How many inspection deficiencies does SAINT ANTHONY have?

SAINT ANTHONY has 50 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at SAINT ANTHONY?

SAINT ANTHONY has a one-star staffing rating from CMS with 0.46 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is SAINT ANTHONY located?

SAINT ANTHONY is located in CROWN POINT, IN. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does SAINT ANTHONY have?

SAINT ANTHONY has 189 certified beds.

Who owns SAINT ANTHONY?

SAINT ANTHONY is a for profit - corporation facility and is part of the MAJESTIC CARE chain.

What questions should families ask when visiting SAINT ANTHONY?

Families visiting SAINT ANTHONY should ask about daily routines, communication with families, how they handle medical emergencies. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does SAINT ANTHONY compare to other nursing homes?

SAINT ANTHONY has a 1-star overall rating, which is below average compared to other nursing homes in IN. Families should carefully review inspection findings and consider alternatives.

SAINT ANTHONY

Q: What is SAINT ANTHONY's CMS rating?

SAINT ANTHONY has a one-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Q: Is SAINT ANTHONY safe?

SAINT ANTHONY has a clean safety record with no substantiated abuse findings, no immediate jeopardy citations, and is not on any federal watch list.

Q: Do nurses at SAINT ANTHONY stick around?

SAINT ANTHONY has average staff turnover at 51%, which is typical for the nursing home industry.

Q: Was SAINT ANTHONY ever fined?

No, SAINT ANTHONY has no federal fines on record, indicating a clean compliance history with Medicare and Medicaid requirements.

Q: Is SAINT ANTHONY on any federal watch list?

No, SAINT ANTHONY is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

203 FRANCISCAN DR, CROWN POINT, IN 46307 · (219) 661-5100

For profit - Corporation 189 Beds MAJESTIC CARE Data: November 2025

Trust Grade

40/100

#478 of 505 in IN

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Last Inspection: June 2025

Inspected within the last 6 months. Data reflects current conditions.

Overview

Saint Anthony nursing home has a Trust Grade of D, which indicates below-average performance with some concerns. It ranks #478 out of 505 facilities in Indiana, placing it in the bottom half of the state, and #19 out of 20 in Lake County, suggesting that there is only one local option that is better. The facility is improving, with the number of issues decreasing from 19 in 2024 to 10 in 2025. However, staffing is a weakness, rated at only 1 out of 5 stars, and the turnover rate is at 51%, which is around the state average. While there are no fines on record, which is a positive sign, there are concerning incidents reported, including a staff member using inappropriate language in front of residents and a resident being found in unsanitary conditions without proper personal care. Additionally, there were issues with medication storage, with loose pills found in multiple medication carts, which raises concerns about medication safety. Overall, families should weigh these strengths and weaknesses carefully when considering this facility for their loved ones.

Trust Score: D
In Indiana: #478/505
Safety Record: Low Risk
Inspections: Getting Better
Staff Stability: 51% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: No fines on record. Clean compliance history, better than most Indiana facilities.
Skilled Nurses: Each resident gets only 27 minutes of Registered Nurse (RN) attention daily — below average for Indiana. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 50 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★☆☆☆☆

1.0

Staff Levels

★★★★☆

4.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 19 issues

2025: 10 issues

The Good

4-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

1-Star Overall Rating

Below Indiana average (3.1)

Significant quality concerns identified by CMS

Staff Turnover: 51%

Near Indiana avg (46%)

Higher turnover may affect care consistency

Chain: MAJESTIC CARE

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 50 deficiencies on record

Jun 2025 7 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure residents had physician's orders for self-administration of medications and an assessment to self-administer their own medications for 1 of 2 residents reviewed for self-administration of medication. (Resident 144) Finding includes: During an observation of Resident 144 on 6/10/25 at 11:13 a.m., there were three small medication cups on the bedside table and night stand containing multiple Tums (an antacid medication). There were also two large Tums medication bottles and an inhaler at the bedside. The resident indicated at the time that she would take the Tums medication whenever she ate and as she needed them for heartburn. On 6/11/25 at 10:24 a.m., Resident 144 was observed in bed. The Tums medication and inhaler were observed at the bedside. On 6/12/25 at 9:57 a.m., Resident 144 was observed in bed. The Tums medication and inhaler were observed at the bedside. Resident 144's record was reviewed on 6/11/25 at 10:33 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, asthma, and gastroesophageal reflux disease (GERD). The Annual Minimum Data Set (MDS), dated [DATE], indicated the resident was cognitively intact. The current June 2025 Physician's Order Summary indicated the resident received albuterol sulfate 108 microgram per actuation (mcg/act) 2 puff inhale orally every 4 hours as needed, patient may keep at the bedside and calcium carbonate tablet 500 milligrams every 6 hours as needed. There were no orders for self-administration of the Tums medication. There were no self-administration of medication assessments completed for the resident to keep Tums or the inhaler at the bedside. There were no care plans related to self-administration of medications. During an interview on 6/16/25 at 4:30 p.m., the Director of Nursing had no further information to provide. A policy titled, Self-Administration of Medications, indicated, .1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment . 3.1-11(a)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed related to antianxiety and antiplatelet medications for 2 of 32 MDS assessments reviewed. (Residents 107 and 375) Findings include: 1. Resident 107's record was reviewed on 6/12/25 at 10:22 a.m. Diagnoses included, but were not limited to, schizoaffective disorder, general anxiety disorder, and dementia with behavioral disturbance. The Quarterly MDS assessments, dated 5/23/25, 5/7/25, and 2/13/25, indicated the resident had not received any antianxiety medications. A Care Plan, updated 5/28/24, indicated the resident had schizoaffective disorder and was currently receiving antipsychotic, antidepressant, anticonvulsant, and antianxiety medications. A Physician's Order, dated 12/2/22, indicated Klonopin (clonazepam, an antianxiety medication) 0.5 mg (milligrams) two times a day. The Medication Administration Record (MAR), dated 5/2025, indicated the resident had received the antianxiety medication twice daily. During an interview on 6/12/25 at 1:42 p.m., the MDS Coordinator indicated the resident was receiving antianxiety medication. It had been coded as an anticonvulsant because that was how it was classified in the computer charting system. She would make corrections. 2. The record for Resident 375 was reviewed on 6/16/25 at 9:44 a.m. Diagnoses included, but were not limited to, history of stroke, congestive heart failure, and chronic kidney disease. The admission MDS assessment, dated 6/4/25, indicated the resident had not received any antiplatelet medications in the past seven days. The current Physician's Order Summary indicated to give ticagrelor (Brilinta, an antiplatelet medication) 90 mg every 12 hours. The MAR, dated 5/2024 and 6/2025, indicated the resident had received the antiplatelet medication twice daily beginning on 5/30/25. During an interview on 6/16/25 at 2:17 p.m., the MDS Coordinator indicated the MDS was incorrect and needed to be modified. 3.1-31(i)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to twice weekly showering and nail care for 2 of 3 residents reviewed for ADLs. (Residents 52 and 105) Findings include: 1. During an interview on 6/10/25 at 10:00 a.m., Resident 52 indicated she did not always receive showers twice a week. Resident 52's record was reviewed on 6/11/25 at 10:37 a.m. Diagnoses included, but were not limited to, heart failure, chronic kidney disease, and stage 3 pressure ulcer of the sacral region. The Quarterly Minimum Data Set assessment, dated 4/30/25, indicated the resident was cognitively intact for daily decision making. The resident had an impairment affecting range of motion to one side of the lower extremities. She was dependent on staff for toileting, showering, bed mobility, and transfers. A Care Plan, revised on 5/1/25, indicated the resident needed assistance with activities of daily living. Interventions included, but were not limited to, the resident required total assistance for bathing/showering, provide additional assistance as needed. The Shower CNA Task was reviewed from 3/27-6/10/25. The resident was scheduled for showers every Tuesday and Friday evening. The Shower CNA Task lacked documentation of the resident receiving a shower on 4/11/25, 4/25/25, 5/2/25, 5/16/25, and 6/6/25. During an interview on 6/12/25 at 1:30 p.m., the Director of Nursing indicated she did not receive her showers twice weekly and was unable to provide any further documentation. A policy titled, Showers, indicated .1. residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety . 2. During an observation and interview on 6/10/25 at 9:23 a.m., Resident 105 was sitting in her bed. She indicated she had asked for someone to cut her toenails and it had not happened yet. At the time, both of the resident's feet were observed with long toenails. Resident 105's record was reviewed on 6/11/25 at 8:53 a.m. Diagnoses included, but were not limited to, edema and type 2 diabetes mellitus. The admission Minimum Data Set assessment, dated 3/18/25, indicated the resident was cognitively intact for daily decision making. The resident was dependent on staff for toileting, showering, and transfers. She required a substantial to maximal assist for personal hygiene. A Care Plan, revised on 6/6/25, indicated the resident required assistance with activities of daily living. Interventions included, but were not limited to, nail care on bath day and as necessary and report any changes to the nurse. The shower sheets were reviewed from April to June 2025. There was no documented nail care performed during that timeframe. During an interview on 6/16/25 at 4:30 p.m., the Director of Nursing had no further information to provide. 3.1-38(b)(2) 3.1-38(a)(3)(E)

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

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Based on observation, record review, and interview, the facility failed to ensure residents received the necessary treatment and services related to the monitoring and assessment of skin discolorations for 1 of 3 residents reviewed for non-pressure related skin conditions. (Resident 100) Finding includes: On 6/9/25 at 11:36 a.m., Resident 100 was sitting in a wheelchair in the hallway. A dark purple discoloration was observed to the top of his right hand. On 6/11/25 at 9:32 a.m., Resident 100 was observed lying in bed with his eyes closed. The dark purple discoloration was still observed to the top of his right hand. Record review for Resident 100 was completed on 6/12/25 at 1:18 p.m. Diagnoses included, but were not limited to, anemia, atrial fibrillation, heart failure, hypertension, and dementia. The Annual Minimum Data Set (MDS) assessment, dated 6/4/25, indicated the resident was cognitively impaired. The resident required a substantial maximal assistance with bed mobility, transfers, and upper body dressing. The resident had received an anticoagulant (blood thinning) medication. A Care Plan, dated 5/31/22 and revised 6/10/25, indicated the resident was at risk for abnormal bleeding secondary to anticoagulant therapy for atrial fibrillation. An intervention included to inspect skin during care for bruising or increased bruising and to notify the nurse of abnormal findings. The June 2025 Physician's Order Summary (POS) indicated the resident had received Eliquis (blood thinner) 2.5 mg (milligrams) twice a day. A Weekly Skin Assessment, dated 6/11/25, indicated the resident had no new skin area concerns. The record lacked any documentation to indicate the resident's discoloration had been assessed or was being monitored. During an interview on 6/12/25 at 2:53 p.m., the Wound Nurse indicated she was unaware of the resident's discoloration to the top of his hand and staff should have assessed the area. A facility policy for discolorations was not provided. 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

