Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avalon Springs Health Campus during CMS and state inspections, most recent first.
The facility failed to implement infection control measures during a respiratory outbreak. Entrance signage about the outbreak was not posted, a resident with COVID-19 lacked documented symptom and VS monitoring despite being on contact and droplet precautions, and another resident with respiratory symptoms had a negative COVID antigen test but was not retested 48 hours later as required by policy before later testing positive after a family exposure was reported.
Incomplete Documentation of Abuse Allegations in Reportable Incidents: The facility failed to include complete and accurate details in IDOH reportable incidents for two residents. One resident with hemiplegia, hemiparesis, dysphagia, and moderate cognitive impairment reported that someone had been rude, mean, and later said someone had kicked her in the leg, but the report only described a family concern with care and did not identify an abuse allegation. Another resident’s report described a general care concern and bruising, but did not document the actual allegation that a CNA was rough during a transfer; the DON said the facility had been told to keep reports generic.
A resident with severe cognitive deficits, dependence for transfers and toileting, and a history of falls sustained a fall after rolling out of bed and was sent to the hospital with a traumatic subdural hematoma. The care plan included fall interventions such as placing the bed against the wall, but observation showed a standard bed positioned in the middle of the room with an oxygen concentrator between the bed and the wall, and a CNA stated the bed was always in that position.
PICC Line Monitoring Not Consistently Measured A resident receiving IV antibiotics for osteomyelitis and cellulitis had a PICC line with an order for dressing changes and external catheter length measurement. The MAR/TAR showed widely varying external catheter measurements documented by staff, and the ADON stated staff were not measuring the catheter the same way. The DON reported no additional information and no policies related to PICC line care or measurements.
PICC line care was not documented in accordance with professional standards for two residents receiving IV antibiotics. Both residents had PICC lines in the right upper arm and physician orders for normal saline flushes before and after medication, but the MARs did not show flush documentation for certain piperacillin-tazobactam and daptomycin doses. The DON stated the orders were entered as twice daily/once per shift, while nurses knew to flush before and after each antibiotic dose, and she could not find a facility policy for IV antibiotic administration.
A resident requiring maximum assistance for activities of daily living was left in bed with a saturated incontinence brief and wet sheets for several hours, despite care plan interventions to provide toileting assistance at regular intervals. Staff confirmed the delay in care, and documentation showed the resident had a history of recurrent UTIs and was always incontinent of bowel and bladder.
Staff failed to use required PPE, including gowns, and did not perform hand hygiene after glove removal while providing care to two residents on Enhanced Barrier Precautions (EBP) for urinary catheters and intravenous lines. Care plans and facility policy specified the need for gowns and gloves during high-contact care, but staff were observed omitting gowns and not completing hand hygiene, even after handling soiled materials.
A resident with cognitive impairment and a history of falls was found without bolsters on his bed, despite their inclusion in his care plan. The resident experienced multiple falls while attempting to reposition himself using a trapeze bar. Interviews confirmed the absence of bolsters, indicating a failure to implement necessary fall prevention measures.
A facility failed to ensure a resident had a Physician's Order to self-administer medication. The resident, with multiple health conditions and moderate impairment in decision-making, was observed with nasal saline spray on their overbed table without an order for self-administration. Interviews with an LPN and the DON confirmed the absence of necessary orders.
A resident with heart failure and hypertension was not properly monitored for low heart rates while on carvedilol. Despite multiple instances of heart rates below 55 bpm, the physician was not notified, and the medication was administered without parameters for withholding it. The resident was hospitalized twice, and the dosage was adjusted, but the facility failed to follow its policy for physician notification.
A resident's privacy was compromised when an RN left the electronic medication record (EMR) open and unlocked in the hallway during a medication pass. The RN was observed disconnecting intravenous medication and left the computer screen accessible, displaying the resident's personal information. The RN later acknowledged the oversight, and the Director of Nursing confirmed the screen should have been locked.
The facility failed to involve two residents in decisions about their care, including new medications and care planning conferences. One resident was not informed about new medications and lab tests, while another was not invited to care plan conferences and was not kept informed of medication changes. The Director of Nursing and Administrator acknowledged these oversights.
