Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oak Grove Christian Retirement Village during CMS and state inspections, most recent first.
A resident with dementia, osteoporosis, impaired lower extremity function, and dependence for bed mobility was care planned and documented on the Kardex as requiring two-person assistance for bed mobility. An agency CNA, unaware of this requirement, performed incontinence care and rolled the resident in bed alone, during which the resident’s arm extended to the opposite side and the resident began sliding off the bed, resulting in a fall to the floor that the CNA partially controlled.
The facility failed to provide required medically-related social services follow-up after an abuse allegation by a resident with dementia, Alzheimer's disease, and anxiety. The resident reported that a CNA shoved her into a chair and threw her walker, and although no injuries were observed, a subsequent care plan documented a history of false allegations and called for Social Service involvement. However, there was no Social Service follow-up to monitor the resident’s psychosocial status, despite an abuse policy requiring increased monitoring and support after an allegation and the absence of a clear post–abuse allegation procedure while a staff member was filling in for the Social Service Director.
A resident with a history of stroke and vascular dementia had a UA obtained and sent to the lab without a Physician/NP order. An RN documented collecting the urine specimen and notifying the lab, and later stated that the DON had requested the UA and that the NP was notified. The resident was catheterized to obtain the urine sample. The DON reported she had only suggested they might want a UA and assumed the RN would obtain an NP order, but no such order was present in the record, resulting in lab services being performed without proper authorization.
A resident with dementia and Alzheimer’s disease reported that a CNA shoved her into a chair and threw her walker, with no injuries observed. Although this allegation was reported to the state health department, there was no documentation of the abuse allegation in the resident’s medical record, despite facility policy requiring that actions taken be documented. At the time of the allegation, a staff member was filling in for the Social Service Director.
A resident with COPD, heart failure, dementia, and other conditions, who was on oxygen therapy, developed a cough and later received a new order for albuterol nebulizer treatments twice daily for the cough. The medical record lacked documentation that the resident’s representative was informed of this change in condition and new medication order. In interview, an LPN confirmed she did not document any communication with the representative, and the DON stated that such communication and documentation should have occurred.
A resident with COPD and other comorbidities, who was on oxygen and cognitively impaired, developed a cough that led an LPN to contact a physician and obtain an order for albuterol nebulizer treatments twice daily. Although the treatments were administered as scheduled, the record contained no documentation of the respiratory assessment that prompted the new order and no pre- and post-treatment respiratory assessments, despite facility policy requiring baseline vital signs and respiratory assessments for nebulizer use. The LPN acknowledged not documenting her assessment, and the DON confirmed that required pre- and post-assessments were not found in the record.
A resident with Alzheimer's disease, heart failure, and hypertensive chronic kidney disease did not receive prescribed metoprolol as ordered. The medication was held on several occasions when blood pressure and heart rate were within the parameters for administration, or when no vital signs were recorded to justify withholding the dose. The DON could not provide further information regarding these decisions.
Two residents with cardiac and respiratory conditions did not receive necessary care and treatment related to oxygen therapy, including failures to monitor oxygen saturation, ensure oxygen tanks were filled, and document respiratory assessments as required by physician orders and facility policy.
The facility did not maintain complete and accurate clinical records for two residents, resulting in missing documentation for the administration of prescribed medications, oxygen therapy, and respiratory treatments. The MARs lacked entries for several scheduled doses and interventions, and the DON was unable to provide additional documentation to account for these omissions.
Two residents suffered serious injuries after staff failed to follow established care plans and safety protocols. One resident, dependent for transfers, was manually lifted by a CNA without using the required mechanical lift, resulting in leg and rib fractures. Another high fall-risk resident was left unattended in the bathroom and fell, sustaining a head laceration requiring staples.
A resident who returned from the ER with a fractured tibia and multiple rib fractures did not receive thorough or frequent nursing assessments as required. Documentation lacked detailed evaluation of the injuries, and follow-up assessments were not completed, despite ongoing pain and changes in condition. The DON confirmed that expected monitoring and documentation were missing.
The facility failed to ensure a sanitary kitchen environment due to inadequate dishwasher temperature monitoring. Observations revealed that the dishwasher's wash cycle temperature was below the required 180 degrees Fahrenheit, and the temperature logs showed frequent non-compliance with the required standards. The facility's policy on recording water temperatures before each meal was not consistently followed, potentially affecting all 52 residents receiving meals from the Main Kitchen.
