Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Life Care Center Of Michigan City during CMS and state inspections, most recent first.
A resident with a history of stroke and epilepsy, identified as at risk for constipation, went over five days without a documented bowel movement despite care plan interventions and a facility bowel protocol requiring action after three days. The resident experienced nausea and abdominal pain, received stool softeners and laxatives with limited effect, and ultimately required hospital transfer for severe constipation and proctitis. The facility did not consistently follow its bowel management protocol or promptly escalate care.
A resident with chronic respiratory conditions was observed receiving oxygen at 4 lpm via nasal cannula, contrary to a physician's order for 2 lpm. The resident, who was cognitively intact, confirmed the correct flow rate, and an LPN later identified and corrected the discrepancy after observation.
Dirty and Damaged Resident Areas: The facility failed to keep resident rooms and bathrooms clean and in good repair on the East Unit and the [NAME] Unit. Surveyors observed dirty and sticky floors, a dirty bed rail, loose trim and baseboards, chipped paint, torn floor mats, stained curtains, debris and food crumbs on the floor, marred doors, a rust-stained sink, and dust accumulation in ceiling vents. The Maintenance Director and Housekeeping Director stated the observed areas needed cleaning or repair.
A resident with CKD, lymphoma, glaucoma, and moderate cognitive impairment had re-wetting eye drops at the bedside and said he used them independently, but the record lacked a self-administration assessment and MD order for the medication. An expired bottle was also observed among the eye drops, and the ADON stated that a self-administration assessment and MD order should be in place for self-administration.
Failure to notify the physician/NP of repeated insulin refusals. A cognitively intact resident with DM2, stroke, heart disease, HF, neuropathy, and chronic pain refused sliding scale Humalog multiple times across morning, midday, and evening doses, but there was no documentation that the MD or NP was informed during those months. The first note about the refusals appeared later in an NP entry stating the resident's blood sugars were over 200 and the resident was very noncompliant with medications.
A resident with an open surgical wound had a wound vacuum and tubing observed on the floor, and a foam dressing was found on the back of the hand without an order or documentation of a skin issue. Another resident with chronic constipation and frequent PRN opioid use had missing bowel movement documentation and little evidence that ordered laxatives were given. A third resident with an NG tube had limited monitoring documentation, including no verification of placement, equipment function, or skin checks, despite the tube being connected to suction and showing dark brown flecks in the tubing.
Failure to arrange optometry care for a resident who wanted in-facility eye services. The resident, who had multiple chronic conditions and was cognitively intact, said she needed to see the eye doctor for another cataract surgery after a prior surgery earlier in the year. Although a signed consent showed she wanted optometry care, the SSD was unaware of the need, did not follow up after the consent, and the resident was not seen when the optometrist visited the facility.
Failure to provide appropriate foot care occurred for a resident with DM, diabetic neuropathy, stroke, heart disease, HTN, HF, chronic pain, MDD, migraines, and a history of thrombosis. The resident was cognitively intact, had signed consent for podiatry care, and stated she wanted podiatry services at admission, but she had not been seen by a podiatrist since admission. The SSD said the resident was on the list to be seen, but the facility’s usual podiatrist was out of the country and the replacement provider was behind on visits.
Failure to offer psych services for a resident with depression: A resident with a femur fracture and documented depression reported feeling depressed and wanting to talk to someone, but she was not on an antidepressant and had no psych services order. The MDS and care plan reflected mood symptoms, yet there was no SS note addressing the resident’s mood after the quarterly assessment, and the SS Director stated she would obtain a psych order when new mood issues were identified.
Medication Storage Not Secured: Two residents had medications and biologicals left unsecured in their rooms. An unopened insulin vial labeled for one resident was found on a nightstand even though she had dementia, needed substantial ADL assistance, and had no order for insulin or care plan allowing in-room storage. A bottle of castor oil was also left on another resident’s over-bed table while she was at dialysis; she said she used it for her hair only, and there was no care plan allowing OTC meds to be stored in her room.
Incomplete skin and meal intake documentation was identified for two residents. One resident with legal blindness and edema had a physician order for daily treatment of leg blisters, but the record did not document the blisters even though the ADON said she had been monitoring them. Another resident with rectal and liver cancer, a colostomy, and intestinal obstruction was NPO with an NG tube to suction, yet the task record documented meal intakes even though the DON stated the resident had not eaten since admission.
