WELLBROOKE OF CARMEL
For profit - Limited Liability company
74 Beds
TRILOGY HEALTH SERVICES
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
46/100
#202 of 505 in IN
Photo by Wellbrooke of Carmel
Photo by Wellbrooke of Carmel
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1 / 6 photos
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Wellbrooke of Carmel has a Trust Grade of D, indicating below-average performance with some significant concerns. Ranking #202 out of 505 facilities in Indiana places them in the top half, but their county rank at #7 of 17 suggests that there are better local options available. The facility is experiencing a worsening trend, with issues increasing from 6 in 2024 to 7 in 2025. Staffing is a weak point, with a rating of 2 out of 5 stars and a high turnover rate of 59%, compared to the state average of 47%. Additionally, the facility has incurred $15,646 in fines, which is concerning as it is higher than 90% of Indiana facilities, reflecting ongoing compliance issues. On the positive side, Wellbrooke of Carmel has received a 4 out of 5 star rating overall, with quality measures rated as excellent. However, there have been serious incidents, including one critical finding where a resident died after being provided the wrong diet texture, leading to choking. Another serious issue involved a resident who was hospitalized due to inadequate catheter care, resulting in a life-threatening infection. Furthermore, there was a failure to ensure RN coverage for 8-hour shifts on two occasions, which could potentially impact the care of all residents. Families should weigh these strengths and weaknesses carefully when considering this facility for their loved ones.
- Trust Score
- D
- In Indiana
- #202/505
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 59% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ⚠ Watch
- $15,646 in fines. Higher than 95% of Indiana facilities. Major compliance failures.
- Skilled Nurses ○ Average
- Each resident gets 38 minutes of Registered Nurse (RN) attention daily — about average for Indiana. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 35 deficiencies on record. Higher than average. Multiple issues found across inspections.
46/100
Top 40%
Review needed
6 → 7 violations
★★★★☆
4.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★★
5.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 6 issues
2025: 7 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
Staff Turnover: 59%
13pts above Indiana avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $15,646
Below median ($33,413)
Minor penalties assessed
Chain: TRILOGY HEALTH SERVICES
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (59%)
11 points above Indiana average of 48%
The Ugly 35 deficiencies on record
1 life-threatening 1 actual harm
Sept 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure pain assessments were completed prior to and after the administration of narcotic pain medication for 2 of 3 residents reviewed for ...
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Based on interview and record review, the facility failed to ensure pain assessments were completed prior to and after the administration of narcotic pain medication for 2 of 3 residents reviewed for quality of care. (Resident B and C)Findings include:1. The clinical record for Resident B was reviewed on 9/12/25 at 3:00 p.m. The diagnoses included, but were not limited to, dementia, chronic kidney disease, malignant melanoma of the skin, anxiety disorder, and chronic degeneration of the lumbar region.A physician's order, dated 3/17/25, indicated to administer Oxycodone (a narcotic pain medication) 5 mg (milligrams) once a day as needed for pain. The Electronic Medication Administration Record (EMAR) indicated a pain assessment was to be completed prior to administering the medication and to follow-up on the effectiveness of the medication after it was administered.A pain assessment was not documented on the EMAR prior to or after the medication was administered on the following dates and times:a. On 7/18/25 at 12:00 a.m.b. On 7/23/25 at 12:25 a.m.c. On 7/24/25 at 12:00 a.m.d. On 7/27/25 at 8:00 p.m.e. On 8/5/25 12:00 a.m.f. On 8/6/25 at 9:00 p.m.g On 8/19/25 at 9:30 p.m. 2. The clinical record for Resident C was reviewed on 9/12/25 at 3:15 p.m. The diagnoses included, but were not limited to, dysarthria following cerebral infarction, stiffness of the right shoulder, type II diabetes mellitus with diabetic neuropathy, and major depressive disorder.A physician's order, dated 5/31/24, indicated to administer Oxycodone 5-325 mg as needed every six hours for moderate to severe pain. The Electronic Medication Administration Record (EMAR) indicated a pain assessment was to be completed prior to administering the medication and to follow-up on the effectiveness of the medication after it was administered.A pain assessment was not documented on the EMAR prior to or after the medication was administered on the following dates and times:a. On 8/15/25 at 1:15 a.m.b. On 8/19/25 at 11:00 p.m. During an interview, on 9/12/25 at 12:40 p.m., Resident B indicated she had not asked for pain medication over the last few weeks, except for one day last week for pain in her shoulder.During an interview, on 9/12/25 at 2:11 p.m., Resident C denied asking for pain medication over the last few weeks. Resident C's daughter was present during the interview and indicated her Resident C would not have asked for the strong pain medication, she preferred Tylenol if she needed something for pain. During an interview, on 9/12/25 at 3:34 p.m., the Executive Director indicated LPN 2 should have completed a pain assessment prior to administering narcotic pain meds to Resident B and C. LPN 2 should have also completed a follow-up pain assessment after the administration of the narcotic pain medication to assess how effective the pain medication was for each resident.This Citation was related to Intake 2598338.3.1-37(a)
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure narcotic pain medications were documented as administered on the medication administration record for 2 of 3 residents reviewed for ...
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Based on interview and record review, the facility failed to ensure narcotic pain medications were documented as administered on the medication administration record for 2 of 3 residents reviewed for controlled medications. (Resident B and C) The deficient practice was corrected on 8/22/25, prior to the start of the survey, and was therefore past noncompliance.Findings include:A facility reported incident, dated 9/4/25, indicated there was an irregularity noted in the narcotic sign out sheets for Residents B and C. When both residents were interviewed, they indicated they had not requested the as needed narcotics which were signed out on 8/19/25 and 8/20/25.1. The clinical record for Resident B was reviewed on 9/12/25 at 3:00 p.m. The diagnoses included, but were not limited to, dementia, chronic kidney disease, malignant melanoma of the skin, anxiety disorder, and chronic degeneration of the lumbar region.A physician's order, dated 3/17/25, indicated to administer Oxycodone (a narcotic pain medication) 5 mg (milligrams) once a day as needed for pain. Resident B's narcotic count sheet indicated Oxycodone was given on the following dates and times, but there was no signature on the electronic medication administration record (EMAR) to indicate the resident had received the medication.a. On 7/18/25 at 12:00 a.m.b. On 7/23/25 at 12:25 a.m.c. On 7/24/25 at 12:00 a.m.d. On 7/27/25 at 8:00 p.m.e. On 8/5/25 12:00 a.m.f. On 8/6/25 at 9:00 p.m.g On 8/19/25 at 9:30 p.m. 2. The clinical record for Resident C was reviewed on 9/12/25 at 3:15 p.m. The diagnoses included, but were not limited to, dysarthria following cerebral infarction, stiffness of the right shoulder, type II diabetes mellitus with diabetic neuropathy, and major depressive disorder.A physician's order, dated 5/31/24, indicated to administer Oxycodone 5-325 mg as needed every six hours for moderate to severe pain. Resident C's narcotic count sheet indicated Oxycodone was given on the following dates and times, but there was no signature on the EMAR to indicate the resident had received the medication. a. On 8/15/25 at 1:15 a.m.b. On 8/19/25 at 11:00 p.m. During an interview, on 9/12/25 at 12:40 p.m., Resident B indicated she had not asked for pain medication over the last few weeks, except for one day last week for pain in her shoulder.During an interview, on 9/12/25 at 2:11 p.m., Resident C denied asking for pain medication over the last few weeks. Resident C's daughter was present during the interview and indicated her Resident C would not have asked for the strong pain medication, she preferred Tylenol if she needed something for pain. During an interview, on 9/12/25 at 3:34 p.m., the Executive Director indicated LPN 2 should have documented the narcotics she administered to Resident B and C on the EMAR's as well as the narcotic sign out sheets.A current facility policy, titled The 6 Rights of Medication Administration, undated and provided by the Executive Administrator on 9/12/25 at 2:00 p.m., indicated .Right Documentation: Record the administration of a medication after you give it to your individual. Follow your agency policy for proper documentation.The deficient practice was corrected by 8/22/25, after the facility implemented a plan which included a thorough investigation, staff and resident interviews, staff education and narcotic medication audits.This citation relates to Intake 2598338.3.1-25(b)(3)
Jan 2025
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's code status was changed when an out of hospital...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's code status was changed when an out of hospital do not resuscitate declaration and order was received for 1 of 3 residents reviewed for advanced directives. (Resident 9)
Finding includes:
The clinical record for Resident 9 was reviewed on [DATE] at 2:35 p.m. The diagnoses included, but were not limited to, Alzheimer's disease, hypertension, attention-deficit hyperactivity disorder, anxiety disorder, depressive disorders, bipolar II disorder, and chronic kidney disease.
A physician's order, dated [DATE], indicated the resident's code status was a full code.
An out of hospital do not resuscitate declaration and order form, dated [DATE], was signed by the resident on [DATE]. The physician signed the form on [DATE]. It was scanned into the electronic medical record on [DATE].
The physician did not sign the form until 6 days after the resident signed the form.
A social service note, dated [DATE] at 9:57 a.m., indicated the resident's code status was reviewed and updated to do not resuscitate during her care plan meeting.
A physician's progress note, dated [DATE] at 1:03 p.m., indicated the resident was a full code.
A physician's progress note, dated [DATE] at 12:15 p.m., indicated the resident was a full code.
On [DATE] at 11:35 a.m., the resident was listed as a full code at the top of her electronic medical record and on her face sheet.
On [DATE] at 3:54 p.m., Resident 9 was listed as a full code in the information banner of the electronic medical record.
During an interview, on [DATE] at 2:53 p.m., the Director of Nursing (DON) indicated the signed form was scanned into the resident's medical record, but the facility was just now updating their charting system with the correct order and changing it in the electronic medical record. It had been missed and was listed incorrectly until now.
During an interview, on [DATE] at 3:11 p.m., LPN 2 indicated in an emergency, staff would check the computer and look at the resident's top banner information to find out if they should start CPR or if resident wished to be a DNR.
A current facility policy, titled Guidelines for Advanced Directives, dated as revised on [DATE] and provided by the Clinical Support Nurse 3 on [DATE] at 10:25 a.m., indicated .To ensure facility staff obtains and follows resident's advanced directives regarding end-of-life care .The nursing staff will confirm the desired code status and obtain an order from the physician .Designation of code status and obtainment of physician order will be part of the medical record.
3.1-4(f)(5)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
2. The clinical record for Resident 29 was reviewed on 1/14/25 at 3:29 p.m. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, insomnia, and visual hallucinations.
A revie...
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2. The clinical record for Resident 29 was reviewed on 1/14/25 at 3:29 p.m. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, insomnia, and visual hallucinations.
A review of the Resident First Meeting Minutes indicated the facility had not conducted a care plan meeting for Resident 29 since 5/30/24. The resident had not had a quarterly care plan meeting held since that time.
A nursing progress note, dated 10/11/24, indicated Resident 29 had been experiencing intermittent hallucinations.
A psychiatry note, dated 10/16/24, indicated Resident 29 had been experiencing visual hallucinations since her husband's death in April 2024. The hallucinations had started to occur more frequently, and Resident 29 was started on Risperidone (an antipsychotic medication) for the visual hallucinations.
During an interview, on 1/16/25 at 3:01 p.m., the Clinical Support Nurse 3 indicated the facility had not held a care plan meeting for Resident 29 since 5/30/24 and the last quarterly meeting had been missed.
3. During an interview, on 1/13/25 at 11:37 a.m., Resident 30 indicated she had not been invited to attend a care plan meeting in a long time.
The clinical record for Resident 30 was reviewed on 1/14/25 at 3:37 p.m. The diagnoses included, but were not limited to, malignant neoplasm of upper lobe, left bronchus or lung, severe protein-calorie malnutrition, and muscle weakness.
A review of the Resident First Meeting Minutes indicated the facility had not conducted a care plan meeting for Resident 30 since 7/15/24.
During an interview, on 1/16/25 at 3:01 p.m., the Clinical Support Nurse 3 indicated the facility conducted a care plan meeting in January 2025, but it was after the last quarterly care plan meeting was due. She indicated the facility had significant employee turnover and had focused on conducting care plan meetings for the rehab residents.
A current facility policy, titled Resident's First Meeting Guidelines, dated as last reviewed on 12/17/24 and received from the Clinical Support Nurse 3 on 1/16/25 at 2:59 p.m., indicated .To facilitate communication and participation regarding the residents plan of care, medical condition and care needs between the resident, family, resident representative and care givers .Subsequent meetings for non-Medicare residents should be conducted at a minimum of quarterly and with significant change .Subsequent meetings for Medicare residents should be conducted minimally quarterly .Director of Social Services or designee should send invitations to the resident and/or representative notifying them of the date and time of the conference as far in advance as possible .Prior to the meeting the interdisciplinary team members should: Review the resident's condition since the last assessment .Review recent changes in medications and physician's orders .Make sure issues related to Falls, Restraints, Skin breakdown, Psychotropic medications, and Weight loss/gain are discussed and that reasonable, measurable goals and effective interventions are implemented and documented .The Resident First Meeting is a time to communicate information related to care needs and medical condition and seek input from the resident or representative .Review the residents condition since the last meeting. Recent changes in medications and physician's orders, problems, and any areas of concern should be discussed with the team, family, and resident .Discuss additions or changes that may be needed to goal areas or care routine allowing input from the resident and/or representative
3.1-35(a)
3.1-35(b)(1)
3.1-35(d)(2)(B)
3.1-35(e)
Based on interview and record review, the facility failed to ensure a care plan meeting was offered or held for 3 of 3 residents reviewed for care plan meetings. (Resident 23, 29 and 30)
Findings include:
1. The clinical record for Resident 23 was reviewed on 1/15/25 at 2:20 p.m. The diagnoses included, but were not limited to, depression, anxiety disorder, and Alzheimer's disease.
The record for Resident 23 did not have a quarterly care plan meeting documented between 4/17/24 and 12/4/24.
During an interview, on 1/17/25 at 10:03 a.m., the Clinical Support Nurse 3 indicated the resident had a care plan meeting on 4/17/24 and 12/4/24, but nothing in between.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure a blood pressure medication was held according to the physician's ordered hold parameter and to ensure the physician was notified fo...
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Based on interview and record review, the facility failed to ensure a blood pressure medication was held according to the physician's ordered hold parameter and to ensure the physician was notified for an elevated blood sugar level according to the call parameter for 3 of 3 residents reviewed for quality of care. (Resident 194, 4 and 2)
Findings include:
1. The clinical record for Resident 194 was reviewed on 1/15/25 at 11:29 a.m. The diagnoses included, but were not limited to, metabolic encephalopathy, hypotension, anemia, dementia, and type 2 diabetes mellitus.
A physician's order, dated 1/9/25, indicated to give midodrine (a medication used to treat orthostatic hypotension) 5 milligrams (mg) twice a day with special instructions to hold the medication for a systolic blood pressure greater than 120.
A review of the January 2025 Medication Administration Record, dated January 8 through 17, 2025, indicated the medication was administered to Resident 194 when the systolic blood pressure was greater than 120 on the following days:
On 1/9/25, the resident's systolic blood pressure was 122 in the morning and 126 in the evening, and the medication was administered.
On 1/10/25, the resident's systolic blood pressure was 132 in the morning and 129 in the evening, and the medication was administered.
On 1/11/25, the resident's systolic blood pressure was 128 in the evening, and the medication was administered.
On 1/12/25, the resident's systolic blood pressure was 126 in the morning, and the medication was administered.
On 1/13/25, the resident's systolic blood pressure was 130 in the morning and 129 in the evening, and the medication was administered.
On 1/14/25, the resident's systolic blood pressure was 130 in the morning and 135 in the evening, and the medication was administered.
On 1/15/25, the resident's systolic blood pressure was 136 in the morning and 132 in the evening, and the medication was administered.
On 1/16/25, the resident's systolic blood pressure was 137 in the morning and 136 in the evening, and the medication was administered.
On 1/17/25, the resident's systolic blood pressure was 134 in the morning, and the medication was administered.
The electronic medical record did not include documentation of notification to the physician of the medication being administered outside the ordered hold parameters.
During an interview, on 1/15/25 at 3:11 p.m., LPN 2 indicated the staff member's initials were in parenthesis when a medication was held. When there was no parenthesis, the medication was administered.
During an interview, on 1/16/25 at 12:06 p.m., the Clinical Support Nurse 3 indicated the nurse should follow the ordered hold parameters and not administer the medication.
2. The clinical record for Resident 4 was reviewed on 1/14/25 at 3:42 p.m. The diagnoses included, but were not limited to, hypertension, hyperlipidemia (high cholesterol), and type 2 diabetes.
A physician's order, dated 5/29/24, indicated to give carvedilol (an antihypertensive medication) 12.5 milligrams twice a day. The order had special instructions to hold the medication if the systolic blood pressure was less than 100 or if the heart rate (pulse) was less than 65 beats per minute.
A review of the November 2024 Medication Administration Record indicated the medication was administered to Resident 4 when her heart rate was less than 65 beats per minute on the following days:
On 11/05/24, the resident's heart rate was 64 in the morning, the medication was administered.
On 11/11/24, the resident's heart rate was 64 in the morning, the medication was administered.
On 11/20/24, the resident's heart rate was 64 in the evening, the medication was administered.
A review of the December 2024 Medication Administration Record indicated the medication was administered to Resident 4 when her heart rate was less than 65 beats per minute on the following days:
On 12/09/24, the resident's heart rate was 60 in the morning, the medication was administered.
On 12/13/24, the resident's heart rate was 64 in the morning, the medication was administered.
On 12/14/24, the resident's heart rate was 62 in the morning, the medication was administered.
On 12/15/24, the resident's heart rate was 63 in the morning, the medication was administered.
On 12/16/24, the resident's heart rate was 63 in the morning, the medication was administered.
On 12/20/24, the resident's heart rate was 63 in the morning, the medication was administered.
On 12/23/24, the resident's heart rate was 61 in the morning, the medication was administered.
On 12/24/24, the resident's heart rate was 60 in the morning, the medication was administered.
On 12/24/24, the resident's heart rate was 63 in the evening, the medication was administered.
On 12/30/24, the resident's heart rate was 64 in the evening, the medication was administered.
A current care plan, dated as last revised on 12/17/24, indicated the resident had a potential for cardiovascular distress due to a diagnosis of hypertension and to administer medications as ordered.
During an interview, on 1/16/25 at 10:12 a.m., LPN 1 indicated she followed the physician's order and would not give the carvedilol medication if the heart rate was less than 65.