The facility failed to administer blood pressure medications according to prescribed parameters for two residents. One resident received Hydralazine and Metoprolol despite blood pressure and heart rate being below specified limits. Another resident was given Carvedilol without parameters, even when heart rate was below 55 bpm. The DON acknowledged the issue, but no policy was provided.
The facility failed to properly document and manage urinary catheters for three residents. A resident with a neurogenic bladder had urine output recorded only during day shifts, contrary to the care plan. Another resident's catheter bag was observed on the floor, and urine output was not documented every shift. A third resident's urine output was recorded less frequently than ordered. The DON confirmed the documentation issues.
A facility failed to monitor the nutritional intake and weight of a resident with significant weight loss. The resident, with multiple health issues, was at risk for malnutrition. Despite a care plan, weekly weights were not documented as recommended, and there were numerous instances of undocumented supplement and meal consumption. Interviews confirmed these deficiencies.
A facility failed to maintain a PICC line for a resident, leading to a deficiency in IV fluid administration. The resident reported that the PICC line bandage had not been changed since admission, and observations confirmed the bandage was unchanged with dried blood visible. The care plan required IV site care, and physician's orders specified dressing changes every five days, but the Treatment Administration Record showed missed changes. The Director of Nursing could not provide additional information, and the facility's catheter care policy was not followed.
A resident with multiple respiratory and cardiac conditions was observed receiving oxygen therapy at an incorrect flow rate, set at 2.5 liters per minute instead of the physician-ordered 3 liters per minute. The error was identified and corrected by an LPN, and the DON was informed but had no further information.
A resident with multiple medical conditions, including spinal stenosis and opioid use, experienced unmanaged pain despite being on Fentanyl and Norco. The facility failed to administer diclofenac gel or attempt non-pharmacological interventions as per the resident's care plan. The resident was not informed about the availability of the gel, which was only applied after the issue was highlighted.
A facility failed to maintain accurate clinical records for a resident with multiple diagnoses, including dysphagia, who was receiving nutrition through a peg tube. The resident's medications were administered both orally and through the tube, despite physician's orders specifying oral administration only. An RN confirmed administering medications through the peg tube without a physician's order, while the DON noted a change in administration route following the resident's decline.
The facility failed to implement infection control guidelines during wound treatment and medication administration for two residents. A hospice CNA and RN did not use enhanced barrier precautions (EBP) while treating a resident with pressure ulcers, failing to don gowns and change gloves between treatments. Another RN did not follow hand hygiene protocols during a medication pass for a resident with a PICC line, neglecting to wash hands between glove changes and allowing IV tubing to touch the floor. The facility's policies on dressing changes, EBP, and hand hygiene were not adhered to.
A resident with a history of stroke and cellulitis experienced worsening edema and wheezing, but the facility failed to follow up with the physician after sending faxes. Despite the facility's policy requiring phone notification if no response was received within 12 hours, this was not done. The physician assessed the resident two days later and adjusted the medication regimen.
The facility failed to provide proper care for PICC lines for three residents, including lack of documentation and assessments upon admission, incorrect administration of flushes, and missed dressing changes. The DON was unable to locate necessary documentation for the PICC line care.
The facility failed to ensure staff were aware of Enhanced Barrier Precautions (EBP) and did not use correct PPE for residents with PICC lines. Observations revealed missing EBP signs and carts, and staff interviews indicated a lack of training. CNA 3 and LPN 2 did not follow EBP protocols, such as donning gowns and changing gloves, potentially affecting residents with conditions like cellulitis.
