Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Chesterton Manor during CMS and state inspections, most recent first.
The facility failed to follow physician orders for insulin administration, leading to inappropriate dosing for a resident with diabetes. Additionally, skin conditions for several residents were not properly assessed or monitored, and constipation management was inadequate for two residents, with bowel protocols not being followed and PRN medications underutilized.
The facility failed to implement fall interventions for two residents with a history of falls. One resident had improperly placed floor mats, while another had an inaccessible call light and a high bed position. Additionally, hot water temperatures exceeded safe levels in multiple rooms, posing a risk to residents.
A facility failed to protect a resident from misappropriation of property involving bank fraud by an agency CNA. The resident, who was cognitively intact, experienced fraudulent charges on her checking account, discovered by her daughter and reported to the police. The facility was informed by a detective, and the CNA involved had not worked at the facility since her certificate expired. The resident declined a lock box for valuables, opting to use a locked dresser. The facility conducted interviews with no additional concerns raised, and the resident's bank refunded the lost funds.
A facility failed to conduct a quarterly care plan meeting for a resident with pneumonia and hypertensive heart disease. The resident, who was cognitively intact, had their last care plan meeting in March, and although they declined a meeting in September, there was no documentation of further meetings. Facility policy requires quarterly reviews with the MDS assessment, which was not adhered to.
A resident with a Stage 3 pressure ulcer did not receive treatments as ordered by the physician, with multiple instances of missed treatments documented in the TARs. Despite the resident's cognitive intactness and a care plan in place, treatments were not consistently administered, and the resident reported receiving treatment only once a week. The resident also refused debridement and was noncompliant with lying down during the day, preferring to smoke. The Unit Manager acknowledged that treatments were to be completed as ordered.
A facility failed to ensure an orthotic device was in place for a resident with limited ROM in the left hand. The resident, with a history of stroke and left hemiplegia, reported not having seen the splint in a long time. Observations confirmed the absence of the device, and documentation inconsistencies were noted. The Unit Manager indicated the device was attached to an unused wheelchair, and the order should have been discontinued.
The facility failed to document food intake for two residents with nutritional risks, leading to incomplete records of their dietary consumption. One resident with protein calorie malnutrition and dysphagia had missing documentation for several meals, while another resident with severe malnutrition also had incomplete food logs. The Unit Manager confirmed that meal consumptions should have been recorded as per facility policy.
The facility failed to administer oxygen at the correct flow rate for two residents. One resident with COPD and other conditions was observed with oxygen set below the prescribed 3 liters per minute. Another resident with multiple diagnoses was observed with oxygen set below the prescribed 2 liters per minute. These discrepancies were confirmed by the Unit Manager.
A resident experienced inadequate pain management due to the facility's failure to provide timely medication and ensure transportation to a pain clinic. The resident, with a history of arthritis and other conditions, reported frequent pain and missed doses of Methocarbamol and Oxycodone due to medication shortages. Additionally, the resident missed two pain clinic appointments because of transportation cancellations.
The facility failed to secure medications properly for two residents, with medicated creams left unsecured in their rooms. An LPN and the Unit Manager confirmed that the medications should have been stored in a locked treatment cart, as per the facility's policy.
The facility failed to implement proper infection control practices during wound care for three residents under enhanced barrier precautions (EBP). The ADON was observed not wearing a gown during treatments, despite the residents' medical conditions and care plans requiring EBP. The facility's policy mandated the use of gloves and gowns for high-contact activities like wound care, but this was not consistently followed.
The facility failed to ensure the call light system was functioning properly for two residents and at the nurses' station. A resident's call light was activated, but there was no staff response, and the hallway light was not triggered. Another resident's call light worked outside her room but not at the nurses' station, requiring staff to visually check the hallway. The Maintenance Director confirmed the malfunction and was aware of the issue.
Two residents in a facility did not receive timely incontinence care, resulting in soiled briefs and bedding. One resident was found with a strong urine odor and soiled sheets, while another reported their brief had not been changed since the previous day. Both residents required substantial assistance for toileting, as outlined in their care plans, which were not adhered to.
A facility failed to ensure correct PPE use and proper hand hygiene by staff during care for a resident under Enhanced Barrier Precautions (EBP). A CNA did not initially wear a gown while handling a urinary catheter, and another CNA did not perform hand hygiene immediately after care, contrary to facility policies.