A facility failed to maintain accurate documentation and accountability for narcotic medications, affecting a resident on a routine pain regimen. Discrepancies were found in the narcotic sign-out sheet, with missing doses and altered entries. An LPN reported the irregularities, leading to an investigation that revealed further documentation issues by a nurse who did not record administered medications in the MAR. The facility could not determine who was responsible for the missing medications.
A facility failed to notify a resident's Responsible Party in writing about a hospital transfer. The resident, with conditions like heart failure and diabetes, was significantly impaired in decision-making. Despite standard procedures, the State-approved transfer form was not completed, and the Responsible Party was not informed. Interviews confirmed the oversight.
A facility failed to provide a resident and their Responsible Party with the bed hold policy before and upon hospital transfer. The resident, with conditions including heart failure and diabetes, was significantly impaired in decision-making. Despite procedures to send the policy with the resident, documentation was missing, and the DON could not locate it.
A facility failed to update a resident's care plan to reflect the discontinuation of IV fluids. The resident, with a history of serious medical conditions, was observed without IV supplies and confirmed not receiving IV fluids since returning from the hospital. Despite this, the care plan still indicated a need for IV fluids, and there were no physician's orders for such treatment. The DON acknowledged the need for care plan modification.
A facility failed to establish parameters for physician notification regarding weight changes for a resident with CHF, diabetes, and fluid overload. The resident was weighed thrice weekly, but the physician's order lacked specific guidelines for notifying weight changes. The DON later received orders to notify the nurse practitioner if there was a five-pound increase in a week.
A facility failed to provide proper wound care for a resident with pressure ulcers, as the Wound Care Nurse did not follow hand hygiene protocols and was unaware of the daily treatment changes required by the physician's orders. The resident, who had multiple health issues and required assistance for mobility, did not receive the necessary treatment to promote healing, as the nurse did not adhere to the specified wound care regimen.
A resident with a history of infection had their urinary catheter bag improperly placed, uncovered, and hanging off a garbage can, contrary to care plan instructions. The resident, who was moderately cognitively impaired and required significant assistance, had a care plan that included specific catheter care instructions. Despite this, the catheter bag was not maintained properly, as observed by staff.
The facility failed to implement non-pharmacological interventions before administering anti-anxiety medication to a resident with Alzheimer's and depression, as documented in their medication administration record. Additionally, another resident with dementia and depression was not monitored for side effects of prescribed antidepressants, despite the care plan indicating a risk for adverse effects. The Director of Nursing confirmed the lack of documentation and monitoring, which is inconsistent with the facility's policy.
A facility failed to ensure complete and accurate clinical records for a resident's self-medication assessment. The resident, with moderate cognitive impairment and multiple medical conditions, was permitted to self-administer medication. However, the evaluation form lacked the resident's name, as the ADON mistakenly wrote her own name instead.
A Wound Care Nurse failed to follow infection control guidelines during a wound treatment for a resident, neglecting to perform hand hygiene and change gloves between tasks. The nurse also did not sanitize hands after reaching into her pocket during the procedure. The nurse later acknowledged the lapse in protocol, and the facility administrator could not provide further information or a policy.
The facility failed to provide proper respiratory care for three residents, leading to deficiencies in oxygen equipment maintenance and administration. A resident with COPD had outdated respiratory equipment, while another resident's oxygen concentrator was set at an incorrect flow rate. A third resident also had outdated equipment, contrary to facility policy requiring weekly changes.
The facility failed to document oxygen administration and saturation levels for two residents with COPD and cognitive impairments. Resident B's records lacked documentation for specific shifts in July, despite a care plan requiring saturation checks every shift. Similarly, Resident C's records were incomplete for a specific shift. The DON confirmed the missing documentation, which violated the facility's policy on oxygen administration.
The facility failed to report an allegation of abuse/neglect to the Administrator and IDOH for a resident with reddened skin after spilling hot coffee. Despite the Responsible Party's accusation of neglect, the DON did not conduct an investigation or report the incident, violating the facility's abuse policy.
The facility failed to provide adequate supervision and follow care plan interventions, resulting in a fall for one resident and a hot coffee spill for another. Resident D, with dementia, was left alone in her room and fell, hitting her head. Resident C, with Alzheimer's, was served hot coffee in her room, leading to a spill and skin redness. Staff interviews confirmed that care plan interventions were not followed.
The facility failed to ensure a resident received necessary treatment and services after a fall. The resident, with Alzheimer's and fractures, was lowered to the floor during a transfer. Initial assessments were incomplete, and no further assessments were done until the next morning, revealing significant injuries. The DON confirmed that post-fall assessments should have been conducted for 72 hours, but this was not done.