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Based on observation, record review, and interview, the facility failed to ensure residents with a history of falls with injuries had preventions in place to prevent more falls/injuries related to a resident's call light not in reach and a Dycem (non slip mat) and non-skid strips were not in place as ordered for 2 of 2 residents reviewed for falls. (Residents 95 and 117) Findings include: 1. On 6/11/25 at 9:35 a.m., Resident 95 was observed sitting in a wheelchair next to her bed in her room watching television. The resident had darkened discolorations to the top and right side of her head and right hand. The resident also had a visible lump to the top of her head. The resident indicated she had fallen recently out of her wheelchair when she was trying to reach for something out of her nightstand. The resident's call light was not visibly in reach to the resident. The resident indicated she was unsure where her call light was located. On 6/11/25 at 11:28 a.m., Resident 95 was observed sitting in her room in the same position. The resident's call light was still not in reach to the resident. The call light cord was halfway underneath the resident's mattress and the call button at the end of the cord was not visible. The resident indicated she was unsure where her call light was located. Record review for Resident 95 was completed on 6/11/25 at 9:49 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, anemia, atrial fibrillation, hypertension, dementia, depression, and anxiety. The Significant Change Minimum Data Set (MDS) assessment, dated 5/19/25, indicated the resident was cognitively intact. The resident required a substantial maximal assistance to propel herself in her wheelchair and was dependent for bed mobility and transfers. The resident had no falls since the previous assessment. A Care Plan, dated 8/16/23 and revised 5/28/25, indicated the resident was at risk for falls or fall related injuries. An intervention included to keep the call light and frequently used personal items within reach. A Progress Note, dated 6/8/25 at 8:15 a.m., indicated the resident was calling for help. When the nurse entered the room she found the resident laying on her right side next to the bed and nightstand with her wheelchair behind her. The resident was sent out to the hospital. During an interview on 6/11/25 at 11:29 a.m., LPN 1 indicated the resident was able to use her call light and the call light should be in reach at all times. The resident had fallen recently while attempting to reach for something. She would locate the resident's call light and make sure it was within the resident's reach. 2. On 6/9/25 at 11:35 a.m., Resident 117 was observed lying in bed. He had sutures to his left eye area and a sling in place to his left arm. On 6/11/25 at 12:05 p.m., the resident was seated in the recliner in his room. There were no non-skid strips observed to the floor anywhere near his recliner. There were non-skid strips on the floor on the other side of the room, near the dresser. There was no Dycem observed to the resident's wheelchair. The resident indicated he had fallen recently and gone to the hospital. On 6/11/25 at 2:13 p.m., the resident was seated in the recliner in his room. There were no non-skid strips observed to the floor anywhere near his recliner. There was no Dycem observed to the resident's wheelchair. Record review for Resident 117 was completed on 6/11/25 at 9:18 a.m. Diagnoses included, but were not limited to, fracture of left humerus, type 2 diabetes mellitus, and congestive heart failure. The admission MDS assessment, dated 4/4/25, indicated the resident was cognitively intact and required a substantial/maximal assist with bed mobility and transfers. A Care Plan, updated 6/9/25, indicated the resident was at risk for falls or fall related injury. The interventions included: Dycem to wheelchair seat and non-skid strips in front of recliner. An Indiana Department of Health (IDOH) Reportable Incident, dated 6/1/25, indicated the resident was found on the floor in his room. He indicated he was trying to pull his pants up from sitting on his recliner and fell. He was sent to the emergency room for evaluation and was found to have a left humerus fracture. The Interdisciplinary Team (IDT) recommendation was non-skid strips in front of the recliner. The resident returned to the facility on 6/5/25. A Progress Note, dated 6/6/25 at 1:47 p.m., indicated the resident was yelling out and was found sliding out of his wheelchair. Staff was able to assist him back to the wheelchair. A Dycem was placed in the wheelchair to prevent sliding out. During an interview on 6/11/25 at 3:47 p.m., the Director of Nursing was made aware of the Dycem and non-skid strips not in place. She indicated the resident's daughter may have moved the recliner. During an interview on 6/11/25 at 3:54 p.m., the Executive Director indicated she had placed the non-skid strips in front of the recliner herself, and the recliner had been near the dresser. Someone must have moved the recliner since then. The resident did not like the Dycem and was noncompliant with interventions frequently. She had provided him with education on Friday. A current facility policy, titled Incidents, Accidents & Supervision, indicated, .Supervision. The resident will remain as free of accident hazards as possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: .3. Implementing interventions to reduce hazards and risks. 4. Monitoring for effectiveness and modifying interventions when necessary . 3.1-45(a)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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Based on observation, record review and interview, the facility failed to ensure a resident received the necessary care and treatment related to oxygen not administered as ordered for 1 of 1 resident reviewed for respiratory care. (Resident 51) Finding includes: On 6/10/25 at 9:21 a.m., Resident 51 was observed lying in her bed. She had a nasal cannula in place and oxygen was flowing at 5 liters per minute (lpm). On 6/11/25 at 9:59 a.m., the resident was again observed in bed with oxygen flowing at 5 lpm. The resident's record was reviewed on 6/11/25 at 8:45 a.m. Diagnoses included, but were not limited to, dementia, asthma and chronic obstructive respiratory disease. The admission Minimum Data Set assessment, dated 5/16/25, indicated the resident had severe cognitive impairment, and was dependent for bed mobility, transfers and toileting assistance. The current Physician's Orders indicated the resident was to receive oxygen at 3 lpm continuously. During an interview on 6/11/25 at 10:00 a.m., LPN 4 indicated the resident's oxygen should be set at 3 lpm. She entered the room and adjusted the oxygen to the correct flow rate. 3.1-47(a)(6)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation, record review and interview, the facility failed to ensure a medication cart drawer was closed and locked while unattended for 1 of 5 medication carts observed. (1A Medication Cart) Finding includes: On 6/12/25 at 9:00 a.m., QMA 1 was observed preparing Resident 18's medications. She finished preparing the medications, locked the medication cart, and entered Resident 18's room at 9:12 a.m. The bottom drawer on the right side of the medication cart was not pushed in all the way and medications were visible. QMA 1 administered the medications to Resident 18 and returned to the medication cart at 9:18 a.m. During an interview on 6/12/25 at 9:18 a.m., QMA 1 indicated she was not aware the drawer had not been closed all the way. During an interview on 6/12/25 at 1:16 p.m., the Director of Nursing was made aware the medication cart drawer had been left open. The medication storage policy was requested. A current facility policy, titled Medication and Biological Storage Requirements, indicated, .2. The facility is required to secure all medications in a locked storage area and to limit access to only authorized or licensed personnel consistent with state or federal requirements and professional standards of practice. a. Storage areas may include, but are not limited to, drawers, cabinets, medication rooms, refrigerators, and carts . 3.1-25(m)

Jan 2025 3 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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure care-planned interventions to prevent injuries due to a fall were in place, related to a non-slip pad not on the wheelchair pad when the resident was sitting in the wheelchair and a mat not placed on the floor next to the bed when the resident was lying in bed, for 1 of 3 residents reviewed for falls and fall interventions. (Resident D) Finding includes: Resident D was observed on 1/14/25 at 9 a.m., 10:05 a.m. and 11:31 a.m., sitting by herself in the wheelchair in her room. During an observation on 1/14/25 at 11:35 a.m., QMA 3 and CNA 4 assisted the resident from the wheelchair to the bed. The resident was assisted to stand from the wheelchair. A non-slip pad was not under the resident in the wheelchair. During an interview at the time of the observation, QMA 3 and CNA 4 indicated they were unsure if a non-slip pad was to be on the wheelchair pad and both indicated it was not on the wheelchair. The resident was assisted in a lying position on the bed and incontinence care was completed. She was positioned for comfort in bed and CNA 4 indicated the resident would be assisted up in the wheelchair before lunch. QMA 3 and CNA 4 left the room. The floor mat was not placed on the floor next to the resident's bed and was left leaning against the wall in the room. During an interview on 1/14/25 at 12:26 p.m., CNA 4 indicated the staff have care cards available with the interventions to be used to prevent falls and other care information. Review of the care card with CNA 4 indicated a non-slip pad was to placed on the wheelchair. The floor mat next to the bed was not on the care card. CNA 4 indicated the care cards were not always kept up to date. Resident D's record was reviewed on 1/14/25 at 10:15 a.m. The diagnoses included, but were not limited to, dementia and repeated falls. A Quarterly Minimum Data Set assessment, dated 12/24/24, indicated a moderately impaired cognitive status and a past fall. A Care Plan, dated 2/10/20, indicated a risk for falls and a history of falls. The interventions included on 11/5/24, a non-slip pad would be applied to the seat of the wheelchair and on 3/15/20, a mat was to placed on the floor next to the bed. This citation relates to Complaints IN00449543 and IN00449574. 3.1-45(a)(2)

CONCERN (E) 📢 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 F0557 (Tag F0557)