3. The clinical record for Resident 2 was reviewed on 1/15/23 at 10:29 a.m. The diagnoses included, but were not limited to, diabetes mellitus, hypertensive, anxiety disorder, major depressive disorder, and acute kidney failure.
A care plan indicated the resident was at risk for hypoglycemia and hyperglycemia related to diabetes mellitus. Interventions included, but were not limited to, give medication per the physician's order and monitor blood sugars per the physician's order.
A physician's order, dated 6/13/24, indicated to give Humalog U-100 Insulin solution subcutaneously before meals per the sliding scale.
If the blood sugar was less than 70, call the physician.
If the blood sugar was 151 to 200, give 0 units.
If the blood sugar was 201 to 250, give 4 units.
If the blood sugar was 251 to 300, give 6 units.
If the blood sugar was 301 to 400, give 10 units.
If the blood sugar was greater than 400, call the physician.
The Medication Administration Record indicated the resident's blood sugar was 576 on 7/11/24.
There was no documentation the physician was notified of the blood sugar greater than 400.
During an interview, on 1/16/25 at 8:58 a.m., the Director of Nursing (DON) indicated there was no notification to the physician on 7/11/24 for the 576-blood sugar reading. The nurse did not notify the physician of the blood sugar and should have.
During an interview, on 1/16/25 at 11:12 a.m., Licensed Practical Nurse (LPN) 5 indicated if the resident's blood sugar was out of range, she would give the highest amount on the sliding scale and call the doctor to ask if any additional insulin was needed.
The facility did not have a policy for blood glucose monitoring.
A current facility policy, titled Medication Administration-General Guidelines, dated as revised 1/2017 and received from the Clinical Support Nurse 3 on 1/17/25 at 10:25 a.m., indicated .Medications are administered in accordance with written orders of the prescriber
3.1-37(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
2. The clinical record for Resident 1 was reviewed on 1/14/25 at 3:32 p.m. The diagnoses included, but were not limited to, sepsis (a life-threatening complication of an infection), urinary tract infe...
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2. The clinical record for Resident 1 was reviewed on 1/14/25 at 3:32 p.m. The diagnoses included, but were not limited to, sepsis (a life-threatening complication of an infection), urinary tract infection (UTI), urethral stricture (a condition which blocks the flow of urine), and urinary retention.
A physician's order indicated Resident 1 had a suprapubic catheter (a tube which drains urine directly from the bladder through a small incision in the lower abdomen) due to urethral stricture.
A physician's order, dated 5/16/24, indicated to monitor Resident 1's urinary output three times a day, every shift.
A Treatment Administration Record (TAR), dated 12/1/24 through 1/15/25, indicated the following documented urinary outputs:
On 12/1/24 between 6:00 a.m. to 2:00 p.m., medium was recorded.
On 12/1/24 between 2:00 p.m. to 10:00 p.m., medium was recorded.
On 12/3/24 between 6:00 a.m. to 2:00 p.m., medium was recorded.
On 12/3/24 between 2:00 p.m. to 10:00 p.m., medium was recorded.
On 12/17/24 between 6:00 a.m. to 2:00 p.m., large was recorded.
On 12/17/24 between 2:00 p.m. to 10:00 p.m., large was recorded.
On 12/18/24 between 6:00 a.m. to 2:00 p.m., large was recorded.
On 12/19/24 between 6:00 a.m. to 2:00 p.m., medium was recorded.
On 12/20/24 between 6:00 a.m. to 2:00 p.m., medium was recorded.
On 12/20/24 between 10:00 p.m. to 7:00 a.m., large was recorded.
On 12/21/24 between 6:00 a.m. to 2:00 p.m., large was recorded.
On 12/23/24 between 6:00 a.m. to 2:00 p.m., medium was recorded.
On 12/30/24 between 6:00 a.m. to 2:00 p.m., medium was recorded.
On 1/4/25 between 2:00 p.m. to 10:00 p.m., large was recorded.
On 1/4/25 between 2:00 p.m. to 10:00 p.m., large was recorded.
On 1/5/25 between 6:00 a.m. to 2:00 p.m., medium was recorded.
On 1/5/25 between 2:00 p.m. to 10:00 p.m., medium was recorded.
On 1/6/25 between 6:00 a.m. to 2:00 p.m., large was recorded.
On 1/6/25 between 2:00 p.m. to 10:00 p.m., large was recorded.
On 1/8/25 between 6:00 a.m. to 2:00 p.m., medium was recorded.
On 1/10/25 between 6:00 a.m. to 2:00 p.m., medium was recorded.
On 1/10/25 between 2:00 p.m. to 10:00 p.m., large was recorded.
On 1/11/25 between 6:00 a.m. to 2:00 p.m., large was recorded.
On 1/13/25 between 6:00 a.m. to 2:00 p.m., medium was recorded.
During an interview, on 1/16/25 at 11:03 a.m., Certified Nursing Assistant (CNA) 4 indicated to measure urinary output from a catheter, the catheter bag would be emptied into a urinal and the amount would be documented in mL (milliliters). CNAs document the output in the Matrix (a facility charting platform). The catheter bag would be emptied at least once a shift, or when the catheter bag looked like it needed emptied.
During an interview, on 1/16/25 at 11:16 a.m., LPN 5 indicated the nurse would obtain the urinary outputs from the CNAs and document the output in the Treatment Administration Record (TAR). The urinary output amount should be documented in milliliters.
During an interview, on 1/16/25 at 12:16 p.m., Clinical Support Nurse 3 indicated the facility did not have a policy regarding documentation of intake and outputs.
The Indiana State Department of Health Nurse Aide Curriculum, revised 11/19/15, indicated .Resident Care Procedure (RCP) 50 .Empty Urinary Drainage Bag .Detach spout (if bag has one) and point the drainage tube into center of graduated cylinder without letting tube touch sides .Unclamp spout and drain urine .Check urine for color, odor, amount and characteristics and report unusual findings to nurse .Changes may be first signs of medical problem. By alerting the nurse you ensure that the resident receives prompt attention .Measure and accurately record amount of urine .Accuracy is necessary because decisions regarding resident ' s care may be based on your report
3.1-41(a)(2)
Based on interview and record review, the facility failed to ensure the suprapubic catheter urine output was accurately recorded for 2 of 3 residents reviewed for urinary catheters. (Resident 20 and 1)
Finding includes:
1. The clinical record for Resident 20 was reviewed on 1/15/25 at 2:40 p.m. The diagnoses included, but were not limited to, obstructive and reflux uropathy (hindrance of normal urine flow), feeling of incomplete bladder emptying, retention of urine, and the presence of urogenital implants (helps provide normal urine flow).
A care plan, dated 2/9/23, indicated the resident had a suprapubic catheter (a tube which drains urine from the bladder through a small incision in the lower abdomen). Interventions included, but were not limited to, record the resident's urinary output and assist with catheter care.
A physician's order, dated 2/24/23, indicated to monitor catheter output every shift.
A Treatment Administration Record (TAR), dated 12/28/24 through 1/15/25, indicated to empty the catheter every shift and document the output. The following was documented:
On 12/29/24 at 8:46 p.m., large was recorded.
On 12/30/24 at 2:40 a.m., medium was recorded.
On 12/30/24 at 12:00 p.m., medium was recorded.
On 12/31/24 at 6:53 a.m., medium was recorded.
On 1/1/25 at 9:20 a.m., large was recorded.
On 1/2/25 at 8:57 p.m., large was recorded.
On 1/3/25 at 1:37 p.m., large was recorded.
On 1/4/25 at 8:52 p.m., large was recorded.
On 1/5/25 at 9:18 p.m., large was recorded.
On 1/5/25 at 11:01 p.m., medium was recorded.
On 1/6/25 at 2:16 p.m., medium was recorded.
On 1/8/25 at 1:31 p.m., medium was recorded.
On 1/9/25 at 12:51 p.m., large was recorded.
On 1/9/25 at 1:30 p.m. large was recorded.
On 1/12/25 at 1:58 p.m., medium was recorded.
On 1/14/25 at 1:39 p.m., medium was recorded.
On 1/15/25 at 5:31 a.m., large was recorded.
On 1/15/25 at 11:53 a.m., large was recorded.
On 1/15/25 at 3:22 p.m., large was recorded.
During an interview, on 1/16/25 at 10:38 a.m., Licensed Practical Nurse (LPN) 5 indicated the Certified Nursing Assistant (CNA) normally charted the urine output. If they did not have time, she would add them into the electronic medical record. The urine output should have been documented as milliliters.
During an interview, on 1/16/25 at 10:51 a.m., CNA 6 indicated she did not know why the exact urine amount was not documented when the CNA emptied the catheter into the graduated cylinder. When she charted the amount of urine, she would add the amount in milliliters. When the bag was full to the top, she would consider the amount large, halfway would be medium and small would be hardly anything in the bag.
During an interview, on 1/16/25 at 11:02 a.m., CNA 7 indicated staff should not chart the catheter outputs by using small, medium, and large for the amounts.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure medication administration or reason medication was not given was documented in the Medication Administration Record for 1 of 7 resid...
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Based on interview and record review, the facility failed to ensure medication administration or reason medication was not given was documented in the Medication Administration Record for 1 of 7 residents reviewed for documentation. (Resident 30)
Finding includes:
The clinical record for Resident 30 was reviewed on 1/14/25 at 3:43 p.m. The diagnoses included, but were not limited to, adjustment disorder with mixed anxiety and depressed mood, constipation, and bilateral pulmonary embolism (a clot in the lungs).
The Medication Administration Record (MAR) was missing documentation of medication administration or lack of administration on the following days:
A physician's order for buspirone (an anxiety medication) 5 milligrams (mg) was to be given twice a day for an adjustment disorder. There was no documentation, on 12/12/24, to indicate the evening dose was administered.
A physician's order for cholecalciferol (a supplement) 50 micrograms (mcg) was to be given once a day. There was no documentation, on 12/12/24, to indicate the dose was administered.
A physician's order for Cymbalta (an antidepressant) 20 mg was to be given once a day for an adjustment disorder. There was no documentation, on 12/12/24, to indicate the dose was administered.
A physician's order for docusate sodium (a stool softener) 100 mg was to be given twice a day for constipation. There was no documentation, on 12/12/24, to indicate the morning dose was administered.
A physician's order for gabapentin (a medication used to treat nerve pain) 300 mg was to be given three times a day for neuropathy. There was no documentation, on 12/12/24, to indicate the morning or afternoon dose was administered.
There were seven (7) additional missed medication administration documentation opportunities found in the December MAR.
During an interview, on 1/17/25 at 9:24 a.m., the Corporate Support Nurse 3 indicated medications were to be documented after they were given.
A current facility policy, titled PREPARATION AND GENERAL GUIDELINES, dated as revised January 2017 and received from the Corporate Support Nurse 3 on 1/17/25, indicated .If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time .it is documented on MAR or in the EHR (electronic health record)
3.1-50(a)(2)
Aug 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure a resident's credit card was kept safe and secure during her admission for 1 of 3 residents reviewed for misappropriati...
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Based on observation, interview and record review, the facility failed to ensure a resident's credit card was kept safe and secure during her admission for 1 of 3 residents reviewed for misappropriation of property. (Resident B) The deficient practice was corrected on 7/18/24, prior to the start of the survey, and therefore was past noncompliance.
Finding includes:
A document, titled Indiana State Department of Health Survey Report System, dated 7/18/24, indicated Resident B reported missing a credit card which had charges on it she was not responsible for. The card was deactivated. The local police were notified, and an investigation was started. A staff member was terminated for stealing Resident B's credit card.
The clinical record for Resident B was reviewed on 8/1/24 at 10:13 a.m. The diagnoses included, but were not limited to, chronic kidney disease stage 3, dependence on dialysis, hypertension, type II diabetes mellitus, and personal history of thrombus and embolism.
The employee record for Housekeeper 1 was reviewed, on 8/1/24 at 11:45 a.m. The record included, but were not limited to, the following documents:
a. An Indiana State Police screening report indicated Housekeeper 1's information provided inclusive results, and it was recommended to obtain her fingerprints.
b. A document, titled Personal Action Form, dated 7/16/24, indicated Housekeeper 1 was suspended on 7/15/24, due to being involved in a theft investigation. She left on her lunch break and never returned.
c. A document, titled Personal Action Form, dated 7/18/24, indicated Housekeeper 1 was terminated from the facility, on 7/18/24, for quitting without notice and no call no show. The comment section indicated Housekeeper 1 was involved in a theft investigation. She was asked to give her statement. On 7/15/24, she left for her lunch break and never returned. She did not answer calls or respond to texts from the facility. She was a no call no show for her 7/16/24 and 7/17/24 shifts with no response to her supervisor or the Executive Director (ED). The police were investigating the theft of Resident B's credit card.
The facility investigation of Resident B's credit card included, but were not limited to, the following documents:
a. A document, titled Investigation Summary, indicated on 7/13/24 at 5:00 p.m., Resident B reported her credit card was missing with charges she was not responsible for. The resident indicated her credit card was in her phone case wallet at approximately 9:00 a.m. She left her room around 10:00 a.m., to go do an activity, then went to physical therapy in the gym then to lunch at approximately 12:50 p.m. After the resident returned to her room, she picked up her phone case wallet and noticed her credit card was not in her wallet. She called her bank and reported the credit card missing. She found the credit card had an unknown transaction at a McDonald's at 12:30 p.m. The card was deactivated, and she reported the stolen credit card to the nurse on duty. Her credit card came up missing between the timeframe of 10:00 a.m. and 1:40 p.m., on 7/13/24.
b. A typed statement by Housekeeper 3, dated 7/16/24, indicated she was training Housekeeper 1 on 7/13/24. Housekeeper 3 asked Housekeeper 1 if she needed a break and she indicated Yes, so they left and went on a lunch break. Housekeeper 1 mentioned to Housekeeper 3 she was going to her car, and she would be back. When Housekeeper 3 went to the employee break room to grab her iPad, she observed Housekeeper 1 eating McDonalds. Housekeeper 1 told Housekeeper 3 her husband had gotten her some food to eat for lunch. Housekeeper 1 disappeared randomly at approximately 2:00 p.m.
During an interview, on 8/1/24 at 11:00 a.m., Resident B was observed sitting in her standard wheelchair in the therapy room. She indicated she had opened her phone wallet case where her credit card was kept prior to getting her morning care and her credit card was there. She received her morning care at approximately 9:00 a.m., then went to an activity at approximately 10:00 a.m. She went straight to therapy from the activity, then went to lunch and went back to her apartment at approximately 12:50 p.m. She opened her phone wallet case to look for something and noticed her credit card was missing. She called the bank and deactivated her credit card. At that time, she found out her credit card had been used at a McDonalds to buy food for $10.50 at approximately 12:30 p.m. The person who stole it had also tried to use it at a store and it was denied three times due to the card being deactivated. She reported to a nurse her credit card had been stolen. The Executive Director (ED) told her a housekeeper was the staff member who stole her credit card. She received her $10.50 back from the bank. The police officers were investigating the theft.
A current policy, titled Abuse and Neglect Procedural Guidelines, dated as revised July 2, 2024, and provided by ED on 8/1/24 at 11:11 a.m., indicated .has implemented processes in an effort to provide a comfortable and safe environment .Definitions .Misappropriation of Property-means the deliberate misplacement, exploitation or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent
The deficient practice was corrected by 7/18/24, after the facility implemented a systemic plan which included a thorough investigation with police involvement, all alert and oriented residents were interviewed, Housekeeper 1 was terminated, and all staff members were educated on abuse and misappropriation of property along with resident rights.
This citation relates to Complaint IN00438719.
3.1-28(a)
May 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0839
(Tag F0839)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a staff member had the appropriate qualifications and curren...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a staff member had the appropriate qualifications and current certification to perform the duties of a Certified Nursing Assistant (CNA) and a Qualified Medication Aide (QMA) during the 34 day time period he was hired at the facility and failed to ensure a job specific orientation checkoff list for his CNA was completed and signed by the trainer prior to working alone on the floor as a CNA for 1 of 5 employees reviewed. (Employee 1) The deficient practice was corrected on 5/18/24, prior to the start of the survey, and was therefore past noncompliance.
Findings include:
1. An anonymous complaint was sent to the Indiana Department of Health, which indicated Employee 1 was working as a Licensed Practical Nurse (LPN) without a license at the facility.
Employee 1's employee record was requested during the entrance conference on 5/29/24 at 10:20 a.m.
During an interview, on 5/29/24 at 12:30 p.m., the Executive Director (ED) and the Nursing Clinical Specialist (NCS) were in attendance. The ED indicated Employee 1 worked at the facility as a Certified Nursing Assistant (CNA) and Qualified Medication Aide (QMA). He worked at the facility, from 11/15/23 to 12/20/23, for a total of 34 days. One week of the 34 days he did not work due to COVID-19 and one week he was suspended for a staff-to-staff incident, then he was terminated for poor job performance. He worked a total of 14 shifts while employed at the facility. A news reporter was outside on the facility property, on 5/17/24, and reported Employee 1 had worked at the facility as an LPN without a license. At that time, the facility discovered he had worked as a QMA and CNA under the name of another person. He was not working at the facility at the present time, he had been terminated for poor job performance in December 2023.
On 5/29/24 at 2:30 p.m., the employee file of Employee 1 was requested and received.
On 5/30/24 at 11:48 a.m., Employee 1's CNA certification was provided by the ED, which had a different last name than the last name the employee was hired by. When the ED was asked why Employee 1's name was different on his certification then on his employment records, she indicated he told the facility when asked why his names were different on his CNA and QMA certification than his driver's license and social security card, that he had gotten married.
A document, titled Investigation Summary, dated 5/18/24, indicated on 5/17/24 at 10:00 p.m., Channel 13 News aired a live report from in front of the facility at 6:00 p.m. The news report indicated a hospice company had an employee using someone else's LPN license to practice. The news report indicated he was a former employee of the facility and there were licensure concerns when this employee worked at the facility. The Summary of the Investigation indicated Employee 1 was employed at the facility from 11/15/23 and terminated on 12/20/23, due to unsatisfactory performance and poor interactions with staff. He was hired at the facility under one name and indicated his name was another name due to him getting married and he had changed his last name. He provided the CNA and QMA certification under his [NAME] name and the payroll person noted the name was his [NAME] name on top of his certifications.
There was no marriage license found in his employee file.