Infection Control Failures During Respiratory Outbreak
Penalty
Summary
The facility failed to ensure infection control measures were in place and implemented during a respiratory outbreak. On 1/8/26, the entrance to the facility did not have signage posted indicating there was a current respiratory outbreak or listing current precautions such as masking being optional or available. During the initial tour, resident rooms were observed with droplet precaution signs and PPE bins outside the rooms, and staff stated the residents on precautions had tested positive for COVID-19 and lived on the 100 and 300 halls. The DON stated masks were to be made available to visitors and residents, but the facility did not have signs up advising visitors there was an outbreak in the facility. The Nurse Consultant stated there was a sign at the entrance for visitors with flu signs or symptoms to wear a mask or defer visiting, and the Executive Director stated posting anything elsewhere was not required. Resident 19 had diagnoses including hypertension, CHF, and atrial fibrillation. The resident was readmitted from the hospital and tested positive for COVID-19 while in the hospital. A physician order placed the resident on contact and droplet precautions due to COVID-19. However, the MAR and TAR for 1/2026 lacked documentation of assessment and monitoring of COVID symptoms or vital signs, and the vital signs tab showed vitals were recorded only on 1/7/26 at 5:14 p.m. and 1/11/26 at 8:02 p.m. The Infection Preventionist stated COVID-positive residents should be assessed once per shift or twice a day and that there should have been an order for monitoring symptoms and checking vital signs twice a day. Resident 44 had diagnoses including dementia and stroke and was moderately cognitively impaired. The resident had contact precautions for C. difficile and developed respiratory symptoms including rhonchi, wheezing, cough, diminished breath sounds, and later pneumonia confirmed by chest x-ray. A POC COVID-19 antigen test on 1/1/26 was negative, and the resident remained symptomatic over the following days. On 1/12/26, after a family member reported testing positive for COVID-19 and recent visitation with the resident, the resident was tested again and was positive, with no symptoms noted at that time. The IP Nurse Manager stated the resident was symptomatic when the initial COVID test was negative and should have been tested again after 48 hours, and the facility policy stated that a negative antigen test should be confirmed by a negative PCR or a second negative POC test 48 hours later, with the resident remaining in TBP until confirmation.
Incomplete Documentation of Abuse Allegations in Reportable Incidents
Penalty
Summary
The facility failed to ensure complete and accurate information was included in IDOH Reportable Incidents related to abuse allegations for 2 residents. One resident, who had diagnoses including hemiplegia, hemiparesis following a cerebral infarction, and dysphagia, also had moderate cognitive impairment on a Significant Change MDS assessment. In one incident, the resident told staff that someone had been rude and mean to her and later told the DON that someone had kicked her in the leg, but the reportable incident described only a family concern with care and did not identify that an abuse allegation had been made. The resident was assessed and no injury was noted, and the investigation noted no psychosocial changes and that abuse could not be substantiated. For another resident, the facility’s reportable incident stated only that the resident voiced concerns related to care and that bruises were found on the left forearm and right elbow, with a CNA suspended pending investigation. The follow-up report stated the bruises were from bumping the arms on a wheelchair while reaching for items, and that the resident had no further concerns with care. However, the report did not document what the resident’s care concerns were or that the resident had alleged the CNA was rough during a transfer. The DON stated the facility had been instructed to keep reportable incidents generic and acknowledged the need to accurately document the details of future incidents.
Fall Intervention Not in Place for Resident With History of Falls
Penalty
Summary
The facility failed to ensure fall interventions were in place for a resident with a history of falls. The resident had diagnoses including traumatic subdural hematoma, acute and chronic respiratory failure, and Alzheimer's dementia. The Significant Change MDS assessment indicated severe cognitive deficits and dependence for transfers and toileting. An Indiana Department of Health reportable incident showed the resident fell and was sent to the hospital for evaluation after sustaining a traumatic subdural hematoma to the head. The interdisciplinary team note stated the root cause of the fall was that the resident rolled out of bed, and the intervention was to place the bed against the wall. The fall care plan identified the resident as at risk for falls related to weakness and impaired physical functioning and included interventions such as using a larger bed to allow for a larger surface area; the bed-against-the-wall intervention was added later. During observation, the resident's room had a standard size bed placed in the middle of the room with the headboard against the wall and an oxygen concentrator between the bed and the wall. A CNA stated the bed was always in that position and was not pushed against the wall, and the DON stated the care plan had been updated and some interventions had been closed.