Failure to Follow Two-Person Bed Mobility Care Plan Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow a care-planned intervention requiring two staff members for bed mobility assistance, which resulted in a resident falling from the bed. The resident had diagnoses including dementia and osteoporosis, a moderately impaired cognitive status, impairment to one side of the lower extremities, and was documented as dependent for bed mobility with use of a pressure-reducing device. The resident’s Kardexes dated 7/7/25 and 3/22/26, as well as a care plan revised on 1/28/26, all indicated that two staff members were required for bed mobility. On the date of the incident, a post-fall evaluation and fall investigation documented that an agency CNA performed incontinence care and bed mobility alone, without a second staff member, contrary to the resident’s care plan and Kardex. The CNA rolled the resident toward herself while standing on one side of the bed; during this maneuver, the resident’s arm extended to the opposite side and the resident began sliding off the bed. The CNA then moved around the bed and was able to lower the resident to the floor. The CNA later reported being unaware that the resident required two-person assistance for bed mobility, despite this requirement being documented on the Kardex.
Failure to Provide Social Services Follow-Up After Abuse Allegation
Penalty
Summary
The facility failed to provide medically-related social services following an allegation of abuse for one resident. Resident D, who had dementia, Alzheimer's disease, moderately impaired cognition, and documented anxiety with fixation on staff, reported that a CNA had shoved her into a chair and thrown her walker; no injuries were observed. A care plan dated 8/29/25 identified anxiety and fixation on staff, with interventions for staff to assist the resident in developing more appropriate coping and interaction methods. After the abuse allegation was reported to the Indiana Department of Health on 2/3/26, a new care plan dated 2/4/26 documented that the resident had a history of making false allegations and exaggerations of the truth and specified that Social Service would be involved with the resident. Despite this care plan intervention, there was no documented Social Service follow-up after the allegation to monitor the resident’s psychosocial status. During interview, the Executive Director stated that at the time of the allegation a staff member was filling in for the Social Service Director and acknowledged there was no policy outlining procedures for post–abuse allegation care. The facility’s abuse policy indicated that after an allegation was voiced, the resident would receive increased monitoring and support, but this was not carried out through Social Service follow-up for Resident D.
Unauthorized Urinalysis Performed Without Practitioner Order
Penalty
Summary
The facility failed to ensure laboratory services were only completed when ordered by a Physician or NP, as evidenced by a urinalysis (UA) obtained for Resident B without a corresponding practitioner order. Resident B, who had diagnoses including stroke and vascular dementia, had a urine specimen collected and the lab company notified, as documented in a progress note dated 3/23/26 at 11:35 a.m. by RN 1. Record review showed there was no Physician/NP order for this urine specimen. In interview, RN 1 stated that the DON had requested the UA and that she notified the NP, and that the resident was catheterized to obtain the urine sample. In a separate interview, the DON reported she had only verbalized that they “may want to get a UA,” had not directly instructed RN 1 to obtain one, and had assumed RN 1 would notify the NP to obtain an order, resulting in the UA being performed without a valid practitioner order. This deficiency was cited under 410 IAC 16.2-3.1-49(f)(1).
Failure to Document Resident Abuse Allegation in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident related to an allegation of abuse. Record review on 4/14/26 showed that Resident D, who had diagnoses including dementia and Alzheimer’s disease, had made a reported allegation on 2/3/26 that a CNA shoved her into a chair and threw her walker; no injuries were observed. This allegation was documented in an Indiana Department of Health reported incident form, but there was no corresponding documentation of the abuse allegation in the resident’s medical record. During interview, the Executive Director indicated that at the time of the allegation a staff member was filling in for the Social Service Director. The facility’s abuse policy dated 7/15/25 stated that actions taken would be documented, but this documentation was absent from the resident’s record.
Failure to Notify Resident Representative of Change in Condition and New Breathing Treatment
Penalty
Summary
The facility failed to ensure a resident’s representative was informed of a change in condition and new treatment order. A cognitively impaired resident with diagnoses including COPD, heart failure, hypertension, dementia, atrial fibrillation, and depression, and who was receiving oxygen therapy, was noted in a progress note on 12/21/25 at 6:22 a.m. to have slept well overnight, with staff noticing a cough and clear lung sounds. Later that day at 10:07 p.m., a progress note documented a physician’s order for albuterol sulfate nebulization twice daily for cough until 12/27/25, indicating a change in the resident’s condition and treatment. Record review showed no documentation that the resident’s representative was informed of this change in condition or the new breathing medication order. During interview, the LPN acknowledged she did not document that she spoke with the resident’s representative about the change in condition and new medication, and the DON stated the nurse should have documented that she spoke with the family regarding the change in condition and medication change.