2. On 5/30/24 at 1:15 p.m., Employee 1's file was reviewed and there were no completed and signed job specific orientation checklists signed by the trainer and employee, for his CNA or QMA job titles. Those job specific orientation checklists were requested from the Nursing Clinical Specialist.
An employee profile indicated, on 11/15/24, he was hired as a Certified Resident Care Associate or a CNA.
An employee profile indicated, on 11/21/24, his job was reclassified to a Certified Resident Medication Assistant or a QMA
An employee profile indicated, on 12/20/24, he was terminated for unsatisfactory Medication Assistant performance.
Employee 1's IN Licensed Package background check had his name on it. There was a red flag on the subject data which indicated he went by another name as well. That name he went by was also on his social security card. All the other areas of the background check he passed with his name and social security number, including the Professional Licensing section. Under the Professional Licensing section there were some research history notes, which were as follows:
Tuesday 11/7/23 at 6:29 a.m., problem notification sent to client/applicant services
Wednesday 11/8/23 at 11:48 a.m., organization uses automated system-processing request
Wednesday 11/8/23 at 11:48 a.m., quality control review
A document, titled Employee Corrective Action Form, dated 12/5/23 and signed on 12/7/23, indicated Employee 1 was being given a verbal warning for his job performance. On 12/5/23, after he left the facility for the day, it was brought to the Director of Nursing and the Executive Director's attention Employee 1 failed to perform his duties as a CNA, worked within his scope of practice only, and followed the direction of the nurse on duty or any other member of management and nursing supervision. He was expected to pick up room trays, linens, and trash at the end of each shift, per policy. Failure to do so would result in further corrective, progressive disciplinary action, up to and including termination from employment with the campus.
A document, titled Personnel Action Form, dated 12/14/23, indicated Employee 1 was suspended due to poor interaction with peers, poor patient care, and poor job performance.
A document, titled Personnel Action Form, dated 12/21/23, indicated Employee 1 was terminated for unsatisfactory performance and he was not eligible for rehire.
On 5/30/24 at 1:37 p.m., the Nursing Clinical Specialist provided a blank copy signed by Employee 1 of the Job Specific Orientation Checklist for the QMA position at that time. She indicated this copy had been uploaded onto the computer, so it was not in his employee file. The facility did not have the signed copy with the trainer's initials showing what he had been checked off on thus far because the employees kept the signed original copies with them until the orientation was complete. When they were all checked off, their trainer signed his or her name and the employee handed the paper in to be uploaded to their file. All new employees signed a blank job specific orientation checklist for each job description when they were hired, then it was uploaded into the computer in their file.
There was no CNA job specific orientation checklist provided at that time.
The deficient practice was corrected by 5/18/24, after the facility implemented a systemic plan that included the following actions: A house wide audit of all employees' records checking all licenses and certifications back to 11/15/23 was completed. An audit was to be completed by the ED on 5 new employee records, if available, to ensure licenses and certifications and names matched. The payroll person would audit 100% of new hires for valid and matching names with certifications and licenses and any concerns will be brought to the ED.
This citation relates to Complaint IN00435005.
3.1-14(s)
Feb 2024
2 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Menu Adequacy
(Tag F0803)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff followed the physician's order for a resident on a mec...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff followed the physician's order for a resident on a mechanical soft diet when the wrong texture of the diet was provided and failed to provide assistance with meals which resulted in a resident choking for 1 of 4 residents reviewed for dietary requirements. (Resident B) This deficient practice resulted in Resident B's death.
The Immediate Jeopardy began on 1/24/24, when it was identified Resident B was provided a regular diet in place of a mechanical soft diet. Resident B choked on her dinner, was provided the Heimlich Maneuver, lost consciousness, and expired in the facility. The Executive Director (ED), Director of Health Services (DHS), and the Clinical Support Nurse were notified of the immediate jeopardy on 2/23/24 at 11:48 a.m. The Immediate Jeopardy was removed and the deficient practice corrected on 1/25/24 prior to the start of survey and therefore was past non-compliance.
Finding includes:
An Indiana Department of Health (IDOH) incident report, dated 1/25/24, indicated Resident B experienced a change in condition upon leaving the dining room, on 1/24/24. The report indicated the resident appeared to be blue in color and was alert and able to speak with staff prior to the event. The resident choked on food during the evening meal, the Heimlich Maneuver (a first-aid procedure for dislodging an obstruction from a person's windpipe) was unsuccessfully performed, the resident lost consciousness, and emergency services (EMS) was contacted.
The clinical record for Resident B was reviewed on 2/21/24 at 12:35 p.m. The diagnoses included, but were not limited to, dysphagia (difficulty swallowing), dementia, and mild cognitive impairment of uncertain or unknown etiology.
The resident was admitted to the facility on [DATE].
A hospital Speech Therapy (ST) evaluation, dated 1/10/24, indicated the ST recommendations were for a soft and bite sized diet with thin liquids and medications crushed in puree or as tolerated. Per husband, the patient had a history of dysphagia including pocketing and occasional choking of solid foods. During the evaluation, the patient ate at a rapid rate and benefited from verbal and tactile cueing to slow her pace. Recommend soft and bite sized diet with thin liquids and 1:1 assistance for pacing strategies when family was not present. Patient had a history of choking with solids and her husband had completed the Heimlich once due to choking.
A physician's order, dated 1/14/24, indicated the resident was to have a mechanical soft diet with thin liquids.
A profile care guide, initiated on 1/15/24, indicated the interventions included, but were not limited to, mechanical soft diet with thin liquids, eating supervision/assist of (1) one, and the resident pocketed food in her mouth at times.
A care plan, initiated on 1/16/24, indicated the resident was at risk for aspiration due to having a swallowing problem related to dysphagia and pocketing food in her mouth. The goal was the resident would not choke, aspirate, or have adverse effects while consuming food or liquids. The interventions included, but were not limited to, diet as ordered.
A care plan, initiated on 1/16/24, indicated the resident had impaired cognition with associated short term memory impairment and was at risk for confusion, disorientation, altered mood, and impaired or reduced safety awareness related to dementia. The goal was that the resident would remain safe and not injure herself secondary to impaired decision making. Interventions included, but were not limited to, providing cues and supervision for decision making.
A care plan, initiated on 1/16/24, indicated the resident had a potential for alteration in nutritional status. Interventions included, but were not limited to, assisting with meals as needed and providing the diet as ordered.
A care plan, initiated on 1/16/24, indicated the resident had a potential for mouth pain. Interventions included, but were not limited to, to observe and report difficulties chewing and swallowing, and to observe for the need to change diet consistency to increase the ease of eating.
A Minimum Data Set (MDS) scheduled 5-day assessment, dated 1/17/23, indicated the resident was severely impaired cognitively, held food in her mouth/cheeks or had residual food in her mouth after meals. It also indicated the resident had a mechanically altered diet and required supervision or touching assistance for eating.
A nursing progress note, dated 1/24/24 at 6:20 p.m., indicated LPN 6 was alerted by a CNA, the resident was choking. Upon entering the unit, LPN 6 observed another nurse administering the Heimlich Maneuver on the resident. Her face was purple, lips were blue, and her eyes were rolled in her head. Another nurse swept the resident's mouth and there was food removed. LPN 6 attempted the Heimlich Maneuver but was not successful in clearing the airway. The resident was moved to her room, the nurse swept the resident's mouth, and removed food from the oral cavity. A suction machine was retrieved, and suction attempted, however the resident remained purple in color. LPN 6 and another nurse assessed for a pulse, but the resident was found to be without a pulse. Emergency Medical Services arrived and assessed for a pulse, but no pulse was found.
In a facility witness statement, dated 1/24/24, Scribe 4 indicated she was sitting at the nurses' station reviewing paperwork sometime around 5:45 p.m., to 5:55 p.m. She heard LPN 8 say she's choking, she's choking. They both ran to the area where staff were surrounding the resident. Scribe 4 observed the resident to be off colored with a blue hue. She observed LPN 8 begin to provide the Heimlich Maneuver. She overheard [NAME] 7 call 911. She looked up the resident's code status and informed the nurse the resident was a do not resuscitate. When she returned to the scene, CNA 6 was observed to be holding a piece of silverware and was attempting to clear food from the resident's mouth. LPN 8 had left the scene to obtain the crash cart and suction machine. Upon LPN 8's return she told CNA 6 to stop and move away from the resident. CNA 6 did not stop after being told to stop. Scribe 6 observed food coming from the resident's mouth and described it as chunky but unidentifiable other than bread and something she believed to be fruit.
In a facility witness statement, dated 1/24/24, CNA 6 indicated she observed the resident being taken towards the hallway and heard them ask where the nurse was because someone was choking. CNA 6 approached them, and noted the resident was slightly blue in color. CNA 6 began the Heimlich Maneuver and CNA 3 assisted in getting food out of the resident's mouth. Mostly fruit was coming out, a grape was identified. Other food had been chewed and was not identifiable. LPN 8 came and took over doing the Heimlich and brought a suction machine.
In a facility witness statement, dated 1/24/24, CNA 9 indicated she observed CNA 3 take the resident toward her room. She observed LPN 6 performing the Heimlich Maneuver and CNA 3 performing a sternal rub. The resident was more purple/blue in color than white, and she noticed chunks of food being swept from the resident's mouth. She was not able to identify the food.
In a facility witness statement, dated 1/24/24, [NAME] 7 indicated she was the cook for the evening shift and did not observe the resident when she arrived in the dining area, as she was preparing meals. [NAME] 7 took a break, around 5:45 p.m., when she returned to the dining room CNA 3 alerted her to the resident's condition. She noticed the resident's mouth was full of food, she was shaking, and had signs of choking. CNA 3 remained with the resident while the cook ran to the hall and yelled for help. The Heimlich Maneuver was started on the resident. A nurse called out to call 911 and [NAME] 7 did. [NAME] 7 indicated meal service began at 4:30 p.m., Resident B had a hamburger with cheese and French fries. The cheeseburger had been quartered for smaller bites. A hamburger patty had been used for the meal. [NAME] 7 indicated a red meal ticket indicated a special/altered diet. She put the food on the resident's plate. The resident's meal did not include green beans and the meal was prepared per the meal ticket. There were no toppings with the cheeseburger because they were not mechanically soft.
In a witness statement, dated 1/24/24, LPN 6 indicated she was on break when a CNA came to her and said, they need you, one of your resident's is choking. LPN 6 indicated she came back into the facility and found LPN 8 doing the Heimlich on the resident. LPN 8 then went to sweep food out of the resident's mouth and LPN 6 took over the Heimlich. LPN 6 indicated when clearing the airway, a large, chewed chunk of bread and meat, pineapple chunks and other melons were noted. The bread and burger were chewed up and hard to distinguish, but the fruit was unchewed and identifiable.
In a witness statement, dated 1/24/24, CNA 3 indicated she went into the dining room to see which residents needed assistance leaving the dining room after the meal service. She noticed Resident B was attempting to get fruit out of her fruit cup, so she stayed in the dining room with the resident. She noticed the resident's C-collar was dirty and assisted to clean the resident up. CNA 3 indicated it seemed food was falling out of the resident' mouth so she cleared the food away. CNA 3 went to the drink station to fill up a cup and when she turned back around, Resident B was attempting to fork fruit and put it in her mouth and CNA 3 felt her motions seemed off. CNA 3 noted cantaloupe fruit in the resident's mouth and attempted to remove it. CNA 3 noticed the resident had a blue-ish hue to her and was shaking. CNA 3 took the resident in her wheelchair quickly towards the hall where she resided. CNA 3 indicated she helped clear fruit from the resident's mouth while the nurse was doing the Heimlich. She was not able to quantify how much food was cleared from the resident's airway, but it seemed like a decent amount and the majority was fruit. She saw the resident's plate in the dining room and the resident had a cheeseburger cut into quarters on her plate. The resident had consumed 2 quarters of the cut-up cheeseburger.
In a witness statement, dated 1/24/24, LPN 8 indicated when she arrived at the resident, she was blue in color. CNA 3 had what looked like a piece of silverware and was sweeping the resident's airway of visible food. LPN 8 told CNA 3 to stop, and LPN 8 began the Heimlich. Food immediately started to come out. LPN 8 pulled what looked like unchewed chunks of bun out of the resident's mouth.
A coroner's report, dated 1/25/24 and received on 2/22/24 at 2:34 p.m., indicated the cause of death was from choking due to food bolus at the vocal cord level obstructing the airway. The bolus was described firmly impacted ground red meat and bread material.
During an interview, on 2/22/24 at 3:09 a.m., the Corporate Support Nurse indicated the physician's ordered diet had not been followed for Resident B.
During an interview, on 2/22/24 at 3:29 p.m., CNA 5 indicated at about dinner time, a CNA and a dietary employee came to the unit with a resident. The resident was looking blueish. CNA 5 ran to the resident and began the Heimlich Maneuver. Some of the stuff came out of her mouth like fruit, a grape, and some food which was soft and mashed up. During that time, another nurse from the other unit took over and suctioned the resident and CNA 5 left the room.
During an interview, on 2/22/24 at 3:56 p.m., [NAME] 7 indicated at the time of the incident she had completed meal service, returned from her break, and was delivering employee meals. CNA 3 said What's wrong with her. Resident B was shaking and had food in her mouth. It looked like she was choking, so [NAME] 7 went to get a nurse. She returned to the dining room and CNA 3 was taking Resident B to the other nursing station. [NAME] 7 called 911. She indicated Resident B had been served a hamburger with French fries for the meal. [NAME] 7 indicated the hamburger was cut into smaller pieces and to her knowledge that was mechanical soft. She indicated she knew now mechanical soft meant to grind up the meat and a mechanical soft diet also required the use of canned fruit, not fresh.
During a telephone interview, on 2/22/24 at 4:23 p.m., CNA 3 indicated she was in the dining room to return residents to their units. There were only two residents left, one of which was Resident B. [NAME] 7 said she would assist the other resident. When CNA 3 turned around and observed Resident B jabbing her fork into a fruit cup. It was grapes, pineapple, and cantaloupe. [NAME] 7 indicated the resident's mouth was blue. They both ran to the resident. She had a piece of cantaloupe stuck in her mouth. CNA 3 hit her back and the cantaloupe flew out. She then grabbed the resident and took her to a nurse who began the Heimlich Maneuver. CNA 3 indicated she grabbed a spoon to scoop food out the resident's mouth because the finger sweep was not getting the food. The resident had a lot of food in her throat. A whole grape, pineapple, a whole French fry, and hamburger which was chunky came out. It was like she did not even chew the food and just swallowed it.
During an interview, on 2/23/24 at 9:16 a.m., the Director of Food Service indicated the only canned fruit the facility used were pears and peaches. The facility dd not have mixed canned fruit with pineapple, grapes, and melon.
During an interview, on 2/23/24 at 10:02 a.m., the Speech and Language Pathologist (SLP) indicated she had worked with Resident B for swallowing and cognition. She had seen the resident for meals; sometimes breakfast, sometimes lunch, but she was not in the facility for dinner. She described the resident as impulsive. She would take large bites when she should have been taking small ones and was very fast with eating, even with maximum cueing. It was difficult for Resident B to follow directions due to her severe dementia. Cueing included telling the resident to take smaller bites, alternate her liquids with food, to slow down, and to make sure no residual food was in her mouth. Typically, she had a lot of residual food in her mouth. The SLP indicated the recommendation from the hospital was a mechanical soft diet. She described a mechanical soft diet as soft texture food which would exclude anything that needed to be really chewed like nuts, hard vegetables, fried bread, toast, and meat. Meat needed to be ground up. They could have fruit, but no grapes due to the skin. Pineapple and melon would have to be small pieces. It was recommended, typically, for residents on a mechanically altered diet to have supervision, preferably sitting with the resident if they were impulsive like Resident B. The recommendation for supervision with dining would be verbally relayed to the Director of Nursing, Assistant Director of Nursing or the CNAs as the facility did not want speech therapy to add the order. The order would be added by the nursing staff.
A facility meal ticket, titled Wednesday-Dinner Daily Special, received from the Director of Nursing on 2/21/23 at 12:50 p.m., indicated Resident B was to receive a mechanical soft diet consisting of a burger and fries. The meal ticket was red.
A facility document, titled Inservice Topic: Altered Diets and Resident Meal Service, dated 1/24/24 and received from the Director of Nursing on 2/21/24 at 12:50 p.m., indicated .Colored meal tickets mean there was an altered diet, liquid, major allergy, etc
A facility document, titled Trilogy Health Service Mechanical Soft Cheat Sheet, dated as reviewed and approved on 10/2023 and received from the Director of Nursing on 2/21/24 at 12:50 p.m., indicated .Meats .All meats are ground .All ground meats should have gravy/sauce .No fresh fruit (may have bananas, canned fruit) .No Coated/battered French Fries (May have Soft or Crinkle cut-no hard, burnt or crispy ends)
A facility document, titled Guidelines for Meal Service, dated as last reviewed on 12/31/23 and received from the Executive Director on 2/23/24 at 3:46 p.m., indicated .Staff will be available to assist with .eating
A facility document, titled Comprehensive Care Plan Guideline, dated as last reviewed on 12/31/23 and received from the Executive Director on 2/23/24 at 3:45 p.m., indicated .PURPOSE .To ensure appropriateness of services and communication that will meet the resident's needs, severity/stability of conditions, impairment, disability or disease in accordance with state and federal guidelines
A facility document, titled Meal Service, dated as last revised 01/2023 and received from the Director of Nursing on 2/21/24 at 12:50 p.m., indicated .Staff will assist the individual as needed
A facility document, titled Abuse and Neglect Procedural Guidelines, last reviewed on 8/29/19 and received from the Executive Director on 2/21/23 at 9:36 a.m., indicated .DEPRAVATION OF GOODS AND SERVICES BY STAFF: staff has the knowledge and ability to provide care and services, but choose not to do it .which result in care deficits to a resident(s) .ADVERSE EVENT-An adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof .UNUSUAL DEATH-means the death of a resident that is unusual and/or the result of an accident .NEGLECT-is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm
The Past Noncompliance Immediate Jeopardy began on 1/24/23 The Immediate Jeopardy was removed and corrected by 1/25/24, after the facility implemented a systemic plan which included the following actions: a full investigation of the incident to include witness statements, staff in-service education on altered diets and meal service, placement of suction machines in the dining room(s), all residents with mechanically altered diets were audited with the tray cards (meal tickets) for accuracy and the residents had assessments both of oral and respiratory systems to include vital signs and oxygen saturation readings, audits to ensure altered diets were being followed appropriately, and education to the Dietary Supervisor related to having the spreadsheets and recipe book accessible at all times on the cook's line.