EBP Not Followed During Foley Catheter Care: Staff were observed providing high-contact care to a resident with an indwelling Foley catheter and emptying Foley drainage bags for two residents while wearing gloves but not an isolation gown. One resident had moderate cognitive impairment, a neurogenic bladder, and a care plan that included EBP; the other resident had a door sign indicating EBP was required. The DON stated the staff should have worn gowns during these tasks.
A resident with dementia and a history of falls experienced an unwitnessed fall resulting in a head bruise and hip/back soreness. Although the nurse assessed the resident and notified the Nurse Practitioner, the resident's responsible party was not informed until several hours later, contrary to facility policy requiring immediate notification after such incidents.
A resident with severe cognitive and physical impairments experienced multiple falls over a two-month period, resulting in injuries. Despite these incidents, the care plan was not updated to address the resident's recurrent falls from the wheelchair, and no new interventions were implemented as required by facility policy.
A resident with paraplegia and chronic conditions was discharged home without a complete discharge summary. Key sections, including medication reconciliation and oxygen therapy needs, were left blank. Although social services coordinated with home health, this was not documented. The DON acknowledged the oversight.
A resident was administered nystatin powder for skin irritation despite no documented skin conditions. The resident, dependent on staff for daily activities, had a physician's order for the antifungal powder to be applied every shift. Weekly skin assessments showed no abnormalities, and the ADON confirmed the lack of documentation and indicated the medication should have been prescribed as needed.
A resident with cognitive impairment and hearing difficulties did not receive necessary hearing aids as per physician's orders, leading to communication issues. Staff interviews revealed a lack of awareness and documentation regarding the resident's hearing aid use, and the facility had previously replaced lost hearing aids. The Director of Nursing was unsure why the order for hearing aids did not appear for documentation.
The facility failed to document food consumption for three residents with a history of weight loss. One resident experienced an 11.01% weight loss, another an 8.47% loss, and a third a 28.57% loss. Despite care plans requiring meal intake documentation and dietician alerts, numerous meals were undocumented. The DON and ADON confirmed that CNAs were expected to complete these logs.
The facility failed to administer oxygen at the correct flow rate for two residents. One resident, with a history of atrial fibrillation and dementia, was observed with an oxygen flow rate below the prescribed 2 liters per minute. Another resident, with conditions including hemiplegia and COPD, had varying flow rates above the prescribed 2 liters per minute. The discrepancies were acknowledged by the DON.
The facility failed to ensure proper assessments and Physician's Orders for residents to self-administer their medications. Four residents were found with medications at their bedside or in their possession without the necessary documentation and assessments. The DON confirmed the lack of orders and assessments for self-administration.
The facility failed to ensure a resident was sent to the hospital in a timely manner for leg pain and swelling, resulting in multiple fractures. Additionally, treatments for diabetic ulcers were not completed as ordered for another resident, and wound assessments were not documented for two other residents. The Director of Nursing confirmed that treatments should have been completed as ordered.
The facility failed to notify the Physician in a timely manner regarding a resident's increased pain and leg swelling. Despite signs of discomfort and a deformed leg, the LPN did not contact the NP immediately due to the resident's denial of pain and the NP's working hours. The delay led to a late diagnosis of multiple fractures.
A resident with a history of falling and cognitive impairment fell and hit their face in the shower after leaning in their shower chair. Despite the CNA's attempts to readjust the resident, the chair tipped over. The DON indicated that the CNA should have called for additional assistance.
Failure to Adequately Monitor and Intervene for Constipation
Penalty
Summary
The facility failed to ensure adequate monitoring and timely interventions for constipation in a resident with a history of hemiplegia, hemiparesis following a stroke, and epilepsy. The resident was identified as being at risk for constipation due to decreased mobility and medication side effects, with care plan interventions including daily bowel movement documentation, following the facility's bowel protocol, and monitoring for complications. Despite these interventions, the resident experienced a period of over five days without a documented bowel movement, during which time there were also complaints of nausea and abdominal pain. The facility's bowel protocol required interventions if a resident had not had a bowel movement in three days, but there was a delay in implementing effective treatment. During this period, the resident received docusate sodium and later Miralax, but bowel movements remained infrequent and ineffective. The resident's condition worsened, with increasing abdominal pain and continued inability to have a bowel movement, eventually requiring a Fleet enema and subsequent transfer to the hospital. Hospital evaluation revealed significant stool retention and proctitis. Documentation and interviews confirmed that the facility did not consistently follow its bowel management protocol or promptly escalate care as required by the resident's condition and care plan.
