Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aperion Care Demotte during CMS and state inspections, most recent first.
A resident with diabetes and documented dependence for toileting and frequent bowel and bladder incontinence did not have a comprehensive care plan for urinary incontinence. The ADL care plan noted an ADL deficit but did not document the resident’s usual toileting performance or specify the amount of assistance needed. A separate care plan identified potential skin integrity impairment related to incontinence but lacked any defined interventions for incontinence care. The MDS assessment showed the resident was frequently incontinent, and the MDS Coordinator acknowledged that there was no specific incontinence care plan in place.
Surveyors found that the facility did not consistently provide scheduled bathing for three residents who were dependent on staff for ADLs. One resident with bilateral lower extremity fractures, another with seizures and bipolar disorder, and a third with diabetes and a below-the-knee amputation all had care plans and MDS assessments indicating dependence or extensive assistance needs for bathing, along with specified preferred bathing days on day shift. Review of shower sheets and task forms over multiple months showed several missed baths for each resident, and the DON acknowledged that one resident was supposed to receive baths three times weekly due to poor hygiene and was unable to find documentation or confirm completion of several missed baths for another resident.
Improper medication storage and labeling were observed on medication carts and in resident rooms. An opened insulin pen and an opened insulin vial had no open dates, topical Medihoney and diclofenac were found in a resident bathroom even though neither resident was prescribed them, and a bag of saline-filled syringes was hanging from an IV pole in a resident room while an LPN flushed an IV line with one of the syringes.
Failure to Maintain Resident Dignity: A resident with severe cognitive impairment, ADL dependence, and hospice status was repeatedly observed with a Foley catheter urine bag visible from the hallway without a dignity bag, wearing a hospital gown during the day, and at one point not fully dressed with bare skin exposed while staff walked past the room. A physician order required the catheter bag to be covered, and the care plan stated the resident would suffer no loss of dignity.
Resident bathing preference was not honored when staff assigned showers at night despite the resident repeatedly stating she wanted morning showers and did not like going to bed with wet hair. The resident was cognitively intact, required partial moderate assist with bathing, and her MDS showed bathing choice was very important to her. Documentation reflected an assigned bathing schedule, and the ADON stated the facility had no process to reassess changing bathing preferences after admission.
PRN Antipsychotic Given Without Documented Prior Interventions: A resident with alcohol dependence with induced psychotic disorders, dementia, and HTN received PRN quetiapine for agitation without documentation showing the indication for use or that nonpharmacologic interventions were attempted first. After a fall and on another occasion when the resident was found naked and walking around, the medication was administered without supporting documentation, and the NC confirmed no documentation of prior interventions.
A resident was discharged to another healthcare facility, but the facility did not complete the discharge MDS assessment in a timely manner. Record review found no documentation that the discharge MDS had been completed after the resident left, and the MDS Coordinator stated she had worked on the discharge but forgot to finish the assessment.
Inaccurate MDS documentation was found for two residents. One resident’s MDS incorrectly indicated anticoagulant use, and another resident’s MDS incorrectly indicated 7 days of insulin injections, but record review found no physician orders or documentation supporting either medication during the assessment periods. The MDS Coordinator stated the entries were made by mistake and that the residents had not received those medications.
Failure to assess and document a reopened surgical wound. A resident with a right leg amputation had a dressing on the stump and reported the incision had healed and then reopened. The chart showed the resident was seen by ortho and wound care for a stump infection, but there were no wound assessments after the wound reopened. An LPN noted several small open areas along the incision, and the corporate wound nurse confirmed the wound had reopened, but no further documentation was available.
Smoking materials were not secured for a resident with dementia and COPD whose care plan and smoking safety assessment required his electronic vapes to be kept in a locked, designated area; instead, the vapes were observed on his bedside table and staff were unsure about the storage requirement. The facility also failed to maintain ordered fall precautions for a resident with a recent fall and cervical fracture, as the wheelchair lacked Dycem and the bathroom lacked non-skid strips despite care plan interventions for fall risk.
Incomplete meal intake documentation was identified for a resident with dementia, heart disease, a buttock pressure ulcer, and significant recent wt loss. The resident’s record lacked 3 daily meal intake entries on multiple days, even though the care plan directed staff to monitor and record intake each shift and facility staff stated intake should be documented once per shift.
Medication Administration Errors Exceeded Allowed Rate: An RN prepared a resident's Flomax capsule and senna tablet by crushing them, leaving the capsule intact but flattened, and stated she did not know capsules could not be crushed. The nurse also prepared only 1 senna tablet even though the order called for 2 tablets every evening. Surveyors identified 2 errors during 26 opportunities, resulting in a 7.69% medication error rate, and the DON confirmed the correct administration should have been opening the capsule and giving the ordered senna dose.
A resident’s MAR contained duplicate orders for two eye drop entries, both listed as 1 drop in both eyes once daily and both signed out as given each morning. An LPN stated the resident received one drop in each eye every morning and that the duplicate order had been entered in error, while the resident had dementia, diabetes, and moderate cognitive impairment.
Infection control was cited during wound care for a resident with an open buttock wound. A Wound Nurse used gauze placed directly on a visibly dirty bedside table to cleanse the wound, and a Wound Care MD removed and replaced gloves from his pocket multiple times while debriding and cleansing the wound without performing hand hygiene after glove removal. Facility policy required a clean work area or a protected/disinfected table and hand hygiene after glove removal.
