Inspection Reports for
Ignite Medical Resort Crown Point LLC
1555 S MAIN STREET, CROWN POINT, IN, 46307
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
22.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
431% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
91% occupied
Based on a June 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 9, 2025
Visit Reason
The inspection was conducted to investigate complaints related to the facility's failure to properly care for midline catheters in residents, including issues with flushing orders, medication administration, documentation, and catheter assessments.
Complaint Details
This citation relates to Intake 1839939.3.1-47(a)(2) concerning inadequate midline catheter care, medication administration failures, and documentation issues.
Findings
The facility failed to provide appropriate care for midline catheters for 3 residents, including lack of flushing before and after medication administration, incomplete documentation of catheter insertion and discontinuation, missed antibiotic doses, and failure to assess catheter sites as ordered.
Deficiencies (1)
F 0694: The facility failed to provide safe and appropriate administration of IV fluids and care for midline catheters, including flushing per orders, medication administration, and documentation for 3 residents.
Report Facts
Deficiencies cited: 1
Antibiotic doses: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding midline/PICC line care and flushing orders |
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 0
Date: Jun 27, 2025
Visit Reason
This visit was conducted for the investigation of Complaints IN00460764 and IN00461188.
Complaint Details
Complaint IN00460764 - No deficiencies related to the allegations are cited. Complaint IN00461188 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations in Complaints IN00460764 and IN00461188 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type - SNF: 70
Census Bed Type - Residential: 26
Total Census: 96
Census Payor Type - Medicare: 67
Census Payor Type - Other: 3
Total Census Payor: 70
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 29, 2025
Visit Reason
Paper compliance review to the Investigation of Complaint IN00457153 completed on May 1, 2025.
Complaint Details
Investigation of Complaint IN00457153 completed on May 1, 2025; facility found in compliance.
Findings
Ignite Medical Resort Crown Point was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the complaint investigation.
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 6
Date: May 1, 2025
Visit Reason
This visit was for the investigation of complaints IN00457153 and IN00458560. Complaint IN00457153 resulted in federal/state deficiencies cited, while Complaint IN00458560 had no deficiencies related to the allegations.
Complaint Details
The complaint investigation was triggered by complaints IN00457153 and IN00458560. Deficiencies related to IN00457153 were substantiated and cited, while no deficiencies were cited related to IN00458560.
Findings
The facility was found deficient in multiple areas including failure to notify a resident's physician and responsible party of medication unavailability, failure to provide timely incontinent care, improper care of PICC/midline catheters, delayed administration of IV antibiotics due to pharmacy issues, failure to ensure ordered lab services were completed, and failure to use proper PPE for residents on Enhanced Barrier Precautions.
Deficiencies (6)
Failed to notify a resident's physician and responsible party that a medication was unavailable for 1 of 9 residents reviewed for physician/responsible party notification.
Failed to provide incontinent care in a timely manner and failed to ensure the deficient practice does not recur for 2 of 3 residents reviewed for ADL care.
Failed to care for a midline catheter in accordance with professional standards related to non-sterile dressing change and lack of dressing changes, assessments, and flushes for 2 residents.
Failed to ensure a resident was provided with an intravenous antibiotic in a timely manner due to pharmacy medication unavailability for 1 of 3 residents reviewed.
Failed to ensure a resident received laboratory services as ordered by the physician for 1 of 3 residents reviewed.
Failed to ensure correct Personal Protective Equipment (PPE) was used by staff when providing care to residents on Enhanced Barrier Precautions for two random observations.
Report Facts
Census SNF beds: 63
Census Residential beds: 28
Total Census: 91
Medicare Census: 59
Other Payor Census: 4
Antibiotic doses missed: 4
Audit frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Petty | Administrator | Signed the inspection report |
| LPN 3 | Named in findings related to PICC line dressing change and infection control PPE compliance | |
| Director of Nursing | Interviewed regarding physician notification, medication availability, PICC care, and infection control policies |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: May 1, 2025
Visit Reason
The inspection was conducted in response to Complaint IN00457153 to investigate allegations of deficiencies related to medication administration, incontinence care, IV line care, laboratory services, infection control, and pharmaceutical services at Ignite Medical Resort Crown Point LLC.
Complaint Details
This citation relates to Complaint IN00457153.
Findings
The facility was found to have multiple deficiencies including failure to notify a resident's physician and responsible party about missed medication doses, inadequate incontinence care, improper sterile technique during PICC line dressing changes, failure to provide timely IV antibiotics due to pharmacy delays, incomplete laboratory testing, and failure to use correct personal protective equipment during care of residents on Enhanced Barrier Precautions.
Deficiencies (6)
F 0580: The facility failed to notify a resident's physician and responsible party that a medication was unavailable and not administered as ordered for 1 of 9 residents reviewed.