PICC Line External Catheter Measurements Not Consistently Monitored
Penalty
Summary
The facility failed to ensure a PICC IV access site was assessed and monitored accurately as ordered for one resident receiving IV antibiotics for osteomyelitis and cellulitis of the lower limbs. The resident’s admission MDS indicated moderate cognitive impairment, intermittent oxygen therapy, IV antibiotic use, and a central IV access site. The care plan directed staff to assess the IV each shift for complications such as infection or dislodgment and to provide IV site care as ordered. A physician’s order required PICC line dressing changes every 5 days and measurement of the external catheter length. The December 2025 and January 2026 MAR/TAR documented dressing changes with widely varying external catheter measurements, including 25 cm, 3 cm, 26 cm, 12 cm, 11 cm, 17 cm, and 3.5 cm. During interview, the ADON stated the resident had not had problems with the PICC line and that staff were not all measuring the external catheter the same way, resulting in varying documented measurements. The DON stated she had no further information and no policies related to PICC line care/measurements.
PICC Flush Documentation Not Recorded for Two Residents Receiving IV Antibiotics
Penalty
Summary
The facility failed to document PICC line care in accordance with professional standards for 2 of 3 residents reviewed for IV care. Resident 14 had a PICC line in the right upper arm and was receiving IV antibiotics for bacteremia and type 2 diabetes mellitus. The physician’s order directed the PICC to be flushed with 10 cc normal saline before and after medication twice a day, but the MAR did not document PICC flushes before and after the 4:00 p.m. and 12:00 a.m. doses of piperacillin-tazobactam or the 2:00 p.m. dose of daptomycin. Resident 59 also had a PICC line in the right upper arm and was receiving IV antibiotics after foot surgery for osteomyelitis and atrial fibrillation. The physician’s order directed the PICC to be flushed with 10 cc normal saline before and after medication twice a day, but the MAR did not document PICC flushes before and after the 2:00 p.m. dose of piperacillin-tazobactam. During interview, the DON stated the flush orders were entered as twice a day/once per shift, but nurses knew to flush the PICC before and after every dose of the antibiotic medication, and she was unable to find a facility policy related to IV antibiotic medication administration.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A resident who required maximum to dependent care for activities of daily living did not receive timely incontinence care. Observations showed that the resident was left in bed with a saturated incontinence brief and wet sheets, with the last incontinence care documented at 7:30 a.m. Staff acknowledged the resident was incontinent of a large amount of urine, and the resident had been waiting for assistance to get out of bed after breakfast. The resident's care plan indicated she should be offered toileting assistance upon rising, before and after meals, and before bedtime, and that she was always incontinent of bowel and bladder and unable to recognize the need to void. Record review revealed the resident had a history of metabolic encephalopathy, multiple urinary tract infections, and sepsis, with recurrent UTIs noted in a recent physician's note. The facility did not have a specific policy for how often residents should be checked for incontinence, but the DON stated residents were usually checked before and after meals and before bedtime. The Indiana State Department of Health Nurse Aide Curriculum recommends frequent monitoring and perineal care for residents with incontinence. The failure to provide timely incontinence care was observed and confirmed by staff.
Failure to Ensure Proper PPE and Hand Hygiene During Enhanced Barrier Precautions
Penalty
Summary
Staff members failed to use appropriate Personal Protective Equipment (PPE) when providing care to residents requiring Enhanced Barrier Precautions (EBP). In one instance, a CNA assisted a resident with a urinary catheter and intravenous line into the bathroom while only wearing gloves and not a protective gown, despite signage and care plans indicating EBP was required. The Director of Nursing observed this lapse and confirmed that a gown should have been worn. The CNA exited the bathroom with a soiled brief in a clear garbage bag for disposal, still without the required gown. In another case, a CNA assisted a resident with an indwelling urinary catheter who required EBP, but only wore gloves and a mask, omitting the protective gown. The CNA was also unsure which resident required EBP and, after changing a urinary drainage leg bag, exited the room still wearing gloves, removed them in the hallway, and failed to perform hand hygiene before proceeding to the nurses' desk. Both residents involved had diagnoses including urinary tract infections and required EBP for high-contact care, as documented in their care plans. Facility policies required the use of gowns and gloves for EBP and mandated hand hygiene before and after resident contact and glove removal.