Failure to Document Respiratory Assessments for Nebulizer Treatments
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not documenting a respiratory assessment when a resident experienced a change in condition and by not completing required pre- and post-nebulizer assessments. The resident had multiple diagnoses including COPD, heart failure, hypertension, dementia, atrial fibrillation, and depression, and was receiving oxygen therapy. A quarterly MDS indicated the resident was cognitively impaired. On one date, a progress note documented that the resident appeared to sleep well but staff noticed a cough, with lungs described as clear. Later that same day, a physician’s order was obtained to start albuterol sulfate nebulizer treatments twice daily for cough for a specified period, and the MAR showed the medication was administered as ordered. Despite the initiation and ongoing administration of nebulizer treatments, the clinical record lacked documentation of the respiratory assessment that led to the new breathing treatment order, as well as any pre- and post-respiratory assessments for each nebulizer treatment. In an interview, an LPN stated that a CNA had reported the resident’s cough, that she performed a respiratory assessment, and then contacted the physician who ordered the nebulizer, but she acknowledged she did not document her assessment and that pre- and post-assessments should have been completed. The DON confirmed that the nurse should have documented the respiratory assessment supporting the start of nebulizer therapy and that staff should have completed and documented pre- and post-assessments with each treatment, but she was unable to find any such documentation. The facility’s nebulizer policy required obtaining vital signs and performing respiratory assessments to establish a baseline.
Failure to Administer Medication as Ordered
Penalty
Summary
A deficiency was identified when a resident with diagnoses including Alzheimer's disease, heart failure, and hypertensive chronic kidney disease did not receive medication as ordered. The resident's care plan required administration of metoprolol tartrate 25 mg twice daily, with instructions to check blood pressure (BP) before administration and to hold the medication if BP was less than 100/50 or heart rate was less than 60. Review of the Medication Administration Records (MAR) for June, July, and August showed that the medication was held on several occasions when the resident's BP and heart rate were within the parameters to administer, or when no vital signs were recorded to justify holding the dose. Specifically, the medication was withheld on multiple dates despite recorded BP and heart rate readings that did not meet the criteria for holding the medication, and in some instances, there was no documentation of vital signs to support the decision to withhold. During an interview, the Director of Nursing was unable to provide further information regarding the rationale for holding the medication when the parameters were not met. This failure to administer medication as ordered constituted a deficiency in following physician orders and the resident's care plan.
Failure to Ensure Safe and Appropriate Respiratory Care and Oxygen Monitoring
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required oxygen therapy. For one resident with diagnoses including heart failure and chronic pulmonary edema, there were multiple incidents where the resident's portable oxygen tank was found empty, both in the morning and at dinner time, resulting in low oxygen saturation levels. Documentation did not show that a respiratory assessment was completed after the resident was found without oxygen, and there was a lack of consistent monitoring and documentation of oxygen saturation. The resident experienced episodes of respiratory distress and was ultimately sent to the hospital after her oxygen saturation dropped significantly despite interventions. Another resident with heart failure and atrial fibrillation was observed receiving continuous oxygen therapy via nasal cannula, although the physician's order specified oxygen as needed for shortness of breath to maintain saturation above 90%. The medication administration record did not indicate that oxygen had been administered as needed, and the last documented oxygen saturation was several days prior, showing the resident was on room air. There was no ongoing documentation of oxygen saturation monitoring as required by the physician's order and facility policy. Facility policy required that oxygen be administered per physician order, with initial and ongoing assessment and documentation of the resident's condition and response to therapy. The policy also required staff to check portable oxygen tanks for sufficient supply and to regularly monitor tanks while in use. These requirements were not consistently met, as evidenced by the lack of respiratory assessments, insufficient monitoring of oxygen saturation, and failure to ensure oxygen tanks were adequately filled for residents requiring oxygen therapy.
