Crown Point Health Suites

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide information to residents and their representatives on their rights related to filing grievances for 10 of 10 confidential residents. The facility failed to ensure 10 of 10 confidential residents were provided, through postings in prominent locations, the Grievance Procedure. The facility failed to provide information in regards to who the facility Grievance Officer was and their contact information. The facility failed to educate residents on how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in facility 1 of 1 kitchen reviewed for food safety. 1) The facility failed to ensure food items in the refrigerator (x1), and freezer (x1), were labeled and stored in accordance with the professional standards for food service. 2) The facility failed to ensure the iced tea machine's outer surface was free from dirt and stains. 3) The facility failed to ensure the refrigerator and freezer outer handle surface were free from greasy stains. 4) The facility failed to ensure the faucets were free from corrosion. These failures could place residents at risk for food-borne illness and cross contamination.

Inspectors wroteBased on interviews and record reviews, the facility failed to coordinate assessments resident Pre-admission Screening and Resident Review (PASARR) to avoid duplicate test and effort for 1 of 24 residents (Resident #1) reviewed for PASARR screening, in that: Resident #1 did not have an accurate and updated PASRR Level 1 assessment reflecting a diagnosis of mental illness. These failures could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to immediately notify, consistent with his or her authority, the resident representative(s) when there was a change in the residents physical, mental, or psychosocial status for 1 of 5 residents (Residents #1) reviewed for notification of changes. The facility failed to notify the resident representative for Resident #1 regarding a fall on 09/29/25. This failure could affect the residents by causing their representatives to be unaware of changes in a Resident's condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals were stored in locked compartments and permit only authorized personnel to have access to the keys for 1 of 5 (Resident #1) residents in that: 1. MA failed to ensure medications for Resident #1 were secured when she left Resident #1's medications in a cup on the bedside table unattended. This failure could place residents at risk for harm and result in drug diversion due to medications not being properly secured.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for elopement. The facility failed to ensure Resident #1 who was exit seeking on the night of 04/14/25 around 11:00 PM and the morning of 04/15/25 before 8 AM and then eloped (via motorized w/c) from the facility to a local church (.17 miles) the afternoon of 04/15/25 at 2:20 PM. Staff were unaware of Resident #1's elopements when the facility was notified by a Community Member via telephone on 04/15/25 at 2:39 PM that the resident was at a church. An Immediate Jeopardy (IJ) was identified on 5/08/25 at 4:53 PM. The IJ template was provided to the facility on 5/08/24 at 6:38 PM and approved on 05/09/25 at 9:55 AM. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality and the facility failed to protect and promote the rights of the resident for 3 of 19 residents (Resident #18, Resident #136, and Resident #145) reviewed for resident rights in that: 1. CNA D and CNA E provided peri care for Resident #18 and failed to close the blinds. 2. The facility failed to provide a privacy cover for Resident #136's urinary catheter bag. 3. CNA A failed to provide full privacy while assisting Resident #145 to the toilet. These failures could place residents at risk for diminished quality of life and loss of dignity and self-worth.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that each resident has a right to personal privacy and confidentiality of his or her personal medical records for 14 of 14 resident was reviewed for privacy (Resident #25 and 12 residents listed in the 24-hour report book, Resident#7, #8, #10, #11, #15, #36, #44, #56, #58, #186, #187, #188). 1. CNA F failed to protect residents personal care information by leaving the 24-hour report book open on a table in the hallway on Emerald Hall. 2. MA B failed to protect Resident #25 name and medication information by writing the resident's information on a sticky note and dropping it in the living area on Emerald Hall. These failures could place residents at risk of having medical information personal, or care instructions exposed to others and misuse of personal information. Findings Included: Resident #25: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 4 of 4 kitchens (Kitchen A, Kitchen B, Kitchen C, and Kitchen D) reviewed for dietary services. 1) The facility failed to keep drawer and oven handles clean in Kitchen A. 2) The facility failed to keep refrigerator and freezer handles clean in Kitchen A and Kitchen C. 3) The facility failed to keep the microwave clean in Kitchen B. 4) The facility failed to properly store food refrigerator and freezer in Kitchen A and Kitchen B. 5) The facility failed to keep the ice machines clean in Kitchen A and Kitchen D. 6) The facility failed to properly store plates and bowls in Kitchen A and Kitchen C. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of communicable diseases for 6 of 16 residents (Resident #12, Resident #13, Resident #52, Resident #65, Resident #145, and Resident #299) and 7 of 7 staff (RN A, LVN B, CNA A, CNA B, CNA C, and MA A, reviewed for infection control. 1. LVN B failed to follow policy and procedure for handwashing while providing wound care for Resident #12. 2. RN A failed to follow policy and procedure for handwashing while providing wound care for Resident #13. 3. MA A failed to sanitize hands between residents during medication administration for Resident #65 and Resident #52. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder or had a urinary catheter received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 5 Residents (Resident #136) reviewed for incontinence care in that: The facility failed to position Resident #136's catheter tubing in a manner to prevent infections. This failure had the potential to affect residents by placing them at an increased risk of urinary tract infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly for 1 of 4 medication carts (Ruby House medication cart), reviewed for medication storage. The medication cart assigned to [NAME] House contained a loose pill. This failure could place residents at risk of not receiving prescribed medications as ordered and place the facility at risk of drug diversions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to be treated with respect and dignity for one of six resident (Resident #1). The facility failed to ensure staff did not go through and/or remover Resident #1's personal possessions without the resident's permission. This failure could place residents at risk of feeling disrespected, having reduced dignity and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to personal privacy, including the right to receive unopened mail and other letters, packages and other materials delivered to the facility for 1 (Resident #1) of six resident reviewed for privacy. Facility staff opened a package mailed to the facility addressed to Resident #1 without the consent or presence of the resident. This failure could place residents at risk of feeling disrespected, having reduced dignity and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable and sanitary environment to help prevent the development and transmission of communicable diseases for 3 of 3 (Residents #1, #2, #3) and 4 of 5 staff (CNA A, CNA B,CNA D, CNA E ) reviewed for infection control. 1. CNA A failed to change gloves and sanitize hands during and after providing incontinent care for Resident #1. CNA A failed to wear proper PPE when providing care for Resident #1 who was on Enhanced Barrier Precautions. 2. CNA B failed to wear proper PPE when providing care for Resident #1 who was on Enhanced Barrier Precautions. 3. CNA D failed to sanitize hands between glove changes during incontinent care for Resident # 2. 4. CNA E failed to change gloves and sanitize hands during incontinent care for Resident #3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 4 of 16 residents (Resident #21, #49, #56, and #349) reviewed for Respiratory Care. The facility failed to follow MD orders for initial and dating oxygen supplies for Resident #21, #49, #56, and #349. This deficient practice has the potential to affect residents by placing them at an increased risk of respiratory compromise, infections, pneumonia, respiratory distress, and sepsis.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder or had a urinary catheter received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 Residents (Resident #1) reviewed for incontinent care, in that: 1. CNA B failed to properly clean the groin area and right and left buttock area while providing perineal care for Resident #1., leaving urine on the skin of Resident #1. This failure could affect residents by placing them at increased risk of exposure to communicable diseases, spread of infections, and skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 of 4 medication carts (med cart on Diamond Hall for rooms 414-429), The facility failed to ensure that medication carts were secured when unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm, drug overdose, or drug diversions.