Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ignite Medical Resort Chesterton during CMS and state inspections, most recent first.
Failure to develop care plans for IV/PICC line care, urinary catheter use, and constipation risk. Two residents had invasive lines or catheters and prolonged periods without bowel movements, while one resident also received narcotic pain meds and the other had orders for bisacodyl and PICC/IV dressing care. The current care plans did not address these needs.
Failure to provide ordered bowel management and wound care: one resident had prolonged constipation with no documented bowel sounds assessment, delayed physician notification, and incomplete bowel documentation; another resident’s ordered wound treatment was not signed out on the TAR; and a third resident had no documented BM for days, no constipation care plan, no physician notification, and a missed PRN suppository order.
A resident receiving IV NS for dehydration had gaps in IV initiation, flush orders, and site monitoring. An RN observed blood in the tubing, flushed the line without cleaning the port, and replaced the bag and tubing, while the record showed missing documentation for IV initiation/discontinuation, no flush or dressing-change orders, and no documented insertion-site assessments during continuous infusion.
A facility failed to follow ordered pain regimens for multiple residents. One resident with spinal fractures had repeated late, early, or missed oxycodone doses with incomplete pain assessments; another resident with stroke-related pain requested Tylenol but none was available in the cart or Pixus, and ordered analgesics were not immediately available; a third resident with chronic pain had a fentanyl patch still in place past the scheduled change time.
Medications Not Available for Administration: Two residents did not receive ordered routine meds because the pharmacy supply was not available in the med cart or emergency drug kit. One resident’s supplements and PRN pain meds, including Tylenol and later ibuprofen, were unavailable during a med pass while the resident reported back pain rated 8/10. Another resident’s Miralax, thiamine, and Lasix were also missing, and staff reported the pharmacy had changed from auto-refill to a 15-day supply without informing the facility.
A QMA made multiple medication pass errors for a resident, including incorrect carvedilol and omeprazole counts, an incorrect potassium chloride dose, and omission of ordered ferrous sulfate and lactobacillis. The MAR also showed medications documented as given even though they were not administered. Surveyors observed 5 errors in 33 opportunities, resulting in a 15.151% medication error rate.
A resident with an abdominal surgical incision and left flank wound had a wound culture ordered after green drainage was noted from the wound vac, along with IV vancomycin and aztreonam. The culture was cancelled because the wrong tube was used, the wound was not re-cultured, and the wound nurse stated she had swabbed the fluid instead of the surgical site and believed the culture had already been completed.
Failure to Provide Required ADL Care: A resident with paraplegia was documented as dependent for bathing, oral care, and hygiene, with a shower preference noted in the care plan. The MDS showed max assist for oral hygiene, set-up for hygiene, and dependence for bathing, but CNA task records showed missed hygiene and oral care on multiple days, and bathing documentation was incomplete. The resident was bathed only once over the reviewed period.
A resident with cellulitis of the R lower limb did not receive an ordered IV antibiotic as scheduled. The MAR showed one missed dose with no reason documented and another dose not given because the resident was sleeping; an interview confirmed the antibiotic had not been administered.
Missed wound treatments, supplements, and antibiotics for residents with pressure ulcers. Three residents with pressure injuries had ordered care not completed or not documented as given. One resident with infected sacral and heel ulcers missed IV antibiotics, a protein supplement, and multiple ordered dressings and wound therapies. Two other residents with coccyx or gluteal pressure injuries also had ordered wound treatments not signed out on the TAR.
Foley catheter care, urine output documentation, and catheter positioning were not properly maintained for two residents with urinary catheters and UTI. One resident had a Foley catheter hanging off the bed with no TAR documentation of ordered catheter care, while another resident was repeatedly observed with the catheter bag on the floor and had multiple missed output entries plus no catheter care documentation despite orders and a positive urine culture.
A resident with paraplegia and a colostomy had a care plan and MDS noting the ostomy, but the record contained no documentation that colostomy care was provided, the bag was changed, the stoma was cared for, or the ostomy site was assessed. There were also no physician orders for colostomy care, and the Nurse Consultant had no further information about the resident’s colostomy care.
PICC line care was not documented or completed as ordered for three residents receiving IV meds. An LPN administered an antibiotic through a PICC after flushing it, but records lacked site assessments, flush documentation, and weekly dressing changes. For two other residents, the chart showed missed flushes, missing dressing-change documentation, and no timely insertion site assessments; one PICC was later noted to be pulled out about 1/2 inch with redness at the site.
A resident who was ordered for EBP related to a wound, catheter, and feeding tube did not have EBP signage posted, and a CNA was observed providing incontinence care, then continuing with dressing and transfer assistance without changing gloves between dirty and clean tasks. The resident’s record showed he was not cognitively intact for daily decision-making and had a urinary catheter; the care plan and physician order both identified EBP.
Posted nurse staffing information was not kept current and the daily staffing postings were not retained for the required period. During observation, the staffing notice at the front door showed an outdated date, and the Nurse Consultant stated the posting should be changed daily. She also reported that the Scheduler had been shredding the daily postings and was unaware they had to be kept.
Failure to monitor ordered weights and complete reweights for significant weight changes affected multiple residents. Residents with conditions including CHF, ESRD, dementia, malnutrition, and failure to thrive had missed or inconsistent weights, including large unexplained losses, while the DON acknowledged that weights were not being monitored as scheduled and that staff were not weighing residents correctly.
An LPN and the Administrator were observed with 12 insulin pens in a medication cart that were labeled for refrigeration until opened, but none had opened-on dates documented. The pens had stickers with space for the date, and the LPN stated they should be dated when opened. The DON later provided guidance stating insulin products may be left unrefrigerated between 59 and 86 degrees Fahrenheit for up to 28 days.
Surveyors identified that midodrine was administered to two residents outside of ordered blood pressure parameters and withheld once when within parameters, based on MAR entries showing doses given despite systolic BP readings above the ordered hold thresholds and one dose not given when BP was within range. In addition, a resident with diabetes, a tibia fracture, lower extremity impairment, edema, and anticoagulant therapy had compression leg wraps and a connected machine present and set up in the room without any corresponding physician order, and staff were initially unaware of the device’s presence or orders.
A resident had latanoprost eye drops at the bedside and stated he was administering them himself, but the chart contained no physician order for self-administration and no nursing assessment for self-administration. The resident did have an order for latanoprost eye drops at bedtime for eye pressure, and the DON had no further information.
The facility failed to ensure complete care plans were in place for two residents. One resident with heart failure, renal dialysis dependence, and hypotension had a care plan started for hypotension, but it had no goals or interventions despite an order for midodrine. Another resident with hemiplegia, cognitive impairment, and limited ROM had an order for a left-hand brace, but the record lacked any care plan related to splint use.
A resident with hemiplegia and impaired ROM was observed wearing a left-hand splint during the day even though the MD order directed staff to apply the brace at bedtime and remove it in the morning. The DON said the family may have put the splint on the resident, while the facility policy stated nursing is responsible for applying and removing the splint per schedule.
A resident with a history of UTI and neurogenic bladder had an indwelling urinary catheter, but the catheter bag and tubing were observed on the floor while the resident sat in a wheelchair. The care plan directed staff to check tubing placement each shift and monitor for UTI signs, and the MD ordered catheter output to be recorded every shift; however, output was not documented on multiple day and night shifts. The DON stated the family had been emptying the catheter and that it should not have been on the floor.
A resident with diabetes mellitus and moderate cognitive impairment had an order for Novolog before meals, to be held if blood sugar was below 200 mg/dL. The resident said he often did not get insulin before meals as ordered, and MAR review showed multiple entries where insulin was marked given even though blood sugar was below 200, along with many entries documenting it was held for being out of parameters. The DON stated staff needed education on how to document holding insulin.
A nurse entered a resident’s room under contact/droplet precautions for COVID-19 wearing a gown, gloves, and an N95 mask, but did not wear protective eyewear. The room was marked for isolation, and the Administrator was notified after the observation. A requested isolation policy was not provided.