F 0677: The facility failed to provide timely incontinent care and bathing after a large amount of urinary incontinence for 2 of 3 residents reviewed for activities of daily living.
F 0694: The facility failed to care for a midline catheter using sterile technique and failed to perform dressing changes, assessments, and flushes as required for 2 residents with PICC lines.
F 0755: The facility failed to ensure a resident was provided an intravenous antibiotic in a timely manner due to pharmacy delays for 1 of 3 residents reviewed.
F 0772: The facility failed to ensure a resident received ordered laboratory services; pre-albumin and CBC tests were not completed or documented for 1 of 3 residents reviewed.
F 0880: The facility failed to ensure correct Personal Protective Equipment was used by staff when providing care to residents on Enhanced Barrier Precautions during two observations.
Report Facts
Residents reviewed for physician/responsible party notification: 9
Residents reviewed for activities of daily living: 3
Residents reviewed for antibiotic medications: 3
Residents reviewed for laboratory services: 3
Medication doses missed: 4
IV antibiotic doses administered: 3
PICC line dressing change frequency: 1
Admission dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 3 | Named in findings related to incontinent care, PICC line dressing change, and PPE use. | |
| CNA 2 | Named in findings related to incontinent care and PPE use. | |
| CNA 5 | Named in incontinent care observation for Resident E. | |
| LPN 4 | Interviewed about night shift CNA rounds timing. | |
| CNA 6 | Named in PPE use observation for Resident J. | |
| CNA 7 | Named in PPE use observation for Resident J. | |
| Director of Nursing | Interviewed regarding notification policies, PICC line care, pharmacy delivery, and PPE policies. | |
| Wound Nurse 1 | Interviewed regarding incomplete laboratory testing. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 10, 2025
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey and the Investigation of Complaint IN00449507 completed on January 13, 2025.
Complaint Details
Investigation of Complaint IN00449507 completed on January 13, 2025; found in compliance.
Findings
Ignite Medical Resort Crown Point was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Recertification and State Licensure Survey and complaint investigation.
Inspection Report
Life Safety
Census: 67
Capacity: 70
Deficiencies: 2
Date: Feb 3, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness requirements but was not in compliance with Life Safety Code requirements. Deficiencies included failure to provide an approved method for returning cooking appliances to their approved location under the kitchen hood extinguishing system, and failure to have current inspection certificates for six fuel-fired water heaters.
Deficiencies (2)
Failed to provide an approved method for returning cooking appliances to their approved design location under the kitchen hood extinguishing system.
Failed to ensure 6 of 6 fuel fired water heaters had current inspection certificates to ensure safe operating condition.
Report Facts
Certified beds: 70
Census: 67
Fuel fired water heaters: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Petty | Administrator | Signed the report |
| Environmental Services Director | Interviewed regarding deficiencies | |
| General Manager | Interviewed regarding deficiencies | |
| Maintenance Director | Present at exit conference |
Inspection Report
Life Safety
Deficiencies: 0
Date: Feb 3, 2025
Visit Reason
The visit was conducted as a Life Safety Code Recertification and State Licensure Survey to assess compliance with fire safety and state licensure requirements.
Findings
Ignite Medical Resort Crown Point was found in compliance with Medicare/Medicaid participation requirements, the Life Safety Code from Fire, and applicable state regulations with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Jan 13, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to multiple concerns including medication self-administration, resident transfer notifications, medication administration, wound and edema care, catheter care, nutrition, feeding tube care, IV fluid administration, and infection control.
Complaint Details
This citation relates to Complaint IN00449507.
Findings
The facility was found deficient in multiple areas including failure to ensure physician orders and assessments for medication self-administration, failure to notify residents or representatives timely about hospital transfers and bed-hold policies, failure to administer medications as ordered, inadequate assessment and treatment of an abdominal hernia and edema, improper catheter care, failure to follow dietary recommendations timely, incorrect feeding tube flow rate, failure to maintain PICC dressing as ordered, and improper use of personal protective equipment in isolation rooms.
Deficiencies (9)
F 0554: The facility failed to ensure residents had physician's orders and assessments for self-administration of medications for 1 of 1 resident reviewed.
F 0623: The facility failed to notify a resident and/or their responsible party in writing related to a hospital transfer for 1 of 4 residents reviewed.
F 0625: The facility failed to send the bed-hold and reserve bed payment policy to a resident and/or their responsible party before and upon hospital transfer for 1 of 4 residents reviewed.
F 0684: The facility failed to provide medications as ordered, hold medications outside ordered parameters, assess and monitor an abdominal hernia, and provide treatment for leg swelling for residents reviewed.
F 0690: The facility failed to ensure a urinary catheter collection bag was kept off the floor for 1 of 1 resident reviewed.
F 0692: The facility failed to ensure timely follow-up on dietary recommendations for a resident with a feeding tube for 1 of 3 residents reviewed.