Deficiencies in Insulin Administration, Skin Assessment, and Constipation Management
Penalty
Summary
The facility failed to adhere to physician orders regarding insulin administration for a resident with type 2 diabetes and chronic kidney disease. The resident was to receive 6 units of Lispro insulin subcutaneously three times a day, with the instruction to hold the insulin if the resident's blood sugar was 150 or less. However, the Medication Administration Records (MAR) for January, February, and March 2025 indicated that insulin was administered on multiple occasions when the resident's blood sugar was 150 or less, contrary to the physician's order. The facility also failed to assess and monitor skin conditions for several residents. One resident with dementia and atrial fibrillation was observed with a bruise on the right hand, but there was no order to assess and monitor this discoloration. Another resident with hypertension and a femur fracture had reddish/purple discoloration on the left hand, which was not documented or monitored. Additionally, a resident with a surgical wound and rheumatoid arthritis had a large bruise below the right buttock, which was not assessed or documented, despite the resident being on a blood thinner. Furthermore, the facility did not adequately monitor and treat constipation for two residents. One resident, who was always incontinent of bowel, reported being very constipated, yet the facility's bowel protocol was not followed, and PRN medications were rarely administered. Another resident, who was cognitively intact and had constipation related to decreased mobility, also did not receive appropriate bowel management, as indicated by the lack of documentation and administration of prescribed medications. These deficiencies highlight the facility's failure to provide appropriate treatment and care according to orders and resident needs.
Failure to Implement Fall Interventions and Control Hot Water Temperatures
Penalty
Summary
The facility failed to implement fall interventions for two residents with a history of falls. Resident 46, who has a history of stroke, hemiplegia, and other conditions, was observed multiple times with floor mats not properly placed as per the care plan. The resident's care plan required thicker mats on the floor beside the bed, but observations showed mats folded against the wall or partially under the bed. Despite multiple falls documented in the resident's notes, the required interventions were not consistently in place. Resident 13, diagnosed with dementia and rheumatoid arthritis, was observed with her bed in a high position and her call light out of reach on the floor. Her care plan indicated the need for the call light to be within reach to prevent falls. Despite this, observations showed the call light was not accessible, and the resident had a history of falls, including one at a doctor's appointment and another in her room. Interviews with staff revealed a lack of awareness regarding the resident's fall history and the necessary interventions. Additionally, the facility failed to maintain safe hot water temperatures, with readings exceeding 120 degrees Fahrenheit in multiple rooms across three hallways. The Maintenance Director acknowledged the issue, noting that the water heater settings might have changed unexpectedly. This failure to control water temperature posed a risk to the residents, with several rooms having water too hot to touch, affecting numerous residents throughout the facility.
Misappropriation of Resident's Property Due to Bank Fraud by Agency CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of property, specifically involving bank fraud by an agency CNA. The incident involved a resident who was cognitively intact and had diagnoses including rheumatoid arthritis, scoliosis, spinal stenosis, and anxiety. The resident's checking account was subject to fraudulent charges, which were discovered by the resident's daughter and reported to the police. The police then informed the facility of the alleged involvement of an agency CNA. The resident had been offered a lock box for her valuables, which she declined, opting instead to keep her personal items in a locked dresser. The facility was notified by a detective about the fraudulent activity, which had been occurring since November. The CNA involved had not worked at the facility since her certificate expired, and the staffing agency was informed of the investigation. The facility conducted interviews with staff and residents, but no additional concerns were raised. The resident's bank refunded the lost funds, and the facility offered to secure the resident's cash and checks in the facility safe. The investigation was ongoing, with the detective pressing charges against the CNA and investigating other potential aides involved.
Failure to Conduct Quarterly Care Plan Meeting
Penalty
Summary
The facility failed to conduct a care plan meeting at least quarterly for a resident, as required. The resident, who was cognitively intact and had diagnoses including pneumonia and hypertensive heart disease, had their last care plan meeting on March 14, 2024. Although the resident declined a care plan meeting on September 18, 2024, there was no documentation of any subsequent care plan meetings being conducted or refused. The facility's policy, as provided by the Director of Nursing, mandates that the Interdisciplinary Team (IDT) review and update the care plan at least quarterly in conjunction with the required quarterly Minimum Data Set (MDS) assessment. However, this requirement was not met for the resident in question.
Failure to Complete Pressure Ulcer Treatments as Ordered
Penalty
Summary
The facility failed to ensure that pressure ulcer treatments were completed as ordered by the physician for a resident with a Stage 3 pressure ulcer. The resident, who had a history of stroke, left hemiplegia, heart failure, and major depressive disorder, was cognitively intact and had an unhealed pressure ulcer. The care plan required nursing staff to provide treatment as ordered, which included cleaning the coccyx wound with normal saline, applying collagen, and covering it with a bordered gauze. However, the Treatment Administration Records (TARs) indicated multiple instances where the treatment was not signed out as completed over several months. Interviews revealed that the resident reported receiving treatment only once a week, contrary to the physician's orders. The Wound Nurse Practitioner noted that the resident's wound was improving, but the resident frequently refused debridement and was noncompliant with lying down during the day, preferring to stay up and smoke. The Unit Manager confirmed that treatments were supposed to be completed as ordered by the physician, highlighting a failure in adhering to the prescribed treatment regimen for the resident's pressure ulcer.