Could have caused harm · This affected multiple residents

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Based on record review and interview, the facility failed to ensure residents on the Memory Care Unit were treated with respect and dignity, related to a staff member yelling and using foul language in the hallway where residents could hear the staff member. This had the potential to affect all the residents on the Memory Care Unit. (Terminated Employee 1 and Resident G). The deficient practice was corrected on 12/16/24, prior to the start of the survey, and was therefore past noncompliance. Finding includes: A facility initiated staff to resident incident reported to the Indiana Department of Health (IDOH), dated 12/6/24, was reviewed on 1/15/25 at 1:03 p.m. The incident indicated an altercation between Terminated Employee 1 and Resident G. Review of the facility's finished investigation of the incident, dated 12/11/24, indicated staff to resident abuse had not occurred. Terminated Employee 1 was immediately placed on administrative leave and was instructed to leave the building. She admitted to using some profanity in front of the residents. A typed statement from the ED, dated 12/6/24 at 9 p.m., indicated CNA 2 indicated Resident G had grabbed Terminated Employee 1's hair. CNA 2 and RN 1 assisted and and separated the resident from Terminated Employee 1. Terminated Employee 1 was upset and called RN 1 a, f****** b**** when RN 1 instructed her to leave the facility. A typed statement from the ED, dated 12/6/24 at 9 p.m., indicated RN 1 and CNA 2 assisted Terminated Employee 1 with freeing the grasp Resident G had on her hair. Terminated Employee 1 called RN 1 a f****** b**** when she was instructed to leave the facility. The ED and Administrator were contacted immediately. A typed statement from the Administrator and Executive Director (ED), dated 12/9/24, indicated Terminated Employee 1 indicated during the incident with Resident G the employee began to yell out profanity due to the pain of the resident pulling her hair. She stated, get this b**** off of me. The co-workers assisted with the resident and the employee's hair was released. Terminated Employee 1 then indicated she was yelling at RN 1, f*** you b**** because she was upset about the incident. During an interview on 1/15/25 at 2:18 p.m., RN 1 indicated Terminated Employee 1 was not violent with the resident and the altercation was a reaction from the CNA and not purposeful harm. Terminated Employee 1 had refused to leave the unit/facility when instructed to do so and was yelling foul language and calling her a b****, and saying f*** you as she was walking down the hallway. There were residents in the hallway and the common area when this occurred and could hear Terminated Employee 1 using the foul language. She indicated the incident occurred on the Memory Care Unit and the residents on the unit have diagnoses of Alzheimer's disease and/or dementia. The deficient practice was corrected by 12/16/24 after the facility implemented a systemic plan that included the following actions: staff were interviewed, head to toe assessments were completed on all the residents with severely impaired cognitive status on Memory Care Unit with no negative findings, all residents who had a moderate to intact cognitive status on the units Terminated CNA 1 had worked in the past 30 days were interviewed to determine if there were concerns. There were no negative findings. All staff members were educated on abuse prevention/policy and reporting abuse. The background checks for all CNA's were audited and validated they were completed with no outstanding background check. Weekly audits have been and continue to be completed for abuse concerns of five random residents are to be completed until it is deemed compliant in the QAPI (quality assurance and performance improvement) meeting. Weekly audits have been and continue to be completed of five random staff members in regards to how they respond to aggressive dementia residents and the abuse policy until deemed compliant in the QAPI meeting reviews. All grievances were reviewed fro the last 30 days to identify trends and no trends were found. Resident G has psychosocial follow up assessments with no concerns or change of behavior. This citation relates to Complaints IN00449543 and IN00449574. 3.1-3(t)

MINOR (C) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Minor Issue - procedural, no safety impact

Staffing Information (Tag F0732)

Minor procedural issue · This affected most or all residents

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Based on observation, record review, and interview, the facility failed to ensure the posted Nurse Staffing information was up-to-date and current. THis had the potential to affect all residents in the facility. Finding includes: The Nurse Staffing Information was posted on the desk by the front door of the facility and was observed on 1/13/25 at 9:13 a.m. The information posted was dated 1/8/25. During an interview on 1/13/25 at 9:15 a.m., the Administrator indicated either the Scheduler or the Nursing Supervisor was responsible for posting the current Nurse Staffing Information daily. This citation relates to Complaints IN00449509 and IN00450162.

Oct 2024 3 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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and interview, the facility failed to ensure fall interventions were in place for a resident with a history of falls for 1 of 3 residents reviewed for accidents. (Resident D) Finding includes: On 10/8/24 at 2:05 p.m., Resident D's room was observed. There were no non-skid strips on her bathroom floor. The record for Resident D was reviewed on 10/8/24 at 11:15 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, hypertensive chronic kidney disease, type 2 diabetes mellitus, osteoarthritis, dementia, and repeated falls The Quarterly Minimum Data Set (MDS) assessment, dated 8/29/24, indicated the resident was severely cognitively impaired and required substantial assistance with activities of daily living. A Care Plan, updated 10/23/23, indicated the resident was at risk for falls. An intervention, dated 9/23/24, indicated non-skid strips were to be placed on the bathroom floor, near the toilet. An Indiana Department of Health reportable incident, dated 9/9/24, indicated new bruising was found under the resident's eye and on both arms. Staff reported the resident had behaviors of hitting/ punching/kicking walls, bumping into objects as she self-propelled in her wheelchair, and self-transferring without assistance. A Nurse's Note, dated 9/22/24 at 4:01 p.m., indicated the resident was propelling herself in her wheelchair on the unit, in and out of rooms, banging on exit door and yelling. A Fall IDT (interdisciplinary team) Note, dated 9/23/24 at 1:30 p.m., indicated the resident was found sitting on her bathroom floor, yelling for help, with her wheelchair nearby. The suggested new intervention was to place non-skid strips on the bathroom floor, near the toilet. A Nurse's Note, dated 10/6/2024 at 11:21 a.m., indicated the resident was observed propelling herself in her wheelchair to both exit locations, banging her hands on and kicking the doors. During an interview on 10/8/24 at 2:10 p.m., CNA 1 indicated she thought the resident had non-skid strips on her bathroom floor. After observing the bathroom, CNA 1 confirmed there were no non-skid strips on the floor. During an interview on 10/9/24 at 11:00 a.m., the Administrator indicated the non-skid strips were just placed on the resident's bathroom floor. A facility policy, titled Fall Management, received as current from the facility on 10/9/24, stated, .Fall risk will be assessed upon admission, quarterly and with significant change . All falls will be discussed by the interdisciplinary team at the 1st IDT meeting after the fall to determine root cause and other interventions to prevent future falls . This citation relates to Complaint IN00443996. 3.1-45(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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 10/9/24 at 12:28 p.m., Resident C was observed sitting up in her bed. A CNA was seated at the resident's bedside assisting her with eating lunch. The record for Resident C was reviewed on 10/8/24 at 3:45 p.m. Diagnoses included, but were not limited to Alzheimer's disease, chronic kidney disease, and coronary artery disease. The Quarterly Minimum Data Set (MDS) assessment, dated 9/23/24, indicated the resident was cognitively impaired and required substantial assistance with eating. A current Care Plan, updated 6/26/24, indicated the resident had potential nutritional risk related to her mechanically altered diet. An intervention indicated to document food and fluid intakes. The resident's weight on 9/18/24 was 170 and on 9/24/24 was 154. The food consumption task documentation, dated 9/10/24 through 10/8/24, indicated there was no meal consumption documented for the following days and meals: 9/10/24 breakfast and lunch 9/13/24 dinner 9/14/24 breakfast and lunch 9/15/24 breakfast and lunch 9/16/24 dinner 9/18/24 breakfast and lunch 9/20/24 breakfast and dinner 9/21/24 breakfast and dinner 9/22/24 dinner 9/27/24 dinner 9/29/24 breakfast and lunch 10/2/24 breakfast and lunch 10/5/24 dinner During an interview on 10/9/24 at 11:07 a.m., the Director of Nursing (DON) was made aware of the missing food consumption documentation and indicated she would look into it. No further information was provided. This citation relates to Complaint IN00441181. 3.1-46(a)(1) 3.1-46(a)(2) Based on observation, record review, and interview, the facility failed to ensure food consumption logs were completed for residents with a history of weight loss for 2 of 3 residents reviewed for nutrition. (Residents F and C) Findings include: 1. Record review for Resident F was completed on 10/8/24 at 2:34 p.m. Diagnoses included, but were not limited to, atrial fibrillation, heart failure, hypertension, [NAME] syndrome (body makes too much cortisol hormone), diabetes mellitus, and end stage renal disease. The admission Minimum Data Set (MDS) assessment, dated 8/20/24, indicated the resident was cognitively intact. The resident required partial assistance with eating. A Care Plan, dated 8/14/24, indicated the resident was at risk for complications and symptoms of hypoglycemia or hyperglycemia due to diabetes. An intervention included to document the resident's meal and snack intake. An IDT Risk Review, dated 10/3/24, indicated the resident's most recent weight on 10/3/24 was 203 pounds. The previous weight on 9/24/24 was 227 pounds. The resident's meal intakes had recently declined related to depression. The Task Meal Consumption Logs were documented with percentage of meals eaten. The last 30 days lacked documentation for the following meals: - Breakfast on 9/11, 9/14, 9/15, 9/19, 9/20, 9/21, 9/22, 9/23, 9/25, 9/26, 9/27, 9/29, 10/1, 10/3, 10/4, and 10/5/24. - Lunch on 9/15, 9/20, 9/21, 9/22, 9/25, 9/27, 9/29, 10/1, 10/3, 10/4, 10/5, and 10/7/24. - Dinner on 9/11, 9/13, 9/14, 9/16, 9/17, 9/18, 9/19, 9/20, 9/22, 9/24, 9/25, 9/26, 9/27, 9/28, 9/30, 10/1, 10/3, 10/4, 10/5, 10/6, and 10/7/24. During an interview on 10/9/24 at 2:46 p.m , the Director of Nursing (DON) indicated she was unable to provide any documentation the resident's meal consumption logs were completed on the above dates.

