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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 Spring Mill Health Campus during CMS and state inspections, most recent first.
A resident receiving hospice care with multiple complex medical conditions was administered PRN Lorazepam and Morphine Sulfate without proper documentation of the specific indications for use prior to administration. Nursing notes did not consistently record the resident's symptoms or reasons for giving the medications, and there was no explanation for administering both drugs simultaneously. The DON was unable to provide further information regarding the missing documentation.
A facility failed to implement its admission policy by not ensuring an Admission Agreement was explained and signed by a resident. Despite having an intact cognitive status, the resident's file lacked a signed agreement detailing consent for treatment, resident rights, and financial responsibilities. The Admission's Manager did not complete the agreement, citing the resident's confusion post-dialysis, and the Administrator confirmed the agreement should be completed for all admissions.
A facility failed to monitor a resident's blood sugar levels as required, impacting insulin administration. The resident, with a history of stroke and diabetes, had a Physician's Order for blood sugar checks before meals and at bedtime, with insulin to be given if levels were 151 or higher. However, records showed multiple instances where blood sugar was not checked, violating facility policies.
A resident in contact isolation due to MRSA was confined to her room, despite being cognitively intact and previously leaving her room regularly. Staff, including an LPN and CNA, were unsure about isolation protocols, leading to the resident's misunderstanding that she could not leave her room. The ADON later clarified that the resident could leave if her wound was covered, but the resident had been told otherwise by the wound nurse.
The facility failed to ensure staff were aware of the code status for three residents due to missing documentation in their records. The Social Service Director found signed POST forms for these residents, but they were not included in the residents' charts or communicated to the nursing staff, contrary to facility policy.
A resident was observed with caried and broken teeth, yet their records inaccurately indicated no dental issues. The resident's MDS assessments showed cognitive intactness and no oral problems, and there was no dental care plan. Interviews with staff revealed unawareness of the dental issues.
Two residents in the facility did not receive the required number of baths and hair washes as part of their ADLs. One resident, dependent on staff for all ADLs, reported not receiving a bed bath twice a week and not having his hair washed weekly, with observations confirming greasy hair. Another resident, also dependent on staff for bathing, reported not having her hair washed since admission, with records indicating missed bed baths. Interviews with nursing staff confirmed the expectation for residents to receive at least two complete bed baths weekly and to be offered hair washing.
A resident's surgical bandage was not changed as ordered by the physician, with the bandage observed to be dated several days prior to the scheduled change. The resident, who was dependent on staff for daily activities, had specific physician orders for bandage changes that were not followed. The Treatment Administration Record inaccurately showed the treatment as completed, and the Director of Nursing confirmed the oversight.
A resident with multiple health issues, including a stage 2 pressure ulcer, was not provided with proper care as their heels were not floated off the bed, contrary to a physician's order. Despite the care plan indicating impaired skin integrity and the need for heel offloading every shift, observations revealed non-compliance, which was acknowledged by the DON.
A resident with a PEG tube for decompression was found with dried blood under the flange, indicating a lack of daily cleaning as required by facility policy. Interviews revealed that the wound nurse cleaned the tube when changing bandages but did not document this care, and the LPN assumed the wound nurse was responsible. There were no physician's orders or care plans for the PEG tube, despite the DON stating it should be cleaned daily.
A facility failed to ensure proper care and monitoring of a resident's PICC line due to the absence of Physician's Orders. Observations revealed the PICC line bandage was outdated and peeling, and the resident's record lacked a Care Plan or active orders for PICC line care. The resident had multiple health issues and was severely impaired in decision-making. The DON confirmed the lack of PICC line orders.
A facility failed to limit the use of a PRN psychotropic medication for a resident with multiple health conditions, including paranoid schizophrenia and depressive disorder. The resident was prescribed Alprazolam as needed for anxiety, which was administered beyond the 14-day limit without documented clinical rationale for extended use, contrary to the facility's policy.
A resident was found with Diclofenac cream improperly stored at the bedside without a care plan or physician's order, and an LPN had 10 loose pills in a medication cart. The facility's medication storage policy was not followed, leading to deficiencies in medication management.
The facility failed to ensure a clean and sanitary environment by leaving an uncontained bed pan on a chair in a resident's room. The resident had used the bed pan multiple times due to diarrhea. The DON confirmed that the bed pan should have been stored properly after use, as per the facility's policy on storing continence devices.