3.1-20(a)
3.1-20(h)
3.1-20(i)(4)
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to protect a resident from misappropriation of property, specifically medications, when the facility discovered the resident was missing 12 ox...
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Based on interview and record review, the facility failed to protect a resident from misappropriation of property, specifically medications, when the facility discovered the resident was missing 12 oxycodone (a narcotic) from the narcotic box for 1 of 3 residents reviewed for misappropriation of property. (Resident C) The deficient practice was corrected by 2/15/24 prior to the start of survey and was therefore past noncompliance.
Finding includes:
An Indiana Department of Health (IDOH) incident report, dated 2/10/24, indicated a resident was noted to have 12 missing oxycodone 10/325 milligrams (mg). The resident had an order for the administration of the medication one tablet, twice a day.
The clinical record for Resident C was reviewed on 2/21/24 at 12:08 p.m. The diagnoses included, but were not limited to, spinal stenosis cervical region (the neck area of the spine), other cervical disc degeneration, and weakness.
A physician's order, initiated on 10/03/23, indicated to give oxycodone/acetaminophen 10/325 mg one tablet twice a day for pain.
A facility witness statement, dated 2/10/24, indicated QMA 5 counted the narcotics and received the medication cart from the day shift nurse. The count was correct. She administered the resident's pain medication and signed it out on the narcotic count sheet. She removed one card and documented on the back of the narcotic sheet the card had been removed. She could not recall if she counted the narcotics with the staff member coming on for the next shift. There was a handwritten addendum, dated 2/15/24, which indicated .On shift-to-shift count sheet, I wrote -1. The -2 written over it was not written by me The statement was dated 2/15/24 and signed by QMA 5.
A facility witness statement, dated 2/10/24, indicated RN 11 came in at 10:00 p.m., and took over both medication carts on the unit. She did not count the carts. The QMA told her the count was okay and gave her the keys. She did not administer any medications to the resident during the night. The resident's spouse usually asked for a pain pill about 1:00 a.m. She documented on the narcotic sheet she had removed one card and one sheet because she thought she would be administering the medication from the card which contained one tablet. The resident's spouse did not request the pain medication, and RN 11 forgot to correct the numbers on the narcotic count sheet. She did count the cart with the day shift on-coming nurse and the count was correct based on the number of cards and sheets.
During an interview, on 2/23/24 at 3:19 p.m., the Director of Nursing indicated the facility did not know what happened to the narcotics.
During an interview, on 2/23/24 at 3:19 p.m., the Corporate Support Nurse indicated the narcotics and the narcotic sign-off sheet had not turned up.
During an interview, on 2/23/24 at 3:30 p.m., QMA 5 was unable to say why she did not count the narcotics with RN 11 for the shift change to hand off the medication cart.
During a telephone interview, on 2/23/24 at 5:12 p.m., RN 11 indicated there were usually two nurses/QMAs on the unit and the nurse left after counting with the QMA. The nurse gave her keys, to the QMA. RN 11 indicated QMA 5 told her the cart was good and without counting the cart she accepted the keys and the carts. RN 11 indicated it was totally her fault and she had learned to count the cart. It would never happen again.
A facility policy, titled IIA7: CONTROLLED SUBSTANCES, dated as last revised 11/18 and received from the Executive Director on 2/21/24 at 12:24 p.m., indicated .Accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance is administered, the licensed staff member administering the medication immediately enters the following information on the accountability record and the medication administration record .Date and time of the administration .Amount administered .Remaining quantity .Initials of the staff member administering the dose, completed after them medication is actually administered
A facility policy, titled Guidelines for Narcotic Count, dated as last reviewed 12/31/23 and received from the Executive Director on 2/21/24 at 12:24 p.m., indicated .At the time one nurse or other staff qualified to pass medications relinquishes the keys to the medication cart to another staff member the narcotic shall be reconciled by comparing the medication in the cart to the count sheets
This deficient practice was corrected by 2/15/24, prior to the start of the survey and was therefore past non-compliance. The facility investigated the missing narcotics, suspended QMA 5, RN 11 and LPN 12 pending the investigation and drug testing. Staff received in-service on narcotics on 2/12/24 and an audit of all PRN (as needed) pain medications documented in the Medication Administration Record began on 2/10/24. All drug test results were completed on 2/15/24.
This citation relates to complaint IN00428611.
3.1-28(a)
Jan 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident was free from verbal abuse when a staff member wa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident was free from verbal abuse when a staff member was heard speaking to a resident loudly and using profanity for 1 of 3 residents reviewed for abuse. (Resident 2) This deficient practice was corrected on 12/26/23, prior to the start of the survey, and was therefore past noncompliance.
Finding includes:
An incident report to the Indiana Department of Health, dated 12/25/23, indicated a nurse heard a verbal altercation between an employee and a resident.
The record for Resident 2 was reviewed on 1/2/24 at 11:51 a.m. Diagnoses included, but were not limited to, dementia, anxiety, and weakness.
Resident 2 admitted to the facility on [DATE] and discharged to another facility on 12/29/23.
Resident 2 had a Brief Interview for Mental Status completed on 12/19/23 and scored a 12 indicating he was moderately impaired mentally.
A facility document, titled .Statement of Witness Form for Resident 2, dated 12/25/23, indicated the male aid was pushy. He was not very nice, and he was harsh with him (Resident 2) while in the shower.
A facility document, titled .Statement of Witness Form for Dietary Aide 2, dated 12/25/23, indicated Dietary Aide 2 heard CNA 2 using profanity while talking to a resident. Another staff member tried to calm the CNA down. Dietary Aide 5 heard CNA 2 say .I'm tired of this s**t He also heard the CNA say to Resident 2 .F**k that. I already got him together in the shower As CNA 2 was walking away Dietary Aide 5 told him to calm down, he should not talk to residents that way and he could lose his license/certification. The CNA responded he did not .give a f**k
A facility document, titled .Statement of Witness Form for CNA 8, dated 12/25/23, indicated CNA 8 was sitting at the desk charting and heard the nurse asked CNA 2 to get residents' weights. CNA 2 stated .Y'll are getting on my d**n nerves with this Resident 2 wheeled around the corner and CNA 2 said .Hell, I guess I'll get him CNA 2 grabbed Resident 2's wheelchair, Resident 2 yelled out .Hey, what's going on? CNA 2 responded .you don't ask what I am doing The nurse told CNA 2 not to talk to residents like that and the facility was the home of the residents. The CNA responded .Yeah, he learned his lesson in the shower today, didn't you? The nurse removed Resident 2 from the CNA for resident's safety and another nurse sent CNA 2 home.
A facility document, titled .Statement of Witness Form for LPN 9, dated 12/25/23, indicated LPN 9 heard CNA 2 speaking loudly. He was getting residents' weights and was transferring Resident 2 from the wheelchair to the weight chair but was not telling the resident what he was doing. CNA 2 raised his voice and said to the resident .just get your a*s over here in this chair. You tried your luck with me this morning in the shower. Didn't you learn from that? LPN 9 and another nurse told CNA 2 to stop, then removed Resident 2 from the CNA. CNA 2 was told to clock out and leave the facility. CNA 2 went to the nurse's desk to chart. LPN 9 then called the Director of Nursing. There were no other residents near CNA 2 while he was at the desk.
A facility document, titled .Statement of Witness Form for LPN 10, dated 12/25/23, indicated LPN 10 observed CNA 2 getting residents' weights. She heard CNA 2 tell Resident 2 to get his a*s in the chair. She told the CNA not to curse at the resident, she would take over care of the resident and told the CNA to clock out and go home. The CNA went to the desk and began to chart, Nurse 10 told him it would be best for him to clock out and go home. CNA 2 apologized for his behavior and then left the facility. She notified the Director of Nursing.
A facility document, titled .Statement of Witness Form for CNA 2, dated 12/26/23, indicated he was giving Resident 2 a shower and the resident grabbed the shower head and sprayed him. Resident 2 continued to make the shower difficult. He told the resident to .stand here and be still and take this shower The resident began yelling and screaming at the CNA and he was getting bowel movement/feces everywhere.
A document, titled Timeline of Events, dated 12/25/23, indicated at 11:30 a.m., the nurse asked CNA 2 to get residents' weights. Without telling Resident 2 what he was doing, CNA 2 told the resident to get his a*s in the chair and then stated, you tried your luck with me this morning in the shower, didn't you learn anything from that? Safety was provided to Resident 2 and CNA 2 was asked to leave. The CNA went to the nursing station. At 11:45 a.m., the Director of Nursing was notified and informed CNA 2 would not leave. All residents were accounted for and safe. At 11:50 a.m., the Director of Nursing contacted CNA 2 and asked him to leave the facility, he exited the campus at 11:55 a.m. At 12:05 p.m., staff statements were initiated. A head-to-toe assessment was completed on Resident 2 at 12:10 p.m. The resident was interviewed at 2:30 p.m., and another head-to-toe assessment was completed. Other residents were interviewed and assessed at that time. The responsible party and physician were notified at 5:00 p.m. At 6:00 p.m., all staff in-service on abuse and resident rights was initiated. On 12/26/23 all statements and assessments had been completed. Social Services had completed mental anguish assessments, CNA 2 was terminated from employment at 3:00 p.m., the police had been notified at 3:15 p.m., and the facility received a case number.
CNA 2 was terminated from employment, on 12/26/23, for verbal abuse and gross misconduct.
During an interview, on 1/2/24 at 1:38 p.m., LPN 3 indicated abuse could be verbal, physical, sexual, emotional, and financial. All abuse needed to be reported immediately. She indicated she was recently re-educated on abuse and abuse reporting.
During an interview, on 1/2/24 at 1:43 p.m., QMA 6 indicated staff was re-educated on abuse about a week ago. Abuse could be verbal, physical, sexual, emotional, or as misappropriation of the residents' belongings.
During an interview, on 1/2/24 at 1:48 p.m., Physical Therapist (PT) 7 indicated he was contracted staff and he needed to follow the facility policies. He was educated on abuse and indicated abuse was physical, verbal, misappropriation of resident belongings or financials or emotional. Abuse needed to be reported immediately.
During an interview, on 1/2/24 at 2:09 p.m., Dietary Aide 5 indicated he was on the Keystone Unit stocking snacks by the refrigerator. He heard CNA 2 say, to Resident 2, he was tired of this s**t and he did not give a F**k. He attempted to talk to CNA 2 and told him to calm down; he could lose his license/certification. CNA 2 told him he did not care. Dietary Aide 5 then returned to the kitchen and reported the incident to his immediate supervisor.
A facility policy, titled Abuse and Neglect Procedural Guidelines, dated as last updated 6/2023 and received from the Corporate Support Nurse on 1/2/24 at 10:16 a.m., indicated .Verbal Abuse .includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability
A facility policy, titled Resident Rights Guidelines, dated as last reviewed on 12/31/22 and received from the Corporate Support Nurse on 1/2/24 at 3:37 p.m., indicated .Our residents have the right to be .treated with respect and dignity .Be free of .verbal .abuse
This deficient practice was corrected on 12/26/23, after the facility implemented a systemic plan which included the following actions: they completed interviews of staff who were witness to the incident, conducted assessments and interviews of residents residing on the unit, provided abuse and resident right training to employees, Social Services conducted mental anguish assessments, CNA 2 was terminated, and a police report was filed.
3.1-27(b)
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide toileting assistance when a resident had asked for assistance to use the toilet for 1 of 1 resident reviewed for Activ...
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Based on observation, interview and record review, the facility failed to provide toileting assistance when a resident had asked for assistance to use the toilet for 1 of 1 resident reviewed for Activities of Daily Living (ADL) care. (Resident 3)
Finding includes:
During an observation, on 1/2/24 at 2:39 p.m., Resident 3 was in an activity, painting a wooden Christmas tree. She was sitting in a wheelchair, clean and dry. She had an apron over her clothing and was actively engaged in the activity.
During an observation, on 1/2/24 at 3:39 p.m., Resident 4 was in an activity, painting a wooden Christmas tree. She was sitting in a wheelchair, next to Resident 3. She was clean and dry and was actively engaged in the activity.
During an interview, on 1/2/24 at 2:13 p.m., CNA 4 indicated on 12/24/23, Resident 3 reported to her she had requested assistance to use the toilet and CNA 2 told her to use her brief. CNA 4 indicated she reported the conversation to the Director of Nursing, also wrote a statement, and put it under the Director of Nursing's door.
During an interview, on 1/2/24 at 2:42 p.m., Resident 4 indicated she was blind. She heard her roommate, Resident 3, ask CNA 2 if she could get up and go to the restroom. CNA 2 responded for her to go in her pants, and he would change her later. She then indicated it sounded as if he walked quickly, the pace was quick, then she heard the door shut and she did not hear his voice in the room anymore.
During an interview, on 1/2/24 at 2:50 p.m., Resident 3 indicated CNA 2 told her No when she asked to use the toilet and told her to use her brief. She indicated it made her feel like dirt.
The record for Resident 3 was reviewed on 1/2/24 at 340 p.m. Diagnoses included, but were not limited to, Alzheimer's dementia, aphasia (difficulty speaking), and traumatic brain dysfunction.
A Brief Interview for Mental Status (BIMS) was completed, on 12/12/23, and the resident scored a 15 (resident was alert and oriented).
The OBRA assessment, completed on 12/12/23, indicated the resident required moderate assistance to use the toilet with a helper/assistant and did most of the work.
The record for Resident 4 was reviewed on 1/2/24 at 3:37 p.m. Diagnoses included, but were not limited to, anxiety, depression, and end stage renal disease.
The resident had a BIMS score of 15 on 12/5/23.
A handwritten document, dated 12/24/23, indicated the staff member was called to Resident 3's room as a witness to the resident's statement. The resident told two (2) staff members she had activated her call light to go to the bathroom and CNA 2 came in. CNA 2 told the resident to go in her brief. The resident's roommate, Resident 4, told CNA 4 she did hear the conversation between Resident 3 and CNA 2. The document was signed by CNA 4.
During an interview, on 1/2/24 at 2:59 p.m., the Director of Nursing indicated she was notified of the incident where CNA 2 had told Resident 3 to use her brief to relieve herself. She did receive a statement from a staff member.
A facility document, titled Certified Resident Care Associate (CNA/STNA/SRNA/CENA) Expectations of Excellence, dated 4/29/10 and received from the Corporate Support Nurse on 1/2/24 at 10:51 a.m., indicated .If a resident .needs assistance, help then get the assistance they need
A facility policy, titled Resident Rights Guidelines, dated as reviewed on 12/31/23 and received from the Corporate Support Nurse on 1/2/24 indicated .Residents shall not leave their .basic human rights behind when they move to a health campus .Our residents have a right to .Be treated with dignity and respect .Be treated fairly, courteously and with respect by staff
A facility policy, titled Abuse and Neglect Procedural Guidelines, dated as reviewed on 8/29/19 and received from the Corporate Support Nurse on 1/2/24 at 10:51 a.m., indicated .Neglect .the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid .mental anguish or emotional distress
3.1-38(a)(2)(C)
Nov 2023
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure the discharge MDS (Minimum Data Set) assessment was coded correctly for 1 of 1 resident reviewed for hospital discharge. (Resident 5...
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Based on record review and interview, the facility failed to ensure the discharge MDS (Minimum Data Set) assessment was coded correctly for 1 of 1 resident reviewed for hospital discharge. (Resident 54)
Findings include:
The record for Resident 54 was reviewed on 11/16/23 at 12:41 p.m. Diagnoses included, but were not limited to, acute respiratory failure with hypoxia, pleural effusion (fluid in the lining of the lungs), morbid obesity, cardiomegaly (enlarged heart), paroxysmal atrial-fibrillation (irregular heart beat), pulmonary hypertension (condition which affects the vessels in the lungs), fibromyalgia, COPD (Chronic Obstructive Pulmonary Disease), chronic diastolic heart failure, and CKD (Chronic Kidney Disease) stage 3.
A progress note, dated 10/26/2023 at 1:42 p.m., indicated the resident was discharged to another skilled nursing facility.
An MDS assessment, dated 10/26/23, indicated the MDS was coded to reflect a discharge to a short-term general hospital.
During an interview, on 11/20/23 at 10:28 a.m., the MDS Coordinator indicated the discharge MDS assessment was incorrectly coded, and the facility followed the RAI (Resident Assessment Instrument) manual.
A current, RAI Manual, Version 1.17.1, October 2019, indicated .entry and discharge reporting MDS assessments and tracking records that include a select number of items from the MDS used to track residents and gather important quality data at transition points, such as when they leave a nursing home or when a resident's Medicare Part A stay ends, but the resident remains in the facility .entry/discharge reporting includes entry tracking record, OBRA (omnibus reconciliation act) discharge assessments, Part A PPS (prospective payment system) discharge assessment, and death in facility tracking record
3.1-31(b)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
2. The record for Resident 20 was reviewed on 11/14/23 at 4:14 p.m. Diagnoses included, but were not limited to, dementia, schizoaffective disorder (a mental health disorder) bipolar type, and psychot...
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2. The record for Resident 20 was reviewed on 11/14/23 at 4:14 p.m. Diagnoses included, but were not limited to, dementia, schizoaffective disorder (a mental health disorder) bipolar type, and psychotic disorder (a mental health disorder) with delusions due to known physiological condition.
A PASRR level 1, dated 11/20/2020, indicated no level II was required due to no significant mental illness, intellectual disability, or related condition. The listed diagnoses were dementia with psychotic disorder with delusions due to known physiological condition and major depressive disorder. The behaviors or symptoms listed were delusions or hallucinations. The outcome rationale indicated the level 1 screen did not identify a PASRR disability, because there was no evidence of a PASRR condition of intellectual/developmental disability or a serious behavioral health condition. If changes occur or new information refutes these findings, a new screen must be submitted. Although the diagnosis of major depression was reported further screening was not indicated at that time.
A care plan, dated 10/16/22, indicated the resident presents with a diagnosis of schizoaffective disorder, bipolar type which was treated with anti-psychotic medication.
The diagnosis list indicated schizoaffective disorder bipolar type, dated 6/1/23.
A physician's order, dated 9/24/23, indicated Risperdal (an antipsychotic medication) 0.5 mg twice daily for schizoaffective disorder, bipolar type.
