Crown Point Health Campus

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure infection control measures were in place and implemented related to correct isolation precautions in place for a resident on contact isolation, contracted staff not following enhanced barrier precautions during care and staff not cleaning a shared blood pressure cuff between residents. (Resident 6, phlebotomist and RN 1)

Inspectors wroteBased on observation, record review, and interview, the facility failed to keep the kitchen clean and in good repair related to dirty fans, trash cans, floors, and baseboards for 1 of 1 kitchen. (The Main Kitchen) The facility also failed to ensure a microwave and a refrigerator on 2 of 4 units were clean. (The Memory Care Unit and Independence Hall)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a self-administration of medication assessment was complete and a physician's order to self-administer medication was in place, for 1 of 1 resident reviewed for self-administration of medication. (Resident 127)

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) comprehensive assessment was accurately completed related to a Wanderguard alarm (wearable device that alarms when approaching a restricted area) not documented for a resident with history of wandering for 1 of 23 MDS assessments reviewed. (Resident 30)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the current care plan was implemented related to documentation of food intake for 1 of 6 residents reviewed for nutrition and documentation of urinary catheter output for 2 of 3 residents reviewed for catheters. (Residents 32, 62 and 80)

Inspectors wroteBased on record review and interview, the facility failed to ensure ADL (activities of daily living) care was provided to a dependent resident related to lack of documentation of incontinence care for 1 of 1 resident reviewed for ADL care. (Resident 4)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure compression wraps were used for 1 of 1 resident with edema. The facility also failed to ensure physician's orders were in place for a biliary drain (abdominal drain inserted into the liver to assist with bile duct blockage) and the drain was monitored for 1 of 3 residents reviewed for catheters. (Residents 89 and 6)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident with a colostomy (opening in the colon that lets stools pass from the body) received appropriate treatment and services related to a lack of documentation of completed colostomy bag changes and stoma care for 1 of 1 resident reviewed for ostomies. (Resident 1)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure G-tube (gastrostomy tube, a tube inserted directly into the stomach) flushes were instilled via gravity for 1 of 9 residents observed for medication administration. (Resident 9)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure clinical records were complete and accurately documented related to clarification orders for diet and assistive devices for 1 of 6 residents reviewed for nutrition. The facility also failed to ensure urinary catheter care was accurately documented for 1 of 3 residents reviewed for catheters. (Residents 41 and 6)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's family/Responsible Party was notified for a new medication order, for 1 of 3 residents reviewed for family/Responsible Party notification. (Resident O)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure adequate supervision was in place to prevent elopement of a resident with diagnoses of dementia and bipolar in a manic state with psychotic features. The resident had indicators of being an elopement risk and behaviors of wanting to exit the facility. The facility was unaware of the resident's where abouts and the resident was found by a Good Samaritan standing in the road, approximately 0.15 miles from the facility, on a highly traveled road. The resident was returned to the facility by the Good Samaritan. (Resident E) The Immediate Jeopardy began on 6/24/25, when the facility was unaware the resident had exited the facility without supervision. The resident walked independently and was found standing on the road that runs in front of the facility at approximately 4:50 a.m. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents received necessary care and services, related to, treatments to surgical sites were not completed, glucometer monitoring (blood sugar checks) were not completed and orders not clarified for the glucometer monitoring, a thorough admission assessment was not completed, a elopement risk assessment was not completed accurately, insulin was not administered as ordered, and bruising un unknown cause was not investigated and monitored, for 4 of 12 residents reviewed for quality of care. (Residents D, E, F, and M)

Inspectors wroteBased on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act related to an allegation of physical and sexual abuse for 1 of 1 resident reviewed for abuse. (Resident E)

Inspectors wroteBased on observations, record review, and interview, the facility failed to ensure a resident's tube feeding was infusing at the correct flow rate for 1 of 3 residents reviewed for feeding tube usage. (Resident H)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a PICC (peripherally inserted central catheter) line had physician's orders for the care and monitoring and the dressing was changed once weekly for 1 of 1 resident reviewed for PICC line care. (Resident D)

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were stored properly for 2 of 2 medication carts observed. (B wing medication cart and C wing medication cart)

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were complete and accurately documented related to an elopement incident and antibiotic administration for 2 of 24 residents reviewed for medical record documentation. (Residents E and D)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection control practices were in place related to hand hygiene during medication pass for 3 random medication pass observations. (LPN 1 and LPN 3, Residents Z, X and Y)

Inspectors wroteBased on observation, record review, and interview, the facility failed to notify the physician and the resident that a medication was unavailable for 1 of 3 residents reviewed for medications. (Resident E)

Inspectors wroteBased on record review and interview, the facility failed to document incontinence care for a resident who was dependent on staff for activities of daily living (ADLs) for 1 of 4 residents who were reviewed for ADLs. (Resident B)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice related to a medication not administered as ordered by the physician for 1 of 3 residents reviewed for quality of care. (Resident F)