Lack of Documentation for PRN Medication Administration in Hospice Resident
Penalty
Summary
The facility failed to ensure that as-needed (PRN) medications were administered with proper documentation of the specific indication for use for a resident receiving hospice care. The resident, who had multiple diagnoses including stroke, dysphagia, chronic kidney disease, quadriplegia, vascular dementia, and heart failure, was cognitively impaired and at risk for pain as noted in the care plan. Physician orders were in place for Lorazepam for anxiety, restlessness, and insomnia, and for Morphine Sulfate for pain or shortness of breath, both to be given as needed. The Medication Administration Record showed that both medications were administered on several occasions. However, the nurses' notes did not consistently document the specific reason or indication for administering these medications prior to their use. In several instances, there was no documentation that the resident had experienced pain, anxiety, or restlessness before receiving the medications, nor was there an explanation for administering both medications at the same time. The Director of Nursing was unable to provide additional information regarding the lack of documentation. This deficiency was identified during a complaint investigation.
Failure to Implement Admission Policy for Resident
Penalty
Summary
The facility failed to implement its admission policy by not ensuring that an Admission Agreement was explained and signed by a resident, identified as Resident D, who was admitted to the facility. Resident D's record review revealed multiple admissions and discharges to an acute care hospital, with the most recent discharge to another facility. Despite having an intact cognitive status as per a Quarterly Minimum Data Set assessment, there was no signed Admission Agreement on file. This agreement should have included consent for treatment, explanations of resident rights, and details about financial responsibilities, among other important information. During an interview, the Admission's Manager admitted that the Admission Agreement was not explained or signed by Resident D. The manager expressed discomfort in going over the paperwork with the resident, citing the resident's confusion after returning from dialysis as a reason for not completing the agreement. The facility's Administrator confirmed that the Admission Agreement should be completed for all admissions, indicating a lapse in following the facility's admission procedures for Resident D.
Failure to Monitor Blood Sugar for Insulin Administration
Penalty
Summary
The facility failed to ensure proper blood sugar monitoring for a resident with a history of stroke and diabetes mellitus, which is crucial for determining the need for insulin administration. The resident's record indicated a severely impaired cognitive status and a requirement for insulin based on blood sugar levels, as per a Physician's Order dated 11/13/24. This order specified that blood sugars should be checked before meals and at bedtime, with Humalog insulin to be administered if the blood sugar was 151 or higher, following a sliding scale. However, the Medication Administration Records (MAR) for December 2024 and January 2025 showed multiple instances where blood sugar levels were not obtained, thus failing to determine if insulin was required. The Director of Nursing (DON) was informed of these missed blood sugar monitoring instances, but no further information was provided at the end of the Exit Conference. The facility's glucose testing policy, dated 1/2/21, required that the Physician's Order be reviewed prior to testing and that all results be recorded on the MAR. Additionally, the facility's medication administration policy, dated 2/17/20, mandated that medications be administered in accordance with the Prescriber's orders. This deficiency was related to a specific complaint, IN00452516.
Failure to Honor Resident's Choice During Contact Isolation
Penalty
Summary
The facility failed to honor a resident's preferences regarding leaving her room while in contact isolation. Resident 261, who was cognitively intact and used a wheelchair, was placed in contact isolation due to Methicillin-resistant Staphylococcus aureus (MRSA) in a wound. Despite her cognitive ability to make decisions, she was confined to her room, which she expressed to staff. The resident had a history of leaving her room regularly, but due to the isolation status, she was unsure if she could continue to do so. Staff members, including LPN 3 and CNA 1, were uncertain about the requirements of contact isolation and whether the resident could leave her room. The Assistant Director of Nursing (ADON) later clarified that the resident could leave her room as long as her wound was covered. However, the resident had been told by the wound nurse that she did not need to leave her room for activities, which may have led to a misunderstanding. The Director of Nursing (DON) and Nurse Consultant acknowledged the issue of staff not understanding contact isolation protocols but did not provide additional information.