During an interview, on 11/15/23 at 4:31 p.m., the Clinical Support Nurse indicated a new screen was not submitted for the changes of schizoaffective diagnosis and the antipsychotic medication.
During an interview, on 11/17/23 at 11:35 a.m., the Clinical Support Nurse indicated the facility did not have a PASARR policy and utilized the state guidelines for PASARR.
3.1-16(d)(1)(B)
Based on record review and interview, the facility failed to ensure a PASARR (Preadmission Screening and Resident Review) Level I had accurate information and a Level I was completed when residents had an added mental health diagnosis and psychotropic medications prescribed for 2 of 2 residents reviewed for PASARR. (Resident 38 and 20)
Finding includes:
1. The record for Resident 38 was reviewed on 11/14/23 at 4:09 p.m. Diagnoses included, but were not limited to, bipolar disorder, dementia, and anxiety disorder.
The transfer paperwork from a previous long term care facility indicated the resident had been prescribed Risperdal (an antipsychotic medication) 1 mg (milligram) once a day starting on 11/10/22.
A care plan, dated 12/6/22, indicated the resident presented with diagnoses of bipolar, anxiety, and depression which was treated with an antipsychotic medication.
A PASARR Level I, dated 12/21/22, indicated the resident had no known or suspected mental health diagnoses, no diagnosis of dementia or neurocognitive disorder, no mental health symptoms, and no mental health medications were prescribed.
The resident had been prescribed the Risperdal since 11/10/22 and this was not added to the PASARR Level I.
A pharmacy recommendation, dated 1/22/3, indicated the resident had been receiving Risperdal since admission and needed an assessment for abnormal involuntary movement.
A psychiatry note, dated 1/20/23, indicated the resident had a mood disorder and anxiety. The resident's bipolar disorder was improving but the anxiety and depression remained a problem. The medications included, but were not limited to, Risperdal 1 mg at bedtime.
A physician's order, dated 9/24/23, indicated to give Risperdal at bedtime for bipolar disorder.
During an interview, on 11/16/23 at 12:13 p.m., the Social Services Director (SSD) indicated it was a group effort with social services, admissions, and the Minimum Data Set (MDS) staff to make sure the PASARR process was completed for the residents.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure a resident received the correct dosage of a narcotic for 1 of 1 resident reviewed for quality of care. (Resident C)
Finding includes...
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Based on interview and record review, the facility failed to ensure a resident received the correct dosage of a narcotic for 1 of 1 resident reviewed for quality of care. (Resident C)
Finding includes:
During an interview, on 11/13/23 at 1:42 p.m., Resident C's family member indicated the resident was receiving poor care. The Certified Resident Medication Aides (CRMA) passed the medications and made many errors. The CRMA gave the wrong amount of hydromorphone to the resident.
The record for Resident C was reviewed on 11/15/23 at 9:17 a.m. Diagnoses included, but were not limited to, traumatic hemorrhage of cerebrum, dementia without behavioral disturbance, malignant neoplasm of esophagus, pacemaker, need for assistance with personal care, and cognitive communication deficit.
A care plan, dated 9/12/23, indicated the resident was at risk for potential complications related to diagnoses of esophageal cancer. Interventions included, but were not limited to, manage pain and other uncomfortable symptoms, and provide the resident with medication.
A care plan, revised 9/12/23, indicated the resident was at risk for pain. Interventions included, but were not limited to, administer medications as ordered, notify the physician of any side effects observed or lack of effectiveness, and notify physician of increased pain.
A physician's order, dated 10/21/23 and discontinued on 10/25/23, indicated hydromorphone (a pain medication) 1mg/ml liquid, to give 3 ml every 4 hours for pain.
A physician's order, dated 10/25/23, indicated hydromorphone 1mg/ml liquid, to give 1 ml every 4 hours for pain.
A Controlled Drug Use Record indicated the resident received the following:
a. On 10/25/23 at 8:00 p.m., the resident received 3 ml of the hydromorphone.
b. On 10/26/23 at 12:00 a.m., and 4:00 a.m., the resident received 3 ml of the hydromorphone.
c. On 10/27/23 at 12:00 a.m., and 4:00 a.m., the resident received 3 ml of the hydromorphone.
During an interview, on 11/20/23 at 10:45 a.m., the Director of Nursing (DON) indicated she was unaware of the incorrect dosages given for the hydromorphone. The medication was given incorrectly five times after the physician's order was changed. The resident should have been given 1 ml every 4 hours and not 3 ml.
A current policy, titled Guidelines for Medication Error Reporting, dated as revised 12/31/22 and received from the DON on 11/20/23 at 11:59 a.m., indicated .In the event of a medication error, nursing personnel should first take whatever immediate action is necessary to protect the resident's safety and welfare .Notify the attending physician promptly of the error .Implement physician's orders .Notify the resident or responsible party .Initiate the appropriate Event form. Monitor the resident closely for 72 hours or as directed .Document the following in the resident's clinical record .A description of the error (brief) .Name of physician and time notified .Physician's subsequent orders .Medication errors will be reviewed by the Quality Assurance Committee to identify trends and/or actions for implementations
3.1-37(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to implement timely interventions after a fall with a stand-up lift which resulted in another fall with a stand-up lift for 1 of 4 residents r...
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Based on interview and record review, the facility failed to implement timely interventions after a fall with a stand-up lift which resulted in another fall with a stand-up lift for 1 of 4 residents reviewed for falls. (Resident 33)
Finding includes:
The record for Resident 33 was reviewed on 11/15/23 at 3:47 p.m. Diagnoses included, but were not limited to, dementia with agitation, diabetic neuropathy, cognitive communication deficit, altered mental status, repeated falls, and pain in the right hip.
A care plan, dated 8/30/21 and last reviewed on 8/25/23, indicated the resident would remain free of falls with major injury. The approaches included, but were not limited to, therapy to screen 8/4/23 and staff education on stand-up lift on 8/4/23.
A fall event, dated 8/3/23, indicated the resident was lowered to the floor while being transferred with a stand-up lift. The resident's arm was coming out of the pad for the lift. The intervention was for therapy to screen the resident.
A therapy screen, dated 8/9/23, indicated the resident had a fall and physical therapy was recommended for the use of an assistive device.
A therapy referral, dated 8/11/23 at 7:36 a.m., indicated a therapy screen due to falls/transfer. The resident needed increased assistance on transfers from the bed, the toilet, the wheelchair, and increased assistance with adaptive transfer equipment. Physical therapy was recommended.
There was no physical therapy provided by the facility between 8/11/23 and 8/20/23.
A fall event, dated 8/20/23, indicated the evening shift Certified Nursing Assistant (CNA) reported having to lower the resident to the floor while she was being transferred with the stand-up lift. The CNA was using the stand-up lift and the resident slid through the safety strap and on to the floor. The resident received a small abrasion to the back of her right thigh. A PT/OT referral was placed by nursing for transfer training due to increasing difficulty and decreasing safety with staff transfers because of functional declines, behaviors, and impaired cognition and memory.
A physician's order, dated 8/21/23, indicated for physical therapy (PT) and occupation therapy (OT) to evaluate and treat for the appropriate lift to be used for transfers and increased weakness.
A physical therapy (PT) evaluation, dated 9/7/23 through 10/6/23, indicated the resident was referred by nursing for transfer training due to increased difficulty and decreased safety with staff transfers because of functional declines, behaviors, and impaired cognition/memory.
The fall intervention of PT treatment did not occur until 37 days after the initial fall and 29 days after the PT screen on 8/11/23. The facility did not include any other new fall interventions during the lapse in PT treatment being started.
During an interview, on 11/16/23 at 3:39 p.m., Physical Therapy Assistant (PTA) 10 indicated a payer verification for physical therapy services had to be submitted. The resident could have been waiting for insurance approval before the physical therapy was started.
During an interview, on 11/17/23 at 10:59 a.m., the Clinical Support Nurse indicated if there was one intervention in place such as a physical therapy referral and the resident had not obtained the service and the resident had another fall then the facility should have implemented other interventions. Resident 33's documentation did not include any new interventions for the fall on 8/3/23 and 8/20/23 since the physical therapy could not be started right away.
During an interview, on 11/17/23 at 11:22 a.m., the Physical Therapy Department Director indicated the facility had to run a payer verification for long term care residents prior to the start of PT. The resident and families would have to be notified of the insurance copays and give permission for the physical therapy to start.
During an interview, on 11/17/23 at 1:37 p.m., the Director of Nursing (DON) indicated the only staff education after the fall, on 8/3/23, were the two staff who were involved in the stand-up lift incident. No other staff were educated on the use of the stand-up lift.
A current policy, titled Falls Management Program Guidelines, dated as reviewed on 3/16/22 and received from the Clinical Support Nurse on 11/17/23 at 1:46 p.m., indicated .strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures .A fall is considered to be .'any intentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force .An episode where a resident lost his/her balance and would have fallen, if not for staff interventions, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggested otherwise, when a resident is found on the floor, a fall is considered to have occurred ' .Should the resident experience a fall the attending nurse shall complete the 'Fall Event' .This includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the IDT [interdisciplinary team] to evaluate thoroughness of the investigation and appropriateness of the interventions .Nursing staff will monitor and document continued resident response and effectiveness of interventions for 72 hours .Discuss risks and interventions with resident and/or responsible party and communicate interventions during shift report
3.1-45(a)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain an admission weight upon admission and to obtain a timely re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain an admission weight upon admission and to obtain a timely reweight after the weight was determined to be invalid for 1 of 3 residents reviewed for nutrition. (Resident 13)
Finding includes:
The record for Resident 13 was reviewed on 11/15/23 at 11:47 a.m. Diagnoses included, but were not limited to type 2 diabetes, acute on chronic combined systolic (pressure of the arteries when the heart beats) and diastolic (pressure of the arteries between the heart beats) congestive heart failure, and anemia.
A progress note, dated 10/17/23 at 6:14 p.m., indicated the resident was admitted on [DATE].
The resident had the following weights:
On 10/22/23, the weight was 130 pounds. The weight was struck out and marked as an invalid weight. This weight was obtained 5 days after the resident admitted to the facility.
On 10/30/23, the weight was 113.8 pounds. This weight was taken 8 days after the admission weight was taken and struck out as an invalid weight.
A progress note, dated 10/24/23 at 2:21 p.m., indicated the RD (Registered Dietician) reviewed the resident's weight and it was 130 pounds.
During an interview, on 11/16/23 at 10:06 a.m., the Clinical Support Nurse indicated the note from the RD on 10/24/23 which indicated the resident weighed 130 pounds was a weight from admission the facility had struck out.
During an interview, on 11/16/23 at 2:49 p.m., the Clinical Support Nurse indicated the admission weight was deemed a false weight due to other supporting documents from the resident's dialysis treatments.
During an interview, on 11/16/23 at 3:23 p.m., the Clinical Support Nurse indicated the facility had used the weight from dialysis on 10/18 as the resident's admission weight. The facility policy could be interpreted as the facility was supposed to weight the resident instead of using a weight from an outside source such as dialysis.
A current policy, titled Guidelines for Weight Tracking, dated as last revised on 1/16/2021 and received from the Clinical Support Nurse on 11/16/23 at 11:00 a.m., indicated .Residents will have their weight taken and recorded upon admission to establish a baseline .Scales shall be properly maintained and calibrated to ensure accuracy of weight .Residents who have a weight that seem out of normal range shall be re-weighed to determine the accuracy of the original weight
3.1-46 (a)(1)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to dispose of loose pills and have opened dates on medications in 2 of 3 medication carts and 1 of 1 medication room reviewed for medication sto...
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Based on observation and interview, the facility failed to dispose of loose pills and have opened dates on medications in 2 of 3 medication carts and 1 of 1 medication room reviewed for medication storage. (Keystone front cart, Keystone medication room and Brickshire medication cart)
Findings include:
1. During an observation, on 11/16/23 beginning at 3:02 p.m., the Keystone front medication cart had the following:
a. There were three unidentified pills in the bottom of the second drawer.
b. The Ozempic (used for diabetes) 1 milligram (mg) injectable pen did not have an opened date.
2. During an observation, on 11/16/23 at 3:09 p.m., the Keystone medication room had a bottle of lorazepam 2mg/ml in the refrigerator for a resident no longer in the facility.
3. During an observation, on 11/16/23 beginning at 3:15 p.m., the Brickshire medication cart had the following:
a. There were four unidentified pills in the bottom of the second drawer.
b. A Trelegy Ellipta (for chronic obstructive pulmonary disease) 100-62.5-25 mcg (microgram) inhaler had no opened date.
c. A Breo Ellipta (to treat asthma) 200-25 mcg inhaler had no opened date.
During an interview, on 11/16/23 at 3:02 p.m., Certified Resident Medication Assistant (CRMA) 11 could not identify the loose pills in the medication cart and indicated all medication should have an opened date on the bottle.
During an interview, on 11/16/23 at 3:30 p.m., Licensed Practical Nurse (LPN) 5 indicated there should not be any loose pills in the cart and when a medication was opened, a date needed to be added.
During an interview, on 11/16/23 at 3:40 p.m., LPN 4 indicated the medication should have an opened date and when medication was discontinued you need to destroy the medication.
3.1-25(j)
3.1-25(o)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to identify the time frame for the consideration of a gradual dose reduction (GDR) with the use of psychotropic medications and to identify re...
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Based on record review and interview, the facility failed to identify the time frame for the consideration of a gradual dose reduction (GDR) with the use of psychotropic medications and to identify resident specific reasons for the declining of gradual dose reductions for 3 of 5 residents reviewed for unnecessary medications. (Resident 38, 33 and 34)
Findings include:
1. The record for Resident 38 was reviewed on 11/14/23 at 4:09 p.m. Diagnoses included, but were not limited to, bipolar disorder, dementia, and anxiety disorder.
A physician's order, dated 11/28/22 and opened ended, indicated to give Xanax (an antianxiety medication) 0.25 milligram (mg) at bedtime for anxiety.
An order set for target behaviors, dated 11/28/22, indicated to monitor for anxiety behaviors which included agitation, tearfulness, attention seeking, repetitive concerns, and yelling out.
A care plan, dated 12/6/22, indicated the resident had the diagnoses of bipolar, anxiety and depression and was treated with antipsychotic medications. The approaches included, but were not limited to, titrate the medication to the lowest effective dose.
A psychiatric progress note, dated 1/30/23, indicated the resident was prescribed Xanax 0.25 mg at bedtime for anxiety and the Xanax was not subject to the GDR protocol.
A psychiatric progress note, dated 2/27/23, indicated the resident was prescribed Xanax 0.25 mg for anxiety related to the diagnosis of dementia. A dose reduction was contraindicated due to a high risk of symptom escalation.
A psychiatric note, dated 11/6/23, indicated the assessment was for anxiety and depression. The generalized anxiety disorder was chronic and stable. A dose reduction was contraindicated due to a high risk of symptom escalation.
The psychiatric notes did not include the length of time the resident had been on the Xanax, if it was time to consider a GDR and the resident specific clinical rationale for not completing a GDR including what symptoms the resident had or what symptoms would escalate.
2. The record for Resident 33 was reviewed on 11/15/23 at 3:47 p.m. Diagnoses included, but were not limited to, dementia with agitation, a mood disorder due to a known physiological cause, major depressive disorder severe with psychotic symptoms, and generalized anxiety disorder.
A care plan, dated 8/30/21, indicated the resident was at risk for developing adverse effects from the use of antidepressant medications. The approaches included, but were not limited to, attempt a GDR in two separate quarters with at least one month between the attempts during the first year the resident received the medication and then yearly unless clinically contraindicated.
A target set of behaviors, dated 10/24/21, indicated to monitor for depression, mood swings, negative statements, and sad facial expression.
A physician's order, dated 3/31/2022 and open ended, indicated to give venlafaxine (an antidepressant) once a day.
A care plan, dated 11/17/22, indicated the resident was at a risk for developing adverse effects from the use of an anticonvulsant medication prescribed for a mood disorder due to a known physiological condition. The approaches included, but were not limited to, attempt a GDR in two separate quarters with at least one month between the attempts during the first year the resident receives the medication and then yearly unless clinically contraindicated.
A target set of behaviors, dated 10/24/23, indicated to monitor for anxiety, agitation, tearfulness, and attention seeking.
A physician's order, dated 6/2022 and open ended, indicated to give Depakote extended release (an anticonvulsant prescribed as a mood stabilizer) 250 mg daily.
A psychiatric progress note, dated 9/18/23, indicated a GDR for Depakote was contraindicated due to a high risk of symptom escalation. A GDR for venlafaxine was contraindicated due to a high risk of symptom escalation. The Depakote was for mood and depression.
The psychiatric progress note did not include the length of time the resident had been on the same doses of the Depakote and the venlafaxine. The progress note did not include the resident specific symptoms which would escalate of if a GDR had been attempted in the past year. The progress notes did not include the rationale for a mood stabilizer and an antidepressant to be prescribed together.
3. The record for Resident 34 was reviewed on 11/16/23 at 10:42 a.m. Diagnosis included, but were not limited to, generalized anxiety disorder, panic disorder, chronic respiratory failure, and depression.
A care plan, dated 11/17/22, indicated the resident was at a risk for developing adverse effects from the use of an antidepressant medication. The approaches included, but were not limited to, attempt a GDR in two separate quarters with at least one month between the attempts during the first year the resident receives the medication and then yearly unless clinically contraindicated.
A target set of behaviors, dated 8/15/22, indicated to monitor for depression, verbalization of distress, refusals to get out of bed, refusals of care, tearfulness, and refusing to attend favorite activities.
A physician's order, dated 10/19/22 and open ended, indicated to give sertraline (an antidepressant) 125 mg once a day.
During an interview, on 11/17/23 at 1:37 p.m., the Clinical Support Nurse indicated Resident 38 and 33 did not have a GDR recommendation which listed the length of time the residents had been on the medications or a resident specific reason the GDR would not be considered. The psychiatric nurse practitioner did write for each resident the general statement the GDR was contraindicated due to a high risk of symptom escalation and did not give resident specific information. Resident 34 did not have a GDR the past year for the antidepressant.