F 0693: The facility failed to ensure a resident with a gastrostomy received appropriate treatment related to incorrect feeding tube flow rate for 1 of 1 resident reviewed.
F 0694: The facility failed to maintain a peripheral inserted central catheter (PICC) dressing as ordered for 1 of 3 residents reviewed.
F 0880: The facility failed to ensure infection control measures were maintained related to improper PPE worn in an isolation room for 1 of 1 resident reviewed.
Report Facts
Residents reviewed for hospitalization: 4
Residents reviewed for dialysis: 1
Residents reviewed for edema and skin conditions: 3
Residents reviewed for urinary catheters: 1
Residents reviewed for nutrition: 3
Residents reviewed for tube feedings: 1
Residents reviewed for IV fluids: 3
Residents reviewed for respiratory care: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 2 | Licensed Practical Nurse | Named in medication self-administration finding related to Resident 40. |
| Director of Nursing | Director of Nursing | Named in multiple findings including medication self-administration and hospital transfer notifications. |
| C Unit Manager | Unit Manager | Named in medication administration and feeding tube flow rate findings. |
| A Unit Manager | Unit Manager | Named in dietary recommendation follow-up and catheter care findings. |
| RN 4 | Registered Nurse | Named in PICC dressing maintenance finding. |
| LPN 1 | Licensed Practical Nurse | Named in infection control PPE finding. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 13, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to medication administration, discharge medication holding, and assessment and treatment of edema and skin conditions in residents.
Complaint Details
This citation relates to Complaint IN00449507.
Findings
The facility failed to ensure a resident received medications as ordered during dialysis, failed to hold medications according to ordered parameters for a resident being discharged, and lacked assessment and treatment for an abdominal hernia and leg swelling in residents reviewed for edema and skin conditions.
Deficiencies (1)
F 0684: The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals. This included missed medications for a resident on dialysis, improper medication administration for a resident being discharged, and lack of assessment and treatment for an abdominal hernia and leg swelling in residents.
Report Facts
Medication administration errors: 3
Medication administration with blood pressure less than ordered hold parameter: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| C Unit Manager | Interviewed regarding medication scheduling during dialysis. | |
| Nurse Consultant | Interviewed but had no further information to provide. | |
| A Unit Manager | Interviewed regarding orders for ace wraps and hernia assessment. | |
| Director of Nursing (DON) | Interviewed regarding documentation and assessment of hernia and edema treatment. |
Inspection Report
Annual Inspection
Census: 23
Deficiencies: 14
Date: Jan 13, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey and the Investigation of Complaint IN00449507.
Complaint Details
Complaint IN00449507 - Federal/State deficiencies related to the allegations are cited at F684.
Findings
The facility was found deficient in multiple areas including medication self-administration orders, transfer/discharge notifications, accuracy of assessments, quality of care related to medication administration and treatment, infection control, clinical records, and emergency preparedness.
Deficiencies (14)
Failed to ensure residents had Physician's Orders and assessments for self-administration of medications.
Failed to notify resident or Responsible Party in writing related to hospital transfer.
Failed to send facility's bed-hold and reserve bed payment policy before and upon transfer to hospital.
Minimum Data Set (MDS) assessments were inaccurate related to IV access, antipsychotic and anti-anxiety medications.
Failed to ensure resident received medications as ordered for dialysis, hold medications outside ordered parameters, assess and monitor abdominal hernia, and provide treatment for leg swelling.
Failed to keep indwelling Foley catheter collection bag off the floor.
Failed to ensure timely follow-up on dietary recommendations for a resident with a feeding tube.
Failed to ensure appropriate treatment related to incorrect flow rate for tube feeding.
Failed to maintain PICC dressing changes as ordered.
Failed to ensure proper infection control measures and PPE use in isolation room.
Failed to ensure resident Emergency Binder contained all necessary information.
Failed to ensure QMAs received authorization from licensed nurse prior to giving PRN medication.
Failed to ensure medications were given as ordered, including proper application and removal of lidocaine patch.
Failed to ensure residents had annual health statements indicating freedom from communicable diseases.
Report Facts
Survey dates: January 6, 7, 8, 9, 10, and 13, 2025
Census: 23
Facility number: 13452
Provider number: 155835
Deficiency counts: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Petty | Administrator | Signed report as Administrator |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 26, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00447084 completed on December 5, 2024.
Complaint Details
Investigation of Complaint IN00447084 completed on December 5, 2024; facility found in compliance.
Findings
Ignite Medical Resort Crown Point was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the complaint investigation.
Inspection Report
Census: 68
Capacity: 68
Deficiencies: 0
Date: Dec 20, 2024
Visit Reason
An Emergency Preparedness Survey and a Preoccupancy Survey for the addition of one resident room to allow the addition of two licensed comprehensive beds were conducted by the Indiana Department of Health.