Incomplete Documentation of Medication and Oxygen Administration
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents regarding the documentation of medications and oxygen administration. For one resident with diagnoses including heart failure, chronic pulmonary edema, and hypertension, the medical record review revealed missing documentation for the administration of BiPAP, oxygen therapy, and several prescribed medications on specific dates and times. The resident's care plan required continuous oxygen and BiPAP use at bedtime and during naps, with instructions to chart refusals, but the Medication Administration Records (MARs) lacked entries for these interventions. The Director of Nursing was unable to provide any additional documentation to account for the missing records. Another resident, diagnosed with Alzheimer's disease, COPD, and chronic respiratory failure with hypoxia, also had incomplete MARs. The records showed that prescribed inhalers and nebulizer treatments were not documented as administered on several occasions. The care plan required administration of aerosol or bronchodilators as ordered, but the MARs for June and July were missing entries for specific medications at scheduled times. The Director of Nursing confirmed that no further information was available to explain the missing documentation.
Failure to Prevent Accidents Due to Inadequate Supervision and Noncompliance with Care Plans
Penalty
Summary
The facility failed to ensure that residents were protected from accident hazards and received adequate supervision to prevent accidents. In one incident, a CNA transferred a dependent resident with a history of traumatic brain injury, cognitive deficit, and peripheral vascular disease from bed to a chair without using the required mechanical lift and without the assistance of a second staff member, as specified in the resident's care plan. The CNA manually lifted the resident, resulting in the resident sustaining a nondisplaced spiral fracture of the right tibia and multiple left lower rib fractures. Documentation and staff statements confirmed that the mechanical lift was not used, and the transfer was not performed according to the resident's plan of care. Another incident involved a resident with a history of stroke, osteoporosis, severe cognitive impairment, and a high risk for falls. The resident required moderate to maximum assistance for transfers and was identified as a fall risk. While being assisted in the bathroom, the CNA left the resident unattended to retrieve socks, during which time the resident attempted to self-toilet and fell, resulting in a head laceration that required staples. The care plan and CNA care card indicated that the resident should not be left alone due to the high risk of falls, but this protocol was not followed at the time of the incident. Both incidents demonstrate a failure to follow established care plans and safety protocols for residents with significant physical and cognitive impairments. The lack of adherence to transfer and supervision requirements directly led to serious injuries, including fractures and a head laceration, for two residents who were dependent on staff for safe mobility and toileting.
Failure to Assess and Monitor Resident After Return with Fractures
Penalty
Summary
A resident with a history of peripheral vascular disease, traumatic brain injury, and cognitive deficit sustained a spiral fracture of the right tibia and multiple fractured ribs following a facility incident. Upon returning from the emergency room, the resident was assisted to bed with an immobilizer on the right lower leg and complained of pain. Documentation shows that while the immobilizer was noted to be in place, there was no thorough assessment of the right leg or the resident's overall status at that time. No nursing assessments were completed the following day, and subsequent notes focused on pain management without detailed evaluation of the injuries. Further documentation revealed that the resident experienced pain and distress, with pain medication being adjusted accordingly. Edema of the lower extremities was later observed, but again, no comprehensive assessment of the fractured leg or ribs was documented. The Director of Nursing confirmed that follow-up assessments were expected but not found in the records. The facility's acute condition change policy required monitoring and documentation of the resident's progress and response to treatment, which was not consistently followed in this case.
Dishwasher Temperature Monitoring Deficiency
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment due to issues with the dishwasher temperatures not reaching the required levels and a lack of consistent temperature monitoring for a high-temperature dish machine. During an initial kitchen tour, it was observed that the dishwasher's wash cycle temperature was only 105 degrees Fahrenheit, whereas it should have been 180 degrees. The rinse cycle was recorded at 191 degrees, but the Dietary Manager was unsure of the correct temperature for this cycle. A review of the Dish Machine Temperature Log for October 2024 revealed several instances where the recorded temperatures did not meet the required standards, with wash temperatures frequently falling below the necessary 160 degrees. Additionally, there were gaps in the temperature recordings for breakfast, lunch, and dinner throughout the month. The facility's policy on dishwasher temperatures mandates that water temperatures be measured and recorded before each meal or after the dishwasher is emptied or refilled for cleaning. However, this policy was not consistently followed, as evidenced by the incomplete temperature logs and the failure to maintain the required wash temperatures. This deficiency had the potential to affect all 52 residents who received meals from the Main Kitchen.