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 F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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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 each resident's medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being, related to not monitoring the resident's pulse as ordered prior to administering a blood pressure medication for 1 of 3 residents reviewed for unnecessary medications. (Resident F) Finding includes: Record review for Resident F was completed on 10/8/24 at 2:34 p.m. Diagnoses included, but were not limited to, atrial fibrillation, heart failure, hypertension, [NAME] syndrome (body makes too much cortisol hormone), diabetes mellitus, and end stage renal disease. The admission Minimum Data Set (MDS) assessment, dated 8/20/24, indicated the resident was cognitively intact. The October 2024 Physician's Order Summary indicated an order for metoprolol succinate (treats high blood pressure) 100 mg (milligrams) one time a day. Hold the medication for heart rate less than 60. The September and October 2024 Medication Administration Records indicated the metoprolol succinate was administered at 7:00 a.m. on 9/3, 9/4, 9/7, 9/8, 9/15, 9/20, 9/28, 10/1, 10/4, 10/5, and 10/6/24. The record lacked any documentation the pulse was monitored prior to the medication being administered on the above dates. During an interview on 10/9/24 at 11:07 a.m., the Director of Nursing indicated she was unable to provide any documentation the pulse was monitored before the medication was administered on the above dates. This citation relates to Complaint IN00441181. 3.1-48(a)(3)

May 2024 16 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and interview, the facility failed to ensure residents had physician's orders for self-administration of medications for 1 of 1 resident reviewed for self-administration of medication. (Resident 111) Finding includes: On 5/14/24 at 9:21 a.m., Resident 111 was observed in her room in bed. There was a medication cup noted with multiple pills in it on the table next to her. The resident indicated the nurses always had left her morning medications for her to take after she had eaten her breakfast. Resident 111's record was reviewed on 5/15/24 at 1:22 p.m. Diagnoses included, but were not limited to, dementia, heart disease, and anxiety disorder. A Significant Change Minimum Data Set (MDS) assessment, dated 4/5/24, indicated the resident was cognitively intact for daily decision making. She had taken antidepressants, anticoagulants, diuretics, and opioid medications in the last 7 day look back period. An Interdisciplinary Team (IDT) note, dated 5/14/2024 at 9:18 a.m., indicated the IDT met to review the resident and determined the resident was able to self-administer prescribed medications prepared by the nurse or QMA. The medications to be self-administered were furosemide 40 milligrams (mg) everyday, l-methylfolate 15 mg daily, levothyroxine 75 micrograms daily, macrobid 100 mg twice daily until complete, memantine 5 mg daily, norco 5-325 mg every four hours as needed (PRN), potassium 10 milliequivalents daily, pregabalin 200 mg twice daily, rivastingmine 1.5 mg twice daily, senna docusate 8.6 mg every 12 hours PRN, sumatriptan 100 mg every 2 hours PRN, tobramycin 1 drop in both eyes until complete. There were no physician orders for self-administration of the medications. During an interview on 5/16/24 at 11:09 a.m., the Administrator indicated there should have been an order to self administer the medications. 3.1-11(a)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the family/representative of a significant weight loss, a weight loss, and a new order for a nutritional supplement for 2 of 7 residents reviewed for nutrition. (Residents 59 and 143) Findings include: 1. Resident 59's record was reviewed on 5/14/24 at 2:42 p.m. Diagnoses included, but were not limited to, Lewy body dementia, psychotic disorder, depressive disorder and diabetes mellitus. The resident resided on the locked dementia unit. The Quarterly Minimum Data Set (MDS) assessment, dated 3/29/24, indicated the resident had severe cognitive impairment and required limited staff assistance for bed mobility and transfers, and could eat independently after set up. The Current Physician Orders indicated the resident was on a regular diet. There were no nutritional supplements or fortified food ordered. The resident's weights were as follows: 2/5/24: 232 pounds (lbs) 2/11/24: 230 lbs 2/18/24: 218 lbs 2/25/24: 217 lbs 3/6/24: 217 lbs This was a weight loss of 15 lbs, 5%, in one month. There was no documentation the family had been notified. A Quarterly Nutrition Review, dated 3/29/24, indicated the resident had a significant weight loss of 5% in 30 days. The resident did not receive snacks, supplements or fortified food. The resident's weight had been stable since 2/18. The resident's intake of food and fluid was estimated to meet needs at the time. There were no new nutritional recommendations at the time. The resident's continued weights were as follows: 4/2/24: 220 lbs (+3 lbs) 5/3/24: 203 lbs 5/7/24: 203 lbs (reweigh) This was an additional weight loss of 14 pounds, for a total weight loss of 29 pounds, 12.5%, since her admission on [DATE]. There was no documentation the family had been notified. During an interview on 5/17/24 at 12:52 p.m., a family member indicated she had been notified yesterday, 5/16/24, of the current 17 pound weight loss. She had not been notified of additional weight losses. She was unaware of the significant weight loss that occurred from 2/5/24-3/6/24. During an interview on 5/17/24, the Director of Nursing indicated there was no documentation the family had been notified of the initial significant weight loss. 2. Resident 143's record was reviewed on 5/17/24 at 1:55 p.m. Diagnoses included, but were not limited to, Alzheimer's dementia, iron deficiency, and chronic lymphocytic leukemia. The Quarterly MDS assessment, dated 3/11/24, indicated the resident had significant cognitive impairment, required limited assistance with bed mobility and transfers, and could eat independently after set up. The resident's weights were as follows: 11/1/23: 124 lbs 3/6/24: 116 lbs This was an eight pound, 6.45% loss, in four months. There was no documentation the family had been notified. A Physician's Order, dated 3/23/24, indicated to give a health shake with breakfast daily for weight loss. There was no documentation the family had been notified of the new order. During an interview with a family member on 5/20/24 at 1:03 p.m., she indicated her mother was not on a special diet and had not lost any weight that she was aware of. She indicated she was not aware of the eight pound weight loss or new order for health shake daily. During an interview with the Administrator on 5/20/24 at 3:00 p.m., she indicated there was no documentation the family had been notified. The policy, Resident Weight Monitoring, indicated, .The resident's physician and family/guardian will notified of any verified significant weight change . 3.1-5(a)(3)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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Based on observation and interview, the facility failed to ensure a clean and homelike environment related to stained and dirty bed linens for 1 of 35 residents reviewed for a homelike environment. (Resident B) Finding includes: On 5/14/24 at 10:03 a.m., Resident B was observed lying in bed with his eyes closed. There was a dark reddish-brown stain on the bottom sheet next to where his left forearm was resting. His pillowcase also had a large brown stain along the end of it. On 5/15/24 at 10:42 a.m., Resident B was observed lying in bed with his eyes closed. The stains remained to the bottom sheet and the pillowcase. On 5/15/24 at 10:58 a.m., a CNA exited the room after providing care to Resident B. Resident B was now sitting up in his wheelchair in his room. His bed had been made, however, the stains remained to the bottom sheet and the pillowcase. During an interview with the Administrator on 5/15/24 at 11:11 a.m., she indicated the linens were probably already stained when they were put on the bed. She then changed the linens. This citation relates to Complaint IN00431905. 3.1-19(f)(5) 3.1-19(g)(4)