Findings
The facility was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 483.73, and with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Report Facts
Certified beds: 68
Census: 68
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 5, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to the facility's failure to provide residents' medical records to residents or their legal representatives in a timely manner.
Complaint Details
This citation relates to Complaint IN00447084. The complaint involved delays and incomplete provision of medical records to residents or their representatives.
Findings
The facility failed to provide complete medical records timely for 3 residents reviewed (Residents B, C, and D). The medical records requests were delayed or partially fulfilled due to administrative issues including staff turnover and communication failures.
Deficiencies (1)
F 0573: The facility failed to provide residents or their legal representatives access to or copies of all residents' medical records in a timely manner after requests were made for 3 residents.
Report Facts
Pages received: 106
Residents reviewed for medical record requests: 3
Inspection Report
Complaint Investigation
Census: 86
Capacity: 86
Deficiencies: 1
Date: Dec 5, 2024
Visit Reason
The visit was conducted as an investigation of Complaint IN00447084 regarding the facility's failure to provide residents' medical records in a timely manner.
Complaint Details
Complaint IN00447084 was substantiated with federal/state deficiencies cited at F573 related to failure to provide timely access to medical records. The complaint involved three residents whose records were not provided timely or completely as requested.
Findings
The facility failed to provide timely access to medical records for three residents (Residents B, C, and D) after requests were made. Issues included incomplete records sent, communication delays, and improper handling of requests due to staff turnover.
Deficiencies (1)
Failed to provide residents' medical records to the resident/Power of Attorney in a timely manner after a request was made for 3 of 3 residents reviewed.
Report Facts
Census SNF beds: 63
Census Residential beds: 23
Total Census: 86
Medicare Census: 61
Other Payor Census: 2
Pages received on 8/29/24: 106
Date of first medical record request: Aug 28, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Petty | Administrator | Named in relation to the findings and interviews regarding medical record requests |
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 0
Date: Oct 23, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00444670.
Complaint Details
Investigation of Complaint IN00444670 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00444670 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type - SNF: 63
Census Bed Type - Residential: 21
Total Census: 84
Census Payor Type - Medicare: 58
Census Payor Type - Other: 5
Total Census Payor: 63
Inspection Report
Complaint Investigation
Census: 62
Capacity: 83
Deficiencies: 0
Date: Sep 24, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00443033.
Complaint Details
Complaint IN00443033 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
SNF Census: 62
Residential Census: 21
Total Census: 62
Total Capacity: 83
Medicare Census: 37
Other Payor Census: 25
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 0
Date: Aug 1, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00439475.
Complaint Details
Complaint IN00439475 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type - SNF: 63
Census Bed Type - Residential: 24
Census Payor Type - Medicare: 61
Census Payor Type - Other: 2
Total Census Payor: 63
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jul 16, 2024
Visit Reason
The inspection was conducted in response to complaints regarding alleged abuse and concerns about medication administration and nurse staffing at the facility.
Complaint Details
This citation relates to Complaints IN00436496 and IN00437883. The facility was cited for failure to timely report abuse, improper gastrostomy tube medication administration, and inaccurate nurse staffing postings.
Findings
The facility failed to timely report an allegation of abuse to the Administrator and Indiana Department of Health. The facility also failed to confirm gastrostomy tube placement prior to medication administration and inaccurately posted nurse staffing information by including administrative nursing hours.
Deficiencies (3)
F 0609: The facility failed to timely report an allegation of abuse to the Administrator and the Indiana Department of Health within the required 2-hour period for one resident.
F 0693: The facility failed to confirm gastrostomy tube placement prior to medication administration for one resident, contrary to facility policy.
F 0732: The facility posted nurse staffing information that included administrative nursing hours, which did not reflect only staff providing direct resident care, potentially affecting all residents.
Report Facts
Medication cups: 11
Flushing volume: 60
Observation time: 8.28
Observation time: 4.35
Observation time: 4.3
Observation time: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Reported abuse allegation to Director of Nursing. | |
| Director of Nursing (DON) | Received abuse allegation report and interviewed resident. | |
| Administrator | Not initially notified of abuse allegation; later reported to Indiana Department of Health. | |
| LPN 2 | Observed administering medications via gastrostomy tube without confirming placement. | |
| Assistant Director of Nursing (ADON) | Provided current medication administration policy and explained nurse staffing postings. |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 3
Date: Jul 16, 2024
Visit Reason
This visit was conducted for the investigation of three complaints (IN00433869, IN00436496, and IN00437883) regarding alleged violations at Ignite Medical Resort Crown Point LLC.
Complaint Details
The visit was complaint-driven based on allegations of abuse and other concerns. Complaint IN00433869 had no deficiencies cited. Complaints IN00436496 and IN00437883 had substantiated deficiencies related to abuse reporting, gastrostomy tube care, and nurse staffing postings.