Deficiency in Narcotic Medication Documentation and Accountability
Penalty
Summary
The facility failed to maintain an accurate system for accounting, reconciling, and ensuring the disposition of controlled drugs, specifically narcotic medications, for one of the residents reviewed. This deficiency was identified during a review of Resident 211's records, who was cognitively intact and on a routine pain medication regimen that included opioids. The issue arose when discrepancies were found in the documentation of narcotic medications, with missing doses and altered narcotic count sheets. The investigation revealed that the narcotic sign-out sheet had been tampered with, using whiteout to conceal previous entries, and new documentation was written over it. The irregularities were first noticed by an LPN who reported them to the Director of Nursing (DON). Further investigation by the facility's administrator uncovered discrepancies in the Medication Administration Records (MAR) and narcotic count sheets, particularly involving a nurse who failed to document administered medications in the MAR. This nurse was also frequently responsible for administering as-needed narcotics. Despite the audits and investigation, the facility could not conclusively determine who was responsible for the missing medications or the alterations on the narcotic count sheet. The Director of Nursing admitted to not conducting any audits on narcotic medications prior to the incident.
Failure to Notify Resident's Responsible Party of Hospital Transfer
Penalty
Summary
The facility failed to ensure proper notification procedures were followed for a resident's transfer to the hospital. Resident 15, who had diagnoses including heart failure, diabetes mellitus, and fluid overload, was significantly impaired in daily decision-making. The resident was sent to the hospital and returned to the facility, but there was no documentation indicating that the State-approved transfer form was completed or that the resident's Responsible Party received written notification of the transfer. Interviews with RN 4 and the Director of Nursing revealed that while certain documents were typically sent with residents, the required State-approved transfer form could not be located.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to ensure that a resident and their Responsible Party were provided with the facility's bed hold and reserve bed payment policy before and upon transfer to the hospital. This deficiency was identified for one of the two residents reviewed for hospitalization. The resident in question had diagnoses including heart failure, diabetes mellitus, and fluid overload, and was significantly impaired in daily decision-making. The resident was transferred to the hospital and later returned to the facility, but there was no documentation indicating that the bed hold policy was completed and sent with the resident or that the Responsible Party received written notification of the policy. Interviews with facility staff revealed that while the procedure was to send the bed hold policy with the resident, the Director of Nursing was unable to locate the policy documentation.
Failure to Update Care Plan for IV Fluids
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised to reflect changes in the treatment of a resident, specifically regarding the administration of IV fluids. Resident D, who has a medical history including malignant neoplasm of the kidney, urinary tract infection, pathological fracture, bone cancer, paraplegia, and neuromuscular dysfunction of the bladder, was observed without IV supplies or equipment in her room. The resident confirmed that she had not received IV fluids since returning from the hospital. Despite this, her care plan, dated 9/14/24, indicated a need for IV fluids due to dehydration, with interventions such as administering IV fluids and monitoring the IV site. However, there were no physician's orders for IV fluids, and the Director of Nursing acknowledged that the care plan required modification.
Lack of Weight Monitoring Parameters for Resident with CHF
Penalty
Summary
The facility failed to establish parameters for physician notification concerning weight monitoring for a resident with congestive heart failure, diabetes mellitus, and fluid overload. The resident was significantly impaired in daily decision-making, as indicated by the Quarterly Minimum Data Set assessment. A physician's order required the resident to be weighed every Monday, Wednesday, and Friday due to congestive heart failure, but did not specify when to notify the physician of weight changes. The resident's Fluid Maintenance Care Plan highlighted the risk of fluid volume overload and included interventions such as monitoring electrolytes and assessing for edema. However, it lacked specific parameters for weight change notification. During an interview, the Director of Nursing acknowledged the absence of these parameters and noted that orders were later received to notify the nurse practitioner if there was a five-pound increase in a week.
Failure to Follow Wound Care Protocols for a Resident with Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate wound care for a resident with pressure ulcers, as evidenced by the observation of the Wound Care Nurse not following proper hand hygiene protocols and not adhering to the physician's orders for wound treatment. During the wound care observation, the nurse did not perform hand hygiene between glove changes and used a marker from her pocket without changing gloves, which could compromise the sterility of the wound care process. Additionally, the nurse was unaware of the daily treatment changes required by the physician's orders, indicating a lack of communication or understanding of the current treatment plan. The resident in question had multiple diagnoses, including cellulitis, acute kidney failure, and heart failure, and was significantly impaired in daily decision-making, requiring staff assistance for transfers and bed mobility. The physician's orders specified the application of medical-grade honey gel and bordered gauze on specific days, but the wound care progress report indicated a need for daily treatment changes. The discrepancy between the physician's orders and the nurse's actions highlights a failure to ensure the resident received the necessary treatment and services to promote healing of the pressure ulcers.