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

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3. On 5/13/24 at 2:32 p.m., Resident 10 was sitting in a wheelchair in his room. He had scattered discolorations noted to bilateral lower legs, a splotchy reddened area on his neck, and his right arm was red and swollen. He indicated he had lotion to put on his lower legs, but could not reach it himself. He was unsure what happened with his neck and his right arm was swollen. Resident 10's record was reviewed on 5/14/24 at 3:01 p.m. Diagnoses included, but were not limited to, congestive heart failure, respiratory failure, and cellulitis of the right upper limb. The Quarterly Minimum Data Set (MDS) assessment, dated 5/8/24, indicated the resident was severely cognitively impaired for daily decision making. There was no documentation related to the discolorations noted to the bilateral shins or reddened area on the neck in the record. During an interview on 5/16/24 at 3:15 p.m., the Wound Nurse indicated the resident had never had a rash on his neck that she was aware of, but he occasionally had heat rashes. She was not aware of the discolorations to the lower extremities. 3.1-37(a) Based on observation, record review, and interview, the facility failed to ensure residents received the necessary treatment and services related to the monitoring and assessment of skin discolorations for 3 of 7 residents reviewed for non-pressure related skin conditions. (Residents B, 66, and 10) Findings include: 1. On 5/14/24 at 10:03 a.m., Resident B was observed lying in bed with his eyes closed. He had 2 scabbed areas to his right forearm and multiple purple discolorations to his left forearm. On 5/15/24 at 10:42 a.m., Resident B was observed lying in bed with his eyes closed. The scabbed areas and discolorations remained to his arms. Record review for Resident B was completed on 5/15/24 at 3:50 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, dementia with behavioral disturbance, and chronic kidney disease. The Significant Change Minimum Data Set (MDS) assessment, dated 3/5/24, indicated the resident was cognitively impaired and required substantial/maximal assist with upper body dressing. A current Care Plan, updated 3/11/24, indicated the resident was at risk for skin breakdown. An intervention included, skin inspection weekly and as needed, document and notify md of abnormal findings . The most recent Weekly Nursing Summary, dated 4/25/24, indicated there were no current skin issues. During an interview on 5/15/24 at 3:10 p.m., the Director of Nursing (DON) indicated the Wound Nurse would assess the resident's skin. No further information was provided. 2. On 5/13/24 at 10:49 a.m., Resident 66 was observed seated in her Broda chair in her room. There were dark purple discolorations to the tops of both hands. On 5/15/24 at 10:04 a.m., Resident 66 was observed seated in her Broda chair in her room. The dark purple discolorations remained to the tops of both hands. Record review for Resident 66 was completed on 5/16/24 at 1:41 p.m. Diagnoses included, but were not limited to, hypertension, dementia with psychotic disturbance, and hyperlipidemia. The Quarterly Minimum Data Set (MDS) assessment, dated 4/5/24, indicated the resident was cognitively impaired. She was dependent on staff for upper body dressing and received antiplatelet medications. A current Care Plan, updated 4/8/24, indicated the resident was at risk for increased bruising or bleeding due to aspirin therapy. An intervention included, observe for signs of abnormal bleeding such as increased frequency of bruising, increased size of bruises .document abnormal findings and notify MD . The Medication Administration Record (MAR), dated 5/2024, indicated the resident had received aspirin daily. The most recent Weekly Nursing Summary, dated 5/4/24, indicated there were no current skin issues. During an interview on 5/16/24 at 11:13 a.m., the Administrator was made aware of the skin discolorations. No further information was provided.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and interview, the facility failed to ensure a resident received the assistive device needed to maintain vision related to broken glasses not addressed in a timely manner, for 1 of 2 residents reviewed for vision/hearing. (Resident 76) Finding includes: On 5/13/24 at 2:53 p.m., 5/14/24 at 9:11 a.m., and 5/15/24 at 1:20 p.m., Resident 76 was observed lying in his bed. There was a pair of glasses with one of the arms broken off sitting on the overbed table. The resident indicated he used them for reading. The resident's record was reviewed on 5/15/24 at 12:50 a.m. Diagnoses included, but were not limited to, hemiplegia (one sided paralysis) and hemiparesis (one sided weakness) following a cerebral vascular accident, diabetes mellitus, and vascular dementia. The Annual Minimum Data Set assessment, dated 2/8/24, indicated the resident had moderate cognitive impairment and required extensive assistance for bed mobility and toileting. There was no documentation in the record related to the broken glasses or optometry appointments. During an interview on 5/16/24 at 9:47 a.m., CNA 1 indicated the glasses had been broken for several days. She did not know if the nurse or Unit Manager had been notified of the broken glasses because she had been off work for a couple days. The glasses had been broken before and the Social Service Director (SSD) took care of it. During an interview on 5/16/24 at 9:55 a.m., the SSD indicated she had not been notified the glasses were broken but would look into it. 3.1-39(a)(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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure each resident received the necessary treatment and services to promote healing for pressure ulcers, related to ensuring a wound treatment and offloading boots were in place for 2 of 8 residents reviewed for pressure ulcers. (Residents D and E) Findings include: 1. The closed record for Resident D was reviewed on 5/16/24 at 2:52 p.m. Diagnoses included, but were not limited to, anemia, dementia with mood disturbance, and atrial fibrillation. The resident was admitted to the facility on [DATE] and discharged on 4/1/24. The admission Minimum Data Set (MDS) assessment, dated 2/13/24, indicated the resident was cognitively impaired, had no unhealed pressure ulcers, and was at risk for pressure ulcers. A Care Plan, dated 3/19/24, indicated the resident had a pressure ulcer to the left hip. An intervention included, wound treatments as ordered. The Skilled Care Nursing Documentation form, dated 3/18/24, indicated there were no current skin issues. A Pressure Ulcer Note, dated 3/19/24 at 3:03 p.m., indicated the resident had a newly acquired stage 3 pressure ulcer to her left trochanter (hip). This was the first observation of the area, and it measured 0.7 cm (centimeters) x (by) 0.9 cm x 0.1 cm. A Skin and Wound Note by the Wound Nurse Practitioner (NP), dated 3/19/24 at 3:14 p.m., indicated the resident had MASD (moisture associated skin damage) to the left buttock that was healed and had a new pressure injury to the left hip. The left hip area measured 0.7 cm x 0.9 cm x 0.1 cm and was a stage 3. The treatment recommendation for the left hip was, .1. Cleanse with wound cleanser. 2. apply medical grade honey to base of the wound. 3. secure with Bordered gauze. 4. change Daily, and PRN [as needed] . The Pressure Ulcer Weekly Observation, dated 3/26/24, indicated the left trochanter pressure area measured 0.6 cm x 0.9 cm x 0.1 cm and was a stage 3. The area was improving, and treatment orders were in place. A Skin and Wound Note by the Wound NP, dated 3/26/24 at 12:48 p.m., indicated the left hip stage 3 area measured 0.6 cm x 0.9 cm x 0.1 cm and was healing. The treatment recommendation for the left hip was, .1. Cleanse with wound cleanser. 2. apply medical grade honey to base of the wound. 3. secure with Bordered gauze. 4. change Daily, and PRN [as needed] . The Physician's Orders Summary, dated 3/2024, lacked any treatment orders for the left hip area. There was an order, dated 2/20/24, for silver sulfadiazine/miconazole/triamcinolone cream mixture to the left buttock every shift. This order was discontinued on 3/20/24 and a new order for the same treatment was put in as a preventative treatment to the left buttock starting 3/20/24. The Medication Administration Record (MAR), dated 3/2024, lacked documentation of any treatment to the left hip area at any time. During an interview with the Wound Nurse and the Director of Nursing (DON) on 5/17/24 at 9:45 a.m., the Wound Nurse indicated she had made a data entry error and had written left buttock instead of left hip in the treatment order on 3/20/24. She had disagreed with the Wound NP's recommendation for the medical honey treatment to the left hip and continued with the same treatment they had used to the left buttock area previously. She had not documented this. The Wound NP had seen the resident the following week and indicated the wound was healing. 2. On 5/13/24 at 10:47 a.m., Resident E was observed sitting in his Broda chair in his room. The pressure offloading boots were not observed in place to his feet. Two pressure offloading boots were observed on the floor behind his recliner. On 5/13/24 at 10:03 a.m., Resident E was observed sitting in his Broda chair in his room. The pressure offloading boots were not observed in place to his feet. Two pressure offloading boots were observed on the floor behind his recliner. Record review for Resident E was completed on 5/15/24 at 10:34 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, type 2 diabetes mellitus, and anemia. The Significant Change Minimum Data Set (MDS) assessment, dated 2/29/24, indicated the resident had 2 unstageable pressure ulcers and one suspected deep tissue injury. A current Care Plan indicated the resident was at risk for skin breakdown. The interventions included, preventative skin care as ordered. A Wound Nurse Practitioner Note, dated 3/5/24, indicated the deep tissue injury (DTI) to the right heel had resolved. A Physician's Order, dated 3/6/24, indicated bilateral heel offloading boots/float heels as tolerated every shift for preventative. A Physician's Order, dated 2/8/24, indicated to assist resident to elevate heels off the bed with boots every shift for preventative. The Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated 5/2024, indicated the offloading boots had been signed off every shift. During an interview with the DON on 5/15/24 at 3:10 p.m., she was made aware the resident's offloading boots had not been in place. She indicated the order was written to wear the boots as tolerated and the resident may not like to wear them or kick them off. She was unable to provide any documentation the resident had refused to wear the boots or was not tolerating them. This citation relates to Complaint IN00431905. 3.1-40(a)(2)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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2. On 5/13/24 at 2:32 p.m., Resident 10 was sitting in a wheelchair in his room. His right forearm was resting on the armrest of the wheelchair and noted to be red and swollen. He was not wearing any splinting device. On 5/15/24 at 10:21 a.m., Resident 10 was noted in a wheelchair in his room. His right forearm was resting in his lap with no splinting device. On 5/16/24 at 9:32 a.m., Resident 10 was noted in a wheelchair in his room with his right forearm resting in his lap with no splinting device. Resident 10's record was reviewed on 5/14/24 at 3:01 p.m. Diagnoses included, but were not limited to, congestive heart failure, respiratory failure, and cellulitis of the right upper limb. The Quarterly Minimum Data Set (MDS) assessment, dated 5/8/24, indicated the resident was severely cognitively impaired for daily decision making. A Care Plan, dated 3/7/24, indicated the resident needed assistance with activities of daily living. Interventions included, but were not limited to, right hand brace per Physician's Orders. A Physician's Order, dated 5/1/24, indicated right hand splint, circulation checks every shift. During an interview on 5/20/24 at 2:37 p.m., the Director of Nursing had no further information to provide. 3. During an interview on 5/13/24 at 2:55 p.m., Resident 125 indicated his left hand was contracted. He wore a splint at one time, but staff had not assisted with putting it on in a long time. They never look at my hand any more, not even for nail care. On 5/15/24 at 11:12 a.m., Resident 125 was observed in his bed with no splinting device to his left hand. Resident 125's record was reviewed on 5/16/24 at 9:43 a.m. Diagnoses included, but were not limited to type 2 diabetes mellitus and heart failure. The admission Minimum Data Set (MDS) assessment, dated 3/19/24, indicated the resident was cognitively intact for daily decision making. He had no impairment to both lower extremities for range of motion. There was no care plan related to a contracture or splinting device. The May 2024 Physician's Order Summary indicated the resident was to wear a left hand splint for up to 8 hours during the day as tolerated to promote skin integrity and prevent further contracture. During an interview on 5/16/24 at 11:09 a.m., the Administrator indicated the resident had a contracture to the left hand. The staff put the splinting device on and he would take it off. He did not have any care plans related to the contracture or splinting device or documentation of refusals. 3.1-42(a)(2) Based on observation, record review, and interview, the facility failed to ensure a resident's positioning was maintained related to hand splints not applied as ordered, for 3 of 4 residents reviewed for positioning/mobility. (Residents 76, 10 and 125) Findings include: 1. On 5/13/24 at 2:53 p.m., Resident 76 was observed lying in his bed. His left hand was contracted and there was no splint in place. On 5/15/24 at 1:20 p.m., the resident was observed lying in bed. His left hand was contracted and there was no splint in place. The resident indicated he used to wear a splint, but was told he didn't need to wear it anymore. He was unable to open his left hand. The resident's record was reviewed on 5/15/24 at 12:50 a.m. Diagnoses included, but were not limited to, hemiplegia (one sided paralysis) and hemiparesis (one sided weakness) following a cerebral vascular accident, diabetes mellitus and vascular dementia. The Annual Minimum Data Set assessment, dated 2/8/24, indicated the resident had moderate cognitive impairment and required extensive assistance for bed mobility and toileting. A Physician's Order, dated 2/6/24, indicated the resident was to wear a left resting hand splint 6-8 hours daily as tolerated to promote anatomical alignment and prevent contracture. The April and May 2024 Treatment Administration Record (TAR) did not have the splint order, so there was no documentation if it was applied or refused. During an interview on 5/15/24 at 2:17 p.m., LPN 1 indicated she did not know if the resident was supposed to wear a splint or not. During an interview on 5/15/24 at 3:05 p.m., the Director of Nursing provided a copy of the physician's order for the splint and a care card that indicated the resident was to wear a left hand splint as tolerated. She was unaware the treatment was not showing up on the TAR. No additional information was provided.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and interview, the facility failed to ensure fall interventions were in place for 2 of 3 residents reviewed for accidents. (Residents B and 91) Findings include: 1. On 5/14/24 at 10:03 a.m., Resident B was observed lying in bed with his eyes closed. There were no floor mats in place at the bedside. Both mats were leaning up against the wall by the window. On 5/15/24 at 10:42 a.m., Resident B was observed lying in bed with his eyes closed. There were no floor mats in place at the bedside. Both mats were leaning up against the wall by the window. Record review for Resident B was completed on 5/15/24 at 3:50 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, dementia with behavioral disturbance, and chronic kidney disease. The Significant Change Minimum Data Set (MDS) assessment, dated 3/5/24, indicated the resident was cognitively impaired and required substantial/maximal assist with bed mobility and transfers. A current Care Plan, updated 3/11/24, indicated the resident was at risk for falls An intervention included, mat beside bed. During an interview with the Director of Nursing (DON) on 5/15/24 at 3:10 p.m., she was made aware the floor mats had not been in place. No further information was provided. 2. On 5/14/24 at 9:47 a.m., Resident 91 was observed seated in her Broda chair near the Nurse's Station. She was not wearing any socks and had bare feet. On 5/15/24 at 10:03 a.m., Resident 91 was observed seated in her Broda chair near the Nurse's Station. She was not wearing any socks and had bare feet. The record for Resident 91 was reviewed on 5/16/24 at 9:35 a.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, osteoarthritis, and hypothyroidism. The Significant Change Minimum Data Set (MDS) assessment, dated 3/20/24, indicated the resident was cognitively impaired and one fall since the prior assessment. A current Care Plan, updated 3/27/24, indicated the resident was at risk for falls. An intervention included, encourage and assist to wear appropriate non-skid footwear. During an interview with the Director of Nursing (DON) on 5/15/24 at 3:10 p.m., she indicated she was unsure why the resident had not been wearing socks. She would find out and if she liked to keep them off or kick them off, she would update the care plan to reflect that. 3.1-45(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