Failure to Provide Orthotic Device for Resident with Limited ROM
Penalty
Summary
The facility failed to ensure that an orthotic device was in place for a resident with a limited range of motion in the left hand. The resident, who had a history of stroke, left hemiplegia, and other medical conditions, reported that he used to wear a splint on his left hand but had not seen it in a long time. Observations over several days confirmed that the resident's left hand was flaccid and no orthotic device was present. The resident's care plan indicated the need for a wrist orthotic device, and a physician's order required the device to be donned and doffed daily as tolerated by the resident. The Treatment Administration Record (TAR) showed inconsistencies in documentation, with several instances where the orthotic device was not signed out as being used, and no documented refusals by the resident. During an interview, the Unit Manager revealed that the orthotic device was attached to a motorized wheelchair that the resident no longer used, and the order for the device should have been discontinued. This oversight led to the deficiency in providing appropriate care to maintain or improve the resident's range of motion.
Failure to Document Food Intake for Residents with Nutritional Risks
Penalty
Summary
The facility failed to ensure that food consumption logs were completed for residents with a history of weight loss, specifically for two residents reviewed for nutrition. Resident 6, who had diagnoses including protein calorie malnutrition, feeding difficulties, dysphagia, and Alzheimer's disease, was found to have missing documentation of food intake on several occasions in February and March 2025. Despite being at nutritional risk and having a significant weight loss of 6.3% within the last 30 days, there were multiple instances where the resident's food intake was not recorded, as confirmed by the Unit Manager. Similarly, Resident 176, who was admitted with severe protein calorie malnutrition and other health issues, also had incomplete food consumption logs. The resident's admission weight was 73 pounds, and a slight weight decrease was noted. However, the food intake was not documented for several meals in February 2025, which was against the facility's policy of completing meal consumption records before the end of each CNA's shift. The Unit Manager acknowledged the lapses in documentation, which are crucial for monitoring the nutritional status of residents.
Oxygen Flow Rate Discrepancies for Two Residents
Penalty
Summary
The facility failed to ensure that oxygen was administered at the correct flow rate for two residents. Resident 7, who has a history of COPD, asthma, bronchitis, dementia, heart failure, heart disease, and high blood pressure, was observed multiple times with oxygen set at 2 or 2.5 liters per minute, despite a physician's order for 3 liters per minute continuously. The Unit Manager confirmed the incorrect setting during an observation. Similarly, Resident 58, diagnosed with chronic kidney disease, chronic migraines, atrial fibrillation, high blood pressure, major depressive disorder, anxiety, joint disorder, and obsessive-compulsive disorder, was observed with oxygen set at 1.5 liters per minute, although the physician's order specified 2 liters per minute. The Unit Manager also confirmed this discrepancy. These observations indicate a failure to adhere to physician orders for oxygen administration, potentially impacting the residents' health.
Inadequate Pain Management Due to Medication and Transportation Issues
Penalty
Summary
The facility failed to provide adequate pain management for a resident, resulting in the resident experiencing frequent pain that interfered with her sleep and daily activities. The resident, who was cognitively intact, reported not receiving her medications on time or at all due to the facility running out of them. The resident's medical history included rheumatoid arthritis, anemia, anxiety disorder, end-stage renal disease, and osteoarthritis of the hip. Despite having a care plan that required anticipating the need for pain relief, the facility did not ensure the availability of prescribed medications such as Methocarbamol and Oxycodone, leading to missed doses over several days. Additionally, the resident missed two pain clinic appointments due to transportation issues, further exacerbating her pain management problems. The Unit Manager acknowledged the missed appointments and medication doses, citing limited medication supply in the emergency drug kit as a reason for the lapses. The facility's failure to provide timely medication and ensure transportation to the pain clinic resulted in the resident not receiving appropriate pain management services.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure proper medication storage for two residents, leading to deficiencies in medication management. For Resident 58, a tube of Bacitracin medicated cream was observed on the dresser in the resident's room during multiple observations over several days. The resident's medical record indicated a physician's order for the application of Bacitracin to specific areas, but there was no order to keep the cream at the bedside. The resident was cognitively intact, and the LPN confirmed that the cream should have been stored in a locked treatment cart, not left in the room. The Unit Manager also acknowledged that the cream should not have been left unsecured. Similarly, for Resident 13, a tube of Medihoney, a topical wound medication, was observed on the dresser. The Unit Manager was informed of this finding but did not provide additional information. The facility's policy on medication storage, which was current at the time, required all medications to be secured in a locked storage area with access limited to authorized personnel. These observations indicate a failure to adhere to the facility's medication storage policy, resulting in unsecured medications in residents' rooms.