Findings
The investigation found no deficiencies related to complaint IN00433869. Deficiencies related to complaints IN00436496 and IN00437883 were cited, including failure to report an allegation of abuse timely, improper gastrostomy tube medication administration, and inaccurate posted nurse staffing information.
Deficiencies (3)
Failure to report an allegation of abuse to the Administrator and Indiana Department of Health within the required 2-hour timeframe for 1 of 3 residents reviewed (Resident E).
Failure to confirm placement of gastrostomy tube prior to medication administration for 1 resident observed (Resident F).
Failure to ensure posted Nurse Staffing Information included only staff providing direct resident care; administrative nursing hours were incorrectly included.
Report Facts
Census: 89
Medicare Census: 62
Other Payor Census: 4
Medication cups observed: 11
Water flush volume: 60
Audit frequency: 5
Observation frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Reported abuse allegation to Director of Nursing; interviewed regarding abuse allegation reporting | |
| Director of Nursing | DON | Received abuse allegation report from LPN 1; interviewed about follow-up and reporting |
| Administrator | Interviewed regarding notification of abuse allegation and reporting to Indiana Department of Health | |
| LPN 2 | Observed administering medications via gastrostomy tube without confirming tube placement; interviewed about tube placement confirmation | |
| Assistant Director of Nursing | ADON | Interviewed regarding nurse staffing information posting and inclusion of administrative nursing hours |
| Corporate Regional Vice President | Interviewed regarding CMS Staffing Data Report and nurse staffing hours reporting |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 16, 2024
Visit Reason
Paper compliance review to the Investigation of Complaints IN00436496 and IN00437883 completed on July 16, 2024.
Complaint Details
Investigation of Complaints IN00436496 and IN00437883; paper compliance review found facility in compliance.
Findings
Ignite Medical Resort Crown Point was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the complaint investigation.
Inspection Report
Complaint Investigation
Census: 62
Capacity: 68
Deficiencies: 0
Date: May 31, 2024
Visit Reason
An investigation of Complaint Number IN00434243 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Complaint Details
Complaint IN00434243 was investigated and found to have no deficiencies related to the allegation.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety From Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Report Facts
Certified beds: 68
Census: 62
Inspection Report
Follow-Up
Census: 61
Capacity: 68
Deficiencies: 0
Date: May 30, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted for the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey to verify compliance following a previous survey conducted on 05/03/2024.
Findings
At this Post Survey Revisit, Ignite Medical Resort Crown Point was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements. The facility is fully sprinklered, has a fire alarm system with smoke detection, and a 300 kW diesel powered emergency generator. No deficiencies were cited.
Report Facts
Certified beds: 68
Medicare only beds: 65
Dually certified beds: 3
Census: 61
Emergency generator power: 300
Inspection Report
Life Safety
Census: 67
Capacity: 68
Deficiencies: 7
Date: May 3, 2024
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and related NFPA codes.
Findings
The facility was found not in compliance with several Life Safety Code requirements including emergency power system inspections, fire alarm system maintenance, sprinkler system inspections, fire drills, generator testing, and oxygen transfilling procedures.
Deficiencies (7)
Failed to implement emergency power system inspection, testing, and maintenance requirements including missing weekly visual inspections of the generator.
Failed to ensure delayed egress locking arrangements released the lock within required time and activated audible signal.
Failed to maintain fire alarm system in accordance with NFPA 70 and NFPA 72 including overdue smoke detector sensitivity testing and missing annual functional testing documentation.
Failed to maintain sprinkler system inspections and testing in accordance with NFPA 25 including missing monthly inspections of sprinkler gauges and valves for 12 months.
Failed to conduct quarterly fire drills at unexpected times on third shift for 3 of 4 quarters.
Failed to maintain written records of weekly generator inspections for 4 of 52 weeks and failed to exercise the generator monthly for 12 months as required by NFPA 110.
Failed to ensure oxygen transfilling occurred in a designated area separated by a 1-hour fire barrier; door was propped open during transfilling.
Report Facts
Certified beds: 68
Census: 67
Medicare only beds: 65
Dually certified beds: 3
Fire drills missing on third shift: 3
Generator weekly inspections missing: 4
Generator monthly exercises missing: 12
Inspection Report
Annual Inspection
Census: 28
Capacity: 96
Deficiencies: 6
Date: Apr 5, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Complaints IN00429437 and IN00429874. This visit included a State Residential Licensure Survey.
Complaint Details
Complaint IN00429437 and IN00429874 were investigated with no deficiencies related to the allegations cited.
Findings
The facility was found deficient in several areas including failure to complete transfer/discharge paperwork for a hospitalized resident, inaccurate Minimum Data Set (MDS) assessments related to oxygen use and urinary catheter, failure to provide necessary care for a skin tear, lack of physician orders and documentation for urinary catheter care, incorrect respiratory treatment orders and oxygen flow rates, and unsanitary kitchen conditions including undated/unlabeled food and ice buildup in the freezer.