Incorrect Oxygen Flow Rate Administered
Penalty
Summary
A resident with diagnoses including chronic obstructive pulmonary disease, hypertension, and chronic cough was observed on two occasions receiving oxygen via nasal cannula at a flow rate of 4 liters per minute (lpm), despite a physician's order specifying continuous oxygen at 2 lpm. The resident, who was cognitively intact, confirmed she was supposed to be on 2 lpm of oxygen. Review of the resident's medical record corroborated the physician's order for 2 lpm. During an interview, an LPN acknowledged the resident should be on 2 lpm, observed the concentrator set at 4 lpm, and adjusted it to the correct flow rate. The facility failed to ensure the resident received the necessary care and treatment by not providing the ordered oxygen flow rate.
Dirty and Damaged Resident Areas
Penalty
Summary
The facility failed to ensure that residents’ environment was clean and in good repair in 2 of 2 units, the East Unit and the [NAME] Unit. During an environmental tour with the Maintenance Director and Housekeeping Director, surveyors observed dirty and sticky floors and a visibly dirty bed rail with a brown substance in one room on the East Unit. These observations were consistent with earlier observations made in the same room several days prior. On the [NAME] Unit, surveyors observed multiple rooms with environmental concerns including loose trim and baseboards, chipped paint on walls, torn floor mats, dirty floor tile along baseboards, stained privacy curtains, debris and food crumbs on the floor, marred room and bathroom doors, a rust stain in a sink, discoloration of floor tile, and ceiling vents with accumulated dust. In interviews, the Maintenance Director and Housekeeping Director indicated that all of the observed areas were in need of cleaning or repair.
Missing Order and Assessment for Self-Administered Eye Drops
Penalty
Summary
The facility failed to ensure a resident had physician's orders and a self-administration assessment for re-wetting eye drops. During observations on 8/4/25 and 8/5/25, a container with 4 bottles of re-wetting eye drops was seen on the resident's bedside table, including one bottle with an expiration date of 12/2017. The resident stated he used the eye drops regularly and independently. The resident's record showed diagnoses including chronic kidney disease, lymphoma, and glaucoma, and the 7/5/25 Quarterly MDS indicated moderate cognitive impairment and moderate assistance with ADLs. The record lacked a self-administration assessment and physician's orders for the eye drops, and the ADON stated that a self-administration assessment and physician's order should be completed for a resident to self-administer medications.
Failure to Notify Physician of Repeated Insulin Refusals
Penalty
Summary
The facility failed to promptly notify the resident's physician of multiple refusals of sliding scale insulin for Resident 4. The resident was admitted with diagnoses including stroke, heart disease, high blood pressure, type 2 diabetes, diabetic neuropathy, heart failure, chronic pain, low back pain, major depressive disorder, chronic migraines, and a history of thrombosis. The admission MDS dated 5/15/25 indicated the resident was cognitively intact for daily decision making and had received insulin in the last 7 days. The care plan revised on 5/28/25 noted the resident refused care such as repositioning, incontinent checks and changes, and skin assessments, and also identified diabetes mellitus with an approach to educate regarding medications and the importance of compliance. A physician's order dated 5/2/25 directed Humalog insulin by sliding scale three times daily. The 5/2025 MAR showed the resident refused insulin 7 times for the morning dose, 10 times for the midday dose, and 10 times for the evening dose, and the 6/2025 MAR showed refusals of 14 morning doses, 12 midday doses, and 13 evening doses. There was no documentation in May or June 2025 that the physician or NP was notified of the repeated refusals. The first documentation of medication refusals appeared in an NP note on 7/2/25, which stated the patient's blood sugars had been over 200 and that the patient was very noncompliant with medications. The DON later confirmed there was no documentation that the NP had been notified of the insulin refusals during those months, and the NP stated she was not aware the resident had been refusing insulin.