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide supplements as ordered and document nutritional intake for meals for residents with weight loss for 2 of 3 residents reviewed for nutrition. (Residents D and H)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was provided with routine medications in a timely manner by the contracted pharmacy, related to medications not available to be administered as ordered by a physician for 1 of 3 residents reviewed for medications. (Resident F)

Inspectors wroteBased on record review and interview, the facility failed to ensure the residents' medical records included documentation the resident or resident representative was provided education on the benefits and potential risk associated with the COVID-19 vaccination and documentation why the vaccine was not administered for 4 of 5 residents reviewed for COVID-19 vaccinations. (Residents 53, B, 201, and 300)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents were assessed to self-administer medication and had a physician's order to self-administer medication for 2 of 2 residents observed self-administering medications. (Residents 41 and 201)

Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive care plan was developed and in place for residents with significant weight loss for 2 of 24 care plans reviewed. (Residents 75 and 85)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure care plans were updated for 1 of 24 resident care plans reviewed. (Resident 7)

Inspectors wroteBased on record review and interview, the facility failed to document incontinence care for a resident who was dependent on staff for activities of daily living (ADLs) for 1 of 7 residents who were reviewed for ADLs. (Resident C)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure physician's orders were followed for non-pressure skin condition treatments and non-pressure skin areas were assessed and monitored for 2 of 5 residents reviewed for skin conditions, non-pressure related. (Residents 1 and 16).

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents with pressure ulcers received the necessary treatment and services to promote healing related to weekly wound assessments not completed and a physician's treatment order not updated for 2 of 2 residents reviewed for pressure ulcers. (Residents D and 4)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure an order for a palmar guard and a resting hand splint device was followed and in place for a resident with a right hand contracture for 1 of 1 resident reviewed for range of motion. (Resident 42)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure fall precautions were in place for a resident with a history of falls for 1 of 5 residents reviewed for accidents. (Resident 34)

Inspectors wroteBased on record review and interview, the facility failed to ensure urinary output was recorded and the physician was notified for low urinary output as ordered for 1 of 1 resident reviewed for urinary catheters. (Resident 37)

Inspectors wroteBased on record review and interview, the facility failed to monitor weekly weights and document nutritional intake for fluids, meals, and supplements as ordered for residents with significant weight loss for 3 of 3 residents reviewed for nutrition. (Residents 75, 85 and C)

Inspectors wroteBased on record review and interview, the facility failed to provide proper feeding tube (gastrostomy tube) (g-tube) care as per professional standards, related to a lack of documentation of tube feeding administration for a resident with a history of weight loss for 1 of 2 residents reviewed for tube feeding. (Resident 47)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents received the necessary care and treatment related to incorrect oxygen flow rates and not monitoring an oxygen level for 2 of 3 residents reviewed for respiratory care. (Residents 75 and 74)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure routine and emergency drugs were received in a timely manner and procedures for accurate dispensing were provided for 2 of 2 residents reviewed for pharmacy services. (Residents 32 and 77)

Inspectors wroteBased on record review and interview, the facility failed to ensure non-pharmacological interventions were attempted prior to giving narcotic pain medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 75)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure infection control guidelines were in place and implemented related to improper personal protective equipment (PPE) worn in an isolation room and lack of signage in place for a room on contact isolation. (Residents D and B)

Inspectors wroteBased on observation and interview, the facility failed to ensure a controlled substance was double locked at all times for 1 of 2 medication rooms observed (Grace Point). This had the potential to affect the residents on Grace Point who had the ability to access the storage room.

Inspectors wroteBased on record review and interview, the facility failed to notify a resident's physician and responsible party in a timely manner related to abnormal laboratory results for 1 of 3 residents reviewed for change in condition (Resident F).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident received the necessary care and services related to a lack of orders or monitoring in place for a neck collar, a delay in treatment after notification of critical laboratory results, medications not administered as ordered by the Physician, lack of assessment or monitoring of a new skin condition, and labs not completed as ordered by the Physician for 2 of 3 residents reviewed for change of condition. (Residents M and F)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure an x-ray was completed as ordered by the Physician in a timely manner for 1 of 3 residents reviewed for change in condition. (Resident M)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's privacy was respected, related to RN 2 using her private cell phone to take pictures of bruising on the left arm and left breast of a cognitively impaired resident (Resident B) without the approval of the resident's Responsible Party, for 1 of 1 resident reviewed for privacy. See F609 for additional information regarding Resident B.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure an injury of unknown source was immediately reported to the Administrator/Abuse Coordinator and the Indiana Department of Health (IDOH) and failed to ensure the injury was investigated/assessed thoroughly for 1 of 3 residents reviewed for injuries and abuse. (Resident B)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident who required respiratory care received care consistent with profession standards and was administered oxygen as ordered by the physician, for 1 of 1 resident reviewed for respiratory care. (Resident E)