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Based on observation, record review, and interview, the facility failed to ensure urinary output was recorded as per the plan of care for 1 of 1 residents reviewed for urinary catheters. (Resident 89) Finding includes: On 5/13/24 at 1:57 p.m., Resident 89 was observed lying in bed. The resident had a urinary catheter attached to the side of his bed. The bag was observed with a small amount of urine in the bag. The resident indicated staff did not empty his catheter bag and he would have to tell them multiple times a day to make sure they emptied it. Record review for Resident 89 was completed on 5/16/24 at 1:37 p.m. Diagnoses included, but were not limited to, obstructive uropathy, diabetes mellitus, and end stage renal disease. The Quarterly Minimum Data Set (MDS) assessment, dated 4/1/24, indicated the resident was cognitively intact. The resident was dependent for toileting and required substantial assistance with bed mobility. The resident had an indwelling urinary catheter. A Care Plan, dated 5/8/23 and revised 6/28/23, indicated the resident was at risk for infection or complications related to an indwelling catheter. An intervention included to document the catheter output every shift. The Bowel and Bladder Care in the Tasks section, dated 4/16/24-5/15/24, indicated the catheter output was not documented on the following dates and shifts: - Evening shifts on 4/18, 4/19, 4/24, and 4/27/24 - Midnight shifts on: 4/16, 4/17, 4/19, 4/21, 4/22, 4/23, 4/27/24, 4/28, 4/29, 4/30, 5/1, 5/2, 5/3, 5/5, 5/10, 5/12, 5/13, 5/14, and 5/15/24 During an interview on 5/17/24 at 1:38 p.m., the Director of Nursing indicated the staff should have documented the urinary output on the Tasks documentation every shift. 3.1-41(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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 158's record was reviewed on 5/15/24 at 10:26 a.m. Diagnoses included, but were not limited to, congestive heart failure and chronic kidney disease. The admission Minimum Data Set (MDS) assessment, dated 4/23/24, indicated the resident was severely cognitively impaired for daily decision making. He required supervision for eating and received a therapeutic diet. The Weights and Vitals log indicated the resident weighed 175 pounds on 4/21/24 and 162 pounds on 5/10/24. A Physician's Order, dated 5/19/24, indicated weekly weights for four weeks. The Medication/Treatment Administration Record for May 2024 indicated there was not a weekly weight obtained on 5/5/24. The Nutrition - Amount Eaten CNA Task was blank for the following meals: - Breakfast on 4/17/24, 4/24/24, 4/29/24, 5/10/24, and 5/13/24 - Lunch on 4/17/24, 4/19/24, 4/24/24, 4/26/24, 4/29/24, and 5/13/24 - Dinner on 4/18/24, 4/19/24, 4/20/24, 4/21/24, 4/22/24, 4/23/24, 4/26/24, 4/28/24, 4/29/24, 4/30/24, 5/1/24, 5/3/24, 5/4/24, 5/5/24, 5/8/24, 5/9/24, 5/10/24, and 5/13/24 During an interview on 5/17/24 at 2:07 p.m., the Director of Nursing had no further information to provide. 3.1-46(a) 2. The record for Resident 91 was reviewed on 5/16/24 at 9:35 a.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, osteoarthritis, and hypothyroidism. The Significant Change Minimum Data Set (MDS) assessment, dated 3/20/24, indicated the resident was cognitively impaired, required substantial/maximal assist with eating, and had a significant weight loss. A Care Plan, updated 3/27/24, indicated the resident had shown significant weight loss. An intervention included to serve the diet and supplements as ordered and record the amount of consumption. The resident weighed 137 pounds on 1/3/24 and 119 pounds on 3/26/24. A Registered Dietitian (RD) Review, dated 3/27/24, indicated the resident had lost 6% of her body weight in one month. The food consumption task documentation, dated 4/17/24 through 5/15/24, indicated there were no meal consumption intakes documented for the following days and meals: 4/17/24 breakfast 4/18/24 dinner 4/19/24 breakfast and dinner 4/20/24 breakfast and lunch 4/21/24 breakfast and dinner 4/22/24 dinner 4/24/24 breakfast 4/25/24 breakfast and dinner 4/27/24 breakfast and dinner 4/28/24 dinner 4/29/24 dinner 5/1/24 dinner 5/3/24 breakfast, lunch, and dinner 5/4/24 breakfast, lunch, and dinner 5/5/24 breakfast and lunch 5/7/24 breakfast and dinner 5/8/24 dinner 5/9/24 breakfast and dinner 5/10/24 breakfast and dinner 5/11/24 dinner 5/12/24 dinner 5/13/24 breakfast and dinner 5/14/24 breakfast and dinner 5/15/24 breakfast, lunch, and dinner During an interview with the Administrator on 5/16/24 at 11:13 a.m., she was made aware of the lack of documentation of meal consumption. No further information was provided. Based on record review and interview, the facility failed to ensure interventions were implemented for a resident with a significant weight loss, failed to ensure food consumption logs were completed and weekly weights were completed as ordered for 3 of 7 residents reviewed for nutrition. (Residents 59, 91 and 158) Findings include: 1. Resident 59's record was reviewed on 5/14/24 at 2:42 p.m. Diagnoses included, but were not limited to, Lewy body dementia, psychotic disorder, depressive disorder, and diabetes mellitus. The resident resided on the locked dementia unit and was admitted on [DATE]. The Quarterly Minimum Data Set (MDS) assessment, dated 3/29/24, indicated the resident had severe cognitive impairment and required limited staff assistance for bed mobility and transfers, and could eat independently after set up. The current May 2024 Physician Order Summary indicated the resident was on a regular diet. There were no nutritional supplements or fortified food ordered. The resident's weights were as follows: 2/5/24: 232 pounds (lbs) 2/11/24: 230 lbs 2/18/24: 218 lbs 2/25/24: 217 lbs 3/6/24: 217 lbs This indicated a weight loss of 15 lbs in one month. A Quarterly Nutrition Review, dated 3/29/24, indicated the resident had a significant weight loss of 5% in 30 days. The resident did not receive snacks, supplements or fortified food. The resident's weight had been stable since 2/18. The resident's intake of food and fluid was estimated to meet needs at this time. There were no new nutritional recommendations at this time. The resident's continued weights were as follows: 4/2/24: 220 lbs (+3 lbs) 5/3/24: 203 lbs 5/7/24: 203 lbs (reweigh) This was an additional weight loss of 14 pounds, for a total weight loss of 29 pounds, 12.5%, since her admission on [DATE]. There was no documentation in the record the weight loss between 4/2 and 5/7/24 had been identified. There were no progress notes, Nutrition at Risk (NAR) notes, or Nutrition Reviews completed. The food consumption task documentation, dated 4/18/24 through 5/15/24, indicated there were no meal consumptions documented on the following days and meals: 4/18/24 - breakfast, lunch 4/19/24 - dinner 4/20/24 - breakfast, lunch & dinner 4/21/24 - breakfast, lunch 4/22/24 - breakfast, lunch & dinner 4/23/24 - breakfast, lunch 4/24/24 - breakfast, lunch 4/27/24 - dinner 4/29/24 - breakfast, lunch 5/1/24 - lunch 5/2/24 - breakfast, lunch & dinner 5/3/24 - breakfast, lunch & dinner 5/4/24 - dinner 5/6/24 - breakfast, lunch & dinner 5/9/24 - breakfast, lunch 5/10/24 - breakfast, lunch & dinner 5/11/24 - breakfast, lunch & dinner 5/14/24 - dinner 5/15/24 - breakfast, lunch & dinner The Nutrition Care Plan, initiated on 2/7/24, indicated the resident had potential nutritional risk related to above BMI (body mass index) for height. A care plan revision, on 3/20/24, indicated the resident had a significant weight loss since admission with more mobility which was currently stabilizing. The goal was for the resident not to exhibit a significant weight change. Interventions included, but were not limited to, Registered Dietician to evaluate and make diet change recommendations as needed and document food and fluid intakes. During an interview on 5/16/24, the Director of Nursing Services (DNS) indicated she was just made aware of the significant weight loss and she would look into it. During a follow up interview on 5/16/24 at 1:40 p.m., she indicated the resident would be reviewed in the NAR meeting today and they would complete a Significant Change MDS. During an interview on 5/17/24 at 10:15 a.m., the Dietary Technician (DT) indicated she completed the Nutrition Reviews. If a resident had a significant weight loss, the Registered Dieticians (RD) were consulted and they would make recommendations. The DT indicated the first significant weight loss may have been attributed to an incorrect admission weight, but no interventions were put into place and that was an oversight on her part. The current significant weight loss had also been overlooked by her. She was not made aware of it until yesterday, 5/16/24, when surveyors identified it. The policy, Resident Weight Monitoring, indicated, .A weight report will be generated monthly and reviewed by the DM (Dietary Manager), RD, DNS, and MDS for significant changes. A significant weight change is defined as 5% in 30 days, 7.5% in 90 days and 10% in 180 days . and, .Residents with verified significant weight change will be followed by IDT (interdisciplinary team) in the Risk Nutrition meeting .