A facility failed to protect residents from the misappropriation of narcotic medications, affecting three residents. A nurse admitted to taking oxycodone tablets from a resident, and further investigation revealed discrepancies in narcotic counts for other residents. Over 300 narcotic tablets were unaccounted for due to a nurse's actions, who would sign for medications and take them along with the narcotic count records.
The facility failed to provide a complete 5-Day follow-up report to the IDOH regarding a narcotic misappropriation incident. A resident's oxycodone was unaccounted for, and RN 4 admitted to taking it. The report lacked details about two other residents with missing narcotics and the exoneration of RN 3. The Regional President acknowledged the missing information.
A facility failed to investigate the root cause of multiple skin tears in a resident with vascular dementia and diabetes mellitus, who was receiving hospice care. The resident was observed with dressings on the right arm and hand, and despite the presence of skin tears, no investigation was conducted. The ADON noted the resident's tendency to pick at her skin when uncomfortable, but there was no care plan addressing this behavior. The Corporate RN Consultant confirmed that the skin tears should have been investigated.
A facility failed to properly assess and manage a resident's pressure ulcers, leading to a decline in the resident's condition. The ADON was unaware of changes in treatment orders, and there was a lack of communication between staff and hospice care. Weekly skin assessments were inconsistent, and the care plan did not accurately reflect the resident's condition. This deficiency highlights a breakdown in communication and adherence to the facility's skin condition assessment policy.
The facility failed to ensure correct PPE was used by staff when caring for a resident under Enhanced Barrier Precautions. CNAs and an LPN provided care to a resident with an indwelling urinary catheter and skin conditions without wearing gowns, despite facility policy and signage indicating the need for such precautions.
The facility failed to properly store medications in two medication carts, with loose pills found in the drawers. An Agency QMA and an RN were observed with the carts, and it was noted that nursing staff were responsible for cleaning them. The Assistant Director of Nursing indicated that the DON was usually responsible for ensuring the carts were cleaned.
The facility failed to ensure proper assessment and authorization for self-administration of medications for two residents. An LPN administered a nebulizer treatment to a resident without checking vital signs or staying with the resident, and another resident was left with medications to self-administer without proper authorization. Facility policies requiring physician authorization and observation were not followed.
A resident with severe cognitive impairment was involved in a physical altercation with another resident. Although the aggressor was sent to the hospital, the affected resident was not monitored for psychosocial distress as per the facility's usual protocol. The facility's policy lacked specific guidelines for such monitoring.
A facility failed to provide written notification to a resident's Responsible Party regarding a hospital transfer. The resident, with type 2 diabetes and elevated liver enzymes, was sent to the hospital without the State-approved transfer form or written notice to the Responsible Party. The Regional President confirmed the lack of documentation, violating the facility's policy requiring written notification and communication with the State Ombudsman.
A facility failed to notify a resident and their Responsible Party of the bed-hold policy before a hospital transfer. The resident, with type 2 diabetes and elevated liver enzymes, was moderately impaired in decision-making. Despite notifying the Responsible Party of the transfer, the facility did not document sending the bed-hold policy, as confirmed by the Regional President of Operations.
A facility failed to provide timely intervention for a resident with abnormal lab results, leading to hospitalization for renal failure. Two residents did not receive medications as ordered, with one resident's medications not held despite low blood pressure readings, and another resident's medications not administered as ordered. Additionally, a resident's skin discolorations were not assessed or documented, contrary to facility policy.
A resident with encephalopathy, legal blindness, and hearing loss did not receive timely vision and hearing services due to the facility's failure to facilitate access. Despite a physician's order and verbal consent for services, the resident was not on the list for audiology and optometry services, as the Ancillary Service Company required a signed consent. The facility's policy to assist residents in arranging health services was not effectively implemented for this resident.
A resident with a history of falls was found without necessary fall precautions, such as non-skid strips, in her room and bathroom, despite these being identified as necessary interventions. The resident, who was cognitively impaired, had previously fallen and sustained a major injury. The facility's failure to implement these safety measures contributed to an incident where the resident slipped on spilled iced tea, resulting in a fracture.
A resident with acute and chronic respiratory failure did not receive continuous oxygen as ordered. Observations showed the oxygen concentrator was not in use, and the resident stated she only used it at night. The MAR lacked documentation of oxygen administration or refusal, and an LPN was unaware of the continuous order, believing it was as needed.
A facility failed to monitor a dialysis access site for a resident with end-stage renal disease, who had a catheter for hemodialysis. The resident's records lacked current physician orders for dialysis and catheter monitoring after readmission, and there was no documentation of monitoring from 9/13/24 to 9/17/24, contrary to facility policy.
A resident with chronic kidney disease and other conditions had abnormal lab results that were not communicated to the Physician as required. The lab results, which included elevated BUN, creatinine, and potassium levels, were only reviewed by the Nurse Practitioner the following day, leading to the resident being sent to the ER for renal failure. The facility's policy to notify the Physician of significant changes was not followed.
A facility failed to disinfect a blood pressure cuff used on a resident during a medication pass. An LPN used the cuff without cleaning it before or after use, contrary to facility policy. The LPN acknowledged the oversight, and the Regional President of Operations confirmed the requirement for cleaning between uses.