Infection Control Lapses in Wound Care
Penalty
Summary
The facility failed to implement proper infection control practices during wound care treatments for three residents under enhanced barrier precautions (EBP). The Assistant Director of Nursing (ADON) was observed not donning a gown while performing wound care on Resident 3's sacral pressure area, despite the resident's care plan indicating the need for EBP due to a Stage 4 pressure ulcer. Similarly, during wound care for Resident 6, the ADON did not wear a gown while treating the resident's left heel, although the resident had multiple pressure ulcers and a physician's order for EBP. Additionally, Resident 226 reported that the ADON only wore gloves, not a gown, during daily dressing changes, and was observed reaching over an uncovered wound without a gown before completing the wound care. The residents involved had significant medical conditions, including dementia, chronic kidney disease, Alzheimer's disease, and cerebral infarction, which necessitated careful infection control measures. The facility's policy on enhanced barrier precautions required the use of gloves and gowns for high-contact activities like wound care, but this was not consistently followed by the ADON. Interviews with the ADON confirmed the lapses in protocol, acknowledging the failure to wear gowns during the wound care procedures as required by the facility's infection control policy.
Call Light System Malfunction in Resident Rooms and Nurses' Station
Penalty
Summary
The facility failed to ensure the proper functioning of the call light system in two residents' rooms and at the nurses' station. During an observation, Resident 38's call light button was activated, and while the light inside the room was functioning, there was no staff response for 27 minutes. The hallway call light outside the resident's room was not activated, and a nurse confirmed the call light was not working. In another instance, Resident 18 reported that her call light illuminated outside her room but did not function at the nurses' station, meaning staff would only notice if they visually checked the hallway. During an environmental tour, the Maintenance Director confirmed the malfunction of the call light system at the nurses' station and acknowledged awareness of the issue.
Failure to Provide Timely Incontinence Care for Residents
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADLs) related to incontinence care for two residents. Resident C was found in bed with a strong urine odor in the room, and upon checking, it was discovered that the resident's brief was soiled with urine and stool, which had leaked onto the bed sheet. The Certified Nursing Assistant (CNA) indicated that the resident was not soiled at the beginning of her shift at 11:00 p.m. the previous night and had not been checked for incontinence since then. Resident C's care plan required substantial assistance for toileting and personal hygiene, and the resident was always incontinent of bowel and urine. Resident F was observed awake in bed with a soaked brief, which the resident indicated had not been changed since the previous day at 3:00 p.m. Resident F's care plan noted that the resident was totally dependent on staff for toileting and required two staff members for bed mobility. The resident was occasionally incontinent of urine and always incontinent of bowel. Both residents' care plans included interventions for regular incontinence care and skin care, which were not followed, leading to the deficiency.
Failure to Use Correct PPE and Perform Hand Hygiene
Penalty
Summary
The facility failed to ensure correct Personal Protective Equipment (PPE) was used by a staff member when providing care to a resident who was under Enhanced Barrier Precautions (EBP). During an observation, a Certified Nursing Assistant (CNA 3) entered the room of a resident who required EBP due to a suprapubic urinary catheter. Despite being aware of the EBP requirement, CNA 3 initially donned only gloves and proceeded to empty the resident's urinary catheter drainage bag without wearing a gown, which is part of the required PPE. It was only after completing this task that CNA 3 donned a gown over her uniform. Additionally, the facility failed to ensure proper hand hygiene was completed by another staff member (CNA 2) after providing care. CNA 2 entered the room, unaware of the EBP requirement, and assisted with incontinence care. After completing the care, CNA 2 removed one glove, handled the resident's tumbler and trash bag, and exited the room without performing hand hygiene immediately. CNA 2 later washed her hands in the pantry's sink after delivering the trash bag to the soiled utility room. The facility's policies on EBP and hand hygiene were not adhered to during these interactions, leading to the deficiency.
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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.
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Nursing homes near Chesterton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Addison Pointe Health & Rehabilitation Center | 0.6 mi | ★★★★★ | 15 | 0 |
| Ignite Medical Resort Chesterton | 1.3 mi | ★★★★★ | 27 | 0 |
| Life Care Center Of Valparaiso | 6.7 mi | ★★★★★ | 15 | 0 |
| Brickyard Healthcare - Portage Care Center | 7.2 mi | ★★★★★ | 23 | 0 |
| Valparaiso Care & Rehabilitation | 7.4 mi | ★★★★★ | 28 | 0 |
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