Failure to Manage Wound Vacuum, Constipation, and NG Tube Monitoring
Penalty
Summary
The facility failed to ensure a wound vacuum and tubing were kept off the floor and failed to provide treatment documentation for a non-pressure skin area for a resident with an open surgical wound to the left knee. Resident 90, who was cognitively intact and had diagnoses including history of falling, osteoporosis, depression, cirrhosis of the liver, skin infection, and a left knee laceration, was observed with a wound vacuum connected to the left knee bandage and the tubing on the floor. The resident was also observed with a pink foam bandage on the back of the right hand, but there was no physician order for that dressing and no documentation or assessment of a wound or skin issue to that area. The admission assessment noted scattered bruises on both arms, the tops of the hands, and the right leg, but there was no care plan for bruising or skin tears. The facility also failed to adequately address constipation for a resident who reported being constipated all the time and sometimes going longer than 3 days without a bowel movement. Resident 4 was cognitively intact, dependent on staff for toileting, always incontinent of bowel, and not on a bowel program. The resident had orders for PRN oxycodone, docusate sodium, and Miralax, and the MAR showed frequent oxycodone administration across multiple months, but docusate and Miralax were rarely or never given. The bowel and bladder elimination record documented multiple days with no bowel movement, and several dates were blank with no documentation. The DON stated staff had been made aware of the lack of bowel movements, but the bowel movement and laxative use were not documented. The facility failed to assess and monitor a resident with an NG tube for complications. Resident 11, who had diagnoses including rectal and liver cancer, colostomy, and intestinal obstruction, had an NG tube to low intermittent suction and was NPO. During observation, dark brown flecks were seen in the tubing and the suction canister was empty. The record showed only one documented NG output of 10 milliliters, with all other outputs recorded as zero, and it lacked documentation of verification of tube placement, equipment function, and skin inspection for medical device-related pressure injury. The record also lacked a care plan for the NG tube, and staff stated hospice managed the tube, although the DON later indicated nursing care for the NG tube should still have been in place.
Failure to Arrange Optometry Care
Penalty
Summary
Assist a resident in gaining access to vision and hearing services was deficient because the facility failed to ensure Resident 4 received routine eye care and was seen by an Optometrist. Resident 4, who was admitted with diagnoses including stroke, heart disease, high blood pressure, type 2 diabetes, diabetic neuropathy, heart failure, chronic pain, low back pain, major depressive disorder, chronic migraines, and a history of thrombosis, was cognitively intact for daily decision making and had adequate vision with no corrective lens on the admission MDS dated 5/15/25. During interview, the resident stated she needed to see the eye doctor for another cataract surgery after having the first one in 1/2025. A signed consent dated 5/5/25 indicated the resident wished to have optometry care at the facility, but the Social Service Director stated she was unaware the resident needed to see the eye doctor, did not follow up after the consent was signed, and the resident was not seen when the optometrist was at the facility on 6/12/25.
Failure to Provide Requested Podiatry Care
Penalty
Summary
Provide appropriate foot care was not ensured for 1 resident reviewed for foot care. The resident, who was admitted with diagnoses including stroke, heart disease, high blood pressure, type 2 diabetes, diabetic neuropathy, heart failure, chronic pain, low back pain, major depressive disorder, chronic migraines, and a history of thrombosis, was cognitively intact for daily decision making on the admission MDS. A signed consent indicated the resident wished to have podiatry care at the facility, and the resident stated she had told staff at admission that she wanted to see a podiatrist. However, the resident had not seen a podiatrist since admission. The Social Service Director stated the resident was on the list to be seen by the podiatrist and that the facility’s normal podiatrist was out of the country, with a different podiatrist being used and visits running behind. The Social Service Director also stated the last time a podiatrist was in the facility, the resident was not seen.