Improper Catheter Care for Resident
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling urinary catheter, leading to a deficiency. On two separate occasions, the resident's catheter bag was observed uncovered and hanging off the top of a garbage can, with the bag touching the top and side of the can, which contained trash. This was noted during observations on the same day, first at 10:37 a.m. and later at 3:15 p.m., with the Assistant Director of Nursing confirming the improper placement of the catheter bag. The resident, identified as having a history of infection, was moderately cognitively impaired and required substantial assistance with daily activities. The care plan for the resident included catheter care with specific instructions to keep the catheter bag covered and below the waist, and to ensure the tubing did not touch the floor. Despite these orders, the catheter bag was not maintained according to the care plan, as evidenced by its placement on the garbage can. The resident had a recent history of a urinary tract infection, for which they were prescribed an antibiotic, Cipro, indicating the potential for infection was a known risk.
Failure to Implement Non-Pharmacological Interventions and Monitor Medication Side Effects
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted prior to administering anti-anxiety medication to Resident 37, who had diagnoses including Alzheimer's dementia and depression. The resident's medication administration record indicated that alprazolam was given on multiple occasions without documentation of non-pharmacological interventions being attempted, except for two instances. The Director of Nursing confirmed the lack of documentation for the remaining days, which is contrary to the facility's policy requiring such interventions before administering psychotropic drugs. Additionally, the facility did not monitor Resident 48 for side effects of antidepressant medications, despite the resident's diagnoses of unspecified dementia and depression. The resident was prescribed sertraline and buproprion, and the care plan indicated a risk for adverse effects from these medications. However, there was no physician's order or documentation in the resident's record to indicate monitoring for side effects, which the Director of Nursing acknowledged should occur every shift. This oversight is inconsistent with the facility's policy that mandates monitoring for side effects and documenting the resident's response to psychotropic medications.
Incomplete Clinical Records for Self-Medication Assessment
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented, specifically regarding a self-medication administration assessment for a resident. The deficiency involved Resident 23, who had a range of medical conditions including repeated falls, hemiplegia due to a stroke, aphasia, hypertension, and right foot drop. The resident's Quarterly Minimum Data Set (MDS) assessment indicated moderate cognitive impairment and a need for assistance with daily activities. A physician's order allowed the resident to self-administer Econazole nitrate powder topically. However, the Self-Administration of Medication Evaluation form, dated the same day as the physician's order, did not include the resident's name. During an interview, the Assistant Director of Nursing (ADON) admitted to mistakenly writing her own name on the form instead of the resident's.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to adhere to infection control guidelines during a wound treatment procedure for a resident. The Wound Care Nurse was observed performing wound care on a resident's right heel, ankle, and lower leg without following proper hand hygiene and glove use protocols. After removing the old dressings, the nurse changed gloves without performing hand hygiene. She continued to clean each wound without changing gloves or sanitizing her hands between each wound care task. Additionally, the nurse reached into her pocket to retrieve a marker, wrote on a foam dressing, and continued the procedure without changing gloves or sanitizing her hands. During an interview, the Wound Care Nurse acknowledged that she should have performed hand hygiene between glove changes and should have changed gloves after reaching into her pocket. The facility administrator was unable to provide further information or a corresponding policy when requested. This incident highlights a deficiency in the facility's infection prevention and control practices, specifically regarding hand hygiene and glove use during wound care procedures.
Deficiencies in Respiratory Care for Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, resulting in deficiencies related to the maintenance and administration of oxygen therapy. Resident B was observed with outdated respiratory equipment, including a humidification bottle and nebulizer mask dated 10/6/24, despite physician orders requiring weekly changes. Resident B, diagnosed with heart failure, respiratory failure, and COPD, was moderately cognitively impaired and dependent on supplemental oxygen. LPN 1 confirmed the equipment was outdated and should have been changed. Resident C, who had diagnoses including cancer, hypertension, depression, and COPD, was observed with an oxygen concentrator set at an incorrect flow rate of 2 to 2.5 liters, contrary to the physician's order of 3 liters continuously. The ADON confirmed the incorrect setting. Resident D, with diagnoses such as malignant neoplasm of the kidney and paraplegia, was found with an outdated water bottle in her oxygen concentrator, also dated 10/6/24. LPN 1 acknowledged the bottle should have been changed weekly. The facility's policy required weekly changes of oxygen equipment, which was not adhered to in these cases.
