietician (RD) to evaluate and make diet change recommendations as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents received the necessary respiratory care and treatment related to incorrect oxygen flow rate and not monitoring oxygen saturation levels every shift as ordered for 2 of 5 residents reviewed for respiratory care (Resident 51 and C) and 1 of 5 residents reviewed for unnecessary medications. (Resident M) The facility also failed to ensure pre and post nebulizer assessments were completed and the licensed nurse remained with the resident during the nebulizer treatment for one resident observed during medication pass (Resident 51) and 1 of 5 residents reviewed for unnecessary medications. (Resident M)Findings include:1. On 3/29/26 at 2:20 p.m., and 3/30/26 at 9:00 a.m., Resident 51 was observed in her bed with her oxygen on via nasal cannula. The oxygen concentrator was flowing at 1 liter per minute (lpm). The resident's record was reviewed on 3/30/26 at 2:12 p.m. The resident was admitted to the facility on [DATE]. Diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to timely address a pharmacy recommendation as requested for 1 of 5 residents reviewed for unnecessary medications (Resident L). Finding includes:Record review for Resident L was completed on 3/31/26 at 1:38 p.m. Diagnoses included, but were not limited, heart failure, Guillain-Barre syndrome (immune system attacks peripheral nerves), and atrial fibrillation. The resident was admitted to the facility on [DATE].A Consultant Pharmacist Recommendations to Nursing form, dated 3/20/26, indicated the resident's current order for sacubitril-valsartan (heart medication) 24/26 mg (milligrams) was for once a day. Per the hospital discharge summary, the resident was to receive the medication twice a day. Please clarify with the prescriber and update accordingly.There was a lack of documentation to indicate the recommendation was clarified with the prescriber and updated until 3/31/26.During an interview on 3/31/26 at 2:46 p.m., the Director of Nursing (DON)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure clinical records were complete and accurately documented related to a Qualified Medication Aide documenting administration of injectable medications for 2 of 2 residents reviewed for anticoagulant administration. (Residents B and D)Findings include:1. Resident B's closed record was reviewed on 3/31/26 at 2:16 p.m.The Discharge Minimum Data Set (MDS) assessment, dated 3/13/26, indicated the resident was cognitively intact and received anticoagulant and antiplatelet medications while a resident.A Care Plan, dated 1/29/26, indicated the resident received anticoagulant medications. Interventions included, but were not limited to, administer anticoagulant medications as ordered by the physician.A Physician's Order, dated 1/15/26, indicated Lovenox (anticoagulant) injection solution prefilled syringe 40 milligrams/0.4 milliliters, inject 0.4 milligrams (mg) once a day for blood clot prevention.The January and February 2026 Medication Administration Record (MAR) indicated QMA 1 marked the Lovenox injection as administered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure infection control practices were in place and implemented related to guidelines for residents in EBP (Enhanced Barrier Precautions), and staff not wearing a gown during a PICC (peripherally inserted central catheter) medication administration during random infection control observations. (Residents L, 104, and E) Findings include:1. On 3/29/26 at 11:47 a.m., Resident L was observed lying in bed. There were no signs on the doorway or in the room that indicated the resident was on any infection control precautions.Record review for Resident L was completed on 3/31/26 at 1:38 p.m. Diagnoses included, but were not limited, Guillain-Barre syndrome (immune system attacks peripheral nerves), and urinary tract infection in the past 30 days. The resident was admitted to the facility on [DATE].The admission MDS assessment, dated 3/23/26, indicated the resident was cognitively intact. The resident had an impairment to both sides of his upper…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. 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.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.