Failure to Document and Communicate Residents' Code Status
Penalty
Summary
The facility failed to ensure staff were knowledgeable regarding the residents' code status for three residents reviewed for advanced directives. For Resident 160, the Assistant Director of Nursing was unaware of the resident's code status due to a lack of documentation in the clinical record or the advance directive binder. The Social Service Director (SSD) found a POST form on his desk, signed by the resident and nursing staff but not by a physician or nurse practitioner, indicating the resident was a full code. The SSD could not explain why this information was not communicated to the nursing staff. Resident 50's record lacked a code status order and advanced directives documentation. RN 1 was unaware of the resident's code status, and the SSD found a POST form in his office, signed by the resident and physician, but it was not in the resident's chart. Similarly, Resident 261's record had no code status order or POST form in the electronic medical record. RN 1 was unaware of the resident's code status, and the SSD confirmed that POST forms for all three residents were signed but not included in their charts or communicated to the nursing staff. The facility's policy required documentation of advance directives in the resident's medical record, which was not followed.
Inaccurate Dental Assessment for a Resident
Penalty
Summary
The facility failed to ensure an accurate comprehensive assessment of a resident's dental status. During an observation, a resident was found to have caried and broken teeth, and the resident mentioned the need for new dentures. However, the resident's record, including the Annual Minimum Data Set (MDS) assessment and a subsequent Quarterly MDS assessment, indicated that the resident was cognitively intact and had no oral or dental problems. Additionally, there was no care plan in place for dental care. Interviews with the MDS Coordinator and MDS Nurse Consultant revealed a lack of awareness regarding the resident's dental issues.
Failure to Provide Required Bathing and Hair Washing for Residents
Penalty
Summary
The facility failed to ensure that dependent residents received the required number of baths and hair washes as part of their activities of daily living. Resident 41, who was cognitively intact but dependent on staff for all ADLs, reported not receiving a bed bath twice a week and not having his hair washed weekly. Observations confirmed that the resident's hair was greasy. The resident's care plan indicated the need for assistance with bathing, and the facility's records showed missed bed baths on specific dates. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed the expectation for residents to receive at least two complete bed baths weekly and to be offered hair washing. Similarly, Resident 158, who was also cognitively intact and dependent on staff for bathing, reported not having her hair washed since admission. Her care plan required assistance with bathing, and facility records indicated missed bed baths on specified dates. The Assistant Director of Nursing was unaware of the resident's lack of hair washing and confirmed the expectation for residents to receive complete bed baths at least twice a week. These deficiencies highlight the facility's failure to adhere to care plans and ensure proper hygiene for dependent residents.
Failure to Change Surgical Bandage as Ordered
Penalty
Summary
The facility failed to ensure that surgical bandages were changed as ordered by the physician for a resident with a non-pressure skin condition. On September 3, 2024, a resident was observed with a surgical bandage on the abdomen dated August 30, 2024, indicating it had not been changed according to the physician's orders. The Assistant Director of Nursing confirmed that the bandage was supposed to be changed three times a week on Monday, Wednesday, and Friday. However, the bandage was not changed on September 2, 2024, as required. The resident, who was cognitively intact but dependent on staff for all activities of daily living, had a surgical wound upon admission. The physician's orders specified a detailed procedure for changing the bandage, which was not followed. The Treatment Administration Record inaccurately indicated that the treatment was completed on September 2, 2024. The Wound Nurse, who was responsible for changing the bandage, was off on that day, and the nursing staff did not perform the task in her absence. The Director of Nursing acknowledged that the bandage should have been changed as per the physician's orders.
Failure to Float Heels for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to ensure proper pressure ulcer care for a resident with a history of pressure ulcers. Resident 31, who has multiple diagnoses including diabetes, hemiplegia, encephalopathy, dementia, and hypertension, was observed on multiple occasions without their heels floated off the bed, despite a physician's order to do so. The resident, who is severely impaired in daily decision-making and uses a wheelchair, had a stage 2 pressure ulcer and a history of a resolved deep tissue pressure injury to the left heel. The care plan indicated impaired skin integrity, and the physician's order required the heels to be offloaded every shift. However, observations on consecutive days showed that the resident's heels were not floated, and the Director of Nursing confirmed this oversight.
