Oak Grove Christian Retirement Village: Missed Respiratory Meds - IN
The resident was cognitively impaired and required oxygen therapy. Their care plan, dated March 31, 2025, documented COPD and chronic respiratory failure with hypoxia, a condition in which the body does not receive enough oxygen. Interventions listed in the plan included administering inhalers and aerosol bronchodilators as ordered by a physician.
The orders were not followed.
The August physician order summary showed three active respiratory medications: ipratropium/albuterol solution, to be inhaled four times daily; Anoro Ellipta, an aerosol inhaler to be taken once daily; and budesonide suspension via nebulizer, also four times daily. Together, these medications form the kind of layered respiratory regimen prescribed when a patient's lungs cannot be trusted to function on their own.
The June 2025 medication administration record told a different story. The Anoro Ellipta inhaler was not given on June 19 or June 25, both at noon. The budesonide suspension was not administered on June 1, June 19, or June 25, also at noon. That means on at least two separate days in June, this resident went without two of their three breathing medications at the same scheduled hour.
July brought another gap. The ipratropium/albuterol inhaler, the one ordered four times a day, was not given on July 26 at 6:00 a.m.
Six missed doses in total, spread across seven weeks, for a resident with documented chronic respiratory failure.
When inspectors interviewed the Director of Nursing on August 13 at 2:15 p.m., she said she had no further information to provide.
That was the entirety of the facility's response.
The inspection was triggered by a complaint, logged under case number 2587154. The level of harm was categorized as minimal harm or potential for actual harm, and the citation affected a small number of residents. But the clinical picture for this particular resident leaves little room for comfort. COPD is a progressive disease. Chronic respiratory failure with hypoxia means the body is already struggling to maintain adequate oxygen levels under the best circumstances. The medications that were missed are not optional add-ons. Ipratropium/albuterol opens constricted airways. Budesonide reduces inflammation in the lungs. Anoro Ellipta combines a long-acting bronchodilator with a muscarinic antagonist to keep airways open over time. Each one addresses a different mechanism of the same underlying failure. Skipping any one of them, on any given day, removes a layer of protection for someone whose lungs already cannot compensate.
For a cognitively impaired resident, the stakes are compounded. A person who cannot clearly communicate distress, who may not recognize that their breathing has worsened, who cannot ask a nurse why their inhaler hasn't arrived, is entirely dependent on the system working as designed.
On at least six occasions across June and July, it did not.
The facility's care plan acknowledged the resident's condition and spelled out the interventions required. The physician's orders were current. The medications were prescribed. What the medication administration records show is not a documentation dispute or a question of whether the treatments were appropriate. They show, date by date and hour by hour, that the treatments were ordered and did not happen.
The Director of Nursing, the person responsible for overseeing medication administration across the facility, offered nothing to explain why.
Oak Grove Christian Retirement Village sits in DeMotte, a small town in northwestern Indiana. The inspection was conducted on August 13, 2025. The citation covered violations under Indiana administrative code sections 3.1-50(a)(1) and 3.1-50(a)(2).
The resident, cognitively impaired and reliant on oxygen to get through each day, had no way to know their medications had been skipped. They had no way to ask why. They had no way to know whether anyone at the facility would be held accountable.
As of the inspection date, the Director of Nursing's answer remained the same. No further information to provide.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oak Grove Christian Retirement Village from 2025-08-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 23, 2026 · Our methodology
OAK GROVE CHRISTIAN RETIREMENT VILLAGE in DEMOTTE, IN was cited for violations during a health inspection on August 13, 2025.
The resident was cognitively impaired and required oxygen therapy.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.