A current policy, titled Psychotropic Medication Usage and Gradual Dose Reduction, dated as reviewed on 12/31/22 and received from the Clinical Support Nurse on 11/17/23 at 1:46 p.m., indicated .To ensure every effort is made for residents receiving psychoactive medications to obtain the maximum benefit with minimal unwanted side effects through appropriate use, evaluation and monitoring by the interdisciplinary team .Residents shall receive psychotropic medications only if designated medically necessary by the prescriber, with appropriate diagnosis or documentation to support its usage. The medical necessity will be documented in the resident's medical record and in the care planning process .Efforts to reduce dosage or discontinue psychotropic medications will be ongoing, as appropriate .A gradual does reduction [GDR] will be attempted for two [2] separate quarters [with at least one month between attempts] per the physician's recommendation. Gradual dose reductions must be attempted annually thereafter, unless medically contraindicated .Reviews of medication use will be conducted by the consultant pharmacist monthly and will .Notify the physician and the nursing staff whenever a psychotropic medication is due for review
3.1-48(b)(2)
Oct 2022
15 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Incontinence Care
(Tag F0690)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident received treatment and care in accordance with pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for 1 of 2 residents reviewed for catheter care. (Resident 44) Resident 44 was not provided care to address concerns which developed after a urinary catheter was placed which led to a hospitalization with intravenous antibiotic intervention for the development of urosepsis.
Finding includes:
The record for Resident 44 was reviewed on 10/21/22 at 1:39 p.m. Diagnoses included, but were not limited to, sepsis (life-threatening complication of an infection), urinary tract infection (infection in any part of the urinary system), benign prostatic hyperplasia (BPH) (enlargement of the prostate gland) and chronic kidney disease (loss of kidney function).
A care area assessment (CAA), dated 9/28/22, indicated the resident had triggered for an indwelling catheter related to BPH, hematuria, urinary retention and CKD.
A physician's order, on 9/22/22, indicated staff were to change the catheter bag as needed, use an indwelling urinary catheter size 16 Fr (French) with a 10 cc (cubic centimeter) balloon for the diagnosis of urinary retention.
A Vitals Report, dated 9/24/22 to 10/24/22, indicated Resident 44 had the following recorded:
On 9/29/22 at 4:32 p.m., a large amount of urine output was recorded.
On 9/30/22 at 12:26 a.m., a large amount of urine output was recorded.
On 10/1/22 at 5:50 a.m., 250 ml (milliliters) of urine output was recorded.
On 10/1/22 at 1:47 p.m., 400 ml of urine output was recorded.
On 10/1/22 at 9:17 p.m., 100 ml of urine output was recorded.
On 10/2/22 at 5:05 a.m., 1000 ml of urine output was recorded.
On 10/2/22 at 3:27 p.m., 800 ml of urine output was recorded.
The documentation indicated the resident had a large output once on each day, of the 9/29 and 9/30, but lacked indication the resident had urine output the rest of the day.
A nurse progress note, dated 9/22/22 at 5:34 p.m., indicated Resident 44 was admitted to the facility with a 16 French Foley catheter and had yellow urine.
A physician's progress note, dated 9/23/22 at 10:51 p.m., indicated Resident 44 was admitted with a Foley catheter, to attempt a voiding trial and follow up with urology.
A review of the nurse progress notes, from 9/29/22 at 8:15 p.m., until 10/1/22 at 4:55 p.m., indicated Resident 44 had no bladder scan completed, no assessment and no call to the provider to notify of concerns of decreased urine output. The staff did not document the voiding trial or when the catheter was removed or reinserted.
A nurse progress note, dated 10/1/22 at 4:55 p.m., indicated Resident 44 had a distended abdomen, fever of 99.6 and was given Tylenol. Resident 44 had an in and out catheterization completed and resulted with 2200 ml of urine. The first 1000 ml of urine had been reported as gross hematuria (blood in the urine) and 1200 cc was reported as dark amber with a foul odor. A urine sample was obtained and on call provider notified.
A nurse progress note, dated 10/1/22 at 6:22 p.m., indicated orders were received by the on call provider to re-anchor the Foley catheter. Resident 44 had a Foley 14 Fr 30 cc catheter anchored and had drained dark colored urine.
A nurse progress note, dated 10/2/22 at 6:47 p.m., indicated Resident 44's temperature was 102.4 degrees Fahrenheit, was very lethargic, had poor appetite and a blood pressure of 102/58. He had a small amount of urine output in his Foley catheter bag and the family requested the resident be transferred to the hospital for evaluation and treatment.
A Lab Report, dated 10/3/22, indicated on 10/1/22, a urine sample was collected. The results indicated his urine was positive for blood, protein, leukocytes and bacteria. His culture was positive for greater than 100,000 enterococcus faecalis bacteria.
A hospital Discharge summary, dated [DATE], indicated Resident 44 was hospitalized for the diagnoses of Urosepsis (sepsis caused by infections of the urinary tract), a complicated UTI related to a catheter associated urinary tract infection.
A nurse progress note, dated 9/29/22 at 8:15 p.m., entered as a late entry on 10/21/22 at 12:07 p.m., indicated Resident 44 had a Foley catheter removed without difficulty with no signs or symptoms of bleeding, pain or discomfort.
During an interview, on 10/20/22 at 9:45 a.m., the Licensed Practical Nurse (LPN) 6 indicated if a resident did not urinate at least once in eight hours after the catheter was removed, the staff should notify the physician. The family had requested Resident 44 be transferred to the hospital for evaluation and treatment.
During an interview, on 10/21/22 at 1:20 p.m., the Infection Preventionist (IP) indicated Resident 44 had a catheter in place and re-anchored. He developed Urosepsis and was admitted to the hospital.
During an interview, on 10/21/22 at 2:00 p.m., the Clinical Nurse Support (CNS) indicated the staff should obtain specific instructions from the physician when an order to remove a catheter was received. Complications to urinary retention included, sepsis, tearing of the bladder, pain and kidney failure.
A current policy, titled Notification of Change in Condition, indicated the staff must inform the resident, physician, and resident representative when a change in the resident's physical, mental, or psychosocial status.
3.1-41(a)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure the IDT (Interdisciplinary Team) determined which medications may be self-administered and failed to ensure a physician...
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Based on observation, interview and record review, the facility failed to ensure the IDT (Interdisciplinary Team) determined which medications may be self-administered and failed to ensure a physician's order to use and keep medications at the bedside was obtained for 1 of 1 resident reviewed for self administration. (Resident 201)
Findings include:
During an observation and interview, on 10/18/22 at 12:10 p.m., Resident 201 was observed, in her room, lying in bed. Next to her was an over the bed table with a bottle of ibuprofen, vitamin D and a nerve supplement. She indicated her daughter had brought in the medication for her to use. She was not aware of whether she was able to keep medications in her room.
During an observation and interview, on 10/20/22 at 10:46 a.m., the Director of Nursing (DON) indicated on the over the bed table Resident 201 had a bottle of Flonase nasal spray, ibuprofen 200 milligrams (mgs), omega 3 and a bottle of nerve supplement. She was unaware if Resident 201 had a self-administration assessment completed or an order was obtained for self-administration of medications. She removed all the medications from Resident 201's room and indicated all medications should be secured in the medication cart.
The record for Resident 201 was reviewed. Diagnoses included, but were not limited to, repeated falls, fracture of the fifth lumbar vertebra, atrial fibrillation (irregular heart rhythm), dementia with behavioral disturbances, pneumonia (infection within the lungs), chronic kidney disease (kidneys are damaged and can't filter blood the way they should.), factor VIII deficiency (genetic disorder caused by missing or defective clotting protein) and hyponatremia (low blood sodium levels).
A care plan, dated 10/14/22, indicated Resident 201's medications were to be administered by facility staff per the physician's order.
The physician's orders lacked indication the resident had an order for the self-administration of medications or she had been prescribed Ibuprofen, Flonase, Nerve Supplement or Omega prior to 10/20/22.
During an interview, on 10/20/22 at 11:05 a.m., the Corporate Support Nurse (CSN) indicated no medications or supplements should be left at a resident's bedside. All medications and supplements should be locked up in the medication cart. If a resident was going to self-administer medication, a self-administration assessment must be completed and an order obtained by the physician.
A current facility policy, titled Guidelines for Self-Administration of Medications, dated with a revision date of 5/22/18, indicated the purpose was to ensure the safe administration of medication for residents who request to self-medicate or when self-medication is a part of the plan of care. Results of the assessment would be presented to the physician for evaluation and an order for self-medication would be obtained. Medication would be kept in a locked drawer in the resident's room.
3.1-11(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide assistance with activities of daily living (ADL's), related to shaving, for 2 of 2 residents reviewed for ADL care. (R...
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Based on observation, interview and record review, the facility failed to provide assistance with activities of daily living (ADL's), related to shaving, for 2 of 2 residents reviewed for ADL care. (Resident 42 and 46)
Findings include:
1. During an observation and interview, on 10/18/22 at 2:45 p.m., Resident 42 had quarter - inch long, white-colored facial hair on her chin. Resident 42 indicated she took pride in her looks and wanted to present herself well.
During an observation and interview, on 10/20/22 at 10:30 a.m., Resident 42 was found, in her room, seated in her wheelchair. She was dressed and had more than 12 white chin hairs which measured more than a quarter inch long. Resident 42 indicated staff had not offered to shave her chin hairs.
The record for Resident 42 was reviewed on 10/19/22 at 3:00 p.m. Diagnoses included, but were not limited to, rhabdomyolysis (a breakdown of muscle tissue which releases a damaging protein into the blood), pneumonia (infection in the lungs), history of falls and a left femur (thigh bone) fracture.
Resident 42's Minimum Data Set (MDS) assessment, dated 9/23/22, indicated she required extensive assistance by one staff for personal hygiene, including shaving.
A Care Area Assessment (CAA), dated 9/23/22, indicated Resident 42 triggered for activity for daily living (ADL) and required extensive assistance for grooming.
A care plan, dated 9/26/22, indicated Resident 42 required staff to assist her to complete ADL tasks completely and safely. The care plan lacked indications to offer or provide assistance to Resident 42 to be shaved.
The record lacked an indication Resident 42 refused or was offered to have her chin hairs shaved.
During an interview, on 10/21/22 at 12:15 p.m., the Corporate Support Nurse indicated Resident 42 did not refuse or decline assistance with shaving.
2. During an observation, on 10/19/22 at 9:58 a.m., Resident 46 was seated, in her wheelchair, near the nurse's station and wore a neck brace. On her chin, she had 10 white-colored facial hairs which measured a quarter inch long.
During an interview, on 10/19/22 at 2:27 p.m., Resident 46 indicated her preference would be to not have the chin hairs and to look clean and neat. She was not physically able to shave herself.
During an observation, on 10/20/22 at 1:30 p.m., Resident 46 was seated, in her wheelchair, in the doorway to her room with her neck brace on. She had 10 quarter inch long white chin hairs.
The record for Resident 46 was reviewed on 10/21/22 at 2:45 p.m. Diagnoses included, but were not limited to, fracture of the second cervical (neck) vertebra, dementia, pain and a fall.
Resident 46's admission MDS assessment indicated she required extensive assistance by one person for personal hygiene, including shaving.
A Care Area Assessment (CAA), dated 10/7/22, indicated Resident 46 triggered for ADL and required extensive assistance for grooming.
The record lacked an indication Resident 46 was offered or refused to have her chin hair shaved.
During an interview, on 10/20/22 at 11:00 a.m., a Nursing Assistant (NA) indicated she had not asked or offered Resident 42 or Resident 46 if they preferred to be shaved when she assisted with their morning care.
During an interview, on 10/21/22 at 10:14 a.m., the Corporate Support Nurse (CSN) indicated residents would be shaved on their shower days or as needed based on the resident's preferences. Staff should follow the resident's preferences which could be found on the resident's care plan or care guide.
During an interview, on 10/21/22 at 10:14 a.m., the CSN indicated they did not have a policy related to shaving.
3.1-38(a)(3)(D)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to implement bowel protocol interventions after a resident did not have a bowel movement (BM) for 1 of 1 resident reviewed for constipation. (...
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Based on interview and record review, the facility failed to implement bowel protocol interventions after a resident did not have a bowel movement (BM) for 1 of 1 resident reviewed for constipation. (Resident 26)
Finding includes:
During an interview, on 10/18/22 at 2:37 p.m., Resident 26's daughter indicated the resident had not had a bowel movement for 6 days and if she did not question it, the staff would not have known.
The record for Resident 26 was reviewed on 10/20/22 at 4:10 p.m. Diagnoses included, but were not limited to, anxiety, depression and constipation.
A care plan, dated 08/30/21 and edited on 07/19/22, indicated the resident was at risk for constipation and interventions included, but were not limited to, administer medications, enemas and suppository as ordered.
A current physician's order, dated 08/23/21, indicated if the resident went greater than 72 hours without a bowel movement then the bowel protocol should be implemented. The bowel protocol was as follows:
a. Start with two tablespoons of natural laxative.
b. If no results within 24 hours after natural laxative, administer Milk of Magnesia.
c. If no results within 12 hours of Milk of Magnesia then administer a Dulcolax suppository.
d. If the results of the suppository within 2 hours or was not sufficient then administer a Fleets enema.
A progress note, dated 10/12/22 at 8:50 p.m., indicated the nurse was made aware by the resident's daughter the resident had not had a bowel movement in the last 3 days and was uncomfortable.
A Vitals Report document, for Resident 26, indicated the resident did not have a bowel movement form 10/06/22 through 10/11/22.
The bowel protocol was not initiated after the resident went greater than 72 hours without a bowel movement.
During an interview, on 10/19/22 at 2:30 p.m., the Clinical Support Nurse indicated after the third day of no bowel movement the nursing staff would initiate the bowel regimen protocol on the fourth day.
A current policy, titled Bowel Protocol Guidelines, dated as reviewed on 03/18/2022 and provided by the Corporate Support Nurse on 10/21/22 at 4:12 p.m., indicated .The Ineffective Bowel Pattern Event should be initiated for any resident not having a BM within 72 hours a. a progress note associated to the Ineffective Bowel Event, should be completed until the resident has a BM .The progress note should include abdominal distention, pain an bowel sounds .If no bowel movement within 72 hours, 2 tablespoon (30cc) [cubic centimeters] of 'Natural Laxative' b. If no results within 24 hours after 'Natural Laxative' give 30 cc of Milk of Magnesia c. If no results within approximately 12 hours after MOM administer Dulcolax suppository d. If results of suppository are not satisfactory within 2 hours give Fleets enema
3.1-37(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure the hot water temperatures remained between 105 degrees and 120 degrees for 1 of 5 residents reviewed for accident haza...
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Based on observation, interview and record review, the facility failed to ensure the hot water temperatures remained between 105 degrees and 120 degrees for 1 of 5 residents reviewed for accident hazards. (Resident 38)
Finding includes:
During an initial environmental observation, on 10/18/22 at 11:10 a.m., Resident 38's hot water was assessed. The hot water, in his bathroom, felt hot to the touch and surveyor's fingers turned bright red after holding them in the water for 10 seconds. The temperature of the water was tested and the thermometer indicated the water was 121 degrees Fahrenheit.
During an interview, on 10/18/22 at 11:14 a.m., Resident 38 indicated the water, in the bathroom, felt hot at times and he had to pull his hands out of the water quickly.
During an observation and interview, on 10/18/22 at 1:06 p.m., the Director of Plant Operations (DPO) measured the hot water temperature at 121.5 degrees in Resident 38's bathroom. The DPO indicated he had concerns regarding the water temperatures and a sensor on the boiler could be off. The gauges on the boiler displayed 120 degrees but when he tested the water, it was hotter. The hot water temperatures needed to measure below 120 degrees to ensure a resident would not get burnt. He had not been notified of concerns regarding the temperature of the hot water.
The record for Resident 38 was reviewed. Diagnoses included, but were not limited to, repeated falls, muscle weakness, malignant neoplasm of the prostate and mild cognitive impairment.
A Care Area Assessment (CAA), dated 9/10/22, indicated the Resident 38 had physical limitation related to weakness and had a fall. Resident 38 needed assistance with mobility and transfers.
A care plan, dated 9/14/22, indicated the resident had a high risk for falling related to the use of high-risk medications, repeated falls and weakness. The care plan directed staff to encourage Resident 38 to do as much as safely possible for himself.
A facility document, titled Travelers Boiler Fired Pressure Vessel Report of Inspection, indicated an inspection was completed, on 8/31/21, and no concerns were found.
A facility document, titled TELS Work Orders, dated 10/1/22 to 10/18/22, was reviewed and no work orders were found related to concerns regarding hot water in the bathrooms.
A facility TELS Logbook Documentation, dated 10/3/22 to 10/14/22, had no indications of elevated water temperatures above 120 degrees Fahrenheit.
During an interview, on 10/24/22 at 2:00 p.m., the Clinical Nurse Support (CNS) indicated the facility did not have documentation of monthly inspections for the boiler.
A current policy, titled Preventative Maintenance Procedures, dated 2/6/18, indicated each piece of equipment or section of the building had its own inspection schedule and procedures to follow to decrease the chances of equipment failure.
A current policy, titled Equipment Care, with a revised date of 2/5/18, indicated the Director of Environmental Services was to inspect environmental equipment monthly and train employees on equipment care. Staff were to generate work orders through TELS when repairs are needed on equipment.
3.1-45(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to assess and documentation Peripherally Inserted Central Catheter (PICC) care for 2 of 2 residents reviewed for PICC line care. (Resident 41 ...
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Based on interview and record review, the facility failed to assess and documentation Peripherally Inserted Central Catheter (PICC) care for 2 of 2 residents reviewed for PICC line care. (Resident 41 and 199)
Findings include:
1. The record for Resident 41 was reviewed. Diagnoses included, but were not limited to, sepsis (overwhelming and life-threatening response to infection), dementia, hip fracture and history of falls.
An admission Referral note, dated 9/20/22, indicated Resident 41 would need to continue intravenously (IV) Vancomycin (antibiotic) for the diagnosis of Methicillin-Resistant Staphylococcus Aureus (MRSA) (a staph infection which is difficult to treat because of resistance to some antibiotics) for six weeks.
An admission nurse progress note, dated 9/21/22 at 6:31 p.m., indicated Resident 41 had a peripherally inserted central catheter line to right upper arm and had received Vancomycin (antibiotic) intravenously. The progress note lacked indication the length of the external catheter of the PICC line.
A physician's order, dated 9/26/22, indicated Resident 41 was to receive Vancomycin 750 mg (milligram) every 12 hours intravenously for MRSA from 9/21/22 to 9/26/22.
A physician's order, dated 9/26/22, indicated Resident 41 was to receive Vancomycin 750 mg every 12 hours intravenously for MRSA from 9/26/22 to 9/28/22.