A resident admitted on hospice care with a full code status did not receive CPR as requested by their Health Care Representative (HCR) when they showed signs of actively dying. Despite the care plan and physician's orders indicating a full code, facility staff did not initiate CPR or transfer the resident to the hospital. The resident expired before the HCR could arrive, and no policy regarding CPR initiation was provided during the survey.
Failure to Develop Comprehensive Care Plan for Urinary Incontinence
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing urinary incontinence care for one resident. Record review showed that this resident, who had diagnoses including diabetes mellitus, had an ADL care plan dated 2/15/26 that documented a deficit in activities of daily living, but the toileting hygiene section did not include the resident’s usual performance and lacked any interventions specifying the level of care required. A separate care plan dated 2/15/26 identified a potential impairment of skin integrity related to incontinence, yet it did not include interventions describing what incontinence care should be provided. An admission MDS assessment dated 2/18/26 documented that the resident was dependent for toileting and was frequently incontinent of bowel and bladder. During interviews, the MDS Coordinator acknowledged that the care plans needed to be tightened up and confirmed there was no care plan in place for incontinence care. This deficiency was cited under 410 IAC 16.2-3.1-35(a) and related to Intake 2707235.
Failure to Provide Scheduled Bathing Assistance for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled bathing and showers for residents who required assistance with activities of daily living (ADLs). Resident B, who had fractures of the right and left lower extremities, had an ADL self-care deficit and was dependent on staff for bathing per the care plan dated 12/11/25 and the admission MDS dated 12/16/25. His plan of care indicated a preference for bathing on the day shift on Wednesdays and Saturdays, yet the January 2026 shower sheets and task forms showed that bathing did not occur on 1/3/26. Resident C, with diagnoses including seizures and bipolar disorder, required moderate to extensive assistance from one to two staff for bathing per the annual MDS dated 3/6/26 and a care plan revised on 3/17/26. Her preferred bathing days were on the day shift on Mondays, Wednesdays, and Fridays, but shower sheets and task forms for January, February, and March 2026 showed missed baths on January 14 and 30, February 23, and March 2 and 4. The DON stated that bathing was supposed to occur three times a week due to the resident’s poor hygiene. Resident D, diagnosed with diabetes mellitus and a below-the-knee amputation, had an ADL self-care deficit and was dependent on staff for bathing per a care plan revised 10/1/25 and a quarterly MDS dated 3/2/26, with preferred bathing days on the day shift on Tuesdays and Fridays. Shower sheets and task forms for January, February, and March 2026 indicated missed baths on January 24, February 14, 24, and 28, and March 10, and during interview the DON could not locate documentation that these baths had been completed or confirm that they occurred.
Improper Medication Storage and Labeling
Penalty
Summary
Medications and biologicals were not stored properly and were not labeled with open dates as required. On observation of the ACU Cart with RN 2, an opened Basaglar KwikPen insulin pen was found with no open date written on the pen, and RN 2 stated she had used the pen that day but was unsure when it had been opened. On the [NAME] Hall Cart with LPN 1, an opened Lantus insulin vial was also found with no open date written on the vial or the box, and LPN 1 stated she did not know when the vial had been opened. The facility also had an open tube of Medihoney and a tube of diclofenac in the bathroom of a resident room, even though neither resident in the room was prescribed those medications. In another resident room, a bag of saline-filled syringes was observed hanging from an IV pole. LPN 2 was observed disconnecting an IV antibiotic from the resident and flushing the line with one of the syringes from the bag, stating they were all pre-filled saline syringes. The Administrator later stated she would remove the medications from the residents' rooms. The facility policy stated medications and biologicals are to be stored safely, securely, and properly, and that when the original seal of a manufacturer's container or vial is broken, the container or vial will be dated and a date-opened sticker placed on the medication.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain Resident 74’s dignity by not keeping the Foley catheter urine collection bag covered with a dignity bag, by allowing the resident to wear a hospital gown during the day, and by observing the resident not fully dressed. Resident 74 had diagnoses including acute respiratory failure, diabetes, and dementia, and the 8/15/25 MDS indicated severe cognitive impairment, dependence in ADLs and transfers, and hospice status. A physician’s order dated 5/22/24 directed staff to ensure the Foley catheter bag was covered and/or in a dignity bag, and the care plan dated 9/20/24 stated the resident had a terminal condition, was receiving hospice services, and would suffer no loss of dignity. During multiple observations, the urine collection bag was visible from the hallway without a dignity bag, the resident was seen wearing a hospital gown, and on one occasion was in bed wearing only a shirt and disposable brief with the brief pulled down and bare skin exposed while staff walked past the room.
Resident Bathing Preference Not Honored
Penalty
Summary
The facility failed to ensure a resident had the right to choose what time of day she received a shower. Resident 18, who was cognitively intact and had diagnoses including heart failure, hypertension, Parkinson's disease, and depression, stated during interview that she took showers twice a week whenever staff had time and that staff gave her showers at nighttime. She reported that she had told staff on multiple occasions that she preferred morning showers and did not like going to bed with wet hair, but staff told her it was her scheduled time and did not ask her preference or when she wanted to shower. Record review showed the resident was admitted to the facility and, on the annual MDS assessment, her bathing preference was marked as very important to her. She required partial moderate assistance with bathing. The bathing tasks documentation listed that she preferred bathing on Wednesday and Saturday evenings, but there was no documentation showing that her preference for bathing was asked rather than assigned. The ADON stated that residents and families were asked about bathing schedules on admission and told what the schedule was, but there was no process for asking residents again after admission if their preferences changed unless they or their family expressed a different preference. The facility could not provide a policy related to choices or preferences for bathing.