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and interview, the facility failed to ensure a resident with a gastronomy tube (g-tube) received appropriate treatment related to not completing water flushes before medication administration as ordered by the physician, for 1 of 7 residents reviewed during medication administration. (Resident 115 and RN 1) Finding includes: On 5/16/24 at 11:11 a.m., RN 1 was observed preparing Resident 115's medication to administer via a g-tube. The nurse crushed Tylenol 325 mg (milligrams) x 2 tablets and poured them into a medicine cup. She then proceeded to add 30 ml (milliliters) of water to the cup with the Tylenol. RN 1 checked placement of the g-tube, attached a syringe to the g-tube and poured the medicine cup into the syringe. After the diluted medication went through the tubing, she then proceeded to administer 30 ml of water into the tubing. Record review for Resident 115 was completed on 5/16/24 at 11:08 a.m. The May 2024 Physician's Order Summary indicated an order to administer 30 ml of water before and 30 ml of water after medication administration via the g-tube. During an interview after the observation, RN 1 indicated she forgot to flush the g-tube with water before she administered the medication. 3.1-44(a)(2)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0699 (Tag F0699)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and interview, the facility failed to ensure to deliver care and services and to address the needs of a resident with a diagnosis of post-traumatic stress disorder (PTSD) related to not following care plan interventions or updating care plans for a PTSD diagnosis for 1 of 1 residents reviewed for behaviors. (Resident 134) Finding includes: On 5/13/24 at 9:54 a.m., Resident 134 was noted to be yelling out. On 5/16/24 at 10:10 a.m., Resident 134 was observed in a broda chair in a common area with other residents. He was observed making noises under his breath. On 5/17/24 at 10:23 a.m., Resident 134 was observed in his room in a broda chair loudly yelling out. Resident 134's record was reviewed on 5/15/24 at 1:57 p.m. Diagnosis included, but were not limited to, dementia, PTSD, psychosis, major depressive disorder, and generalized anxiety disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 3/3/24, indicated the resident was severely cognitively impaired for daily decision making. He displayed inattention, disorganized thinking, and altered level of consciousness. His behaviors were present and fluctuated. He had physical behavioral symptoms directed towards others, verbal behavioral symptoms directed towards others and other behavioral symptoms not directed towards others. A Care Plan, dated 11/24/23, indicated the resident required room visits or one to one activities due to a frequent preference to be in lower stimulating environments along with verbal expressions of comprehension and emotional experiences which may cause the resident to have difficulty participating in group settings successfully. Interventions included, but were not limited to, provide monthly activity calendar, provide room visits of choice, provide sensory stimulation in room, and discuss past interests with resident and family. A Care Plan, revised on 11/24/23, indicated the resident had behavioral symptoms including restlessness, resistive to care, combativeness, and going into other resident's rooms. Interventions included, but were not limited to, assess the resident's needs, document behaviors, identify behavior triggers and reduce exposure to triggers, and provide a diversional activity. A Care Plan, dated 9/26/23, indicated the resident had a history of trauma and diagnosis of PTSD and exhibited yelling out, anxiety, restlessness, and irritability. Interventions included, but were not limited to, the resident would learn and utilize relaxation techniques, have positive social interactions, participation in relaxation exercises, and he would share feelings. An Activities-Quarterly Review note, dated 12/8/23 at 10:45 a.m., indicated the resident was passive in most group programs, he made loud noises that could be heard by peers. One to one activities with staff were provided for more appropriate interactions. He preferred a setting of one to ones and independent. A Psychiatric Note, dated 4/10/2024, indicated during his clinical intake on 9/18/23, the resident was referred to psychiatric services for having ongoing issues with yelling out, anxiety, restlessness, depression, and delusions. There were a lot of times where he would scream out in his room. When asked what is wrong he would often not be able to tell them and would continue screaming. He possibly had some PTSD related to his service as most of his delusions are focused around violence and weapons. He was calm, but very dysphoric and told the writer that everything was wrong and he felt sad. He would also often grind his teeth and squirm in his chair. He sometimes put himself on the floor. His yelling out also often disturbed other residents. An Activities-Quarterly Review note, dated 2/26/24 at 1:09 p.m., indicated the resident attended group activities with peers. He responded and interacted when prompted on a one to one basis. During an interview on 5/17/24 at 11:19 a.m., the Activity Director indicated the resident went to group activities and had never done any one to one activities with staff that she was aware of. During an interview on 5/20/24 at 3:14 p.m., the Social Services Director indicated the resident was having flashbacks and they were unable to determine what the triggers were for those. She had never reached out to the family to see what interventions were appropriate for the resident or what had triggered his yelling out. The family was invited to care plan meetings, but had never attended.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to ensure clinical records were complete and accurately documented related to medication administration, for 1 of 2 residents reviewed for antibiotic use. (Resident 74) Finding includes: During an interview with Resident 74 on 5/14/24 at 9:32 a.m., she indicated she had a urinary infection and was being treated with antibiotics. The record for Resident 74 was reviewed on 5/16/24 at 11:22 a.m. Diagnoses included, but were not limited to, anemia, congestive heart failure, and hypertension. The Quarterly Minimum Data Set (MDS) assessment, dated 5/10/24, indicated the resident was cognitively intact and had septicemia and a urinary tract infection in the last 30 days. A Physician's Order, dated 5/6/24, indicated to give piperacillin-tazobactam (Zosyn, an antibiotic) 3.375 grams intravenously every 8 hours for 7 days for sepsis due to pseudomonas (bacteria). The Medication Administration Record (MAR), dated 5/2024, indicated the antibiotic medication had not been signed off as given on the following dates and times: 6 a.m. on 5/9/24 and 5/10/24 2 p.m. on 5/7/24, 5/8/24, and 5/12/24 10 p.m. on 5/7/24 During an interview with the Director of Nursing (DON) on 5/16/24 at 12:01 p.m., she had checked the medication storage room and there were no antibiotics left. She believed the medication had been administered as ordered, but had not been signed out on the MAR. 3.1-50(a)(1)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure infection control guidelines were in place and implemented related to a lancet disposed of improperly for a random observation during a blood sugar check. (Resident 37 and RN 1) Finding includes: On 5/16/24 at 11:25 a.m., RN 1 was observed testing Resident 37's blood sugar level. The nurse washed her hands, donned gloves, cleaned the resident's finger, and then poked the resident's finger with a lancet to obtain the blood sample. The resident's blood sugar level was then assessed. The nurse then took off her gloves and disposed of them into the resident's garbage can along with the lancet. The nurse then proceeded to walk out of the resident's room into the hallway. During an interview after the observation, RN 1 indicated she disposed of the lancet into the resident's garbage can. She should have disposed of the lancet into the sharps container. A facility policy titled, Sharps Disposal and received as current from the Administrator indicated, .2. Contaminated sharps will be discarded into containers that are: a. Closable .d. Labeled or color-coded in accordance with our established labeling system . 3.1-18(b)