A physician's order, dated 10/20/22, indicated Resident 41 was to receive Vancomycin 750 mg every 12 hours intravenously for MRSA from 10/20/22 to 11/5/22.
The nurse progress notes, dated from 9/21/22 to 9/29/22 at 10:42 p.m., indicated Resident 41 had a PICC line in her right upper arm. The progress notes lacked indications measurements of the external catheter was obtained or documented.
The nurse progress notes, dated from 9/30/22 to 10/2/22, had no documentation related to Resident 41's PICC line.
A nurse progress note, dated 10/3/22 at 11:17 a.m., indicated the PICC line was located in Resident 41's left arm.
A nurse progress note, dated 10/3/22 at 8:50 p.m., indicated the PICC line was missing from Resident 41's forearm.
A nurse progress note, dated 10/4/22 at 11:09 a.m., indicated a PICC line was placed in Resident 41's right upper extremity and measured 40 centimeters (cm).
A nurse progress note, dated 10/4/22 at 12:09 p.m., indicated Resident 41 had missed two doses of her antibiotic, because the PICC line had been pulled out.
A nurse progress note, dated 10/6/22 at 11:06 p.m., indicated Resident 41's PICC line was intact, patent, and clean.
A nurse progress note, dated 10/8/22 at 7:41 p.m., recorded as a late entry on 10/12/22 at 10:42 a.m., indicated Resident 41 was found on the floor lying next to the bed. The progress note lacked indication the PICC line was assessed after the she was found on the floor.
A nurse progress note, dated 10/16/22 at 5:26 a.m., indicated Resident 41's PICC line was found pulled out and under her head. The PICC line was last seen intact and patent at on 10/15/22 at 11 p.m., when the infusion had completed and the PICC line was flushed.
A nurse progress note, dated 10/16/22 at 10:36 a.m., indicated a PICC line was replaced in the right Brachial vein, single lumen, 4 French, non-valved line. Internal length was 38 cm, external length 0 cm, and post arm circumference was 32 cm.
A nurse progress note, dated 10/17/22 at 9:43 p.m., indicated Resident 41 had pulled out her PICC line and a new PICC line was inserted. The progress note, lacked indication the PICC line was placed, length of catheter, or the catheter was intact.
A nurse progress note, dated 10/19/22, indicated the PICC line dressing was changed on Resident 41's right arm, and the external catheter measured 0.4 cm.
A nurse progress note, dated 10/21/22 at 7:58 a.m., indicated Resident 41 had pulled the PICC line out and was found with the PICC line in her hand. The progress note indicated the tip was intact, but lacked documentation of the measurement of the catheter.
During the survey, a care plan dated 10/20/22, indicated the resident had required IV medication related to sepsis. The care plan directed staff to administer IV as ordered, assess for complications, provide IV site cares as ordered and notify the physician with complications.
During an interview, on 10/20/22 at 3:45 p.m., the Assistant Director of Nursing (ADON) indicated she had not received information regarding the PICC line from the hospital discharge records.
2. The record for Resident 199 was reviewed. Diagnoses included, but were not limited to, osteomyelitis (infection in the bone), hypertension (high blood pressure) and COVID-19.
A physician's order, dated 10/8/22 to 10/10/22, indicated Resident 199 received vancomycin one gram in 0.9 percent (%) solution. The order indicated to infuse the antibiotic over 60 minutes two times a day.
A physician's order, dated 10/10/22, indicated Resident 199 received cefepime HCL (an antibiotic) two grams in 250 ml (milliliter) of 0.9 % sodium chloride solution. The order indicated to infuse the antibiotic over 30 minutes three times a day.
A physician's treatment order, dated 10/10/22, indicated to change Resident 199's PICC line dressing every five days, measure the catheter length and enter the measurements in the medication notes.
The Medication Administration Record (MAR) was reviewed on 10/15/22. The MAR indicated Resident 199's PICC line dressing was change. The MAR lacked documentation of a measurement of the PICC line.
A nurse progress note, dated 10/9/22, indicated Resident 199 had a PICC line to her right upper extremity and it was clean, intact and patent. The progress note indicated she received vancomycin through her IV.
A nurse progress note was entered after survey started, dated 10/13/22 at 5:45 p.m., and entered as a late entry on 10/18/22 at 4:29 p.m., indicated Resident 199 had fallen when she attempted to return from the bathroom. She sustained a 3 cm (centimeter) by 3.5 cm bruise to her right chest. Her IV site was assessed to have no bleeding or dislodgement and measured 15 cm.
A nurse progress note, dated 10/18/22 at 1:15 p.m., indicated the PICC line dressing had been changed to her right upper extremity.
During the survey, a care plan dated 10/10/22, was revised on 10/24/22, and indicated to administer IV as ordered, assess for complications, provide IV site care as ordered and to notify physician of any complications.
The clinical record lacked assessments or measurements for Resident 199's PICC line from 10/9/22 to 10/11/22.
During an interview, on 10/18/22 at 4:15 p.m., Licensed Practical Nurse (LPN) 6 indicated she was not aware of the measurements of Resident 199's PICC line when she was admitted . The facility did not have PICC line records and was unsure of the external length after the PICC line was initially placed.
During an interview, on 10/20/22 at 3:45 p.m., the Assistant Director of Nursing (ADON) indicated she had not received information about the PICC line from the hospital for Resident 199.
During an interview, on 10/20/22 at 2:00 p.m., the Clinical Support Nurse (CNS) indicated the facility did not receive information on Resident 41's or Resident 199's PICC line from the hospital discharge. The staff would not be aware of the type of PICC line or measurements related to the PICC for ongoing assessments if they did not have the PICC line documentation. Her expectation for staff would be to obtain the records needed to monitor and assess the residents' PICC lines.
A current policy, titled Overview of Infusion Therapy, with a revised date of 12/15, indicated to monitor the external length of the catheter on admission and with each dressing change for outward migration.
3.1-47(a)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to obtain a physician's order, an assessment, to develop a care plan and obtain a consent for the use of side rails for 1 of 5 re...
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Based on observation, interview and record review, the facility failed to obtain a physician's order, an assessment, to develop a care plan and obtain a consent for the use of side rails for 1 of 5 residents reviewed for accident hazards. (Resident 15)
Finding includes:
During an observation, on 10/18/22 at 1:17 p.m., the resident was resting, in her bed, with her head elevated and her side rails were elevated on both sides of her bed.
During an observation, on 10/19/22 at 12:43 p.m., the resident was sitting up, in her bed, eating her lunch and her side rails were elevated on both sides of her bed.
The record for Resident 15 was reviewed on 10/20/22 at 9:32 a.m. Diagnoses included, but were not limited to, fracture of the right lower leg, muscle weakness and CHF (congestive heart failure - a condition where the heart does not pump blood as it should and can result in fluid in the lungs making it difficult to breath).
The record did not contain a physician's order, an assessment, a care plan or a consent for the side rails.
During an interview, on 10/20/22 at 11:00 a.m., the Corporate Support Nurse indicated Resident 15 did not have an order, a care plan, consent, or an assessment for the use of side rails and she should have had them documented in her medical record.
A current policy, titled Guidelines for the Use of Bed Rails, dated 12/01/2021 and provided by the Director of Nursing on 10/20/22 at 11:30 a.m., indicated .The use of bed rails as an assistive device should be addressed in the resident's care plan .Informed consent for the use of bed rails should be obtained from the resident and/or legal representative
3.1-45 (a)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to indicate targeted behaviors, specific non-pharmacological interventions, develop a resident centered care plan for insomnia and failed to h...
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Based on interview and record review, the facility failed to indicate targeted behaviors, specific non-pharmacological interventions, develop a resident centered care plan for insomnia and failed to have an appropriate diagnosis for the use of a psychotropic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 26)
Finding includes:
The record for Resident 26 was reviewed on 10/20/22 at 4:10 p.m. Diagnoses included, but were not limited to, anxiety, depression, constipation, dementia with behavioral disturbances and insomnia.
A physician's order, dated 08/31/2022, indicated the resident received buspirone (a medication used to treat anxiety) 2.5 mg (milligrams) two times a day for anxiety.
A physician's order, dated 10/14/2021, indicated the resident received trazadone (a medication used to treat depression and insomnia) 25 mg at bed time for insomnia.
A physician's order, dated 06/06/22, indicated the resident received Depakote ER (extended release) (a medication used to treat seizures and psychiatric disorders) once a day for behavioral disturbance.
A care plan, dated 10/16/2022, indicated the resident had a diagnosis of anxiety. Interventions included, but were not limited to, monitor for increasing signs and symptoms of anxiety. The care plan did not include the targeted specific resident centered signs and symptoms of anxiety as well as any non-pharmacological approaches.
The resident's record did not include a resident centered care plan for the use of trazodone and a diagnosis of insomnia.
During an interview, on 10/24/22 at 11:28 a.m., the Corporate Support Nurse indicated she could not provide any documentation of specific anxiety symptoms the resident exhibited, as well as any non-pharmacological interventions to implement and they should have been documented in the resident's care plan. She also could not provide a person centered care plan for the resident's use of trazodone for insomnia and she should have had one initiated.
During an interview, on 10/24/22 at 3:03 p.m., the facility Pharmacist indicated dementia with behaviors was not an approved FDA (food and drug administration) diagnosis for the use of Depakote ER.
During an interview, on 10/25/22 at 4:30 p.m., the Corporate Support Nurse indicated dementia was not an approved or appropriate diagnosis for the use of Depakote ER.
A recent publication of PDR.net indicated .Depakote was indicated for the treatment of bipolar disorder including mania .the black box warning indicates antipsychotic's are not approved for the treatment of dementia-related psychosis in geriatric patients and the use of Depakote in this population should be avoided if possible due to an increase in morbidity and mortality
A current policy, titled Comprehensive Care Plan Guidelines, dated as reviewed on 05/22/2018 and provided by the Corporate Support Nurse on 10/24/22 at 12:46 p.m., indicated .interventions should be reflective of thee individual's needs and risks .Comprehensive care plans need to be accurate and current .New interventions will be added and updated .Newly recognized problems will have a care plan developed
A current policy, titled Psychotropic Medication Usage and Gradual Dose Reductions, dated as revised on 01/09/2012 and provided by the Corporate Support Nurse on 10/25/22 at 3:39 p.m., indicated .To ensure every effort is made for residents receiving psychoactive medications to obtain the maximum benefits with minimal unwanted side effects through appropriate use .Procedures 1. Residents shall receive psychotropic medications only .with the appropriate diagnosis
3.1-48(a)(3)
3.1-48(a)(4)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview, the facility failed to ensure a medication error rate of less than 5 percent, based on medication errors observed during 2 of 25 opportunities for er...
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Based on observation, record review and interview, the facility failed to ensure a medication error rate of less than 5 percent, based on medication errors observed during 2 of 25 opportunities for errors, during a random medication administration observation, resulting in a medication error rate of 8 percent. (Resident 13 and 101)
Findings include:
1. During a random medication administration observation, beginning on 10/21/2022 at 9:33 a.m., QMA (Qualified Medication Aide) 2 was observed to prepare medications. Included in the 7 medications she prepared for Resident 13, she punched out 1 peach colored tablet of Senexon (to treat constipation) 8.6-50 mg (milligrams) into a clear medication cup. The QMA closed the monitoring screen on the computer, locked the medication cart and picked up the medication cup containing Resident 13's medications and a blood pressure cuff and walked away from the medication cart towards Resident 13's room. She told the resident she had his medications and handed him a cup of water.
During an interview, at this time, QMA 2 was questioned if she was going to administer the medications in the cup, to which she responded she was. The QMA was requested to check the order for the resident's Senexon 8.6-50 mg. After reviewing the physician's order, she indicated the resident was to receive 2 tablets and she was unaware the resident was to receive 2 tablets of Senexon.
The record for Resident 13 was reviewed on 10/21/2022 at 10:21 a.m. A physician's order indicated the resident was to receive Senexon 8.6-50 mg 2 tablets.
2. During a random medication observation, beginning on 10/21/2022 at 9:33 a.m., QMA 2 administered 2 squirts of nasal spray into the right and left nostril of Resident 101.
The record for Resident 101 was reviewed on 10/21/2022 at 10:21 a.m. A physician's order indicated the resident was to receive Fluticasone 50 mcg (micrograms) - 1 spray to each nostril.
An undated facility policy, titled Specific Medication Administration Procedures, with the last revision date of 2014 and provided by the Corporate Support Nurse on 10/21/2022 at 4:22 p.m., indicated .Review 5 Rights (3 times): 1) Prior to removing the medication package/container from the cart/drawer; a. Check MAR/TAR for order .2)Prior to removing the medication from the container a. Check the label against the order on the MAR .3) After the dose has been prepared and before returning the medication to storage
3.1-48(c)(1)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to serve food in accordance with professional standards for food service safety when one randomly observed cook failed to remove ...
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Based on observation, interview and record review, the facility failed to serve food in accordance with professional standards for food service safety when one randomly observed cook failed to remove gloves and hand sanitize and another cook failed to wear a hair restraint which completely covered his hair while preparing and serving food for 2 of 2 randomly observed kitchen staff. (Cook 4 and 5)
Findings include:
1. During an observation, on 10/18/22 at 11:04 a.m., with the Director of Food Services present, [NAME] 4 was prepping carrots and lettuce for the salad bar. He had on a baseball cap with an approximate 1 inch pony tail outside his cap in the back. During an interview, at that time, the Director of Food Services indicated he was unsure if [NAME] 4 needed to wear a hair restraint or cover his pony tail because he had on a ball cap and his hair was not that long.
2. During an observation, on 10/19/22 at 11:56 a.m., with the Director of Food Services present, [NAME] 5 was observed to have gloves on while at the steam table preparing and serving foods for lunch. He plated food items from a steam table, turned and touched a card board box. He reached inside a bread bag and removed two slices of bread and set them down on a plate. He then wiped his hands on his apron, picked up menu slips and plated more food items. He stopped and went to the refrigerator. He took a handful of onion rings and placed them into the fryer basket, took two frozen raw hamburger patties and placed them on the oven top and placed fresh onions on top of the burgers. He was not observed to remove his gloves, until 12:01 p.m. He removed his gloves, threw them in the trash and put on another pair of gloves. He was not observed to perform any hand hygiene when removing the gloves.
During an interview, at that time, the Director of Food Services indicated staff should wash their hands and change gloves between touching surfaces and touching food.
During an interview, on 10/21/22 at 1:47 p.m., the Corporate Support Nurse indicated [NAME] 5 should have changed his gloves and washed his hands in-between touching food and other surfaces.
A current policy, titled Hair Restraint, undated and provided by the Cooperate Support Nurse on 10/18/22 at 4:00 p.m., indicated .Those employees that have hair the extrudes out of the cap will be required to have hair .tucked under hat. Food service employees will wear hair restraints while in all food preparation areas
A current policy, titled Yellow Lines/Hair Restraint Policy, dated as reviewed on 08/23/19 and provided by the Corporate Support Nurse on 10/21/22 at 4:15 p.m., indicated .Entering food production areas .requires the proper use of hair restraints to help prevent the chance of hair contaminating food for consumption
A current policy, titled Guideline for Handwashing/Hand Hygiene, dated as reviewed on 12/01/2021 and provided by the Corporate Support Nurse on 10/24/22 at 10:39 a.m., indicated .Handwashing is the single most important factor in preventing transmission of infections .Health Care Workers shall use hand hygiene at times such as .before /after preparing/serving meals
3.1-21(i)(3)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to follow the Centers for Disease Control (CDC) guidelines to prevent and/or minimize the risk of transmission of Methicillin-res...
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Based on observation, interview and record review, the facility failed to follow the Centers for Disease Control (CDC) guidelines to prevent and/or minimize the risk of transmission of Methicillin-resistant Staphylococcus aureus (MRSA) (a cause of staph infection which is difficult to treat because of resistance to some antibiotics) for 1 of 2 residents reviewed for transmission-based precautions. (Resident 41)
Finding includes:
During an observation, from 10/18/22 to 10/20/22, no sign was found to alert for the need of contact precautions or personal protective equipment to be used while providing specific cares. In Resident 41's room, there was an IV pole with a pump, used IV tubing, an empty vial of antibiotic and an IV fluid bag.
The record for Resident 41 was reviewed. Diagnoses included, but were not limited to, sepsis (overwhelming and life-threatening response to infection), Methicillin-resistant Staphylococcus aureus (staph infection which is difficult to treat because of resistance to some antibiotics), dementia, hip fracture and history of falls.
A hospital summary, on 9/14/22, indicated Resident 41's blood culture grew positive for MRSA. Her computerized tomography (CT) scan (series of Xray's) of the femur indicated her thigh had a deep soft tissue abscess (confined pocket of pus which collects in tissues) with cellulitis (a skin infection). Resident 41's wound cultures from her irrigation and debridement were positive for staphylococcus aureus bacteria on 9/15/22. She was to continue intravenous (IV) vancomycin (an antibiotic) until her blood cultures were clear from MRSA.
Her record lacked indication she was placed on contact precautions after admission to the facility.
A Care Area Assessment (CAA), dated 9/6/22, indicated the Resident 41 had impaired cognition and required supervision.
A physician's order, dated 9/26/22, indicated Resident 41 was to receive Vancomycin 750 mg (milligram) every 12 hours intravenously for MRSA from 9/21/22 to 9/26/22.
A physician's order, dated 9/26/22, indicated Resident 41 was to receive Vancomycin 750 mg every 12 hours intravenously for MRSA from 9/26/22 to 9/28/22.
A physician's order, dated 10/20/22, indicated Resident 41 was to receive Vancomycin 750 mg every 12 hours intravenously for MRSA from 10/20/22 to 11/5/22.
A care plan, updated on 10/21/22, indicated the resident had the need for modified contact isolation during dressing changes due to MRSA of her left hip.
During an interview, on 10/19/22 at 11:02 p.m., Licensed Practical Nurse (LPN) indicated Resident 41 had not been placed on precautions when she admitted from the hospital with a surgical wound on her hip.
During an interview, on 10/21/22, at 9:20 a.m., the Clinical Nurse Support (CNS) indicated Resident 41 was not placed on modified contact precautions for MRSA, once she admitted to the facility. Staff should put on gloves and wear a gown over their clothing when providing care to Resident 41 and could come in contact with her wound.