PRN Antipsychotic Given Without Documented Prior Interventions
Penalty
Summary
The facility failed to ensure there was an indication for use and that interventions were attempted before administering a PRN antipsychotic medication for one resident reviewed for unnecessary medications. The resident had diagnoses including alcohol dependence with induced psychotic disorders with delusions, dementia, and hypertension, and was admitted to the facility on an unspecified date. The care plan noted a potential for adverse side effects related to antipsychotic use and directed that medications be administered per order and side effects observed for. A physician's order dated 8/28/25 directed quetiapine fumarate 25 mg, one-half tablet every 24 hours as needed for agitation. After a fall in the resident's room, the resident was brought to the nurse's station and given a snack and milk per request, and later that evening the PRN antipsychotic was administered without documentation showing why it was given nearly an hour and a half after the fall or whether any interventions were attempted first. On another occasion, the resident was found standing naked and walking around, brought to the nurse's station in a Broda chair, and given the PRN antipsychotic medication, again without documentation of prior interventions. The Nurse Consultant stated there was no documentation that prior interventions were attempted before the PRN antipsychotic was administered.
Late Completion of Discharge MDS Assessment
Penalty
Summary
The facility failed to successfully complete the Minimum Data Set (MDS) discharge assessment in a timely manner for 1 of 24 residents reviewed. Resident 6 was admitted to the facility on an unspecified date and was discharged on 5/14/25. A Nurses Note dated 5/14/25 at 2:05 p.m. documented that the resident was discharged to another healthcare facility. During closed record review on 9/9/25, there was no documentation showing that a discharge MDS assessment had been completed after the resident left the facility. In interview on 9/9/25 at 11:15 a.m., the MDS Coordinator stated she had worked on the resident's discharge from the facility but had forgotten to complete the MDS discharge assessment.
Inaccurate MDS Documentation for Anticoagulant and Insulin Use
Penalty
Summary
The facility failed to ensure MDS assessments were accurately completed for two residents related to anticoagulant medication and insulin use. Resident 24 had diagnoses including anemia, hypertension, and diabetes mellitus, and the Significant Change MDS dated 7/2/25 indicated the resident received an anticoagulant during the assessment period; however, record review found no physician order or documentation showing the resident actually received an anticoagulant during that time. Resident 8 had diagnoses including heart failure, hypertension, and dementia, and the Quarterly MDS dated 7/23/25 indicated the resident received 7 days of insulin injections during the assessment period; however, record review found no physician order or documentation showing the resident actually received insulin injections during that time. During interview, the MDS Coordinator stated there was a discrepancy on the assessments and that the residents had not received the anticoagulant or insulin during the assessment period.
Failure to Assess and Document Reopened Surgical Wound
Penalty
Summary
The facility failed to assess and document a wound for one resident with a non-pressure skin condition. During observation, a dressing was seen on the resident’s right leg stump, and the resident stated that the surgical incision from the leg amputation had previously healed but had reopened. The resident’s record showed diagnoses including a bleeding stomach ulcer, stroke, and right leg amputation, and the 5-day MDS indicated the resident was cognitively intact, required maximum assistance with ADLs, and moderate assistance with transfers. The record review found that an orthopedic physician had seen the resident and consulted infectious disease and wound care for a right stump infection, but the chart lacked wound assessments after the wound had reopened. The resident said she had gone to the wound clinic and was scheduled to return for continued treatment. An LPN stated the resident had several small open areas along the previously healed amputation incision, and the corporate wound nurse stated the surgical wound had healed and then opened again, but no additional wound documentation was provided.
Smoking Materials Not Secured and Fall Precautions Missing
Penalty
Summary
The facility failed to ensure that a resident's electronic smoking materials were locked up. Resident 58 had diagnoses including hypertension, diabetes mellitus, dementia, chronic obstructive pulmonary disease, and legal blindness, and the Significant Change MDS dated 8/20/25 indicated he was moderately cognitively impaired and required partial moderate assistance with transfers. His care plan stated he had been deemed an unsafe smoker and could no longer smoke cigarettes, had agreed to an electronic cigarette, and that his smoking materials were to be kept in a secure location. A smoking safety risk assessment dated 7/31/25 indicated all smoking materials would be kept locked in the facility designated area. However, on observation, two electronic cigarette vapes were seen on his bedside table, and his daughter stated they were supposed to be locked up. A later observation again showed the vapes on the bedside table, and CNA 1 stated she was unsure whether the vapes were supposed to be locked up and had not given them to the resident. The facility also failed to ensure fall precautions were in place for a resident with a history of falls. Resident 82 had diagnoses including a displaced fracture of the first cervical vertebra and type 2 diabetes mellitus, and the quarterly MDS dated 6/4/25 indicated he was moderately cognitively impaired and required partial/moderate assistance with bed mobility and transfers. His care plan, updated 6/18/25, identified him as at risk for falls and included Dycem on the wheelchair seat above the cushion and non-skid strips in front of the toilet. On observation, the resident had sutures to his forehead and a neck brace in place and stated he had fallen recently, hit his head, gone to the hospital, and now had to wear a neck brace. The wheelchair seat did not have Dycem in place, and there were no non-skid strips on the bathroom floor during both observations. The DON was informed that the Dycem and non-skid strips were not in place.