The facility did not complete or document required admission, skin, and accident assessments for multiple residents, including missing an admission assessment for a resident with a surgical wound, failing to document initial skin changes after a burn incident for another resident, and not performing or recording weekly skin evaluations for two residents with pressure ulcers, despite physician orders and care plans.
A resident with multiple medical conditions, including diabetes and fractures, developed a pressure injury and required wound care per physician orders. The wound nurse reported completing the required treatments but failed to document them on two occasions, attributing the omission to increased workload while covering alone.
A resident with multiple medical conditions and moderate cognitive impairment was left in her wheelchair without access to her call light while waiting to be put back to bed. The call light was found out of reach and not visible to the resident, delaying her ability to request assistance until staff were notified by other means.
The facility did not ensure that prescribed medications were administered as ordered for a resident with heart failure and two residents with infections. One resident did not receive an additional ordered dose of furosemide, while two others missed multiple doses of cephalexin due to documentation omissions and order changes. These deficiencies were confirmed through record review and staff interviews.
Two residents requiring dialysis did not receive proper pre- and post-dialysis assessments, and their medications were either scheduled incorrectly or not sent with them to dialysis as ordered. The facility failed to follow its own protocol for medication administration and documentation related to dialysis care.
The facility did not send required notifications of resident transfers or discharges to the State LTC Ombudsman, as confirmed by both record review and staff interview. The Administrator was unaware of the ongoing requirement, and the facility's policy states that such notifications must be provided.
The facility did not ensure that cognitively impaired residents received ongoing activities tailored to their preferences, as shown by missing or incomplete documentation of activity participation and offerings. For example, a resident with severe cognitive impairment and multiple health issues was not consistently engaged in preferred activities, and staff failed to document whether scheduled one-on-one visits or independent activities occurred. Similar gaps were found for two other residents, with staff confirming that some activities were provided but not recorded.
A resident with multiple health conditions, including COVID-19, did not receive a timely start of prescribed Paxlovid due to delays in pharmacy delivery and lack of floor stock. The medication, ordered for the resident, was not administered until three days later, despite its arrival at the facility the previous day. The delay was attributed to the facility's reliance on a non-local pharmacy and absence of a contract with a local provider.
A resident dependent on staff for toileting, with a history of falls and impaired cognition, activated her call light and requested bathroom assistance. Despite informing an LPN of her urgent need, there was a significant delay before two CNAs arrived to help, resulting in the resident waiting for assistance while expressing concern about being forgotten. The delay in response failed to honor the resident's right to be treated with respect and dignity.
The facility failed to consistently document and monitor bladder training, post void residuals, and urinary output for three residents with urinary catheters. Orders for catheter clamping, bladder scans, and output monitoring were not followed or recorded as required, and care plans for monitoring signs of UTI were not adhered to. The DON confirmed gaps in documentation and compliance with physician orders and facility policy.
Certified Nursing Assistants failed to don gowns, as required by Enhanced Barrier Precautions, when providing high-contact care to a resident with a wound. Despite clear signage and care plan instructions, staff only wore gloves while assisting the resident with toileting and incontinence care, contrary to physician orders and facility policy.
A resident experienced a delay in receiving assistance to get out of bed, despite requesting help and being assured by an RN that staff would assist her. The resident remained in bed for over two hours, impacting her planned activities. The care plan indicated the need for a mechanical lift and two staff for transfers due to the resident's medical condition, including congestive heart failure.
A facility failed to notify a resident's POA about falls, as required by policy. The resident, with severe cognitive impairment and multiple diagnoses, had a POA listed as the first contact for emergencies. However, the second contact was notified instead on three occasions, with no documentation explaining the oversight. The Clinical President and DON were unable to provide a reason for this failure.
A resident dependent on staff for daily living activities was found with a saturated incontinent brief and wet bedding, indicating a failure in timely incontinence care. Despite being assigned to the resident, a CNA had not checked on him since starting her shift. The resident's care plan required checks every 2-3 hours, but the resident reported not being changed since the previous day.
The facility failed to conduct required skin assessments for two residents with braces and immobilizers, as ordered by physicians. One resident with a right arm fracture did not receive weekly skin checks or monitoring of a surgical splint on multiple occasions. Another resident with a left humerus fracture did not receive weekly skin checks, and the Director of Nursing acknowledged the oversight. This deficiency was linked to a specific complaint.
A facility failed to implement care plan interventions for a resident at high risk for falls. Observations showed the absence of a stop sign and floor mat in the resident's room, despite these being specified in the care plan. The resident, with a history of falls and conditions like dementia, required maximum assistance. A nurse confirmed the lack of these safety measures, and the resident's record indicated multiple falls.
A resident's feeding tube was infusing at 55 cc/hr instead of the physician-ordered 20 cc/hr. Despite a dietician's recommendation to increase the rate, there were no physician orders to authorize this change. The facility's policy required a physician or nurse practitioner order for the feeding rate, which was not followed.
A facility failed to provide proper care for a midline catheter for a resident with severe cognitive impairment and multiple diagnoses, including pneumonia and a hand infection. The facility did not document the catheter placement, lacked physician's orders for flushing and care, and failed to perform necessary flushes, dressing changes, and site monitoring. Despite instructions from a Vascular Access Specialist, the facility did not adhere to its policy for IV fluid administration and monitoring.
A resident with diagnoses including pneumonia and dementia did not receive oxygen therapy as ordered by the physician. Observations revealed the resident's portable oxygen unit was turned off despite a nasal cannula being in place. The Assistant DON later turned on the oxygen to the prescribed two liters per minute. The facility's policy required oxygen to be administered per physician's orders, which was not followed.
A facility failed to ensure correct PPE use by a CNA for a resident on Enhanced Barrier Precautions (EBP). The CNA did not wear a protective gown during care, despite the resident's care plan and facility policy requiring it due to wounds and a central line. The CNA was unaware of the EBP requirement, even though a sign and PPE supplies were present.
The facility failed to maintain cleanliness and proper labeling in the kitchen and resident refrigerator, potentially affecting all residents. Observations included food debris, sticky residues, and incorrect sanitation test strips in the kitchen, as well as improperly labeled and dated food in the D Wing refrigerator. Interviews confirmed that dietary staff should have labeled the items according to facility policy.
The facility's kitchen was found to be unsanitary, with food debris on the freezer floor, an orange substance on the garbage disposal, and dust and dead insects inside light covers. The Executive Chef acknowledged the need for cleaning.
The facility failed to ensure residents had physician's orders and assessments for self-administration of medications. Several residents were observed with medications at their bedside without the necessary orders or assessments, including a resident with a plastic medication cup containing a white powder, another with over-the-counter vitamins, and others with nasal spray, antacids, eye drops, Biofreeze, Venelex cream, and portocort cream. The facility's policy required a physician's order for medications at the bedside, which was not followed.
The facility failed to manage oxygen therapy properly for four residents, with issues including incomplete oxygen orders, incorrect flow rates, and lack of documentation. A resident used oxygen at 3 liters per minute without a specified flow rate in the order, while another had oxygen levels set higher than ordered. Another resident had varying oxygen levels despite a specific order, and a fourth resident's oxygen use was undocumented. The facility's policy required recording oxygen orders in the chart, which was not followed.
The facility failed to ensure proper medication management and storage. An LPN was observed pre-pouring medications, which is against policy, and treatment carts were found unlocked with unlabeled creams. The Chief Nursing Officer confirmed that treatment carts should be locked and creams labeled with resident names.
The facility failed to follow infection control guidelines during medication administration and equipment disinfection. Staff were observed handling medications with bare hands and not using enhanced barrier precautions for a resident with a PICC line. Additionally, a glucometer was improperly disinfected with alcohol wipes instead of bleach wipes. These actions were contrary to the facility's policies and infection prevention standards.