Failure to Implement Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to implement fall prevention interventions for a resident with a history of multiple falls. Resident C, who was cognitively impaired and required substantial assistance with daily activities, was observed without bolsters on his bed, despite the care plan indicating their necessity. The resident had experienced four falls over the past two months, with incidents occurring on 1/6/25, 2/9/25, 2/11/25, and 2/26/25. These falls were associated with the resident attempting to reposition himself in bed using a trapeze bar, which resulted in him slipping and falling out of bed. Interviews with the nursing staff and the Director of Nursing revealed that bolsters, which were part of the resident's care plan to prevent falls, were not present on the resident's bed. The Director of Nursing confirmed the absence of bolsters and had no additional information regarding their omission. This oversight in implementing the care plan's fall prevention measures contributed to the resident's repeated falls, highlighting a deficiency in ensuring the safety and adequate supervision of residents at risk for accidents.
Lack of Physician's Order for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident had a Physician's Order to self-administer their own medications. During multiple observations, a resident was seen with a bottle of nasal saline spray on their overbed table, but there was no order for the resident to self-administer the nasal spray. The resident's medical record indicated diagnoses including heart disease, congestive heart failure, acute pulmonary edema, chronic obstructive pulmonary disease (COPD), and acute respiratory failure. The resident was moderately impaired for daily decision-making and received oxygen therapy. Despite these conditions, there was no care plan in place for self-administration of medications, and the Physician's Orders did not include permission for the resident to self-administer the nasal spray. Interviews with an LPN and the Director of Nursing confirmed the absence of such orders.
Failure to Notify Physician of Abnormal Vital Signs
Penalty
Summary
The facility failed to notify a physician of abnormal vital signs for a resident who was receiving carvedilol for hypertension. The resident, who was cognitively intact and dependent on staff for toileting and transfers, had a history of heart failure, hypertensive heart disease, and diabetes mellitus. The resident's heart rate was documented below 55 beats per minute on multiple occasions in October and November 2024, with no evidence that the physician was informed of these abnormal readings. Despite the low heart rates, the medication was administered without any parameters in place to guide when it should be withheld. The resident was admitted to the hospital twice during this period, and upon return, the carvedilol dosage was adjusted due to low heart rate. However, there was still no documentation of physician notification regarding the low heart rates. The facility's policy required that physicians be notified of any changes in condition or diagnostic results, but this was not adhered to in this case. The Director of Nursing was informed of the oversight, but no additional information was provided to address the lack of physician notification.
Resident Privacy Breach Due to Unlocked EMR
Penalty
Summary
The facility failed to maintain a resident's privacy concerning their electronic medication record (EMR) during a medication pass. On November 21, 2024, at 12:21 p.m., a registered nurse (RN 1) was observed disconnecting intravenous medication for a resident. During this process, the RN left the EMR open and unlocked on a computer in the hallway, making the resident's medications and personal information visible. The RN gathered supplies from the 300 Hall cart and proceeded to the resident's room, leaving the computer screen accessible. At 12:28 p.m., the RN returned to the 300 Unit Nurses' Station, and the computer screen remained open and visible in the hallway. In an interview conducted at 12:28 p.m. on the same day, RN 1 acknowledged not realizing the screen was left open and confirmed that it should always be locked when not in use. The Director of Nursing, interviewed on November 25, 2024, at 2:57 p.m., also indicated that the computer screen should have been locked when the nurse walked away.
Failure to Involve Residents in Care Decisions and Planning
Penalty
Summary
The facility failed to ensure that residents were involved in decisions about their care, specifically regarding new medications and participation in care planning conferences. Resident 38 was not informed about new medications, laboratory tests, or treatments, despite having multiple diagnoses including heart disease and COPD. The resident's daughter was notified of changes, but there was no documentation that the resident was informed. The Director of Nursing acknowledged that the resident should have been notified of these changes. Similarly, Resident 49 was not invited to or informed about care plan conferences and was not kept informed of medication changes. This resident had several health issues, including a knee replacement and chronic kidney disease. Although the resident's wife was informed of new medication orders, there was no documentation that the resident was notified. The Administrator mentioned that the resident was invited to the care plan conference, but the family did not want the resident to attend, and no separate conference was held for the resident.