Incomplete Meal Intake Documentation
Penalty
Summary
Food intake documentation was incomplete for a resident with significant recent weight loss and severe cognitive impairment. The resident had diagnoses including heart disease, a pressure ulcer of the buttock, and dementia, and the 8/18/25 MDS showed the resident required maximal assistance with ADLs and transfers and had lost 5% or more of body weight in the last month or 10% or more in the last 6 months. The record lacked documentation of 3 meal intakes per day on multiple dates in August and September 2025, despite a revised care plan directing staff to monitor and record intake each shift. During interview, the MDS Coordinator stated the resident had lost 8.6 pounds in 3 months and 40 pounds in 7 months based on prior facility dietician notes, and the Nurse Consultant stated meal consumption should be documented three times daily, once each shift. The facility policy titled Food Intake stated food intake will be recorded by assigned staff.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5% for 1 of 11 residents observed during medication pass. During observation, record review, and interview, surveyors identified 2 medication errors during 26 opportunities for error, resulting in a medication error rate of 7.69% for Resident 17. On 9/5/25 at 3:11 p.m., an RN prepared Resident 17's medications by popping out 1 Flomax 0.4 mg capsule and 1 senna 8.6 mg tablet, placing them in a clear plastic bag, and crushing them. The nurse then poured the crushed medications into a cup with pudding. The Flomax capsule was flattened but remained intact, and the nurse stated she was finished and ready to administer the medications. When asked, the nurse said she always crushed capsule medications because she did not want to open the capsule and get it all over, and she was unaware capsules could not be crushed. The resident's senna medication card and current physician's order indicated 2 tablets every evening, but the nurse had only prepared 1 tablet. During interview, the DON stated the nurse should have opened the Flomax capsule instead of crushing it and should have administered 2 senna tablets instead of 1.
Duplicate Eye Drop Orders Documented on MAR
Penalty
Summary
The facility failed to maintain clinical records that were complete and accurately documented when the Medication Administration Record for Resident 10 contained duplicate entries for Carboxymethylcellulose Sodium Ophthalmic Solution 0.5% and Refresh Tears Solution (Carboxymethylcellulose Sodium), with both listed as 1 drop in both eyes once daily and both signed out as given each morning. Resident 10 had diagnoses including dementia and diabetes, and the 8/5/25 Quarterly MDS indicated moderate cognitive impairment and a need for supervision or touching assistance with ADLs and transfers. During interview, an LPN stated the resident received one drop in each eye every morning and that the duplicate order had been entered in error, and she did not notice the duplication when administering and signing out the medications.
Infection Control Lapses During Wound Care
Penalty
Summary
Provide and implement an infection prevention and control program was cited after wound care for Resident 20 was observed with multiple infection control lapses. During wound care on 9/4/25 at 7:10 a.m., the Wound Nurse removed the old dressing, then took gauze that had been placed directly on a bedside table, soaked it in Dakin's solution, and used it to cleanse the resident's open buttock wound. The bedside table had no barrier and was visibly dirty. The Wound Care Physician assessed and measured the wound, removed gloves, put on gloves taken from his pocket, debrided the wound, removed those gloves again, put on another pair from his pocket, and cleansed inside the open wound with gauze from the table without performing hand hygiene after glove removal. The Wound Nurse later stated she had told someone to clean the bedside table earlier but was unsure what happened. The facility policy required a clean, dry work area or a disinfected table with a protective barrier, and the hand hygiene policy required hand hygiene after glove removal.
Misappropriation of Narcotic Medications in LTC Facility
Penalty
Summary
The facility failed to protect residents from the misappropriation of their narcotic pain medications, specifically hydrocodone and oxycodone, affecting three residents. The issue was identified when the facility could not account for Resident B's oxycodone tablets. An investigation revealed that a registered nurse admitted to taking Resident B's medication. Further review of medication records showed discrepancies in the narcotic counts for Residents B, F, and G, indicating a significant number of tablets were unaccounted for. Resident B, diagnosed with peripheral neuropathy and diabetes mellitus, had a physician's order for oxycodone 15 mg to be administered as needed for pain. However, the narcotic count records for several deliveries were missing, and a total of 273 tablets were unaccounted for. Resident F, with diabetes mellitus and dementia, had a physician's order for hydrocodone-acetaminophen for breakthrough pain. The investigation found that 22 tablets were unaccounted for, as they were signed out but not documented as administered. Resident G, diagnosed with osteoarthritis, had a physician's order for hydrocodone-acetaminophen, and 25 tablets were unaccounted for, despite being signed as given. The investigation revealed that RN 4 was involved in the misappropriation of medications. RN 4 would volunteer to come in early on days when narcotics were delivered, sign for the medications, and then take them along with the narcotic count records. This practice led to over 300 narcotics being unaccounted for over the course of a year. The facility's failure to maintain accurate narcotic counts and prevent drug diversion resulted in the misappropriation of residents' medications.