Failure to Develop Care Plans for IV, Catheter, and Constipation Needs
Penalty
Summary
The facility failed to develop care plans for two residents related to peripheral IV/PICC line care, urinary catheter use, and constipation risk. Resident C was observed ambulating with a walker and had a urinary catheter and peripheral IV line in place. His record showed diagnoses including dehydration, fractures of the sacrum and spine, urinary retention, and constipation. Physician orders included narcotic pain medications, and the bowel movement record showed no bowel movement from 7/8/26 through 7/24/26. Despite the catheter, IV line, and prolonged absence of bowel movements, there was no care plan addressing constipation risk from narcotic use or the indwelling urinary catheter. Resident E’s record showed diagnoses including COPD, hypertension, chronic kidney disease, and tremors. The baseline care plan indicated the resident was moderately impaired for daily decision making and needed partial to moderate assistance with toileting. Physician orders included IV dressing checks every shift, PICC line dressing changes every seven days, and bisacodyl twice daily. The bowel and bladder elimination task showed no bowel movement from 7/19/26 through 7/28/26, yet the current care plan did not address the IV/PICC line or constipation.
Failure to Provide Ordered Bowel Management and Wound Care
Penalty
Summary
The facility failed to ensure residents received treatment and care in accordance with professional standards related to bowel management and wound treatment for Residents C, D, and E. Resident C had diagnoses including constipation, was dependent for toileting, and had an order for daily polyethylene glycol. The bowel movement record showed no bowel movement from 7/8/26 through 7/24/26, and a physician progress note documented no bowel movement since 7/3/26. Although additional laxative orders were entered on 7/21/26 and a bowel movement was later documented, there was no documentation of the amount or size of that bowel movement, no bowel sounds assessment documented from 7/7/26 to 7/21/26, and the physician was not notified until 7/21/26. The facility bowel management policy required assessment, monitoring, documentation, intervention, evaluation, and physician notification if there was no bowel movement for more than three days unless otherwise ordered. Resident D had a left above-knee amputation and a physician order for daily wound care to cleanse the site, apply maxorb, and cover with a dry dressing, but the TAR showed the wound treatment was not signed out on 7/25/26. Resident E had diagnoses including COPD, hypertension, chronic kidney disease, and tremors, required assistance with toileting, and had no documented bowel movement from 7/19/26 through 7/28/26. Orders were in place for bisacodyl tablets twice daily and a bisacodyl suppository as needed, but there was no documentation that the physician was notified of the lack of bowel movements, no constipation care plan, and the MAR indicated the rectal suppository was not given during July 2026.
IV Fluids Not Initiated and Monitored per Order
Penalty
Summary
The facility failed to ensure safe, appropriate administration of IV fluids for one resident receiving parenteral fluids. During an observation, an RN found blood in the IV tubing while the resident was lying in bed with 0.9% normal saline infusing at 60 cc/hour into a peripheral IV in the right forearm. The RN disconnected the tubing and flushed the line with 10 cc of normal saline without using an alcohol prep pad on the port, then replaced the IV bag and tubing, primed the tubing, and reattached it. The RN later stated she did not use the alcohol prep pad because it was a closed system. Record review showed the resident had dehydration and had been ordered IV fluids on 7/21/26, but there was no documentation that the peripheral IV had been initiated before transfer to the hospital or upon return, no documentation that the IV had been discontinued after the initial bag infused, and no documentation of flush orders or dressing changes. A later order for 0.9% normal saline at 60 cc/hour every shift was entered on 7/26/26, and the MAR showed the fluids were started that night, but there were no documented assessments of the insertion site after the infusion began. The facility policy required verification of the order and indication upon insertion and assessment of the site each shift, before and after medication administration, and during continuous infusions.
Pain medication administration and patch management failures
Penalty
Summary
The facility failed to ensure pain management regimens were followed as ordered and failed to provide pain medication in a timely manner upon request for three residents reviewed for pain. One resident with fractured sacrum and wedge compression fractures of the spine had an order for oxycodone 5 mg every four hours, with pain to be evaluated when the medication was given. Review of administration details showed multiple doses given late, some doses given too close together, some pain assessments not completed, and at least one dose documented as administered without a corresponding narcotic sign-out. The resident stated that when pain medication was given at the correct time he could push through the pain, but when it was not given as ordered the pain was often unbearable. A second resident with a history of stroke had a care plan for potential pain that directed staff to respond immediately to any complaint of pain and identify prior response to analgesia. During a medication pass observation, the resident asked for Tylenol for pain, but the QMA found none available in the cart. RN staff also found no Tylenol in the emergency drug kit. The resident was assessed with back pain rated 8 out of 10, and staff contacted the physician for stronger pain medication. An order for ibuprofen was received, but ibuprofen was also not available in the Pixus. The resident later received an order for hydrocodone-acetaminophen and the medication was administered. A third resident with chronic pain syndrome, osteomyelitis of the left femur, and an above-the-knee amputation was ordered a fentanyl patch every three days, with instructions to remove the old patch before applying a new one and record the site of the old patch. During observation, the resident reported needing the patch changed, and staff found a fentanyl patch still dated several days earlier on the resident. The patch had not been removed on schedule, and the MAR indicated the patch was signed out for removal and placement on a later date. The nurse consultant later stated that the old patch was removed and a new patch was placed on the resident.
Medications Not Available for Administration
Penalty
Summary
The facility failed to ensure residents received routine medications from the contracted pharmacy as ordered by the physician when medications were not available to administer for 2 of 7 residents reviewed. During a morning medication pass observation, Resident G’s Certivite supplement and vitamin B12 were not in the medication cart and were unavailable to administer. QMA 3 stated the Certivite had last been received on 7/14/26 with only 14 doses sent, and the vitamin B12 had last been received on 7/9/26 with only 13 doses received, and she could not find where the medications had been reordered when the supply decreased. RN 1 checked the emergency drug kit and could not find the medications there, then notified the pharmacy, which said it would send the medication with the next order. Later that morning, Resident G requested Tylenol for pain and stated it had relieved pain in the past, but QMA 3 found no Tylenol available in the medication cart. RN 1 also checked the emergency drug kit and found no Tylenol available, then assessed the resident’s pain as 8 out of 10 in the back and notified the physician for a stronger medication. An order for ibuprofen was received, but RN 1 reported there was no ibuprofen in the emergency drug kit, and the Assistant Director of Nursing later notified the physician that ibuprofen was not available and requested another pain medication. During the same medication pass observation, Resident H’s Mirilax, thiamine, and Lasix were also not available to administer, and QMA 1 stated they would need to be reordered. The Nurse Consultant stated the pharmacy had changed from sending a 30-day supply with auto-refill to sending only a 15-day supply and that the facility had not been informed that auto-refill had been discontinued.
Medication pass errors exceeded allowed rate
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5% for 1 of 7 residents observed during medication pass. During an observation on 7/28/26 at 10:35 a.m., QMA 1 prepared Resident H’s morning medications and initially placed atorvastatin 40 mg, nifedipine 30 mg, Ocuvite, Eliquis 2.5 mg, one carvedilol tablet, one omeprazole tablet, and 20 cc of potassium chloride into the medication cup. QMA 1 stated thiamine and Lasix were not available and needed to be reordered. She counted six tablets in the cup before administration was stopped, then stated there should have been two carvedilol tablets and two omeprazole tablets and added another tablet of each. She also re-read the potassium chloride order and stated the dose should have been 15 cc instead of 20 cc. After re-counting, she indicated there were eight tablets in the cup, and the medications were crushed and administered in applesauce. Resident H’s orders were reviewed later that day and showed ferrous sulfate 325 mg and lactobacillis were also ordered but had been omitted from the medication pass. The MAR for 7/2026 showed QMA 1 documented the medications as administered at the same time as the other medications even though they had not been given. The facility’s medication administration policy dated 4/2026 stated medications were to be removed from the drawer and the label read upon removal, upon pouring, and after pouring, and that the order was to be read entirely to verify the right medication, dose, route, patient, and time. Five errors were observed during 33 opportunities for error, resulting in a medication error rate of 15.151%.