Failure to Offer Psychological Services for Resident With Depression
Penalty
Summary
The facility failed to ensure psychological services were offered for a resident who showed signs and symptoms of depression. During an interview, the resident stated she had some feelings of depression, was not receiving an antidepressant, and wanted to talk to somebody. She also reported that she told the Speech Therapist about her feelings but did not know whether nursing had been informed. The resident’s record showed diagnoses including a displaced comminuted fracture of the shaft of the left femur and depression. The admission MDS indicated no mood issues, but the quarterly MDS later documented moderate cognitive impairment and that the resident had little interest or pleasure in doing things and felt down, depressed, or hopeless during the assessment period. The care plan identified depression and noted she was not currently taking medications, with interventions to observe and report signs and symptoms of depression. However, there was no Social Service progress note addressing her mood after the quarterly MDS, and the August POS showed no antidepressant order and no order for psychological services. The Social Service Director stated that when new onset mood issues were identified, she would notify nursing, the NP, or physician and ask the resident if she wanted psych services, and she would get an order for psych services.
Medication Storage Not Secured
Penalty
Summary
The facility failed to store drugs and biologicals securely when an unopened multi-use vial of insulin labeled with Resident 42’s name was observed on the resident’s nightstand during multiple observations while the resident was in bed in her room. Resident 42’s record showed diagnoses including acute respiratory failure, heart disease, heart failure, dementia without behaviors, and high blood pressure, and the 6/20/25 MDS indicated she was not cognitively intact for daily decision making and needed substantial assistance with activities of daily living. There was no care plan allowing the resident to store medications in her room and no physician’s order for any type of insulin. The Nurse Trainer and DON stated the insulin should not have been on the nightstand and that the DON did not know where it came from. The facility also failed to secure over-the-counter medication when a bottle of castor oil was observed on Resident 3’s over-bed table while the resident was away at dialysis and remained there on later observation. Resident 3 stated she used the castor oil for her hair only and did not consume it. Her record showed diagnoses including stroke, heart disease, end stage renal disease, high blood pressure, heart failure, major depressive disorder, and dependence on renal dialysis, and the modified 6/18/25 Quarterly MDS indicated she was cognitively intact for daily decision making. There was no care plan allowing the resident to store over-the-counter medications in her room, and the Nurse Trainer stated the castor oil should be in a lock box or kept secured in the room.
Incomplete Skin and Meal Intake Documentation
Penalty
Summary
The facility failed to maintain clinical records that were complete and accurately documented for a resident with non-pressure skin conditions. Resident 67, who had diagnoses including legal blindness and edema and required substantial assistance with ADLs and transfers, had a 7/30/25 physician order to cleanse both legs and apply Xeroform, ABDs, and Kerlix one time a day for blisters. During observation, the resident’s legs were wrapped in gauze, and the resident stated there had been blisters on her legs but was not sure whether they were still present. On a later treatment observation, a small dark circular discoloration was seen on the left shin, and the ADON stated it used to be a blister. The record lacked documentation of the resident having blisters on her legs, and the ADON stated she had been monitoring the blisters but had not been documenting it. The facility also inaccurately documented meal consumption for a hospice resident who was NPO. Resident 11, who had diagnoses including rectal and liver cancer, colostomy, and intestinal obstruction, had an NG tube to low intermittent suction and an order for nothing by mouth. The care plan stated the resident was NPO except ice chips and small sips of water. However, the task record documented meal intakes on multiple dates even though the DON stated the resident had not eaten since prior to admission and that meal consumptions should not have been documented because the resident did not eat.
EBP Not Followed During Foley Catheter Care
Penalty
Summary
The facility failed to ensure infection control practices were followed for residents requiring enhanced barrier precautions (EBP). During a random observation on 8/5/25 at 9:15 a.m., an Occupational Therapy Assistant assisted Resident 5 with a toilet transfer while wearing gloves but not an isolation gown. Resident 5 had an indwelling Foley catheter. During another observation on 8/6/25 at 1:11 p.m., a CNA drained Resident 5's Foley catheter leg bag while wearing gloves but not an isolation gown. Resident 5's record showed diagnoses including a displaced comminuted fracture of the left femur and neuromuscular dysfunction of the bladder, with a quarterly MDS dated 6/30/25 indicating moderate cognitive impairment and an indwelling catheter. The care plan identified the resident as having a Foley catheter related to neurogenic bladder and being at risk for infection, with interventions including EBP. The physician's order dated 7/16/25 indicated an 18 French 30 cc indwelling Foley catheter. During the same observation on 8/6/25 at 1:11 p.m., a CNA was also observed emptying Resident 56's Foley catheter drainage bag attached to her leg while wearing gloves but not an isolation gown. A sign on the resident's door indicated she required EBP. The DON stated in interview on 8/7/25 at 3:10 p.m. that the CNA had recently finished training and should have worn a gown while emptying the Foley catheter bag, and therapy staff should have worn a gown while assisting Resident 5 in the bathroom.
