CROWN POINT, IN - A federal complaint investigation at Ignite Medical Resort Crown Point found that a resident with a wound infection went without a prescribed IV antibiotic for more than 18 hours after the facility's contracted pharmacy repeatedly failed to deliver the medication. The May 1, 2025 inspection also documented non-sterile PICC line dressing changes, infection control violations, and prolonged gaps in incontinence care for residents with dementia.
Resident Missed Four Consecutive Antibiotic Doses
Inspectors reviewed the case of a resident diagnosed with osteomyelitis - a serious bone infection of the left ankle and foot - who had a physician's order dated April 29, 2025 for IV ampicillin-sulbactam every six hours to treat a wound infection. The first three doses were administered using the facility's emergency drug kit, but the supply ran out.
Beginning at noon on April 30, the antibiotic was unavailable. Medication administration records confirmed the resident missed doses at 12:00 p.m. and 6:00 p.m. on April 30, then again at 12:00 a.m. and 6:00 a.m. on May 1 - four consecutive missed doses spanning roughly 18 hours.
Nursing notes documented repeated, unsuccessful attempts to obtain the drug. At 11:37 a.m. on April 30, staff noted the antibiotic was not in the emergency drug kit and the pharmacy expected delivery by 1:00 p.m. By 5:05 p.m., the medication still had not arrived, and nursing staff contacted the pharmacy again requesting delivery "as soon as possible." At 4:07 a.m. on May 1, a nurse documented the antibiotic remained unavailable and was still on order.
Interrupting an IV antibiotic course is medically significant. Consistent blood levels of the drug are necessary to eliminate the targeted bacteria. Gaps in dosing allow bacterial populations to recover and can contribute to antibiotic resistance, potentially making the infection harder to treat. For a resident already dealing with osteomyelitis - which requires prolonged, reliable antibiotic therapy - missed doses raise the risk of treatment failure.
The facility's own pharmacy delivery policy, dated January 2023, states that the pharmacy will provide daily delivery of medications and supplies. The Director of Nursing confirmed during an interview that the physician and the resident's power of attorney should have been notified of the missed doses, but no such notification was documented.
Non-Sterile PICC Line Dressing Change
During a direct observation on April 29, inspectors watched a licensed practical nurse (LPN) change a PICC line dressing on the same resident - and documented multiple breaks in sterile technique.
After donning sterile gloves, the LPN lifted the resident's arm and placed a sterile pad underneath it. She then put on a face mask, touching the tops of her ears and hair with the sterile gloves. After removing the soiled dressing and cleaning the insertion site, she removed the gloves and applied a second pair of sterile gloves without washing or sanitizing her hands. During this second gloving, her bare left fingers touched the outside of the right sterile glove. She then handled the underside of the kit wrap, repositioned the kit on the bed, and touched the resident's arm before applying the new dressing.
A PICC line provides direct vascular access, meaning any bacteria introduced at the insertion site can enter the bloodstream rapidly. Catheter-related bloodstream infections carry mortality rates between 12 and 25 percent in vulnerable nursing home populations. Sterile technique during dressing changes exists specifically to prevent this outcome. The Director of Nursing confirmed that PICC line dressing changes were required to follow a sterile process.
For a second resident with a midline IV catheter, inspectors found no documentation that the dressing had been changed within 24 hours of insertion as required, no evidence the line had been flushed before and after medication administration, and no recorded assessments for signs of infection. The Director of Nursing acknowledged that while an order existed for the midline itself, no orders had been written for flushing, dressing changes, or ongoing catheter care.
Infection Control and Incontinence Failures
Inspectors observed staff members entering the rooms of two residents on Enhanced Barrier Precautions (EBP) without wearing the required gowns. In both cases, staff initially stated that EBP was not required - only recognizing the need for gowns after being prompted by the surveyor's presence or after reading the posted signage. Both residents had PICC lines and care plans specifying gown and glove use during high-contact care.
Separately, two residents with dementia were found in urine-saturated bedding during morning observations. On April 29, a CNA acknowledged she had not checked one resident for incontinence since arriving at 6:00 a.m. The resident's gown, brief, two incontinence pads, and bed sheet were all saturated. Despite the extensive urine exposure, staff cleaned only the peri area and buttocks - leaving urine on the resident's abdomen, back, arms, and legs without bathing. A similar situation was documented the following day with a second resident.
The facility's own incontinence care policy requires checks every two hours. The Director of Nursing confirmed both residents should have been checked and changed earlier, and should have received a full bath given the extent of the incontinence.
The full inspection report is available through the [CMS Care Compare](https://www.medicare.gov/care-compare/) database. Readers seeking complete details on all cited deficiencies should consult the official survey documentation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Symphony of Crown Point LLC from 2025-05-01 including all violations, facility responses, and corrective action plans.
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