Incomplete 5-Day Follow-Up on Narcotic Misappropriation
Penalty
Summary
The facility failed to provide a thorough and complete 5-Day follow-up report to the Indiana Department of Health (IDOH) regarding an incident of misappropriation of narcotic medication. The incident involved the unaccounted narcotic pain medication, oxycodone 15 mg, belonging to a resident, which was reported to the Assistant Director of Nursing and the Administrator. The follow-up report, dated 1/3/25, confirmed the drug diversion was substantiated due to RN 4's admission of taking the oxycodone. However, the report lacked critical information from the investigation, including the discovery that two other residents also had missing narcotic medication, the total number of unaccounted narcotics, and the clarification that RN 3 was not involved in the misappropriation. During an interview, the Regional President acknowledged the missing information in the 5-day follow-up report.
Failure to Investigate Skin Tears in Resident
Penalty
Summary
The facility failed to ensure a resident received necessary care and services by not investigating the root cause of multiple skin tears. During an observation, a resident was found with dressings on the right arm and hand due to skin tears. The resident, who had vascular dementia and diabetes mellitus and was receiving hospice care, was noted to have memory problems and was dependent on others for all activities of daily living. Despite the presence of skin tears identified on the resident's forearm and hand, there was no investigation conducted to determine the cause. The Assistant Director of Nursing acknowledged the lack of investigation and noted that the resident would pick at her skin when uncomfortable, yet there was no care plan addressing this behavior. The Corporate RN Consultant confirmed that the skin tears should have been investigated to determine their cause.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure thorough and timely assessment of a resident's pressure ulcers, notify the physician of a decline in the condition, and implement interventions to prevent further pressure ulcers. During an observation, a resident was found with a large dressing on the left hip with copious bloody drainage and a foul odor, indicating a decline in the wound's condition. The Assistant Director of Nursing (ADON), who also served as the Wound Nurse, was unaware of the changes in treatment orders made by the Hospice Nurse and had not been informed of the decline in the resident's condition. The resident's medical record revealed inconsistencies and lack of documentation regarding the assessment and treatment of pressure ulcers. Weekly skin assessments were not consistently completed, and there were no thorough descriptions or measurements of the pressure areas. The care plan did not accurately reflect the presence of pressure ulcers, and there was a lack of communication between the facility staff and the hospice care team regarding the resident's condition. Interviews with facility staff highlighted a lack of communication and coordination in the management of the resident's pressure ulcers. The ADON indicated that the nurses were responsible for obtaining treatment orders and notifying her of concerns, but there was a failure to do so. Additionally, the facility's skin condition assessment policy was not followed, as pressure ulcers were not assessed and measured weekly as required. This lack of adherence to policy and communication breakdown contributed to the deficiency in providing appropriate pressure ulcer care.
Failure to Use Correct PPE for Resident Under Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure correct Personal Protective Equipment (PPE) was used by staff members when providing care to a resident under Enhanced Barrier Precautions (EBP). During an observation, two Certified Nursing Assistants (CNAs) entered the room of a resident with an indwelling urinary catheter, skin tears, and pressure ulcers, without wearing gowns, despite a sign indicating the need for EBP and available PPE in the hallway. The CNAs acknowledged the requirement for gowns during care. In a separate observation, a CNA and a Licensed Practical Nurse (LPN) were repositioning the same resident without wearing gowns, although the LPN confirmed that EBP PPE should have been used. The facility's policy indicated that EBP was necessary for residents with chronic wounds and indwelling catheters.
Improper Medication Storage in Facility Carts
Penalty
Summary
The facility failed to ensure proper storage of medications in two of the four medication carts observed. On September 20, 2024, at 2:33 p.m., the ACU Medication Cart was found with multiple loose pills of different sizes and colors scattered throughout the bottoms of the drawers. The Agency QMA working with the cart indicated it was her first day on the cart. Similarly, at 2:47 p.m., the [NAME] 1 Medication Cart was observed with the same issue of loose pills, and the RN present stated that nursing staff were responsible for cleaning the carts. During an interview, the Assistant Director of Nursing mentioned that the Director of Nursing was typically responsible for ensuring the carts were cleaned.
Failure to Ensure Proper Assessment and Authorization for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly assessed for self-administration of medications and lacked the necessary Physician's Orders for such self-administration. In the case of Resident 9, during a medication pass observation, an LPN administered a nebulizer breathing treatment without checking the resident's oxygen saturation or lung sounds. The LPN left the resident alone during the treatment, unaware of whether a self-administration assessment had been completed. The resident's records did not contain a Physician's Order or assessment for self-administration, and the facility's policy required staff to remain with residents during treatments unless they were assessed and authorized to self-administer. For Resident 32, the resident was observed with a medication cup containing pills and nasal sprays on her dresser and bathroom counter, respectively. The resident indicated that she self-administered these medications, which were left by an LPN. However, the resident's records only authorized self-administration of supplements, eye drops, and saline nasal spray, not the prescribed oral medications or Fluticasone Propionate Suspension. The facility's policy required specific authorization from the attending physician for self-administration and mandated observation to ensure complete ingestion of medications, which was not adhered to in this case.