Delayed Notification to Responsible Party After Resident Fall
Penalty
Summary
The facility failed to ensure timely notification of a responsible party following an unwitnessed fall involving a resident with multiple medical conditions, including a history of falls, dementia, and impaired mobility. The resident was found on the floor by a CNA, assessed as alert and oriented, and noted to have a bruise and bump on the head, as well as complaints of soreness in the left hip and back. Although the nurse left a message for the Nurse Practitioner and administered pain medication, the resident's son was not notified of the incident until several hours later. The resident's medical record indicated severe impairment in daily decision-making and required significant assistance with activities of daily living. The facility's policy required immediate notification of the resident, physician, and resident representative in the event of an accident resulting in injury with potential for physician intervention. Interviews with the Executive Director and DON confirmed the delay in notification, with the nurse focusing on neurological assessments and not immediately contacting the resident's son.
Failure to Update Fall Interventions After Multiple Resident Falls
Penalty
Summary
The facility failed to update fall prevention interventions for a resident with a history of multiple falls. The resident, who had diagnoses including dementia, COPD, hypertension, stroke, and hemiplegia, was assessed as severely impaired in daily decision-making and required substantial to maximum assistance with bed mobility, transfers, and toileting. The care plan identified the resident as being at risk for falls and included interventions such as assistance with ADLs, a mattress on the floor, and keeping the call light within reach. Despite these measures, the resident experienced four falls over a two-month period, with documented injuries including bumps and abrasions to the head and elbow. After each fall, there was no documentation indicating that the care plan was reviewed or revised to address the resident's recurrent falls from the wheelchair or to implement additional interventions related to wheelchair use or positioning. The facility's fall management policy required the interdisciplinary team to review and revise the care plan after each fall event, but this was not done. The Executive Director confirmed that the care plan had not been updated following the resident's repeated falls.
Incomplete Discharge Summary for Resident Requiring Home Health Services
Penalty
Summary
The facility failed to complete a discharge summary for a resident, identified as Resident B, who was discharged home and required home health services. The resident's record review revealed that the Discharge Summary Information assessment was incomplete, with several critical sections left blank. These included the reason for discharge, the reconciliation of pre-discharge and post-discharge medications, the recapitulation of the resident's stay, and the consent from the patient or patient representative. Additionally, the discharge summary did not address the resident's need for continuous oxygen therapy, which was a significant oversight given the resident's medical condition. Resident B had multiple diagnoses, including paraplegia, chronic kidney disease stage 3, and high blood pressure, and was dependent on staff for various activities of daily living. The resident was discharged by ambulance, and although social services had communicated with the home health company to ensure the resident had the necessary equipment and support at home, this was not documented in the discharge summary. The Director of Nursing acknowledged that the discharge summary should have been completed and should have included information about the resident's oxygen therapy.
Unnecessary Antifungal Medication Administered
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, a scheduled antifungal powder, nystatin, was administered to a resident with no documented skin conditions. The resident, who was cognitively intact but dependent on staff for daily activities, had a physician's order for nystatin powder to be applied to skin folds every shift for skin irritation. However, weekly skin assessments conducted over several weeks showed no skin abnormalities, and there was no documentation supporting the need for the antifungal treatment. During an interview, the Assistant Director of Nursing acknowledged the lack of documentation and indicated that the nystatin powder should have been prescribed on an as-needed basis for any new skin conditions.