Failure to Ensure Daily Cleaning of PEG Tube
Penalty
Summary
The facility failed to ensure proper care and cleaning of a PEG tube for a resident, identified as Resident 41, who was observed with dried crusty blood under the flange of the tube. The resident, who was cognitively intact and dependent on staff for all activities of daily living, had a PEG tube placed for decompression purposes and not for feeding. Despite this, there was no care plan or physician's orders for the care or monitoring of the PEG tube, which is a violation of the facility's policy. Interviews with the wound nurse and other staff revealed a lack of clarity and responsibility regarding the cleaning of the PEG tube. The wound nurse indicated that she cleaned around the tube when changing bandages but did not document this care in the clinical record. Additionally, the LPN was aware of the PEG tube but assumed the wound nurse was responsible for its care. The Assistant Director of Nursing confirmed the absence of orders for daily monitoring or cleaning of the PEG tube, while the Director of Nursing stated that the tube should be cleaned at least daily, as per the facility's policy.
Failure to Ensure Proper PICC Line Care and Monitoring
Penalty
Summary
The facility failed to ensure proper care and monitoring of a resident's PICC line, as there were no Physician's Orders for its care and monitoring. During observations on two separate occasions, the PICC line bandage was noted to be dated several days prior and was peeling off, indicating a lack of timely maintenance. The resident, who had multiple diagnoses including diabetes, hemiplegia, encephalopathy, dementia, and hypertension, was severely impaired in daily decision-making and used a wheelchair. The resident's record lacked a Care Plan for the PICC line or intravenous therapy, and there were no active orders for their care. The Director of Nursing acknowledged the absence of PICC line orders during an interview.
Failure to Limit PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a PRN psychotropic medication was not ordered for longer than 14 days for a resident. The resident, who was cognitively intact, had multiple diagnoses including left lung cancer, type 2 diabetes, stroke, osteoarthritis, heart disease, depressive disorder, repeated falls, high blood pressure, paranoid schizophrenia, and atrial fibrillation. The resident's medication regimen included insulin, an antipsychotic, an anxiolytic, an antidepressant, an anticoagulant, and hypoglycemic medications. A physician's order dated July 17, 2024, prescribed Alprazolam 0.5 mg to be given every 8 hours as needed for anxiety. The Medication Administration Record (MAR) indicated that Alprazolam was administered five times in August 2024 and twice in September 2024. During an interview, the Assistant Director of Nursing confirmed that the scheduled dose of Xanax was discontinued in July and was then ordered as PRN. The resident requested the medication, and the resident's daughter would call to ensure it was administered. The facility's policy on psychotropic medication gradual dosage reduction stated that PRN hypnotic, antianxiety, or antidepressant medications should not be used beyond 14 days unless the prescribing practitioner provides a clinical rationale for extended use, which was not documented in this case.
Improper Storage of Medicated Creams and Loose Pills
Penalty
Summary
The facility failed to properly store medicated creams and loose pills, leading to deficiencies in medication management. During observations, a resident was found with a tube of Diclofenac cream on the over-bed table and later inside the nightstand drawer. The resident, who was severely contracted and unable to use his extremities, was cognitively intact but dependent on staff for all activities of daily living. There was no care plan or physician's order to keep the medicated cream at the bedside, and the nursing staff were unaware that the family had brought in the creams. The facility's medication storage policy required all medications to be securely stored in a locked cabinet or cart, which was not followed in this case. Additionally, during a medication pass, an LPN was observed with 10 loose pills of varying sizes, shapes, and colors in the bottom drawers of a medication cart. The LPN acknowledged that the pills should not be loose and disposed of them in a drug buster container. The facility's policy on medication storage emphasized the need for medications to be stored in an orderly manner to prevent crowding, which was not adhered to in this instance.
Uncontained Bed Pan Found in Resident's Room
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for residents, as evidenced by the presence of an uncontained bed pan in one of the units. During observations on September 5, 2024, at various times, a bed pan was found lying on a cloth chair in a resident's room. The resident reported experiencing diarrhea eight times the previous day and night, necessitating the use of the bed pan. The Director of Nursing confirmed that the bed pan should have been contained and stored away after each use. The facility's policy, dated March 21, 2021, requires designated storage areas for devices and supplies used for continence, which was not adhered to in this instance.
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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 Merrillville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brickyard Healthcare - Merrillville Care Center | 0.4 mi | — | 2 | 0 |
| Lincolnshire Health & Rehabilitation Center | 0.6 mi | — | 35 | 0 |
| Colonial Nursing Home | 3 mi | — | 0 | 0 |
| Saint Anthony | 4.5 mi | — | 3 | 0 |
| Ignite Medical Resort Crown Point Llc | 4.9 mi | — | 37 | 0 |
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