Wound Culture Not Completed as Ordered
Penalty
Summary
Timely, quality laboratory services were not provided for a resident with an abdominal surgical incision and left flank wound when a wound culture ordered for the resident was not completed as directed. The resident had diagnoses including COPD, hypertension, chronic kidney disease, and tremors, and the baseline care plan indicated moderate impairment in daily decision making and a need for partial to moderate assistance with toileting. The care plan directed treatment per physician orders for the surgical incision and wound care. A physician order indicated that a culture and sensitivity of wounds could be obtained if indicated, and a skin/wound note documented green drainage from the wound vac on the resident’s left rib. The physician assessed the wound and ordered a wound culture along with IV vancomycin and aztreonam, but the culture collected was cancelled because a red cap viral tube was used instead of the appropriate pink cap culture swab. The wound was not re-cultured, and the wound nurse stated she had swabbed the fluid rather than the surgical site and believed the culture had been completed, while also noting the resident could not start the antibiotics without the culture being completed.
Failure to Provide Required ADL Care
Penalty
Summary
Provide care and assistance to perform activities of daily living for any resident who is unable. Based on record review and interview, the facility failed to ensure a dependent resident received bathing at least twice a week, daily hygiene, and oral care for 1 of 4 residents reviewed for ADLs. Resident D had diagnoses including paraplegia related to trauma and was documented in care plans as dependent for oral care, bathing, and hygiene, with a bathing preference for a shower. The admission MDS indicated maximum assistance was required for oral hygiene, set-up assistance for hygiene, and dependence for bathing. The CNA task record showed hygiene and oral hygiene were not completed on June 20, 21, 28, and 30, 2026. Bathing records also lacked documentation of the bathing type on June 19, 24, and 30, 2026, and the resident was bathed only one time from June 21 through June 30, 2026.
Missed IV Antibiotic Doses
Penalty
Summary
The facility failed to ensure Resident H received an IV antibiotic as ordered by the physician for cellulitis of the right lower limb. The resident’s care plan dated 6/9/26 indicated an antibiotic was being administered and that it would be given as ordered. A physician’s order dated 6/23/26 directed piperacillin sod-tazobactam 3-0.375 g IV every 6 hours for 7 days. The MAR for 6/2026 showed the antibiotic was not administered on 6/24/26 at 12:00 p.m. with no reason documented, and it was also not administered on 6/30/26 at 12:00 a.m. because the resident was sleeping. During interview, the Nurse Consultant acknowledged the antibiotic had not been administered.
Missed wound treatments, supplements, and antibiotics for residents with pressure ulcers
Penalty
Summary
The facility failed to ensure residents with pressure ulcers received ordered treatment and services to support wound healing for 3 of 3 residents reviewed. For Resident D, the record showed diagnoses including an infected unstageable sacral pressure ulcer and a stage 3 heel pressure ulcer, with care plans directing ordered wound care and antibiotic administration. The physician ordered piperacillin sod-tazobactam for infection, Critical Care Active Protein supplement twice daily to promote wound healing, and multiple wound treatments including Santyl, betadine, a wound vac, and Iodosorb for the sacrum, coccyx, left gluteal area, and left heel. The MAR and TAR documented missed antibiotic doses, missed protein supplement doses, and multiple missed wound treatments across several dates. Resident E was admitted with a stage 3 pressure ulcer to the coccyx and was not cognitively intact for daily decision making. The nursing progress note documented slough and pale pink tissue at the coccyx on admission, and the care plan directed treatment per physician orders and measurement and assessment per facility policy. A physician ordered topical Triad paste to the coccyx every day shift, but the TAR for June and July 2026 showed wound treatments were not signed out on multiple dates. Resident F was admitted with a pressure injury and had diagnoses including muscle weakness, abnormal gait and mobility, aphasia, obstructive and reflux uropathy, adjustment disorder, anemia, and hypertension. The care plan directed treatment per physician orders and use of Enhanced Barrier Precautions related to wounds. A physician ordered cleansing of the left inner glute with saline, application of medical honey, and a dry dressing every day shift and as needed, but the TAR showed wound treatments were not signed out on multiple dates. During interview, the Nurse Consultant stated she understood the concerns and had no further information to provide.
Foley Catheter Care and Output Documentation Not Completed
Penalty
Summary
The facility failed to ensure Foley catheter care was provided, urine output was recorded, and catheter bags and tubing were kept off the floor for two residents with urinary catheters and a UTI. One resident, who had diagnoses including muscle weakness, acute kidney failure, and hypertension and was not cognitively intact for daily decision-making, was observed lying in bed with a Foley catheter hanging off the side of the bed. The resident had a care plan for catheter management and a physician order for Foley catheter care every shift and as needed, but the July TAR lacked documentation that catheter care had been provided from 7/1/26 through 7/7/26. During interview, the Nurse Consultant stated the order had never transferred to the TAR. The second resident, who had diagnoses including muscle weakness, abnormal gait and mobility, aphasia, obstructive and reflux uropathy, anemia, and hypertension and was cognitively intact, was observed multiple times sitting in a wheelchair with the bottom of the urinary catheter bag on the floor under the wheelchair. The resident had a care plan for catheter management, an order to record output every shift, an order to change the drainage bag as needed, and later orders for catheter care and to ensure the Foley catheter was in place and intact. The record showed a urine culture positive for infection and treatment with Ciprofloxacin, but the June and July TARs lacked Foley catheter care documentation, and urine output was not recorded on multiple am and pm shifts across June and July. The Nurse Consultant stated the Foley bag should not have been on the floor and acknowledged that output should have been documented and catheter care orders should have been placed sooner.
Failure to Provide and Document Colostomy Care
Penalty
Summary
Facility failed to provide colostomy care and failed to assess the colostomy and the skin surrounding the ostomy for one resident with a colostomy. The resident had diagnoses including paraplegia related to trauma and colostomy. The care plan indicated an ostomy was present and that the stoma would be monitored for changes and ostomy care would be provided, and the admission MDS also indicated a colostomy was present. However, the record contained no documentation that colostomy care had been provided, that the collection bag had been changed, that stoma care had been completed, or that the ostomy site had been assessed. There were also no physician orders for colostomy care. During interview, the Nurse Consultant had no further information on the care of the colostomy.
PICC line care and documentation were incomplete for three residents
Penalty
Summary
The facility failed to care for PICC lines in accordance with professional standards of practice for three residents who received IV medications. For Resident G, an LPN administered an antibiotic through the PICC in the left upper arm after flushing with 10 ml of normal saline, but the dressing was dated 6/26/26, the Nurse Consultant confirmed that date, and there was no documentation that the insertion site had been assessed, that flushes had been completed, or that the dressing had been changed every seven days. Resident G’s admission assessment did not indicate a PICC line, although the care plan and MDS showed IV medications and IV access, and there were no physician orders for PICC flushes or dressing changes. For Resident H, the PICC dressing on the right upper arm was dated 7/7/26, but the record showed the line had originally been placed in the left upper arm and there was no documentation that the dressing had been changed 24 hours after insertion or every seven days. A physician ordered 10 ml normal saline flushes every shift, but the MAR showed flushes were not completed on the day and night shifts on 6/29/26. The record also lacked timely insertion site assessments, and when the site was finally assessed it was noted the PICC had been pulled out about 1/2 inch and the site was reddened. For Resident D, the record showed IV antibiotic therapy and a care plan for PICC dressing observation and weekly changes, along with an order for 10 ml normal saline flushes every shift, but there was no documentation of when the PICC was inserted, when dressing changes were completed, or any insertion site assessments.
EBP Not Followed During Resident Care
Penalty
Summary
The facility failed to ensure infection control practices were in place and implemented for a resident who was supposed to be on Enhanced Barrier Precautions (EBP) related to a wound, urinary catheter, and feeding tube. During observations, the resident was lying in bed and there was no EBP sign on the door or inside the room. CNA 1 was observed providing incontinence care, including removing the brief, performing peri care, and then dressing the resident and assisting him into his wheelchair without changing gloves after completing the dirty-to-clean task transition. The resident’s record showed diagnoses including muscle weakness, acute kidney failure, and hypertension. The 7/4/26 MDS indicated the resident was not cognitively intact for daily decision-making and had a urinary catheter. The care plan dated 6/29/26 identified EBP related to wounds, and a physician’s order dated 7/5/26 indicated the resident was in EBP related to a wound. During interview, CNA 1 stated she would wear a gown, gloves, and a mask if the resident was in EBP and noted there was no EBP sign on the door. The Nurse Consultant stated CNA 1 should have followed EBP and changed her gloves after care, and also stated the facility would check that all doors were updated with appropriate signage.