During an interview, on 10/21/22 at 2:24 p.m., the Assistant Director of Nursing (ADON) indicated she did not put Resident 41 on contact precautions because she was not aware Resident 41 had a diagnoses of MRSA at the time of admission to the facility. The resident's admission note, orders or care plan did not indicate she required special precautions when providing care.
A review of the facility's Infection Log and Antibiotic Stewardship report indicated Resident 41 was on cephalexin and vancomycin for MRSA.
A current policy, titled Guidelines for Contact Precautions, dated 5/22/18, indicated guidelines to prevent the spread of infectious disease organisms. Contact precautions were indicated to prevent and control healthcare associated infections transmission of infection which included MRSA.
The Center for Disease Control and Prevention article, titled Healthcare Settings - Preventing the Spread of MRSA, dated 2/28/19, indicated MRSA was usually spread by direct contact with an infected wound or from contaminated hands, usually those of healthcare providers. MRSA was usually spread by direct contact with an infected wound or from contaminated hands, usually those of healthcare providers.
3.1-18(b)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0909
(Tag F0909)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to implement routine inspections of a resident's bed to ensure a resident's bed was in proper working order for 1 of 16 residents...
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Based on observation, interview and record review, the facility failed to implement routine inspections of a resident's bed to ensure a resident's bed was in proper working order for 1 of 16 residents reviewed for bed safety. (Resident 38)
Finding includes:
During an observation, on 10/18/22 at 11:14 a.m., Resident 38's footboard on his bed was loose and hanging down lower on the left side. The left side of the footboard bracket was not securely attached to the bed frame.
During an observation and interview, on 10/18/22 at 12:36 p.m., the Director of Plant Operations (DPO) indicated Resident 38's footboard was loose and not attached to the bed frame. The bracket on the back of the footboard was not secured to the bed and a bolt needed to be tightened. The DPO indicated Resident 38 could have fell if he would have grabbed onto the footboard.
The record for Resident 38 was reviewed. Diagnoses included, but were not limited to, repeated falls, muscle weakness, malignant neoplasm of the prostate and mild cognitive impairment.
A Care Area Assessment (CAA), dated 9/10/22, indicated Resident 38 had physical limitation related to weakness and had a fall. Resident 38 needed assistance with mobility and transfers.
A care plan, dated 9/14/22, indicated the resident had a high risk for falling related to the use of high-risk medications, repeated falls and weakness. The care plan directed staff to encourage Resident 38 to do as much as safely possible for himself.
A fall event note, dated 9/26/22 at 6:30 p.m., indicated Resident 38 was found on the floor in front of his wheelchair.
During an interview, on 10/19/22 at 12:02 p.m., Resident 38 indicated he had a fall in September but was unsure of what happened.
During an interview, on 10/21/22 at 9:20 a.m., the Clinical Nurse Support (CNS) indicated staff should notify the maintenance department when any concerns regarding patient equipment come up. Staff should be monitoring the equipment for safety concerns each time they work with a resident.
The facility's work order report, dated 10/1/22 to 10/18/22, was reviewed and no work orders were found related to Resident 38's footboard.
A current policy, titled Equipment Care, with a revised date of 2/5/18, directed the Director of Environmental Services to inspect environmental equipment monthly and train employees on equipment care. The policy directed staff to generate work orders through TELS when repairs are needed on equipment.
3.1-19(f)(5)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide a safe, clean, and comfortable interior environment for 1 of 2 residents reviewed who received medications intravenous...
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Based on observation, interview and record review, the facility failed to provide a safe, clean, and comfortable interior environment for 1 of 2 residents reviewed who received medications intravenously. (Resident 41)
Finding includes:
During an observation, on 10/18/22 at 11:26 a.m., in Resident 41's room an intravenous (IV) pole with a pump was in her room covered with a white pillowcase, with used IV tubing, an empty vial of antibiotic and IV fluid bags next to Resident 41's door. The base of the IV pole had white and gray colored spots of dirt and multiple areas of rust on each leg. In the bathroom, on the right side of the sink, was a visibly soiled white washcloth with dry, black colored stain.
During an observation, on 10/18/22 at 2:45 p.m., in Resident 41's room, there was an IV pole with a pump covered with a white pillowcase, with used IV tubing, an empty vial of antibiotic and an IV fluid bag next to Resident 41's door.
During an observation, on 10/19/22, at 2:30 p.m., in Resident 41's room there were two IV poles. An IV pole with a pump was next to her exit side of the bed, and a second pole with used IV tubing, an empty vial of antibiotic, and an IV fluid bag was next to Resident 41's door.
During an observation, on 10/20/22 9:20 a.m., in Resident 41's room, an IV pole with a pump was plugged into a lamp on the bedside table in Resident 41's room. The used IV fluid bag, IV tubing and an empty vial of antibiotic was still hung on the IV pole.
The record for Resident 41 was reviewed. Diagnoses included, but were not limited to, sepsis (overwhelming and life-threatening response to infection), Methicillin-resistant Staphylococcus aureus (staph infection which is difficult to treat because of resistance to some antibiotics), dementia, hip fracture and history of falls.
Resident 41's Minimum Data Set (MDS) assessment, dated 9/23/22, indicated she had a history of falls prior to admission and wandering behavior symptoms at the facility.
A Care Area Assessment (CAA), dated 9/6/22, indicated the Resident 41 had impaired cognition and required supervision.
A care plan, dated 10/21/22, indicated the resident had a risk for safety related to impaired cognition and reduced safety awareness related to her dementia. The care plan directed staff to observe Resident 41 for wandering into unsafe areas.
A nurse progress note, dated 10/8/22 at 7:41 p.m., recorded as a late entry on 10/12/22 at 10:42 a.m., indicated Resident 41 was found on the floor lying next to the bed.
During an interview, on 10/20/22 at 9:24 a.m., the Corporate Facility Maintenance (CFM) representative indicated the IV pump should be plugged directly into a wall outlet and not a bedside table lamp.
During an interview, on 10/20/22 at 1:30 p.m., the Corporate Support Nurse (CSN) indicated staff should remove all used IV tubing and bags from the IV pole once the infusion was completed. The dirt and rust on the IV poles could put a resident at risk for infection.
The Zyno Medical manufacture's document, titled Z800F Infusion Pump, Instructions for Use, undated, indicated the power cord was to be plugged into an AC (alternating current) power outlet.
The facility's work order report, dated 10/1/22 to 10/18/22, was reviewed and no work orders were found related to rusty and dirty IV poles.
A current policy, titled Equipment Care, with a revised date of 2/5/18, directed the Director of Environmental Services to inspect environmental equipment monthly and train employees on equipment care. The policy directed staff to clean all equipment after each use.
3.1-19(f)(5)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an advance directive was reviewed, obtained or updated to re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an advance directive was reviewed, obtained or updated to reflect admitted residents' current wishes for 6 of 55 residents who were reviewed for advance directives. (Resident 26, 42, 46, 100, 200 and 201).
Findings include:
1. On [DATE] at 2:08 p.m., during a random observation, Resident 26 was confused to date, time, and place. She was not able to be interviewed.
The record for Resident 26 was reviewed on [DATE] at 8:52 a.m. Diagnoses included, but were not limited to, cardiomegaly (an enlarged heart), arthritis, depression and anxiety.
Resident 26's record indicated on her banner at the top of her EMR (electronic medical record) screen and face sheet, she wanted all resuscitation procedures if her heart stopped beating and/or she stopped breathing (full code status).
A care plan, dated [DATE], indicated the resident had a full code status and in an event Resident 26 had a cardiac arrest initiate Cardiopulmonary Resuscitation (CPR) and contact Emergency Medical Services (EMS).
A review of the document, titled Out of Hospital Do Not Resuscitate Declaration and Order, indicated the form was signed and dated, on [DATE], by Resident 26.
A physician's order, dated [DATE] at 3:10 p.m., indicated Resident 26 had a do not resuscitate (DNR) status.
A review of a facility document, titled Code Status Audit, dated [DATE], lacked indication the facility found a discrepancy with Resident 26's code status between the banner, face sheet, care plan, the resident's Out of Hospital Do Not Resuscitate Declaration and Order and most current physician's order for DNR status.
2. The record for Resident 42 was reviewed on [DATE] at 3:00 p.m. Diagnoses included, but were not limited to, rhabdomyolysis (breakdown of muscle tissue which releases a damaging protein into the blood), kidney failure (a condition in which the kidneys lose the ability to remove waste and balance fluids.)
Resident 42's record indicated on her banner and face sheet, she had a full code status.
A care plan, dated [DATE] and updated on [DATE], indicated Resident 42 had chosen the advance directive of DNR. Her care plan directed staff to honor her living will.
A review of the document, titled Out of Hospital Do Not Resuscitate Declaration and Order, indicated the form was signed and dated, on [DATE], by Resident 42.
During an interview, on [DATE] at 2:45 p.m., Resident 42 indicated Let me go, if it is my time. She did not want to be resuscitated if her heart were to stop.
During an interview, on [DATE] at 10:32 a.m., the Social Service Director (SSD) indicated Resident 42's code status in her records had her as a full code status. The SSD indicated Resident 42 desired a DNR status.
During an interview, on [DATE] at 10:40 a.m., the Director of Nursing (DON) indicated Resident 42's record and face sheet indicated she had a full code status, while the advance directive form indicated she desired a DNR status.
A review of a facility document, titled Code Status Audit, dated [DATE], indicated the facility updated the order, face sheet and banner to reflect Resident 42 had chosen a DNR status.
3. The record for Resident 46 was reviewed on [DATE] at 9:17 a.m. Diagnoses included, but were not limited to, atrial fibrillation, fracture of the second cervical (neck) vertebrae and atherosclerotic heart disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow).
Resident 46's record indicated on her banner and face sheet, she had a full code status.
A physician's order, dated [DATE] at 5:46 p.m., indicated Resident 46 had full code status.
A review of the document, titled Out of Hospital Do Not Resuscitate Declaration and Order, indicated the form was signed and dated, on [DATE], by Resident 46's representative.
During an interview, on [DATE] at 9:55 a.m., Resident 46 indicated I do not want to be revived if my heart was to stop.
During an interview, on [DATE] at 10:32 a.m., the SSD indicated Resident 46's code status in her records and order was a full code status. The SSD indicated Resident 46's advance directive indicated she had a DNR status.
During an interview, on [DATE] at 10:40 a.m., the DON indicated Resident 46's record, face sheet and order indicated she had a full code status, while the advance directive indicated she desired DNR status.
A review of a facility document, titled Code Status Audit, dated [DATE], indicated the facility updated the order, face sheet and banner to reflect Resident 46 had chosen a DNR status.
4. The record for Resident 100 was reviewed on [DATE] at 8:15 a.m. Diagnoses included, but were not limited to, hepatitis, hypertensive urgency (elevated blood pressure), atrial fibrillation (irregular heart rhythm), chronic obstructive pulmonary disease (a lung disease which block airflow and make it difficult to breathe), heart failure (a chronic condition in which the heart doesn't pump blood well) and end stage renal disease (permanent kidney failure).
Resident 100's record indicated on her banner, physician's order and her face sheet, she had a full code status.
A review of the document, titled Out of Hospital Do Not Resuscitate Declaration and Order, indicated the form was signed and dated, on [DATE], by Resident 100.
A nurse progress note, dated [DATE] at 8:56 p.m., indicated Resident 100 had arrived in a private car and was cooperative with care. The progress note lacked indication Resident 100's code status was reviewed.
A nurse progress note, dated [DATE], at 9:17 p.m. indicated an admission medication second check was completed. The progress note lacked indication Resident 100's code status was reviewed.
A care plan, dated [DATE], directed staff to honor Resident 100's living will. Her care plan lacked indication, Resident 100 had requested a DNR status.
A care plan meeting progress note, dated [DATE] at 5:31 p.m., lacked indication Resident 100's advance directive or code status was reviewed.
A review of the document, titled An Out of Hospital Do Not Resuscitate Declaration and Order, was signed and dated, on [DATE], by Resident 100.
A review of a facility document, titled Code Status Audit, dated [DATE], indicated the facility updated the order, face sheet and banner to reflect Resident 100 had chosen a DNR status.
5. The record for Resident 200 was reviewed on [DATE] at 3:00 p.m. Diagnoses included, but were not limited to, diabetes and hypertension (high blood pressure).
The record lacked indication Resident 200 had an advance care directive or staff reviewed his code status upon admission.
A care plan, dated [DATE], and revised on [DATE], indicated Resident 200 had requested full code status. His care plan directed staff to honor Resident 200's living will.
A review of the document, titled CPR (Cardiopulmonary) Consent, indicated the form was signed and dated, on [DATE], by Resident 200.
A review of a facility document, titled Code Status Audit, dated [DATE], indicated the facility reviewed code status with Resident 200 and uploaded his consent.
6. The record for Resident 201 was reviewed on [DATE] at 10:12 a.m. Diagnoses included, but were not limited to, atrial fibrillation, Factor VIII inhibitor disorder (autoantibodies which affect clotting factor activity and lead to a bleeding disorder), hypotension (low blood pressure) and atherosclerotic heart disease.
The record lacked indication Resident 201 had an advance care directive or staff reviewed his code status upon admission.
A care plan, dated [DATE], and revised on [DATE], indicated Resident 201 had requested full code status. Her care plan directed staff to honor Resident 201's living will.
A Social Service care plan meeting progress note, dated [DATE] at 4:21 p.m., indicated Resident 201's goal was to return home. The progress note lacked indication Resident 201's had an advance care directive or code status had been reviewed or obtained.
A review of the document, titled CPR (Cardiopulmonary) Consent, indicated the form was signed and dated, on [DATE], by Resident 201.
A review of a facility document, titled Code Status Audit, dated [DATE], indicated the facility reviewed code status with Resident 201 and uploaded his consent.
During an interview, on [DATE] at 9:34 a.m., Licensed Practical Nurse (LPN) 3 indicated she could look three places in the Electronic Medical Record (EMR) for the resident's code status. The code status would be on the face sheet, banner or on the Medication Administration record.
During an interview, on [DATE] at 9:38 a.m., a Nursing Assistant (NA) indicated she would follow the code status listed on the care profile. If she found a resident unresponsive, she would notify the nurse since she was not certified in CPR.
During an interview, on [DATE] at 10:40 a.m., the DON indicated on the Code Status Audit Form, dated [DATE], four residents were found to be a Full Code, instead of the residents' wishes to be a DNR. Her expectation for staff would be to review the resident's advance directive or code status upon admission to the facility. The admission Team or admission Nurse would review the code status with the resident or the resident's representative and obtain the order from the physician. The code status would be reviewed during care meetings or care conferences. If an incident occurred, the staff would access the EMR to verify the code status by looking at the banner, order, care plan or care profile.
During an interview, on [DATE] at 9:59 a.m., the Clinical Nurse Support (CNS) indicated since admission, Resident 201's record lacked indication the facility staff reviewed or obtained an advance directive or CPR consent form. A CPR Consent form was reviewed and signed by Resident 201, on [DATE].
During an interview, on [DATE] at 2:00 p.m., the CNS indicated a resident's code status should be reviewed upon admission, at care conferences or as needed with any changes. Once the code status was obtained, it would be entered as an order in the EMR.
A review of a facility document, titled Indiana admission Agreement Checklist, dated [DATE], indicated a CPR Consent or DNR form would be completed.
A current facility policy, titled Guidelines for Advanced Directives, dated as revised on [DATE], indicated Advance Directives would be reviewed with the resident and the resident's representative by the Customer Service representative or designee at time of admission. The facility staff obtained and followed the resident's advance directives regarding the end-of-life care.
3.1-4(f)(4)(A)(ii)
3.1-4(f)(4)(B)
3.1-4(f)(5)
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on site for 8 hours a day for 2 of 30 days, from September 18, 2022 to October 18, 2022. This deficient ...
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Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on site for 8 hours a day for 2 of 30 days, from September 18, 2022 to October 18, 2022. This deficient practice had the potential to effect 51 of 51 residents residing in the facility. (October 1, 2022 and October 15, 2022)
Finding includes:
During review of the schedule for licensed staff, on 10/21/2022 at 1:32 p.m., documentation of the hours worked lacked evidence of a RN for 8 consecutive hours, on October 1, 2022 and October 15, 2022.
During an interview, at that time, the Scheduler reviewed the documents and verified there was no RN coverage, for 8 consecutive hours on those dates.
A current facility policy, regarding RN coverage in the facility, was requested on 10/21/2022 at 3:21 p.m.
During an interview, on October 21, 2022 at 5:14 p.m., the Corporate Support Nurse indicated the facility did not have a written policy regarding RN coverage.
3.1-17(b)(3)
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 1 harm violation(s). Review inspection reports carefully.
- • 35 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $15,646 in fines. Above average for Indiana. Some compliance problems on record.
- • Grade D (46/100). Below average facility with significant concerns.
Bottom line: Trust Score of 46/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Wellbrooke Of Carmel's CMS Rating?
CMS assigns WELLBROOKE OF CARMEL an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Indiana, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Wellbrooke Of Carmel Staffed?
CMS rates WELLBROOKE OF CARMEL's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 59%, which is 13 percentage points above the Indiana average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 67%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Wellbrooke Of Carmel?
State health inspectors documented 35 deficiencies at WELLBROOKE OF CARMEL during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 33 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Wellbrooke Of Carmel?
WELLBROOKE OF CARMEL is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by TRILOGY HEALTH SERVICES, a chain that manages multiple nursing homes. With 74 certified beds and approximately 52 residents (about 70% occupancy), it is a smaller facility located in CARMEL, Indiana.
How Does Wellbrooke Of Carmel Compare to Other Indiana Nursing Homes?
Compared to the 100 nursing homes in Indiana, WELLBROOKE OF CARMEL's overall rating (4 stars) is above the state average of 3.1, staff turnover (59%) is significantly higher than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Wellbrooke Of Carmel?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.
Is Wellbrooke Of Carmel Safe?
Based on CMS inspection data, WELLBROOKE OF CARMEL has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Indiana. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Wellbrooke Of Carmel Stick Around?
Staff turnover at WELLBROOKE OF CARMEL is high. At 59%, the facility is 13 percentage points above the Indiana average of 46%. Registered Nurse turnover is particularly concerning at 67%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Wellbrooke Of Carmel Ever Fined?
WELLBROOKE OF CARMEL has been fined $15,646 across 1 penalty action. This is below the Indiana average of $33,235. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Wellbrooke Of Carmel on Any Federal Watch List?
WELLBROOKE OF CARMEL is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.