Deficiencies (6)
Failed to ensure transfer/discharge paperwork was completed for a resident sent to the hospital.
Failed to ensure Minimum Data Set (MDS) assessments were accurately completed related to oxygen use and indwelling catheter.
Failed to ensure residents received necessary care and treatment related to lack of assessment and treatment order for a skin tear.
Failed to ensure a Physician's Order was obtained for a urinary catheter, catheter care was completed, and urinary output was recorded.
Failed to ensure residents received correct respiratory treatment related to no Physician's Order for oxygen and incorrect oxygen flow rate.
Failed to ensure sanitary kitchen conditions related to undated/unlabeled food, ice buildup in freezer, and spilled substances on floors.
Report Facts
Survey dates: 5
Census Bed Type - SNF: 68
Census Bed Type - Residential: 28
Total Capacity: 96
Census Payor Type - Medicare: 47
Census Payor Type - Medicaid: 0
Census Payor Type - Other: 21
Urine output documentation: 1
Oxygen flow rate: 2.5
Oxygen flow rate ordered: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Petty | Administrator | Signed the report and identified as Administrator |
| Unit Manager | Interviewed regarding transfer paperwork and oxygen orders | |
| MDS Nurse | Interviewed regarding MDS assessment coding | |
| Director of Nursing | Interviewed regarding catheter orders and oxygen therapy | |
| LPN 4 | Licensed Practical Nurse | Interviewed regarding skin tear documentation |
| Cook 1 | Cook | Interviewed regarding kitchen sanitation and food labeling |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 5, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on April 5, 2024.
Findings
Symphony of Crown Point was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Recertification and State Licensure Survey.
Inspection Report
Routine
Deficiencies: 4
Date: Apr 5, 2024
Visit Reason
Routine inspection to assess compliance with healthcare regulations and standards at Ignite Medical Resort Crown Point LLC.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate treatment and care for skin tears, lack of physician orders and documentation for urinary catheter care, incorrect respiratory care related to oxygen orders and flow rates, and unsanitary kitchen conditions with unlabeled food and spills.
Deficiencies (4)
F 0684: The facility failed to provide appropriate treatment and care related to lack of assessment and treatment order for a skin tear for 1 of 1 residents reviewed.
F 0690: The facility failed to ensure a Physician's Order was obtained for a urinary catheter, catheter care was completed, and urinary output was recorded for 1 of 3 residents reviewed for urinary catheters.
F 0695: The facility failed to provide correct and necessary respiratory treatment related to no Physician's Order for oxygen and incorrect oxygen flow rate for 2 of 4 residents reviewed for respiratory care.
F 0812: The facility failed to ensure a sanitary kitchen related to undated and unlabeled food, ice buildup in the freezer, and spilled substances on floors in refrigerator and dry storage room, potentially affecting all 68 residents.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 68
Urine output documented: 1800
Oxygen flow rate: 2.5
Oxygen flow rate order: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 4 | Unaware of skin tear documentation for Resident 31 | |
| Unit Manager | Spoke to nurse about skin tear documentation and oxygen order issues | |
| Director of Nursing | Indicated no orders for urinary catheter care and oxygen therapy issues | |
| [NAME] 1 | Interviewed regarding kitchen sanitation issues |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 29, 2024
Visit Reason
Paper compliance review to the investigation of complaints IN00421580, IN00426084, and IN00428145 completed on February 14, 2024.
Complaint Details
Paper compliance review related to complaints IN00421580, IN00426084, and IN00428145; no deficiencies found.
Findings
Ignite Medical Resort Crown Point was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 14, 2024
Visit Reason
The inspection was conducted in response to complaints IN00421580, IN00426084, and IN00428145 regarding resident care and record-keeping deficiencies.
Complaint Details
This citation relates to Complaints IN00421580, IN00426084, and IN00428145. The findings were substantiated based on record reviews and interviews.
Findings
The facility failed to ensure residents requiring assistance with activities of daily living received bathing/showers at least twice a week for 4 of 5 residents reviewed. Additionally, the facility failed to maintain complete and accurate dietary intake documentation for 3 of 3 residents reviewed.
Deficiencies (2)
F 0677: The facility failed to provide bathing/showers at least twice weekly for residents requiring extensive to dependent assistance, as evidenced by missed baths/showers for Residents D, E, F, and H.
F 0842: The facility failed to maintain complete and accurate dietary intake records for Residents D, F, and G, with multiple days lacking meal consumption documentation.
Report Facts
Residents reviewed for bathing assistance: 5
Residents reviewed for dietary intake documentation: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding bathing schedule and meal consumption charting. |
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 2
Date: Feb 13, 2024
Visit Reason
This visit was for the Investigation of Nursing Home Complaints IN00421580, IN00425544, IN00426084, and IN00428145, and the Investigation of Residential Complaint IN00424886.