Failure to Monitor Resident for Psychosocial Distress After Altercation
Penalty
Summary
The facility failed to provide psychosocial follow-up care to a resident involved in a physical altercation with another resident. Resident 136, who had severe cognitive impairment and diagnoses including unspecified dementia, hypertension, and depression, was involved in an incident where another resident struck him multiple times. Although the residents were separated and assessed for injuries, and the aggressor was sent to the hospital for evaluation, there was no documentation that Resident 136 was monitored for psychosocial distress following the incident. The facility's Social Service Director acknowledged that residents are typically monitored for 72 hours after such events, but this protocol was not triggered in this case. The facility's current Abuse Prevention and Reporting policy lacked specific guidelines for monitoring psychosocial distress.
Failure to Provide Written Notification for Hospital Transfer
Penalty
Summary
The facility failed to ensure that a resident and their Responsible Party were notified in writing regarding a transfer to the hospital. This deficiency was identified for one of the three residents reviewed for hospitalization. The resident in question, who had diagnoses including type 2 diabetes mellitus and elevated liver enzymes, was moderately impaired in daily decision-making according to a recent assessment. On a specific date, a physician ordered the resident to be sent to the hospital due to elevated liver enzymes, nausea, emesis, and epigastric pain. Although the Responsible Party was notified verbally, there was no documentation indicating that the State-approved transfer form was completed or that written notification was provided to the Responsible Party. During an interview, the Regional President of Operations confirmed the absence of documentation related to the State transfer form and written notification to the Responsible Party. The facility's policy requires that residents and their representatives be notified in writing of transfers or discharges, with a copy sent to the State Long-term Care Ombudsman. The lack of documentation and failure to follow this policy resulted in the identified deficiency.
Failure to Notify Resident of Bed-Hold Policy
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 three residents reviewed for hospitalization. The resident in question, who had diagnoses including type 2 diabetes mellitus and elevated liver enzymes, was moderately impaired in daily decision-making according to a recent MDS assessment. On a specific date, the resident was sent to the hospital due to elevated liver enzymes, nausea, emesis, and epigastric pain. Although the Responsible Party was notified of the hospital transfer, there was no documentation indicating that the bed-hold policy was communicated to them. This was confirmed during an interview with the Regional President of Operations, who acknowledged the lack of documentation regarding the bed-hold policy notification.
Deficiencies in Timely Intervention, Medication Administration, and Skin Monitoring
Penalty
Summary
The facility failed to ensure timely intervention for a resident with abnormal lab results, leading to hospitalization. Resident 68, who had diagnoses including cerebral infarction, chronic kidney disease, and type 2 diabetes mellitus, was observed receiving intravenous fluids. Despite being at risk for decreased cardiac output and dehydration, lab results collected on 7/1/24 were not communicated to the physician or nurse practitioner until 7/2/24. The delayed communication resulted in the resident being sent to the emergency room for renal failure after elevated lab values were finally reviewed. The facility also failed to administer medications as ordered for two residents. Resident 24, diagnosed with dementia and hypertension, had orders to hold certain medications if blood pressure was below a specified level. However, the medications were not held on multiple occasions despite low blood pressure readings. Similarly, Resident 55, with diagnoses including hypertension and chronic kidney disease, did not receive medications as ordered on numerous dates. Additionally, midodrine was not held as ordered when blood pressure readings were above the specified threshold. Furthermore, the facility did not assess and monitor skin discolorations for Resident 37, who had large discolorations on her forearms following unsuccessful intravenous line attempts. Despite the presence of these discolorations, weekly skin observations did not document any skin problems. The lack of documentation and monitoring of the bruising was acknowledged during an interview, indicating a failure to adhere to the facility's policy on skin condition assessment and monitoring.
Failure to Provide Timely Vision and Hearing Services
Penalty
Summary
The facility failed to ensure that a resident received necessary vision and hearing services in a timely manner. Resident 27, who was diagnosed with encephalopathy, legal blindness, and hearing loss, expressed during an interview that he could not hear or see and required outside services. Despite his needs, the facility had not facilitated access to these services. The resident's Quarterly Minimum Data Set (MDS) assessment indicated moderate impairment in daily decision-making, moderate difficulty with hearing, and highly impaired vision, yet he did not have hearing aids or corrective lenses. Care plans from earlier in the year noted behavior problems related to hearing difficulties and impaired communication due to hearing deficits. The facility's process for arranging ancillary services was not effectively implemented for Resident 27. Although a physician's order was made to add the resident to the eye doctor list, and verbal consent for ancillary services was documented, the Ancillary Service Company required a signed consent and order to treat, which had not been provided. The Social Services Director acknowledged that the resident was not on the current list for audiology and optometry services and planned to address this at the next Care Plan Meeting. The facility's policy stated that it would assist residents in arranging health services on-site as needed, but this was not executed for Resident 27, leading to the deficiency.
Failure to Implement Fall Precautions for Resident
Penalty
Summary
The facility failed to implement fall precautions for a resident with a history of falls, leading to a deficiency in ensuring a safe environment. The resident, who was cognitively impaired and had a history of falls, was observed in her room and bathroom without non-skid strips, which were previously identified as necessary interventions. Despite a care plan update indicating the need for non-skid strips in front of the bed and in the bathroom, these safety measures were not in place during observations on two separate occasions. The resident had a history of falls, including one with a major injury, and was involved in an incident where she slipped on spilled iced tea in the bathroom, resulting in a fracture. The facility's policy required safety interventions for residents at risk of falls, but the necessary interventions were not implemented for this resident. The lack of non-skid strips, as previously recommended by the interdisciplinary team, contributed to the unsafe conditions that led to the resident's fall and subsequent injury.