Posted Nurse Staffing Information Not Kept Current or Retained
Penalty
Summary
The facility failed to ensure that posted nurse staffing information was current and failed to retain the posted daily nurse staffing data for at least 18 months. During an observation at the front door, the posted staffing information was present but the date on the posting was 7/2/26. During interviews, the Nurse Consultant stated that the posted information was supposed to be changed daily, and later stated that the Scheduler had been shredding the daily postings. The Nurse Consultant also stated she started the position in February and was unaware that the posting was required to be kept.
Failure to Monitor Ordered Weights and Reweigh Significant Weight Losses
Penalty
Summary
The facility failed to ensure resident weights were monitored as ordered and failed to complete reweights when significant weight changes were identified for 5 of 8 residents reviewed for nutrition. Resident 5, who had dependence on renal dialysis and heart failure, had a physician order to be weighed daily for three days, then weekly for four weeks, then monthly, but only one weight was documented after admission. Resident 58, who had adult failure to thrive and diabetes mellitus, had a physician order for daily weights for three days, then weekly for four weeks, then monthly, but the record showed a weight of 215.2 pounds on 12/30/25 and 201.4 pounds on 1/11/26, a loss of 13.8 pounds in less than two weeks, with no documentation of a reweigh. Resident 6, with heart failure, hypertension, and end stage renal disease, had a weight of 191.1 pounds on 12/5/25 and 175.6 pounds on 1/11/26, an 8.11% loss, and there was no documentation that a reweigh was completed after the significant loss. Resident 27, who had protein calorie malnutrition and dementia, had a quarterly MDS indicating moderate cognitive impairment, weight loss, and set-up assistance for eating. The resident lost 16.2 pounds from 166 pounds to 149.8 pounds in one month, and no reweigh was completed at that time. Resident 17 had a care plan addressing potential alterations in nutrition and hydration and a physician order for daily weights for three days, then weekly for four weeks, then monthly, but the record showed weights only on 1/31/26, 2/2/26, and 2/17/26, with a 10.54% loss from 265.6 pounds to 237.6 pounds and no documented weights after that loss. The DON stated weights were not documented anywhere else, acknowledged issues with weights not being monitored as scheduled, and stated that abnormal weights should have been rechecked because staff were not weighing residents correctly each time, resulting in discrepancies.
Insulin Pens Not Dated After Opening
Penalty
Summary
Drugs and biologicals were not labeled in accordance with accepted professional principles because insulin pens in Medication Cart C1 did not have opened-on dates documented. During observation of the cart with an LPN, 12 different insulin pens were found in plastic baggies labeled "Refrigerate Until Opened," and each pen had a sticker with space for an opened-on date, but none of the pens had an opened-on date written on them. The LPN stated the pens should be dated when opened and refrigerated if not opened. The Administrator later stated that all of the insulin pens had been opened but still did not have opened-on dates. A DON-provided document stated insulin products may be left unrefrigerated between 59 and 86 degrees Fahrenheit for up to 28 days.
Medication Parameter Errors and Unauthorized Compression Device Use
Penalty
Summary
The deficiency involves failures to follow physician orders and to ensure appropriate orders were in place for treatments and medications. For one resident with dependence on renal dialysis and heart failure, a physician’s order dated 2/16/26 directed administration of midodrine 10 mg three times daily for hypotension, to be held if blood pressure was greater than 130/90. The February 2026 MAR showed midodrine was administered on multiple occasions when the systolic blood pressure exceeded 130 (including readings of 150/86, 146/59, and 141/78), and on one date the medication was not given when the blood pressure was 119/64, with a note stating the blood pressure was outside parameters. The DON stated the midodrine parameters came from hospital discharge orders, acknowledged the order was not clear, and indicated staff education was needed. Another resident with heart failure had a physician’s order dated 1/31/26 for midodrine 2.5 mg by mouth three times a day, to be held if systolic blood pressure was greater than 110. The February 2026 MAR indicated midodrine was administered several times when systolic blood pressure was above 110, including readings of 123/75, 136/74, 135/87, 129/72, and 117/63. A separate deficiency involved the use of compression leg wraps without a corresponding physician order. One resident with diabetes mellitus, a left tibia fracture, bilateral lower extremity impairment, and care plans for diuretic therapy related to edema and anticoagulant therapy for DVT prevention was observed with compression leg wraps and a connected machine in his room. Initially, the wraps were folded in a bag on the bed, and the resident reported not knowing who brought them or whether he or staff were supposed to apply them. On a later observation, the wraps were opened and connected to the machine on the bed. Record review showed no physician orders for the compression leg wraps. An RN stated she was unaware the wraps were on the bed and confirmed there was no order, and the DON stated the resident was supposed to wear the leg wraps for leg swelling and that the company must have dropped them off without notifying staff, adding that there should have been an order in the computer.
Failure to Assess and Order Self-Administration of Eye Drops
Penalty
Summary
The facility failed to ensure a resident was assessed for self-administration of medications and had a physician's order to self-administer medications. During observation, latanoprost eye drops were seen on the resident's bedside, and the resident stated that he administered the eye drops himself. Record review showed a physician's order for latanoprost ophthalmic emulsion 0.005% one drop in both eyes at bedtime for eye pressure, but there were no physician's orders for self-administration of medications and no assessment for self-administration of medications in the record. The DON stated she had no further information at the time. The facility policy indicated that if a resident is determined to self-administer medications, it is documented in the chart, the physician is called for an order to self-administer and keep medications at bedside, and nursing completes an assessment for self-administration.
Incomplete Care Plans for Hypotension and Splint Use
Penalty
Summary
The facility failed to ensure complete care plans were in place and implemented for hypotension and splint use for 2 of 25 resident care plans reviewed. Resident 5 had diagnoses including heart failure and dependence on renal dialysis, and a physician order dated 2/16/26 directed midodrine 10 mg three times daily for hypotension. Although a hypotension care plan was initiated on 2/1/26, it contained no goals or interventions. Resident 38 had diagnoses including hemiplegia of the left non-dominant side, and the admission MDS dated 1/30/26 indicated moderate cognitive impairment and impairment in range of motion on one side of the upper and lower extremities. A physician order dated 1/24/26 directed application of a brace to the left hand at bedtime and removal in the morning every day, but the record lacked any care plans related to the resident's limited range of motion with splint use.
Failure to Follow Ordered Splint Schedule
Penalty
Summary
The facility failed to provide a physician-ordered splinting treatment for Resident 38, who had diagnoses including hemiplegia of the left non-dominant side and was assessed as moderately cognitively impaired with impaired range of motion on one side of the upper and lower extremities. The physician's order dated 1/24/26 directed staff to apply a brace to the resident's left hand at bedtime and remove it in the morning every day. However, during observations on 2/17/26 and 2/20/26, the resident was seen sitting in a wheelchair with the splinting device on her left hand during the day. The DON stated during interview that the family was involved with care and may have put the splint on the resident. The facility's Splint Policy stated that nursing is responsible for applying and removing the splint per schedule.
Urinary Catheter Bag and Output Not Properly Monitored
Penalty
Summary
The facility failed to ensure an indwelling urinary catheter collection bag and tubing were kept off the floor for a resident with a history of urinary tract infections and neuromuscular dysfunction of the bladder. On 2/17/26, the resident was observed sitting in a wheelchair with the catheter collection bag and tubing underneath on the floor. The resident’s record showed a care plan for a urinary catheter with interventions to check tubing placement each shift and monitor, record, and report signs and symptoms of UTI, and a physician’s order to record catheter output every shift. The February 2026 MAR/TAR showed urinary catheter output was not documented and was marked NA on multiple day and night shifts. During interview, the DON stated the family had been emptying the catheter and that the catheter should not have been on the floor.
