28 health deficiencies
Top issue: Quality of Life and Care (15 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Crown Point, IN
1-star overall rating with 1-star inspections with Special Focus status with $39,485 in total fines with 28 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
6685 East 117th Avenue, Crown Point, IN
(219) 662-0642
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
145
Certified beds
Average residents
116
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Casa Consulting
Operator or chain grouping
Approved since
1997-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 1 overall / 1 health / 1 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Program rank
13,412
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
5.53
Composite VBP score used to determine payment impact.
Payment multiplier
0.9806
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 18.66% · Performance 22.22% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.23% · Performance 9.13% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0.55
Performance 61.42% · Measure score 0.55 · Achievement 0.55 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.66
Baseline 4.81 hours · Performance 3.55 hours · Measure score 1.66 · Achievement 1.66 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.56% |
10.72%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 273 · Observed rate 13.92% · Lower 95% interval 9.7% |
| Discharge to community | 59.71% |
50.57%
9.1 pts better
|
Better than the National Rate · Eligible stays 267 · Observed rate 54.31% · Lower 95% interval 52.09% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 77.91% |
95.27%
17.4 pts worse
|
Numerator 134 · Denominator 172 |
| Falls with major injury | 0.58% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 172 |
| Discharge self-care score | 48.03% |
53.69%
5.7 pts worse
|
Numerator 61 · Denominator 127 |
| Discharge mobility score | 53.54% |
50.94%
2.6 pts better
|
Numerator 68 · Denominator 127 |
| Pressure ulcers or injuries, new or worsened | 7.56% |
2.29%
5.3 pts worse
|
Numerator 13 · Denominator 172 · Adjusted rate 7.16% |
| Healthcare-associated infections requiring hospitalization | 9.13% |
7.12%
2 pts worse
|
No Different than the National Rate · Eligible stays 175 · Observed rate 10.29% · Lower 95% interval 6.4% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 176 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 62.2% |
56.45%
5.8 pts better
|
Numerator 79 · Denominator 127 |
| Transfer of health information to provider | 98.96% |
95.95%
3 pts better
|
Numerator 95 · Denominator 96 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 32 · Denominator 32 |
| Resident COVID-19 vaccinations up to date | 9.76% |
25.2%
15.4 pts worse
|
Numerator 8 · Denominator 82 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.6
0.3 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.5
0.4 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.7 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 84.1% |
93.6%
9.5 pts worse
|
93.4%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 71.4% · Q2 67.4% · Q3 97.6% · Q4 98.0% · 4Q avg 84.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.7% |
95.4%
1.7 pts worse
|
95.5%
1.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
3.8%
2.4 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 1.2% · Q4 3.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.1% |
24.6%
20.5 pts better
|
11.4%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 6.8% · Q3 2.7% · Q4 4.3% · 4Q avg 4.1% |
| Percentage of long-stay residents who lose too much weight | 8.9% |
5.6%
3.3 pts worse
|
5.4%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 14.7% · Q3 9.2% · Q4 6.2% · 4Q avg 8.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.4% |
23.5%
10.1 pts better
|
19.6%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 12.9% · Q3 17.9% · Q4 11.8% · 4Q avg 13.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.4% |
14.8%
2.4 pts better
|
16.7%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 11.5% · Q3 8.8% · Q4 13.2% · 4Q avg 12.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.8% |
13.3%
8.5 pts worse
|
16.3%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.5% · Q2 26.8% · Q3 15.3% · Q4 18.3% · 4Q avg 21.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.1% |
11.7%
1.4 pts worse
|
14.9%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 19.4% · Q3 4.6% · Q4 11.5% · 4Q avg 13.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
0.4%
1.3 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 1.6% · Q3 2.1% · Q4 2.1% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
1.2%
0.5 pts worse
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 1.2% · Q3 1.2% · Q4 2.1% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.4% |
24.2%
3.2 pts worse
|
19.8%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.9% · Q2 41.2% · Q3 12.8% · Q4 26.6% · 4Q avg 27.4% |
| Percentage of long-stay residents with pressure ulcers | 8.3% |
4.1%
4.2 pts worse
|
5.1%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 9.9% · Q3 5.1% · Q4 10.2% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 63.9% |
81.6%
17.7 pts worse
|
81.7%
17.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 33.9% · Q2 42.2% · Q3 78.1% · Q4 98.3% · 4Q avg 63.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.5% |
10.5%
About the same
|
12.0%
1.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.5% · Observed 10.0% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.3%
0.5 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 1.4% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 48.5% |
79.0%
30.5 pts worse
|
79.7%
31.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 48.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.5% |
22.4%
1.1 pts worse
|
23.9%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.5% · Observed 20.7% · Expected 21.0% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (15 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (13 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Quality of Life and Care (7 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2025-04-18
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-18
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-04-18
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-04-18
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-18
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-18
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-18
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-06
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-06
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-06-25
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-06
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-06
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-06-06
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-06-06
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-06-06
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-06
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-06-29
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-06-29
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-29
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-29
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-29
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-06-29
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-29
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-29
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-06-29
Inspection history
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-08-25
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-11
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-25
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-19
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-08-19
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-08-25
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-08-19
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-08-25
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-19
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-04-17
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-04-17
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-17
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-04-17
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-17
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-03-17
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-04-17
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-17
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-03-17
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-04-17
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-17
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-17
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-03-17
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-17
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-04-17
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-04-17
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-03-17
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-17
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-17
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-04-17
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-17
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-01-07
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-01-07
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-07
Health
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Corrected 2025-01-07
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-09-20
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-09-20
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-20
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-03
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-09-03
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-09-03
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-03
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-09-03
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-03
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-05-24
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-05-24
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-16
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-04-16
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-04-16
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-04-16
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-16
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-16
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-04-16
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-16
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2024-04-16
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-02-19
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-02-19
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2023-11-02
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2023-05-26
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-05-26
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-05-26
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-05-26
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-05-26
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-05-26
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-05-26
Health
Provide activities to meet all resident's needs.
Corrected 2023-05-26
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-26
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-05-26
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-05-26
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-05-26
Penalties and ownership
Fine · fine $39,485
Fine
Payment Denial · denial start 2025-08-16 · 9 days
9 day denial
Payment Denial · denial start 2025-04-04 · 13 days
13 day denial
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
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