Failure to Administer Blood Pressure Medications According to Parameters
Penalty
Summary
The facility failed to administer blood pressure medications according to the prescribed parameters for two residents, leading to deficiencies in medication management. Resident 38, who had diagnoses including heart disease and congestive heart failure, was prescribed Hydralazine and Metoprolol with specific parameters to hold the medication if the systolic blood pressure was less than 110 or the heart rate was less than 60. However, the Medication Administration Record (MAR) indicated that these medications were administered on multiple occasions when the resident's blood pressure and heart rate were below the specified parameters. Interviews with staff revealed that the medications were not consistently held as ordered by the physician. Resident 5, who was admitted with conditions such as heart failure and hypertensive heart disease, was prescribed Carvedilol without specific parameters for holding the medication. The MAR showed that the medication was administered even when the resident's heart rate was documented below 55 beats per minute on several occasions. Despite a physician's order to decrease the dosage due to low heart rate, the medication continued to be administered without appropriate monitoring or parameters in place. The Director of Nursing acknowledged that medications should be held if the heart rate was in the 40s, but no policy was provided to guide staff on this matter. The report highlights a lack of adherence to physician orders and inadequate monitoring of vital signs before administering medications, which could potentially lead to adverse effects for the residents. The facility's failure to ensure medications were administered according to the prescribed parameters and the absence of a clear policy for holding medications based on vital signs contributed to the deficiencies identified during the survey.
Deficiencies in Urinary Catheter Care and Documentation
Penalty
Summary
The facility failed to ensure proper documentation and handling of urinary catheters for three residents. Resident 6, who had a neurogenic bladder and an indwelling urinary catheter, had a care plan requiring urinary output to be recorded every shift. However, documentation showed that urine output was only recorded during day shifts over a 30-day period, despite the requirement for 12-hour shift documentation. The Director of Nursing confirmed that urine output should have been documented every shift. Resident 216, with chronic kidney disease and an indwelling urinary catheter, was observed with a catheter bag resting on the floor, which was not addressed in the care plan. The resident's urine output was also not documented every shift as required. Similarly, Resident 13, who had an indwelling urinary catheter and a history of sepsis and urinary tract infections, had urine output documented less frequently than the physician's order of three times per day. The Director of Nursing acknowledged the lack of proper documentation but did not provide further information.
Failure to Monitor Nutritional Intake and Weight
Penalty
Summary
The facility failed to adequately monitor the nutritional intake and weight of a resident with significant weight loss. The resident, who had multiple diagnoses including heart disease, congestive heart failure, COPD, and acute respiratory failure, was identified as being at risk for malnutrition. Despite a care plan that included providing a therapeutic diet, supplements, and regular monitoring, the facility did not document weekly weights as recommended by a Registered Dietitian. The resident experienced a significant weight loss of 8.2% over 30 days, and the dietitian had suggested weekly weight checks for four weeks, which were not completed. Additionally, there were numerous instances where the consumption of prescribed nutritional supplements and meals was not documented. The med pass supplement was not recorded as administered on several specific dates, and meal consumption logs were incomplete for breakfast, lunch, and dinner on various dates. Interviews with the Director of Nursing confirmed the incompleteness of meal and supplement consumption records, as well as the failure to complete weekly weight checks.
Failure to Maintain PICC Line for Resident
Penalty
Summary
The facility failed to maintain a peripherally inserted central catheter (PICC) line for a resident, leading to a deficiency in the administration of intravenous (IV) fluids. The resident, who had a history of wound infection, diabetes, and other health issues, reported that the PICC line bandage had not been changed since his admission to the facility. Observations confirmed that the bandage was unchanged, with brown dried blood visible under the clear tegaderm, and one of the ports was not functioning. The resident's care plan required IV site care as ordered, and physician's orders specified that the PICC dressing should be changed every five days. The Treatment Administration Record (TAR) for November 2024 showed that the PICC line dressing change was not documented as completed on the specified dates of 11/12 and 11/17/24, with the first recorded change occurring on 11/22/24. The Director of Nursing was unable to provide additional information regarding the missed dressing changes. The facility's catheter care policy required dressing changes at specified intervals or when compromised, but this was not adhered to, resulting in a failure to prevent potential catheter-related infections.