Incomplete Insulin Administration Documentation
Penalty
Summary
The facility failed to ensure a resident's record was complete and accurate regarding insulin administration documentation for a resident with diabetes mellitus, moderate cognitive impairment, and an order for Novolog 10 units before meals with instructions to hold the dose if blood sugar was below 200 mg/dL. During interview, the resident stated he often did not receive his insulin before meals as ordered. Review of the February 2026 MAR showed the resident's blood sugar was below 200 before every meal except one on 2/2/26, indicating the insulin should not have been given, yet there were 14 entries marked as given when the blood sugar was less than 200 and 42 entries documenting that insulin was not given because blood sugar was out of parameters. The DON stated she needed to provide education to nursing staff regarding how to document holding the insulin.
Failure to Use Required Eye Protection for COVID-19 Isolation
Penalty
Summary
Infection control guidelines were not followed for a resident who was on contact/droplet precautions after testing positive for COVID-19. During a random observation, RN 2 was seen donning a gown, gloves, and an N95 mask before entering the resident’s room, but she did not don protective eyewear before going inside. The resident’s room door had a sign indicating contact/droplet precautions. When observed leaving the room, RN 2 stated that the resident was on contact/droplet precautions due to COVID-19 and that she would don a gown, gloves, and an N95 mask to enter any contact/droplet rooms. The Administrator was notified that RN 2 had not worn protective eyewear into the room. A policy related to isolation precautions for a COVID-19 positive room was requested and not provided.
Failure to Complete Required Admission, Skin, and Accident Assessments
Penalty
Summary
The facility failed to complete required admission, skin, and accident assessments as ordered and per policy for several residents. For one resident admitted after digestive surgery with multiple comorbidities, there was no documented admission assessment or assessment of the surgical wound upon arrival. Although the wound nurse and primary nurse attempted to assess the surgical site, the assessment was not completed due to the resident's transfer to the hospital, and only vital signs were documented. The resident and family had expressed concerns about care, but no further information was provided. Another resident with a history of femur fracture, stroke, and other significant diagnoses experienced a burn incident involving hot tea. The initial assessment failed to document the presence of reddened skin on the right arm and back immediately after the incident. Blistering was only documented in a subsequent assessment, and the President of Clinical Operations confirmed that the initial assessment should have included the redness observed prior to blistering. For two additional residents with pressure ulcers, the facility did not complete or document weekly skin evaluations as ordered by the physician. In both cases, the electronic medical record lacked required skin evaluations for multiple weeks, despite physician orders and care plans indicating the need for regular skin checks. The Treatment Administration Record also showed missed documentation of these evaluations. The President of Clinical Operations acknowledged the missing documentation and indicated an understanding of the concern.
Incomplete Documentation of Wound Care Treatments
Penalty
Summary
The facility failed to maintain complete and accurate clinical records regarding wound treatments for one resident with pressure ulcers. Specifically, a resident with diagnoses including diabetes and fractures was admitted with surgical wounds and later developed a pressure injury to the left heel. The care plan required following facility protocols and physician orders for wound care. However, review of the Treatment Administration Record (TAR) for the relevant month showed that wound care was not signed out on two specific dates. During interviews, the wound nurse acknowledged performing the treatments but admitted to forgetting to document them, citing increased workload due to being the only wound nurse available that week.
Resident Unable to Access Call Light While Awaiting Assistance
Penalty
Summary
A deficiency occurred when a resident who required substantial to maximum assistance with activities of daily living was left in her wheelchair, unable to access her call light. The resident, who was visibly fatigued and shaking, had been waiting to be put back to bed after her husband requested staff assistance. Staff informed the husband that it would take some time due to other tasks. The resident attempted to use her call light but was unable to locate it, as it was found by a nurse in the back corner of the room, out of the resident's reach and not visible to her. The resident was only assisted back to bed after staff were notified of her inability to access the call light. The resident's medical record indicated diagnoses including muscle weakness, encephalopathy, diabetes, and adult failure to thrive, with moderate impairment in daily decision making. She required significant assistance with transfers and other ADLs. Previous documentation showed that the resident had been lethargic and required hospital admission for a severe urinary tract infection. The Assistant Director of Nursing acknowledged the concern regarding the call light but did not provide additional information.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that residents received necessary care and treatment as ordered, specifically related to medication administration. For one resident with diagnoses including congestive heart failure, diabetes, and acute kidney failure, a physician ordered an additional dose of furosemide for worsening symptoms, but the dose was not administered. The medication administration record (MAR) showed the dose was scheduled but left blank, and a nursing note indicated it was considered a duplicate order, resulting in the resident only receiving the original dose. No further explanation was provided by facility leadership. Two other residents with infections also did not receive medications as ordered. One resident with acute polynephritis and diabetes did not have two scheduled doses of cephalexin signed out as given, with no documentation explaining the omission. Another resident with muscle weakness, encephalopathy, and acute cystitis missed three doses of cephalexin due to pharmacy time changes and discontinuation of the original order, as confirmed by the nurse consultant. These failures were identified through record review and staff interviews.
Failure to Provide Safe and Appropriate Dialysis Care and Medication Administration
Penalty
Summary
The facility failed to provide necessary care and treatment for residents requiring dialysis, specifically related to pre- and post-dialysis assessments, medication scheduling, and medication administration. For one resident with end stage renal failure, the facility did not complete or retain required pre- and post-dialysis assessments, and the resident's seizure medication was scheduled on incorrect days, not aligning with the updated dialysis schedule. The Assistant Director of Nursing (ADON) confirmed that the dialysis days had changed, but the medication order was not updated accordingly, and the required assessments could not be located in the resident's records. Another resident, also dependent on dialysis, did not have her dialysis binder sent to the dialysis center on two occasions, and her prescribed medications were not sent with her as ordered. The resident reported that staff failed to send both her binder and medications, and the ADON confirmed that the prepackaged medications were found in the medication cart rather than being sent with the resident. The facility's own dialysis protocol required that medications to be administered during or after dialysis be labeled and sent with the resident, which was not followed in these instances.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to provide required notifications to the Office of the State Long Term Care Ombudsman prior to transferring or discharging residents. Record review and interviews revealed that since May 2024, the Ombudsman had not received any notifications of resident transfers or discharges from the facility. During an interview, the Administrator stated she was unaware that sending notifications to the Ombudsman was still a requirement and confirmed that the facility had not been sending them. The facility's own policy, updated in May 2024, specifies that a copy of the transfer or discharge notice must be sent to the Ombudsman before or as close as possible to the time of notifying the resident.
Failure to Provide and Document Activities for Cognitively Impaired Residents
Penalty
Summary
The facility failed to provide ongoing activities that met the preferences of cognitively impaired residents, as evidenced by the review of records and interviews for three residents. For one resident with severe cognitive impairment and multiple medical diagnoses, activity assessments indicated preferences for snacks, movies, game shows, outings, pet visits, and religious services. However, documentation was lacking regarding whether scheduled one-on-one visits occurred or what activities were provided, and the resident was observed not actively engaged or alone in her room on multiple occasions. The Activity Director acknowledged inconsistent documentation of participation and activity types. Another resident with severe cognitive impairment and a history of dementia and alcohol dependence had documented preferences for creative arts, crafts, music, outdoor activities, and spiritual activities. Despite this, records only showed sporadic participation in group events, with refusals noted but no details on the types of activities offered or independent activities provided. A third resident's record also lacked documentation of participation in or being offered preferred activities such as reading, music, pet interaction, and outdoor time, despite these being identified as important. Staff interviews confirmed that some activities, like word searches, were provided but not documented, and activity records were only maintained for certain activities like communion.
Delayed Initiation of Antiviral Medication for COVID-19
Penalty
Summary
The facility failed to initiate medication administration in a timely manner for a resident who was admitted with diagnoses including congestive heart failure, COVID-19, and pneumonia. The resident, who had moderate cognitive impairment and required moderate assistance with daily activities, tested positive for COVID-19 and was prescribed Paxlovid on the day of admission. However, the medication was not started until three days after it was ordered. The delay occurred because the facility was waiting for the medication to arrive from their contracted pharmacy, which was not local and did not provide Paxlovid as floor stock. Although the medication arrived on a Sunday, it was not administered until the following day.