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide a safe and sanitary environment to help prevent the potential of transmission of communicable diseases and infections, related to glucometers (blood sugar monitor) used for multiple residents not sanitized before and after each resident use (RN 8) and failed to sanitize an oximeter (oxygen saturation monitor) used for multiple residents after it was used on a resident. (Resident B, LPN 4) This had the potential to affect the 26 residents in the facility who receive glucometer testing and the 25 residents who reside on [NAME] C Hall. The facility also failed to ensure staff were educated on Enhanced Barrier Precautions (EBP), ensure staff were aware of which residents were on EBP, and correct Personal Protective Equipment (PPE) was used by staff members (CNA 5, CNA 6, CNA 7). [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to notify a resident's physician and responsible party in a timely manner, related to a gastrostomy (g-tube, feeding tube) mechanical malfunction requiring hospital intervention, which resulted in medications and flushes not being given as ordered for 1 of 3 residents reviewed for physician and family notifications. (Resident B) See F693 for additional information on Resident B.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents who were dependent on staff for activities of daily living (ADL's) received bathing/showers at least twice a week for 2 of 3 dependent residents who were reviewed for ADL's. (Residents B and H)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident received the necessary care and services related to medications not administered as ordered by the Physician, for 2 of 15 residents reviewed for quality of care. (Residents B and D)

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide proper feeding tube (gastrostomy tube) (g-tube) care as per professional standards, related to water flushes not completed as ordered, verification of the g-tube placement not completed prior to medication administration, failure to flush the g-tube after each medication was administered, a liquid feeding bag not labeled, dated or timed, and a piston syringe (used for water flushing and other care for the g-tube) not changed daily, for 2 of 3 residents reviewed for feeding tube care. (Residents B and J) See F580 for additional information on Resident B

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident who required nebulizer breathing treatments was assessed prior to, during, and/or after the treatment for effectiveness of the treatment, lung sounds, pulse, oxygen status, and blood pressure status for 1 of 1 resident reviewed for oxygen therapy. (Resident B)

Inspectors wroteBased on record review and interview, the facility failed to ensure dependent residents received the necessary ADL (activities of daily living) care, related to lack of documentation of incontinence care for 3 of 4 residents reviewed for ADL care. (Residents F, G, and H)

Inspectors wroteBased on record review, and interview, the facility failed to ensure physician's orders were followed related to an incorrect amount of enteral feeding documented and incomplete meal consumption logs for residents with a history of weight loss for 3 of 4 residents reviewed for nutrition. (Residents F, G, and H)

Inspectors wroteBased on observation and interview, the facility failed to ensure food was stored under sanitary conditions, related to unlabeled and undated food and beverages, and a scoop stored in the dry food storage bin, for 2 of 4 refrigerators reviewed (Main Kitchen), as well as unlabeled and undated staff beverages in 1 of 2 unit refrigerators (Grace Point 2 Unit) observed. This had the potential to affect 103 residents who received food from the kitchen.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents had Physician's Orders for medications and an assessment to self-administer their own medications, for 2 of 2 residents reviewed for self-administration of medication. (Residents 35 and 101)

Inspectors wroteBased on interview, the facility failed to ensure a resident's right to privacy, related to facility staff opening a resident's personal mail, for 1 of 1 residents reviewed for residents' rights. (Resident 35).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure dependent residents received the necessary ADL (activities of daily living) care, related to unshaven facial hair, lack of incontinence care, and long fingernails, for 3 of 3 residents reviewed for ADL care. (Residents 17, B, and 27)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received the necessary care and treatment, related to compression stockings not in place as ordered, a non-pressure skin treatment not completed as ordered, and a fall assessment not completed, for 1 of 1 residents reviewed for edema, 1 of 2 residents reviewed for non-pressure skin conditions, and 1 of 1 resident reviewed for falls. (Residents 64, 52 & 27)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure pressure ulcer care was provided as ordered and a pressure ulcer was correctly assessed, for 2 of 4 residents reviewed for pressure ulcers. (Residents 49 and B)

Inspectors wroteBased on observation, record review, and interview, the facility failed to complete meal consumption logs for a resident with a history of weight loss, for 1 of 1 resident reviewed for nutrition. (Resident 78)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection control practices and standards were maintained, related to staff touching pills during medication administration, for 2 of 5 residents observed during the medication administration observation, and lack of hand hygiene during wound care, for 1 of 4 residents reviewed for pressure ulcers. (Residents 67, 47, and 27)

Inspectors wroteBased on observation and record review, the facility failed to ensure agency staff were provided adequate orientation to the facility and residents care needs, related to Agency CNA 1 delivering a meal tray to a resident who was NPO (nothing by mouth), for a random observation on the 200 C hall. This had the potential to affect 3 residents residing in the facility who were NPO.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident who required minimal assistance with showers received bathing at least twice a week, for 1 of 1 resident who required minimal assistance with bathing. (Resident BB)

Inspectors wroteBased on record review and interview, the facility failed to ensure residents who required extensive to dependent assistance for activities of daily living (ADL's), received bathing/showers at least twice a week, for 2 of 2 residents who require extensive to dependent assistance for ADL's. (Residents DD and EE)

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received medical records within 48 hours of request for 2 of 3 residents reviewed for medical record requests. (Residents H and J)