Failure to Administer Continuous Oxygen as Ordered
Penalty
Summary
The facility failed to provide necessary respiratory care for a resident, as observed and documented by surveyors. Resident 7, who has diagnoses including acute and chronic respiratory failure, was observed with an oxygen concentrator that was not in use as ordered. The resident's physician had ordered continuous oxygen administration at 3 liters per minute via nasal cannula, but the oxygen tubing was found on the floor or stored in a plastic bag during observations. The resident indicated she only used oxygen at night, contrary to the continuous order. The September 2024 Medication Administration Record lacked documentation of oxygen administration or refusal. An LPN interviewed was unaware of the continuous oxygen order and stated the resident refused oxygen, noting there was no place on the MAR to document its use or refusal.
Failure to Monitor Dialysis Access Site
Penalty
Summary
The facility failed to provide necessary care and services for a resident receiving hemodialysis by not monitoring the dialysis access site. Resident 231, who was cognitively intact and diagnosed with end-stage renal disease, hypertension, and type 2 diabetes mellitus, had a catheter in his right chest for dialysis. The resident attended dialysis sessions on Mondays, Wednesdays, and Fridays. Upon review, it was found that there were no current physician orders for dialysis or monitoring of the dialysis catheter after the resident's readmission to the facility on 9/13/24. Previous orders for dialysis services and catheter monitoring had been discontinued on 9/3/24 and were not reinstated upon readmission. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) for September 2024 showed no documentation of monitoring the dialysis catheter from 9/13/24 to 9/17/24. The facility's policy on Dialysis Monitoring and Observation required nurses to assess the catheter site for signs of drainage and the condition of the dressing every shift, which was not adhered to in this case. During an interview, the Regional President of Operations acknowledged the oversight and indicated a review of the dialysis orders would be conducted.
Failure to Report Abnormal Lab Results
Penalty
Summary
The facility failed to ensure that abnormal lab results were promptly communicated to the Physician for a resident who was reviewed for hospitalization. On a specific date, the resident was observed receiving intravenous fluids and had a history of cerebral infarction, chronic kidney disease, and type 2 diabetes mellitus. The resident's care plan included monitoring lab values and reporting results to the Physician. However, lab results collected on another date, which showed elevated levels in several tests, were not communicated to the Physician or Nurse Practitioner as required. The Nurse Practitioner only became aware of the abnormal lab results the following day, which included elevated BUN, creatinine, potassium, alkaline phosphatase, and white blood cell count. Upon reviewing these results, the Nurse Practitioner ordered the resident to be sent to the emergency room for renal failure. The resident was subsequently admitted to the hospital for acute kidney injury, with the admission history indicating acute renal failure and electrolyte abnormalities. The facility's policy required notifying the Physician of significant changes in the resident's condition, which was not adhered to in this case.
Failure to Disinfect Multi-Use Equipment
Penalty
Summary
The facility failed to ensure that multiple-use equipment was disinfected after use on residents, as observed during a medication administration observation. Specifically, an LPN was seen preparing medications for a resident and needed to check the resident's blood pressure before administering the medications. The LPN used a blood pressure wrist cuff from the medication cart, applied it to the resident's wrist, and then returned it to the cart without cleaning it before or after use. During an interview, the LPN admitted that she normally would clean the cuff but did not do so in this instance. The Regional President of Operations confirmed that the LPN should have cleaned the cuff prior to using it on the resident. The facility's policy on cleaning and sanitizing medical equipment states that devices used for more than one resident should be cleaned between each use.
Failure to Initiate CPR for Resident with Full Code Status
Penalty
Summary
The facility failed to initiate cardiopulmonary resuscitation (CPR) for a resident, referred to as Resident B, who was admitted on hospice care with a full code status as requested by the resident's Health Care Representative (HCR). Resident B had multiple medical conditions, including diabetes mellitus, severe vascular dementia, and quadriplegia, and was dependent on all activities of daily living. Despite the HCR's explicit request for CPR to be performed if there was no pulse and the resident was not breathing, the facility did not initiate CPR when the resident showed signs of actively dying and eventually expired. The resident's care plan and physician's orders indicated a full code status, meaning CPR should have been performed if necessary. However, during the resident's decline, the hospice nurse and facility staff did not initiate CPR or transfer the resident to the hospital, even after the HCR was informed of the resident's condition. The HCR had refused to discontinue medications and tube feeding until she could see the resident herself, but the resident expired before her arrival. Interviews with facility staff, including the Director of Nursing and hospice personnel, revealed that CPR was not initiated, and the resident was not transferred to the hospital despite being actively dying. The facility did not provide a policy regarding CPR initiation prior to the survey exit, and the deficiency was related to a complaint investigation.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 379 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Demotte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oak Grove Christian Retirement Village | 1.3 mi | ★★★★★ | 18 | 0 |
| Cedar Creek Health Campus | 12.7 mi | ★★★★★ | 13 | 0 |
| Lowell Healthcare | 13.2 mi | ★★★★★ | 21 | 0 |
| Crown Point Health Campus | 15.4 mi | ★★★★★ | 23 | 0 |
| Ignite Medical Resort Crown Point Llc | 16.3 mi | ★★★★★ | 36 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.