Delay in Assisting Resident to Bathroom Compromises Dignity
Penalty
Summary
A resident with diagnoses including a right femur fracture, pressure wound, and history of falls, who was dependent on staff for toileting, activated her call light to request assistance to use the bathroom. The resident, who had severely impaired cognition but no impairment to her extremities, was observed waiting in her wheelchair with two family members present. Despite informing an LPN of her need to use the bathroom, the nurse left the room after stating she would return shortly. The resident continued to wait, expressing concern that staff had forgotten her request. The call light log indicated the call was activated at 4:38 p.m., and staff did not assist the resident to the bathroom until approximately 17 minutes later, when two CNAs entered and provided the necessary help. The resident was able to void on the toilet after the delay. The care plan and care card both indicated the resident required assistance for toileting and transfers, with one staff member needed for transfers. The delay in responding to the resident's request resulted in a failure to treat her with respect and dignity as required.
Failure to Document and Monitor Catheter Care and Bladder Training
Penalty
Summary
The facility failed to ensure proper bladder training, post void residual (PVR) monitoring, and documentation after urinary catheter removal for three residents. For one resident with a history of femur fracture, stroke, and UTI, there was a lack of documentation regarding catheter clamping, resident-reported urge to void, and completion of bladder scans as ordered. Orders for bladder training and scans were inconsistently followed, and there was no consistent record of urine output or clear documentation of catheter removal and related care in the medical record. Another resident with obstructive uropathy and dementia had a physician's order for urinary output monitoring every shift, but the output was not consistently documented. The care plan required monitoring for signs and symptoms of UTI, including urine output, but the monitoring log showed multiple days without any recorded output, and only sporadic entries were made. A third resident with a groin abscess and an indwelling catheter also had inconsistent documentation of urinary output, with several days missing entries and only a few outputs recorded. The facility's catheter care policy required drainage bag emptying and output documentation at the end of each shift, but this was not followed. The Director of Nursing confirmed the lack of documentation for catheter care, bladder training, and urine output, as well as inconsistencies in following physician orders and facility policies.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
Certified Nursing Assistants (CNA 2 and CNA 3) failed to use the required Personal Protective Equipment (PPE) when providing care to a resident who was under Enhanced Barrier Precautions (EBP) due to the presence of a wound. During an observation, both CNAs entered the resident's room, which was clearly marked with a sign indicating EBP requirements, and donned only gloves before assisting the resident with toileting and incontinence care. When questioned, both CNAs denied that EBP was necessary for the resident and continued care without donning gowns as required. Review of the resident's medical record confirmed diagnoses including a right femur fracture, pressure wound, and falls, with physician orders and care plan interventions specifying the need for EBP, including the use of gowns and gloves during high-contact care. The facility's current EBP policy also required staff to wear gowns and gloves for residents with wounds during such care activities.
Failure to Assist Resident in a Timely Manner
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity, as evidenced by a delay in assisting a resident out of bed upon request. On the specified date, Resident J activated the call light and requested assistance to have her meal tray removed and to get out of bed. RN 1 responded and informed the resident that staff were currently assisting another resident and would help her once available. Despite this assurance, observations showed that the resident remained in bed for over two hours after the initial request. During an interview, the resident expressed that this delay in assistance was a frequent occurrence, impacting her ability to carry out planned activities. RN 1 acknowledged informing a CNA about the resident's need for assistance, noting that a mechanical lift and two staff members were required for the transfer. Resident J's care plan confirmed the need for such assistance due to her medical condition, which included congestive heart failure and a history of falls.
Failure to Notify POA of Resident Falls
Penalty
Summary
The facility failed to notify a resident's Power of Attorney (POA) about falls, as required by their policy, for one of the three residents reviewed for physician/responsible party notification. Resident E, who had diagnoses including pneumonia, a fracture of the right arm, an infection of the right hand, and dementia, was identified as having a severely impaired cognitive status. The resident's record indicated that the POA was the first contact person in case of changes or emergencies. However, during fall investigations on three separate occasions, the person listed as the second contact was notified instead of the POA. There was no documentation explaining why the POA was not informed. During an interview, the Clinical President and Director of Nursing were unable to provide a reason for this oversight. The facility's policy required that communication with the responsible party be documented in the resident's record, and the responsible party should be notified after the physician.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident who was dependent on staff for assistance with activities of daily living. During an observation, it was noted that the resident's call light had been activated by a visitor, and upon response by RN 4 and CNA 5, the resident was found with a saturated incontinent brief, wet gown, top sheet, and abdominal binder. Additionally, the incontinent pad under the resident was soaked, and there were dried urine rings on the bed. The resident indicated that he had last been changed the previous day. Interviews revealed that CNA 2, who was assigned to the resident, had not checked on him since starting her shift at 6 a.m. The administrator mentioned that the resident's call light had been on at 2 a.m., suggesting a possible check at that time. The resident's care plan, dated 3/7/25, indicated he required assistance for hygiene and toileting and should be checked every 2-3 hours for incontinence. The resident had a history of a bloodstream infection due to a central venous catheter and dementia, with a mental status assessment indicating moderately impaired cognition.
Failure to Conduct Required Skin Assessments for Residents with Braces
Penalty
Summary
The facility failed to ensure that residents received necessary care and services as ordered by the physician, specifically related to skin assessments for residents with a brace and an immobilizer. Resident E, who had a brace on the right wrist/forearm due to a fracture, did not receive the required weekly skin checks on several specified dates in January and February 2025. Additionally, the non-removable surgical splint was not monitored on multiple shifts as required. The Clinical President was informed of these missed assessments, but no further information was provided by the facility. Resident H, who had a left humerus fracture and was at risk for skin integrity issues, also did not receive the mandated weekly skin checks on several dates in February and March 2025. The Treatment Administration Record indicated that these checks were not signed out, and the Director of Nursing acknowledged the concern regarding the incomplete skin evaluations. This deficiency was related to a specific complaint, highlighting the facility's failure to adhere to physician orders for skin assessments.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement care plan interventions to prevent falls for a resident identified as high risk for falls. Observations on two consecutive days revealed the absence of a stop sign and floor mat in the resident's room, which were specified interventions in the care plan. The resident, who had a history of falls and was diagnosed with conditions including dementia and a fracture, required maximum assistance with transfers and was dependent for toileting and wheelchair mobility. Despite the care plan's directives, these safety measures were not in place, as confirmed by a registered nurse during an interview. The resident's record indicated multiple falls, underscoring the need for the prescribed interventions to mitigate fall risks.
Feeding Tube Infusion Rate Discrepancy
Penalty
Summary
The facility failed to ensure that a resident's feeding tube was infusing at the correct flow rate. Resident F, who had a gastrostomy tube and required enteral nutrition, was observed with the tube feeding infusing at 55 cc/hr, contrary to the physician's order of 20 cc/hr. This discrepancy was noted during observations on two separate occasions. The resident's care plan indicated that the tube feeding should follow current physician orders, which specified a rate of 20 cc/hr. However, a Registered Dietician's Progress Note recommended an increase to 55 cc/hr, but there were no corresponding physician orders to authorize this change. The facility's tube feeding policy required an order by the physician or nurse practitioner for the type of formula and rate, which was not adhered to in this case.