Complaint Details
Complaint IN00421580 - Federal/state deficiencies related to the allegations are cited at F677. Complaint IN00425544 - No deficiencies related to the allegations are cited. Complaint IN00426084 - Federal/state deficiencies related to the allegations are cited at F677 and F842. Complaint IN00428145 - Federal/state deficiencies related to the allegations are cited at F842. Complaint IN00424886 - No deficiencies related to the allegations are cited.
Findings
The facility was found to have federal/state deficiencies related to bathing assistance for dependent residents and incomplete and inaccurate documentation of dietary intakes for several residents. Some complaints had no deficiencies cited. The facility requested a desk review.
Deficiencies (2)
Failed to ensure residents who required assistance for activities of daily living received bathing/showers at least twice a week for 4 of 5 residents.
Failed to ensure a resident's record was complete and accurate related to documentation of dietary intakes for 3 of 3 residents reviewed.
Report Facts
Census Bed Type: 68
Census Bed Type: 28
Census Bed Type: 96
Census Payor Type: 45
Census Payor Type: 23
Census Payor Type: 68
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Petty | Administrator | Signed report and mentioned in interview regarding bathing schedule and documentation |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 0
Date: Aug 2, 2023
Visit Reason
The visit was conducted to investigate Nursing Home Complaints IN00409243 and IN00409334, as well as Residential Complaints IN00411764 and IN00411793.
Complaint Details
Complaints IN00409243, IN00409334, IN00411764, and IN00411793 were investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies related to the allegations in any of the complaints were cited. The facility was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census Bed Type - SNF/NF: 5
Census Bed Type - SNF: 55
Census Bed Type - Residential: 29
Census Total: 89
Census Payor Type - Medicare: 31
Census Payor Type - Medicaid: 3
Census Payor Type - Other: 26
Census Payor Type - Total: 60
Inspection Report
Follow-Up
Census: 49
Capacity: 68
Deficiencies: 0
Date: May 24, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted for the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey following the initial surveys conducted on 04/12/2023.
Findings
At this Post Survey Revisit, Symphony of Crown Point LLC was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility was fully sprinklered, had a fire alarm system with smoke detection, and was protected by an emergency generator.
Report Facts
Certified beds: 68
Medicare only beds: 65
Dually certified beds: 3
Census: 49
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 0
Date: May 15, 2023
Visit Reason
This visit was conducted for the investigation of Nursing Home Complaints IN00405570 and IN00408443, as well as the investigation of Residential Complaint IN00408244.
Complaint Details
Complaints IN00405570, IN00408443, and IN00408244 were investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies related to the allegations were cited for any of the complaints investigated. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census Bed Type - SNF/NF: 5
Census Bed Type - SNF: 53
Census Bed Type - Residential: 25
Census Bed Type - Total: 83
Census Payor Type - Medicare: 26
Census Payor Type - Medicaid: 3
Census Payor Type - Other: 29
Census Payor Type - Total: 58
Inspection Report
Life Safety
Census: 56
Capacity: 68
Deficiencies: 7
Date: Apr 12, 2023
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with several Life Safety Code requirements including maintenance of smoke barrier door latching hardware, fire barrier door ratings, corridor egress obstructions, delayed egress locking arrangements, hazardous area door self-closing mechanisms, HVAC combustion air intake, and improper use of power strips and extension cords.
Deficiencies (7)
Failed to maintain latching hardware on 1 of 2 smoke barrier doors in the Theater Hall.
Failed to maintain building construction type in 1 of 1 fire barriers; doors rated 20 minutes instead of 2 hours.
Failed to maintain 1 of 8 corridor means of egress free of obstructions; a stationary resident scale was obstructing the corridor.
Failed to ensure 1 of 8 delayed egress locking arrangements released lock within 15 seconds; door did not activate release process.
Failed to ensure 1 of 1 dialysis rooms had a self-closing door that automatically latches into the frame.
Failed to ensure 1 of 1 laundry rooms had intake combustion air from outside; automatic louvers did not open when dryers were running.
Failed to ensure 2 of 2 power strips and extension cords were not used as a substitute for fixed wiring for high power draw equipment.
Report Facts
Certified beds: 68
Census: 56
Deficiency count: 7
Fire barrier door rating: 20
Delayed egress release time: 15
Hazardous area waste container size: 28
Hazardous area size: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and involved in observations and exit conference regarding deficiencies. | |
| Administrator | Participated in exit conference and acknowledged findings. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 27, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey and the Investigation of Complaint IN00393079.
Complaint Details
Investigation of Complaint IN00393079 completed on March 27, 2023; facility found in compliance.
Findings
Symphony of Crown Point was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Recertification and State Licensure Survey and complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Mar 27, 2023
Visit Reason
The inspection was conducted based on complaints regarding medication self-administration, respiratory care, pain management, medication administration competency, unnecessary medications, and infection control practices.