Oxygen Flow Rate Discrepancy for Resident
Penalty
Summary
The facility failed to ensure that oxygen concentrators were set at the correct flow rate for a resident receiving oxygen therapy. During multiple observations, the resident was found wearing oxygen via nasal cannula with the concentrator set at 2.5 liters per minute, despite the physician's order specifying a continuous flow of 3 liters per minute. The resident, who had diagnoses including heart disease, congestive heart failure, acute pulmonary edema, chronic obstructive pulmonary disease (COPD), and acute respiratory failure, was moderately impaired in daily decision-making and required oxygen therapy as part of her care plan. The discrepancy in the oxygen flow rate was identified by an LPN, who adjusted the setting to the correct rate. The Director of Nursing was informed of the issue but had no additional information to provide.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to manage and monitor the pain of a resident, identified as Resident 157, who was observed experiencing significant discomfort. On two separate occasions, the resident was seen grimacing and complaining of back pain, which he rated as 7 out of 10 in severity. Despite being on a Fentanyl patch and Norco, the resident reported that his pain was not well controlled and expressed a need for new or adjusted pain medications. The resident's medical history included conditions such as cellulitis, heart failure, chronic kidney disease, atrial fibrillation, depression, spinal stenosis, and opioid use. The resident's pain care plan aimed to maintain pain at a tolerable level through various interventions, including medication administration and non-pharmacological methods. However, the facility did not adequately implement these interventions. The Medication Administration Record indicated that the resident could receive diclofenac gel as needed, but it had not been administered, and there was no evidence of non-pharmacological interventions being attempted. An RN acknowledged that the resident was not informed about the availability of the diclofenac gel, which was only applied after the issue was raised. The facility's policy on pain management emphasized educating residents about available interventions and evaluating their effectiveness, but these steps were not followed, leading to the deficiency.
Failure to Maintain Accurate Medication Administration Records
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident regarding the administration route of medications. The resident, who had multiple diagnoses including colitis, dehydration, congestive heart failure, dementia, Alzheimer's disease, heart disease, Parkinson's disease, and dysphagia, was receiving nutrition through a peg tube. The resident's daughter reported that medications were administered both orally and through the tube. However, the physician's orders specified oral administration for Carbidopa-Levodopa and Pepcid, with no order for administration through the peg tube. An RN confirmed administering medications through the peg tube without a physician's order, while the Director of Nursing indicated that the resident's medications were initially given orally but were later administered through the peg tube following the resident's decline.
Infection Control Deficiencies in Wound Care and Medication Administration
Penalty
Summary
The facility failed to implement infection control guidelines during wound treatment and medication administration for two residents. In the first instance, a hospice CNA and RN did not use enhanced barrier precautions (EBP) while providing care to a resident with pressure ulcers. They did not don gowns as required, and the RN failed to change gloves between treating different wounds, using the same gloves to apply cream and dress the ulcers. The resident's room had a sign indicating EBP was necessary, but the staff were unaware of this requirement. The Director of Nursing confirmed that a gown was required for such procedures. In the second instance, an RN did not follow proper hand hygiene protocols during a medication pass for a resident with a peripherally inserted central catheter (PICC) line. The RN did not wash her hands before putting on gloves, failed to perform hand hygiene between glove changes, and allowed IV tubing to touch the floor while administering medication. Although the resident was under EBP, the RN did not wear a gown, believing it was not necessary for PICC line medication administration. The Director of Nursing had no additional information to provide regarding this incident. The facility's policies on dressing changes and EBP were not adhered to during these observations. The dressing changes policy required handwashing and glove changes between steps, which were not followed. The EBP policy mandated the use of gowns and gloves during high-contact care activities for residents with chronic wounds or indwelling medical devices, which was not implemented in these cases. The hand hygiene policy also required handwashing before and after glove use, which was not consistently practiced by the staff.