Failure to Administer and Document Hearing Aid Use for Resident
Penalty
Summary
The facility failed to ensure that a resident received the necessary assistive devices for hearing, as the resident's hearing aids were not administered according to the physician's order. Resident 4, who was cognitively impaired and had a history of coronary artery disease, heart failure, and hypertension, was observed without hearing aids on multiple occasions. The resident was noted to have difficulty hearing and frequently said 'huh' when others were speaking. The care plan indicated that the resident required assistance with hearing aids, which were to be put in during the morning and removed at night, with documentation of these actions. However, there was no documentation in the Medication Administration Record and Treatment Administration Record regarding the hearing aid order. Interviews with staff revealed a lack of awareness and adherence to the hearing aid protocol. A CNA was unaware if the resident wore hearing aids, and an LPN could not locate the hearing aids in the medication cart, indicating they might be lost. The LPN mentioned that the resident sometimes removed the hearing aids and misplaced them, and staff were supposed to manage and document their use daily. The Director of Nursing was unsure why the order for hearing aids did not appear for documentation purposes and acknowledged that the facility had previously replaced the resident's hearing aids due to loss. The deficiency was identified as a failure to ensure the resident's hearing aids were managed and documented as per the physician's order.
Failure to Document Food Consumption for Residents with Weight Loss
Penalty
Summary
The facility failed to ensure that food consumption logs were completed for residents with a history of weight loss, affecting three residents. Resident 59, who was cognitively impaired and required substantial assistance with eating, experienced an 11.01% weight loss over several months. Despite a care plan that required alerting the dietician and recording food intake at each meal, numerous meal consumption logs were missing documentation for breakfast, lunch, and dinner over a 30-day period. The Director of Nursing confirmed that CNAs were expected to document meal consumption percentages in the computer system. Resident 14, also cognitively impaired, experienced an 8.47% weight loss. The care plan required recording food intake at each meal, but several meals were not documented over a period of weeks. Similarly, Resident 42, who was severely impaired for daily decision-making and required assistance with eating, experienced a 28.57% weight loss in three months. The care plan required recording food intake and alerting the dietician when supplements were not consumed, yet multiple meals were not documented. The Assistant Director of Nursing acknowledged that the food consumption logs should have been completed for these 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 who were reviewed for oxygen use. Resident 42 was observed multiple times with an oxygen flow rate set under 2 liters per minute, despite a physician's order indicating it should be continuously administered at 2 liters per minute for hypoxia. The resident's medical history included atrial fibrillation, dementia, depression, muscle weakness, adult failure to thrive, anxiety, and a left shoulder fracture. The resident required supervision or assistance with daily activities and was severely impaired in decision-making. Similarly, Resident 48 was observed with varying oxygen flow rates of 3.5 liters and 2.5 liters per minute, while the physician's order specified a continuous flow of 2 liters per minute for shortness of breath. This resident's medical history included hemiplegia, heart failure, stroke, diabetes, hypertension, and chronic obstructive pulmonary disease. The resident was cognitively intact for decision-making but had impairments on one side of the body and used a wheelchair. The discrepancies in oxygen administration were noted, and the Director of Nursing acknowledged the need for correction.
Failure to Ensure Proper Self-Administration of Medications
Penalty
Summary
The facility failed to ensure residents had an assessment and Physician's Orders to self-administer their own medications for four residents. Resident C was observed with Bacitracin ointment and eye drops at her bedside without a self-administration assessment or Physician's Order for the Bacitracin ointment. The resident was confused and not oriented to time and place, and the eye drops were out of her reach. The Director of Nursing (DON) indicated that the resident's son might have brought the eye drops, but the Bacitracin ointment should not have been left at the bedside. Resident F was found with a medication cup containing a Melatonin tablet on his over bed table, which he had requested but not taken. The resident had no self-administration assessment or Physician's Order to self-administer his medications. The DON was aware of the medication cups and the pill but confirmed that there was no order or assessment for self-administration. Resident G was observed with a bottle of eye drops on her over bed table, which she administered to herself every evening. There was no Physician's Order or self-administration assessment for the eye drops. Resident H was found with a medication cup containing three white pills, which she identified as her water pills. Although her care plan included orders for self-administration of certain medications, there was no order or assessment for her daily medications. The DON confirmed the lack of orders and assessments for self-administration for these residents.