Failure to Provide Proper Midline Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a midline catheter for Resident E, who had a severely impaired cognitive status and was diagnosed with pneumonia, a fracture of the right arm, an infection of the right hand, and dementia. A midline catheter was ordered for IV antibiotic administration, but there was no documentation of when the catheter was placed in the resident's clinical record. Additionally, there were no physician's orders for flushing the midline or for the care of the midline catheter. The Medication Administration Record and/or Treatment Administration Record for March 2025 lacked information indicating that flushes were completed, dressing changes to the site were performed, and that the arm circumference and insertion site were monitored. The Director of Nursing and the President of Operations were informed of the lack of care for the IV site and orders for the flushes, but no further information was provided. A form from the Vascular Access Specialist indicated that the midline was placed on March 6, 2025, with specific instructions for flushing and dressing changes. However, these instructions were not followed as per the facility's policy, which required documentation of IV fluid administration and monitoring of the IV site in the clinical record. This lack of adherence to professional standards of practice led to the deficiency in the care of Resident E's midline catheter.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to provide appropriate respiratory care to a resident, identified as Resident E, who required oxygen therapy. During multiple observations, Resident E was seen sitting in a wheelchair with a nasal cannula in place, but the portable oxygen unit was turned off. It was only after the Assistant Director of Nursing intervened that the oxygen was turned on to the prescribed two liters per minute. Resident E's medical record indicated diagnoses of pneumonia, a fracture of the right arm, an infection of the right hand, and dementia. A physician's order dated 3/8/25 specified that oxygen should be administered at two liters per minute every shift, and the care plan dated 3/9/25 confirmed the need for oxygen therapy as per the physician's orders. The facility's policy on oxygen usage, dated 11/2018, required that oxygen be administered according to the physician's orders, which was not adhered to in this instance.
Failure to Use Correct PPE for Resident on Enhanced Barrier Precautions
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 in Enhanced Barrier Precautions (EBP). During two separate observations, a Certified Nursing Assistant (CNA) did not don a protective gown while providing care to a resident who was incontinent and required EBP due to wounds and a central line. On the first occasion, there was no sign on the door indicating the resident was on EBP, and the CNA only wore gloves while providing care. On the second occasion, although a sign and PPE supplies were present, the CNA still did not wear a gown, stating she was unaware of the EBP requirement. The resident involved had a medical history that included pneumonia, a fracture, an infection, and dementia. The resident's care plan required EBP due to wounds present upon admission, and a physician's order had been in place since January for EBP. The resident also had a midline catheter inserted for intravenous antibiotic therapy. The facility's EBP policy required staff to wear gowns and gloves during high-contact care for residents with central lines and wounds, which was not adhered to in this case.
Kitchen and Refrigerator Labeling and Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain cleanliness and proper labeling in the kitchen and resident refrigerator, which could potentially affect all 67 residents receiving food from the kitchen. During an initial kitchen sanitation tour, several issues were observed, including food debris under the salad bar lid, sticky residue on storage bin lids, and dust accumulation on the convection oven. Additionally, opened bags of food in the dry storage room and freezer were not dated, and lemon slices in the cooler were uncovered. The test strips used for sanitation buckets were incorrect, as bleach strips were used instead of quat testing strips. In the D Wing refrigerator, several items were not properly labeled or dated, including a fast food container, a plastic container of food, and a bag of fast food. Despite a sign indicating that resident food must be dated, these items were not compliant. Interviews with the Executive Chef and a CNA confirmed that the dietary staff should have labeled the items, and the facility's policy required labeling with product name, received date, use by date, and resident's name.
Kitchen Sanitation Deficiency
Penalty
Summary
The facility failed to maintain cleanliness in the kitchen area, as observed during a sanitation tour. In the walk-in freezer, there was an accumulation of food debris on the floor and underneath the shelf. Additionally, the garbage disposal next to the dishwasher had a thick accumulation of an orange substance on its exterior. Furthermore, five plastic light covers located above the steam table and food preparation area were found to have an accumulation of dust and dead insects inside. These observations were confirmed during interviews with the Executive Chef, who acknowledged that the areas either had been cleaned or were in need of cleaning.
Failure to Ensure Physician's Orders and Assessments for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents had physician's orders and assessments for self-administration of medications. During observations, several residents were found with medications at their bedside without the necessary physician's orders or assessments to self-administer. For instance, Resident C was observed with a plastic medication cup containing a white powder and a bottle of Ammonium Lactate lotion, neither of which had a physician's order for self-administration. Similarly, Resident E had over-the-counter vitamins on her over bed table without any orders or assessments for self-administration. In another instance, Resident F was found with a nasal spray on her over bed table, which she used frequently, but there was no physician's order for self-administration. Resident G had chewable antacids and nasal spray at his bedside without the necessary orders or assessments. Resident B had eye drops and pills left on her over bed table, and although her care plan indicated a need for reassessment of her ability to self-administer medications, no recent assessment had been completed. Additionally, Resident H had a bottle of Biofreeze on her over bed table, and Resident D had a tube of Venelex cream in his room, both without the required orders or assessments for self-administration. Resident J, who was cognitively impaired, had a tube of portocort cream on his nightstand without the necessary physician's order or assessment. The facility's policy required a physician's order for medications at the bedside, which was not adhered to in these cases.
Deficiencies in Oxygen Therapy Management
Penalty
Summary
The facility failed to ensure proper management of oxygen therapy for four residents, leading to deficiencies in the administration and documentation of oxygen orders. Resident 130 was observed using oxygen at 3 liters per minute via nasal cannula without a specified flow rate in the physician's order, and the oxygen was not documented as being applied in the medication and treatment records. Similarly, Resident C was observed with oxygen levels set higher than the physician's order of 2 liters per minute, with no checks performed by the LPN on the day of observation. Resident F was observed with varying oxygen levels, including 5 liters per minute, despite a physician's order for 3 liters per minute for shortness of breath. The LPN had not checked the oxygen settings on the day of observation. Resident 127 was observed using oxygen at 2 liters per minute without documentation in the medication administration record, and the resident had been wearing oxygen daily since a decline in health. The facility's policy required that oxygen orders be recorded in the resident's chart, which was not adhered to in these cases.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper medication management and storage practices, as observed in two separate incidents. On the C Wing, an LPN was found pre-pouring medications into plastic cups labeled with room numbers, which is against the facility's policy. During an interview, the LPN initially admitted to always pre-pouring medications but then retracted the statement, citing a bad day. The President of Clinical Operations confirmed that there was no policy allowing pre-pouring of medications, and the LPN's actions were inappropriate. Additionally, the facility did not maintain secure and properly labeled treatment carts. A wound nurse was observed with an unlocked treatment cart containing multiple opened and unlabeled tubes of creams, which were used as house stock for residents. Another wound nurse's cart contained numerous opened creams without resident names, including some for a discharged resident. The Chief Nursing Officer acknowledged that the treatment carts should have been locked and creams labeled with specific resident names. The facility's Medication Labeling and Storage policy requires all medications to be labeled according to state and federal laws, and floor stock medications to be kept in their original containers.
Infection Control Deficiencies in Medication Handling and Equipment Disinfection
Penalty
Summary
The facility failed to adhere to infection control guidelines during medication administration for several residents. On multiple occasions, LPNs and RNs were observed handling medications with their bare hands, without performing hand hygiene or donning gloves. This occurred with at least three residents, where pills were popped from medication cards directly into the staff's bare hands before being placed into medication cups or mixed with applesauce for administration. The staff acknowledged the improper handling of medications, indicating a lack of practice or awareness of proper procedures. In another instance, a resident with a peripherally inserted central catheter (PICC) line did not have enhanced barrier precautions (EBP) in place. An LPN administered an antibiotic via the PICC line without wearing a gown, and there was no signage or personal protective equipment (PPE) available to indicate the need for EBP. The resident's physician's order summary did not include an order for EBP, and the infection preventionist confirmed that EBP should have been implemented due to the presence of the PICC line. Additionally, the facility failed to properly disinfect a glucometer after use. An LPN used alcohol wipes instead of the required germicidal bleach wipes to clean the glucometer after performing a blood glucose test on a resident. The LPN admitted to using alcohol wipes due to the unavailability of bleach wipes in the medication cart. The infection preventionist confirmed that bleach wipes were the expected method for cleaning glucometers, as per the facility's policy.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 516 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — 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.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | 1.1 mi | ★★★★★ | 15 | 0 |
| Chesterton Manor | 1.3 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Valparaiso | 5.6 mi | ★★★★★ | 15 | 0 |
| Avalon Springs Health Campus | 6.2 mi | ★★★★★ | 12 | 0 |
| Valparaiso Care & Rehabilitation | 6.2 mi | ★★★★★ | 28 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 October 2026) and official state health department websites.