Complaint Details
This Federal tag relates to Complaint IN00393079.
Findings
The facility was found deficient in multiple areas including failure to ensure physician orders and assessments for medication self-administration, improper oxygen use, inadequate pain management, improper IV medication administration, failure to administer medications as ordered, and inadequate infection control related to glucometer cleaning.
Deficiencies (6)
F 0554: The facility failed to ensure residents had Physician's Orders and an assessment to self-administer medications for 1 of 1 residents reviewed for self-administration of medication.
F 0695: The facility failed to ensure oxygen was properly placed for 1 of 2 residents reviewed for respiratory services.
F 0697: The facility failed to ensure a pain medication was provided for a resident experiencing pain for 1 of 1 residents reviewed for pain.
F 0726: The facility failed to ensure competent nursing staff provided proper medication administration of an IV medication related to heparin flushes during a medication observation.
F 0757: The facility failed to ensure medications were given as ordered for 1 of 5 residents reviewed for unnecessary medications.
F 0880: The facility failed to ensure infection control guidelines were implemented related to not cleaning a glucometer observed during medication pass.
Report Facts
Medication doses not administered: 8
IV flush volume: 10
IV flush volume: 3
Pain medication dosage: 4
Pain medication dosage: 500
Oxygen flow rate: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding multiple deficiencies including medication self-administration, oxygen use, pain management, IV medication administration, medication administration, and infection control. | |
| LPN 1 | Interviewed about pain assessment and medication administration for Resident B. | |
| LPN 2 | Observed and involved in improper IV medication administration related to heparin flush. | |
| LPN 3 | Observed not cleaning glucometer properly during medication pass. |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 7
Date: Mar 20, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey and the Investigation of Complaints IN00393079, IN00395998, IN00397323, IN00404534 and IN00404619. The visit included a State Residential Licensure Survey.
Complaint Details
Complaint IN00393079 resulted in federal/state deficiencies cited at F697. Complaints IN00395998, IN00397323, IN00404534, and IN00404619 had no deficiencies related to the allegations.
Findings
The facility was found deficient in multiple areas including failure to ensure residents had physician's orders and assessments for self-administered medications, inaccurate Minimum Data Set assessments, improper oxygen placement, inadequate pain management, incompetent nursing staff for IV medication administration, failure to administer medications as ordered, infection control lapses including glucometer cleaning, incomplete service plans, missing resident information in emergency binder, and inadequate infection control monitoring for COVID-19.
Deficiencies (7)
Failed to ensure residents had Physician's Orders and assessments for self-administration of medications (Resident 160).
Failed to ensure Minimum Data Set assessments were accurate related to hypnotic and opioid medication use (Residents 5 and 112).
Failed to ensure oxygen was properly placed for respiratory services (Resident 162).
Failed to ensure pain medication was provided for a resident experiencing pain (Resident B).
Failed to ensure competent nursing staff for proper IV medication administration related to heparin flushes (LPN 2 and Resident 29).
Failed to ensure medications were given as ordered for unnecessary medications (Resident 1).
Failed to ensure infection control guidelines were implemented related to cleaning a glucometer during medication pass (LPN 3).
Report Facts
Survey dates: 6
Census Bed Type - SNF/NF: 60
Census Bed Type - NF: 3
Census Bed Type - Residential: 24
Total Census: 87
Medicare Census: 29
Medicaid Census: 3
Other Payor Census: 31
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 28, 2022
Visit Reason
Paper compliance review related to an unrelated citation during the Investigation of Nursing Home Complaint IN00384855 completed on September 7, 2022.
Findings
Symphony of Crown Point was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the complaint investigation.
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 1
Date: Sep 6, 2022
Visit Reason
This visit was conducted for the investigation of Nursing Home Complaint IN00384855 and Residential Complaints IN00388844 and IN00389557.
Complaint Details
Complaint IN00384855 was unsubstantiated due to lack of evidence. Complaints IN00388844 and IN00389557 were substantiated with no deficiencies related to the allegations cited.
Findings
Complaint IN00384855 was unsubstantiated due to lack of evidence. Complaints IN00388844 and IN00389557 were substantiated but no deficiencies related to the allegations were cited. An unrelated deficiency was cited regarding the facility's failure to thoroughly investigate an allegation of misappropriation of a resident's narcotic medication.
Deficiencies (1)
Facility failed to thoroughly investigate an allegation of misappropriation of resident's property related to a missing supply of narcotic pain medication.
Report Facts
Census Bed Type - SNF/NF: 4
Census Bed Type - SNF: 54
Census Bed Type - Residential: 25
Census Bed Type - Total: 83
Census Payor Type - Medicare: 47
Census Payor Type - Medicaid: 4
Census Payor Type - Other: 7
Census Payor Type - Total: 58
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