Incomplete Documentation of Oxygen Administration for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate documentation of medical records related to oxygen administration and saturation levels for two residents. Resident B, who had diagnoses including COPD, hypertension, and dementia, was cognitively impaired and received oxygen therapy. The care plan required checking oxygen saturation every shift. However, documentation was missing for specific dates and shifts in July 2024, where the oxygen administration and saturation levels were not recorded. The Director of Nursing confirmed the lack of documentation during an interview. Similarly, Resident C, with diagnoses including COPD, diabetes mellitus, hypertension, and dementia, was moderately cognitively impaired and also received oxygen therapy. The care plan required continuous oxygen administration, but documentation was missing for a specific date and shift in July 2024. The Director of Nursing was unable to provide further information regarding the missing documentation. The facility's policy on oxygen administration required staff to document the initial and ongoing assessment of the resident's condition and response to oxygen therapy, which was not adhered to in these cases.
Failure to Report Allegation of Abuse/Neglect
Penalty
Summary
The facility failed to report an allegation of abuse/neglect to the Administrator and the Indiana Department of Health (IDOH) for a resident with an allegation of abuse/neglect voiced by a family member. The resident, who had diagnoses including Alzheimer's disease, dementia, and diabetes mellitus, was found with reddened skin on the upper abdomen and underneath the left breast after spilling hot coffee. The incident was reported to the Responsible Party, who accused the facility of willful and criminal neglect. However, the Director of Nursing (DON) did not conduct an investigation or report the allegation to the Administrator or IDOH, as required by the facility's abuse policy. The incident was documented in the Nurse's Progress Notes, and the Responsible Party was informed after multiple attempts to reach them. Despite the Responsible Party's accusation of neglect, the DON did not observe any redness when she checked the resident and did not consider it necessary to report the allegation. The facility's abuse policy mandates that all allegations of abuse, neglect, and exploitation be reported immediately to the Administrator and relevant authorities, but this protocol was not followed in this case.
Failure to Provide Adequate Supervision and Follow Care Plan Interventions
Penalty
Summary
The facility failed to ensure adequate supervision and adherence to care plan interventions, resulting in two separate incidents involving residents. Resident D, who has dementia and is dependent on assistance for mobility, was left alone in her room while in a wheelchair, contrary to her care plan. This led to a fall where she hit her head, resulting in a laceration that required two staples. The incident occurred because the resident forgot to lock her wheelchair brakes and attempted to reach for a TV remote, causing her to slide out of the wheelchair. Staff interviews confirmed that the resident was left alone, and the care plan intervention to not leave her alone in her room was not followed. Resident C, who has Alzheimer's disease and dementia, was served hot coffee in her room despite a care plan intervention that prohibited hot drinks in her room or with meals. This led to the resident spilling the hot coffee on herself, causing reddened and tender skin on her upper abdomen and underneath her left breast. The incident was documented by an Agency LPN, and subsequent notes indicated that the redness and tenderness subsided with cold compresses. Interviews with the Director of Nursing and Assistant Director of Nursing confirmed that staff had access to the care plan, which included the intervention against serving hot drinks in the resident's room.
Failure to Conduct Timely Post-Fall Assessments
Penalty
Summary
The facility failed to ensure a resident received the necessary treatment and services after a fall. Resident B, who had diagnoses including Alzheimer's disease and fractures in the left knee and right ankle, was assisted by an Agency CNA during a transfer and was lowered to the floor in the bathroom. The initial assessment noted no injuries, and vital signs were within normal limits. However, the after-fall assessment was not thorough, lacking significant findings and actual vital signs. No further assessments were completed until the following morning, when significant swelling, bruising, and deformity were observed in the resident's right ankle, leading to a hospital transfer and diagnosis of a right tibia/fibula fracture. The Director of Nursing (DON) confirmed that post-fall assessments should have been conducted for 72 hours following the fall, but no assessments were documented until the morning after the incident. The facility's policy required observation for delayed complications for approximately 48 hours post-fall, with documentation of any signs or symptoms. The failure to conduct timely and thorough assessments after the fall resulted in a delay in identifying the resident's injuries and providing appropriate care.
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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 Demotte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aperion Care Demotte | 1.3 mi | — | 26 | 0 |
| Cedar Creek Health Campus | 12.4 mi | — | 0 | 0 |
| Lowell Healthcare | 12.9 mi | — | 21 | 0 |
| Crown Point Health Campus | 14.3 mi | — | 23 | 0 |
| Ignite Medical Resort Crown Point Llc | 15.5 mi | — | 37 | 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 August 2026) and official state health department websites.