Failure to Follow Up on Physician Notification for Change in Condition
Penalty
Summary
The facility failed to follow up on a notification of a change in condition with a resident's physician for one of the residents reviewed. The resident, who had a history of stroke and cellulitis, exhibited signs of edema in both lower legs and had gained weight over two days. The resident mentioned taking an extra dose of Lasix when experiencing edema. The facility faxed the physician with the assessment information and notified the resident and family, but there was no documentation of a response from the physician or any follow-up phone call regarding the condition changes. Further documentation indicated that the resident complained of wheezing, and a fax was again sent to the physician. Despite the worsening edema and the resident's complaints, there was no record of a physician's response to the faxes sent on consecutive days. The facility's policy required phone notification to the provider if there was no response to a fax within 12 hours, but this protocol was not followed. The physician eventually assessed the resident two days later, noting significant edema and adjusting the medication regimen.
Deficient PICC Line Care in LTC Facility
Penalty
Summary
The facility failed to adhere to professional standards of practice in the care of peripherally inserted central catheters (PICC lines) for three residents, identified as Residents E, F, and C. For Resident E, the facility did not document the presence of a PICC line upon admission, nor did it assess the insertion site, measure the catheter length, or the arm circumference. The LPN administered a flush with 10 cc's of normal saline instead of the ordered 5 cc's. The Director of Nursing (DON) was unable to locate any assessments or documentation regarding the PICC line care upon admission. Resident F's care was similarly deficient, with no documented assessment of the PICC site, catheter length, or arm circumference upon admission. The facility failed to perform scheduled dressing changes and measurements, as indicated by the Medication Administration Record. The DON acknowledged the lack of documentation and was unable to provide further information regarding the PICC line care. For Resident C, the facility did not document the location of the PICC line, assess the site, or measure the catheter and arm circumference upon admission. Scheduled dressing changes and assessments were not consistently documented, and the MAR indicated that the PICC line site was not assessed for signs of complications. The DON confirmed the absence of documentation and was unable to provide additional information on the PICC line care for the residents involved.
Inadequate EBP Implementation and PPE Use
Penalty
Summary
The facility failed to ensure that staff were aware of which residents were under Enhanced Barrier Precautions (EBP) and did not use the correct Personal Protective Equipment (PPE) when providing care to a resident under EBP. During an initial tour, it was observed that there were no signs on the entry doors of residents with PICC lines, indicating they were on EBP. Additionally, there were no carts outside the rooms to indicate the residents' EBP status. Interviews with staff revealed a lack of awareness and training regarding EBP, with some staff unsure about the precautions and others indicating that signs and isolation carts should be present but were not. The report highlights specific instances where staff failed to adhere to EBP protocols. For example, CNA 3 assisted Resident F, who had a PICC line, without initially donning a gown, as required by EBP. The CNA had to leave the room to retrieve gowns, indicating a lack of preparedness and awareness. Similarly, LPN 2, while tending to Resident F's PICC line, initially failed to don a gown and mask and did not change gloves or wash hands after touching contaminated surfaces, which was against the facility's handwashing policy. The facility's infection control nurse admitted that there had not been comprehensive staff education on EBP, and staff had not signed off on any training. The facility's policies on EBP and handwashing were not being followed, as evidenced by the observations and interviews. This deficiency had the potential to affect residents with PICC lines, such as Residents E and F, who were diagnosed with conditions like cellulitis and required intravenous antibiotics.
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Nursing homes near Valparaiso
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of The Willows | 1.2 mi | ★★★★★ | 40 | 0 |
| Valparaiso Care & Rehabilitation | 1.4 mi | ★★★★★ | 28 | 0 |
| Brickyard Healthcare - Valparaiso Care Center | 2.1 mi | ★★★★★ | 1 | 0 |
| Life Care Center Of Valparaiso | 2.1 mi | ★★★★★ | 15 | 0 |
| Ignite Medical Resort Chesterton | 6.2 mi | ★★★★★ | 27 | 0 |
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