Failure to Provide Timely Hospital Transfer and Complete Wound Care
Penalty
Summary
The facility failed to ensure a resident was sent to the hospital in a timely manner, related to complaints of increased pain and leg swelling. Resident D, who had a history of falling, metabolic encephalopathy, and osteomyelitis, was cognitively impaired and dependent on staff for mobility. Despite multiple complaints of leg pain and visible deformities, the resident was not sent to the hospital until the following day, resulting in a diagnosis of multiple fractures and osteoporosis. The LPN did not call the Nurse Practitioner (NP) immediately due to the resident's denial of pain and the NP's posted hours, leading to a delay in appropriate care. The facility also failed to ensure treatments were completed for diabetic ulcers and an assessment was completed for new non-pressure wounds. Resident B, who had multiple severe diagnoses including stroke, sepsis, and type 2 diabetes, had diabetic ulcers that were not treated as ordered. The Treatment Administration Record (TAR) indicated missed treatments, and there was no documentation to support that treatments were completed on the previous shift. The Wound Nurse confirmed that treatments should have been completed as ordered by the doctor. Additionally, Resident C and Resident F had issues with wound care. Resident C, who had contusions and osteoarthritis, was observed with dried blood and open areas on her toes, but there was no wound assessment documented. Resident F, who had osteomyelitis and a diabetic foot ulcer, had a necrotic area on the left foot that was not treated as ordered. The Physical Therapist (PT) only treated the left heel and not the necrotic area between the toes. The Director of Nursing confirmed that treatments were to be done as ordered by the physician.
Failure to Notify Physician of Resident's Increased Pain and Leg Swelling
Penalty
Summary
The facility failed to ensure timely notification of the resident's Physician regarding increased pain and leg swelling for Resident D. The resident, who had a history of falling, metabolic encephalopathy, and osteomyelitis, was cognitively impaired and dependent on staff for mobility. On 3/14/24, a CNA observed the resident's right leg with bruising and a stage one area, and the Nurse Practitioner (NP) was notified. The NP assessed the resident and ordered a pillow to be placed between the resident's legs. Later that evening, the resident appeared to be in pain, but the LPN did not notify the NP because it was after her working hours, and the resident denied pain despite showing signs of discomfort. The next morning, the resident's left leg appeared deformed, and the NP was notified, leading to an x-ray and subsequent diagnosis of multiple fractures and osteoporosis. The Director of Nursing indicated that the Physician should have been contacted earlier when the resident showed signs of pain and leg swelling, regardless of the NP's working hours. The facility's investigation revealed that the LPN noticed the resident's left leg looked different during wound care but did not contact the NP immediately due to the resident's denial of pain and the NP's posted working hours. The following morning, the resident's leg condition worsened, prompting the LPN to notify the NP, who then ordered an x-ray. The delay in notifying the Physician resulted in a late diagnosis of the resident's fractures. The Director of Nursing confirmed that staff should have contacted the Physician or herself for guidance when the resident first showed signs of increased pain and leg swelling.
Inadequate Supervision During Shower Leads to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision for a resident who was leaning in their shower chair, leading to an accident. The resident, who had a history of falling, metabolic encephalopathy, and osteomyelitis, was cognitively impaired and dependent on staff for mobility and transfers. During a shower, the resident was leaning in the shower chair, and despite the CNA's attempts to readjust them, the chair tipped over, causing the resident to fall and hit their face. The resident sustained a bump on the left side of their forehead and required a three-person assist to be placed back in their wheelchair before being transported to the hospital for evaluation. The Director of Nursing (DON) indicated that the CNA should have pulled the emergency call light and waited for additional assistance. The incident was documented in the facility's fall investigation, and the CNA provided a statement confirming the events. The DON noted that the resident did not typically lean in the shower chair during baths, suggesting that the CNA's response to the situation was inadequate, leading to the resident's fall and injury.
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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 Michigan City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aperion Care Arbors Michigan City | 1.8 mi | ★★★★★ | 23 | 1 |
| Addison Pointe Health & Rehabilitation Center | 9 mi | ★★★★★ | 15 | 0 |
| Chesterton Manor | 9.4 mi | ★★★★★ | 0 | 0 |
| Ignite Medical Resort Chesterton | 9.9 mi | ★★★★★ | 27 | 0 |
| Brickyard Healthcare - Terrace Care Center | 11 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.