CONCERN (E) 📢 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

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

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4. On 5/14/24 at 9:39 a.m., Resident C was observed in bed wearing only a t-shirt and appeared disheveled. He had no brief on and the linens under him were soiled. On 5/14/24 at 10:16 a.m., Resident C was observed in bed wearing only a t-shirt. He had no brief on and the linens under him were soiled. Resident C's record was reviewed on 5/14/24 at 2:16 p.m. Diagnoses included, but were not limited to peripheral vascular disease and type 2 diabetes mellitus. The admission Minimum Data Set (MDS) assessment, dated 4/5/24, indicated the resident was severely cognitively impaired. He was dependent on staff for toileting hygiene and required substantial/maximal assistance for personal hygiene and shower/bathing. A Care Plan, dated 4/1/24, indicated the resident needed assistance with activities of daily living. Interventions included, but not limited to, the resident required extensive assistance for toilet use. The Shower Sheets from April and May 2024 indicated the resident had refused on 4/13/24, received a shower on 4/15/24, refused on 4/27/24, and received a shower on 4/28/24. There was nothing further documented. During an interview on 5/16/24 at 10:02 a.m., the Administrator had no further information to provide. 5. During an interview on 5/13/24 at 11:34 a.m., Resident 45 indicated she was not receiving showers twice a week. Resident 45's record was reviewed on 5/16/24 at 1:13 p.m. Diagnoses included, but were not limited to, schizoaffective disorder, anxiety disorder, and bipolar disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 2/21/24, indicated the resident was moderately cognitively impaired for daily decision making. She required substantial/maximal assistance for showering. A Care Plan, dated 9/22/23, indicated the resident needed assistance with activities of daily living. Interventions included, but were not limited to, the resident required extensive assistance with showering and had fluctuations in needs and provide additional staff assistance as needed. The Shower Sheets were reviewed for April and May 2024 and indicated the resident received a shower on 4/5/24, 4/9/24, 4/16/24, 4/19/24, 4/23/24, 5/7/24, and 5/14/24. During an interview on 5/20/24 at 2:37 p.m., the Director of Nursing had no further information to provide. This citation relates to Complaint IN00431905. 3.1-38(a)(3)(D) 3.1-38(b)(2) 3. On 5/14/24 at 10:17 a.m., Resident 52 was observed lying in bed. The resident had long facial hair observed to her chin. The resident indicated the staff would sometimes shave her and was unsure the last time she was shaved. On 5/15/24 at 11:09 a.m., Resident 52 was observed lying in bed. The resident was still observed with long facial hair to her chin. The record review for Resident 52 was completed on 5/15/24 at 11:10 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, heart failure, hypertension, diabetes mellitus, dementia, and stroke. The Quarterly Minimum Data Set (MDS) assessment, dated 4/29/24, indicated the resident was cognitively intact. The resident was dependent for bathing, transfers and mobility. The resident required substantial/maximal assistance for personal hygiene. A Care Plan, dated 1/27/24 and revised 1/30/24, indicated the resident needed assistance with activities of daily living. An intervention included the resident needed an extensive assistance x 1 person for personal hygiene. During an interview on 5/15/24 at 2:04 p.m., CNA 2 indicated the resident was given 1 shower a week and 1 bed bath a week. She was to be shaved weekly with her bathing or when her facial hair was observed. CNA 2 had given the resident a bed bath the day before and did not shave the resident, but she should have shaved her. Based on observation, record review, and interview, the facility failed to ensure dependent residents received the activities of daily living (ADL) care needed related to showers not given as scheduled, facial hair unshaven, and soiled sheets on a resident's bed for 5 of 8 residents reviewed for ADL care. (Residents 76, 121, 52, C, and 45) Findings include: 1. On 5/13/24 at 2:53 p.m., Resident 76 was observed lying in his bed. His hair appeared greasy and there was visible white debris observed. His beard had visible food debris. On 5/14/24 at 9:11 a.m., the resident was observed lying in bed. His hair was greasy with white debris observed. The resident's record was reviewed on 5/15/24 at 12:50 a.m. Diagnoses included, but were not limited to, hemiplegia (one sided paralysis) and hemiparesis (one sided weakness) following a cerebral vascular accident, diabetes mellitus and vascular dementia. The Annual Minimum Data Set assessment, dated 2/8/24, indicated the resident had moderate cognitive impairment and required extensive assistance for bed mobility and toileting. The current ADL Care Plan indicated the resident needed total assistance for bathing/showering due to activity intolerance, hemiplegia, and physical debility. The shower book indicated he was to receive a shower twice weekly on Wednesday and Saturday. Shower sheets for the past 30 days were reviewed as follows: 4/20/24: bed bath 5/1/24: bed bath 5/4/24: bed bath 5/11/24: bed bath 5/15/24: bed bath There were no documented showers, bed baths, or refusals for 4/24, 4/27 or 5/8/24. During an interview on 5/15/24 at 2:26 p.m., CNA 8 indicated if a resident refused a shower, then a bed bath was offered. If they refused the bed bath, a refusal form should be completed and the nurse was to be notified. During an interview on 5/16/24 at 11:15 a.m., the Director of Nursing indicated there were no additional shower sheets available. 2. During an interview on 5/13/24 at 11:17 a.m., Resident 121 indicated he was not getting showers twice weekly as scheduled. The residents record was reviewed on 5/16/24 at 11:45 a.m. Diagnoses included, but were not limited to, congestive heart failure, unspecified dementia, and diabetes mellitus. The Annual MDS assessment, dated 3/15/24, indicated he was cognitively intact and required extensive assistance for bed mobility and limited assistance for toileting and transfers. The current ADL Care Plan indicated he needed total assistance with bathing/showering related to activity intolerance and dementia. The shower book indicated he was to receive a shower twice weekly on Monday and Thursday. Shower sheets for the past 30 days were reviewed as follows: 4/24/24: shower 4/29/24: shower 5/2/24: shower 5/9/24: shower There were no documented showers, bed baths, or refusals for 4/18, 4/22, 5/6 or 5/13. During an interview on 5/16/24 at 11:15 a.m., the Director of Nursing indicated there were no additional shower sheets available.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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Based on observation and interview, the facility failed to ensure medications were properly stored for 4 of 5 medication carts observed. (1A Medication Cart, 2C Medication Cart, 2B Medication Cart, and 3D Medication Cart) Findings include: 1. On 5/20/24 at 9:13 a.m., the 1A Medication Cart was observed with RN 2. There were approximately 20 pills of different sizes and colors that were loose and out of the packages throughout the bottoms of the drawers in the cart. The nurse indicated nursing was responsible for making sure the medication carts were cleaned. 2. On 5/20/24 at 9:26 a.m., the 2C Medication Cart was observed with LPN 2. There were approximately 40 pills of different sizes and colors that were loose and out of the packages throughout the bottoms of the drawers in the cart. The nurse indicated nursing was responsible for making sure the medication carts were cleaned. 3. On 5/20/24 at 9:33 a.m., the 2B Medication Cart was observed with RN 3. There were approximately 12 pills of different sizes and colors that were loose and out of the packages throughout the bottoms of the drawers in the cart. The nurse indicated nursing was responsible for making sure the medication carts were cleaned. 4. On 5/20/24 at 9:47 a.m., the 3D Medication Cart was observed with LPN 3. There were approximately 4 pills of different sizes and colors that were loose and out of the packages throughout the bottoms of the drawers in the cart. The nurse indicated nursing was responsible for making sure the medication carts were cleaned. During an interview on 5/20/24 at 10:48 a.m., the Director of Nursing indicated all of the nursing staff was responsible to making sure the medication carts were cleaned. 3.1-25(j) 3.1-25(o)

Dec 2023 3 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

Deficiency F0573 (Tag F0573)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to provide residents' medical records to the family/Power of Attorney (POA) in a timely manner after a request was made for 2 of 3 residents reviewed for medical record requests. (Residents B and K) Findings include: 1. Resident B's closed record was reviewed on 12/13/23 at 3:40 p.m. The diagnoses included, but were not limited to, Parkinson's disease. The resident was discharged from the facility on 9/11/23. During an interview on 12/14/23, the Medical Records Clerk indicated the family requested the medical records on 10/9/23 and it was faxed to the Corporate Office on 10/10/23. She indicated the request for records has to be filled out and signed and brought to the facility. It is then faxed to the Corporate Office and the records are sent out from there. During an interview with Corporate Medical Records Employee 3 on 12/14/23 at 9:08 a.m., she indicated the resident's records were not sent to the family until 10/26/23. 2. Resident K's closed record was reviewed on 12/15/23 at 9:39 a.m. The diagnoses included, but were not limited to, cancer. The resident was discharged on 11/2/23. The medical records request was received at the Corporate Office on 11/1/23 and the records were sent to the family on 11/10/23. During an interview with the Corporate Medical Records Employee on 12/14/23 at 9:08 a.m., she indicated sometimes it would take five days to get to the request and they were behind schedule with getting the medical record requests completed. This citation relates to Complaint IN00421991. 3.1-4(b)(2)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and interview, the facility failed to ensure Care Plan interventions to prevent falls were in place, related to non-skid strips on the floor and dycem (non-slide material) on the wheelchair to prevent sliding for 1 of 3 residents reviewed for falls. (Resident M) Finding includes: During an observation on 12/15/23 at 10:02 a.m. with Employee 4, there were no non-skid strips on the resident's bathroom floor and no dycem on the wheelchair seat. Resident M's record was reviewed on 12/15/23 at 9:46 a.m. The diagnoses included, but were not limited to, vascular dementia. An Annual Minimum Data Set assessment, dated 12/2/23, indicated a severely impaired cognitive status, maximum assistance required for transfers, moderate assistance required for ambulation, and no falls. A Care Plan, dated 5/13/21, indicated a risk for falls. The interventions included, on 7/31/23 dycem was applied to the seat of the wheelchair and on 12/11/23, non-skid strips were applied to the bathroom floor. A Nurse's Progress Note, dated 7/29/23 at 11:05 a.m., indicated the resident was found sitting on the floor in front of her wheelchair in the front entry of the building. The wheelchair was locked. There were no injuries. A Nurse's Progress Note, dated 12/10/23 at 4:58 p.m., indicated she was found on the bathroom floor and stated she had slid off the toilet. An Interdisciplinary Team (IDT) note, dated 12/11/23 at 10:14 a.m., indicated a new intervention of non-skid strips would be placed on the bathroom floor. During an interview on 12/15/23 at 10:39 a.m., the Director of Nursing indicated the IDT meets after falls and makes decisions on interventions. The non-slid strips were to be applied by Maintenance or Central Supply. The IDT members were to complete rounds daily to ensure interventions were in place. The new interventions were to be put into place immediately. This citation relates to Complaint IN00421991. 3.1-45(a)(2)

CONCERN (E) 📢 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

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

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Based on observation, record review, and interview, the facility failed to ensure residents who required extensive and dependent care for activities of daily living (ADL's), received showers and/or bathing per their preferences and timely incontinent care for 5 of 6 residents reviewed for ADL assistance. (Residents F, J, N, B, and L) Findings include: 1) Resident F was interviewed on 12/13/23 at 10:18 a.m She indicated she has had one shower since being admitted into the facility and has bed baths the rest of the time when they bathed her. She has not received a bed bath twice a week. She also does not get incontinent care timely and has had to sit in urine and bowel movement for long periods of time because they turn her call light off and say they will be back but never come back. During the interview, the resident was observed wearing a purple gown/top. During an observation on 12/13/23 at 11:07 a.m., the call light was activated and answered by Employee 1. Employee 1 and Employee 2 entered the room to provide incontinent care. The incontinent brief was saturated with urine and the skin on the buttock was pink and blanchable. The resident indicated the last time she had her brief changed was at 7 p.m. on 12/12/23. Employee 2 indicated she started her shift at 6:30 a.m. and had not gotten to the resident's room yet. The resident continued to wear the same purple top. During an interview on 12/13/23 at 4 p.m., the resident indicated she usually would let the staff know when she was wet. Someone on night shift had come into her room and lifted her blanket, but had not told her what they were doing. Some staff would ask her if she needed changed, others would check her and change her, and others would wait until she would call them and let them know. The resident continued to wear the same purple top. During an observation on 12/14/23 at 8:40 a.m., the resident was observed to be wearing the same purple top. She indicated a brief change had been completed at 4 a.m. and she had not received a bath or shower on the evening shift as scheduled on 12/13/23. Review of the Bathing Schedule indicated her bathing was to be completed on Wednesday and Saturday evenings. Bathing was scheduled for 12/13/23 and was documented as completed on 12/13/23 evening shift. During an observation on 12/15/23 at 8:44 a.m., the resident wore the same purple top. She indicated she had not received a bed bath. She indicated she prefers a bed bath instead of a shower. Resident F's record was reviewed on 12/14/23 at 11:03 a.m. The diagnoses included, but were not limited to, spinal stenosis. A Quarterly Minimum Data Set (MDS) assessment, dated 11/30/23, indicated an intact cognitive status, required a mechanical lift for transfers, was dependent for showers/bathing and bed mobility, and was always incontinent of bowel and bladder. A Care Plan, dated 2/10/23, indicated assistance was needed for ADL's. The interventions included, total assistance with bathing and total assistance of two for toileting. A Care Plan, dated 2/17/23, indicated incontinence of bladder and bowel. The interventions included routine toileting, check routinely for incontinence and incontinent care was to be provided as needed. The bathing records indicated bathing had not occurred as scheduled on October 4 and 14, November 1, 11, 15, 18, 25, and 29, and December 2, 2023. 2. During an interview on 12/13/23 at 11:26 a.m., Resident J indicated showers were not provided often. They were scheduled for twice a week but she usually only received a shower once a week. She had not received a shower this past Saturday because they could not find a mechanical lift shower pad and they had offered to use her regular pad, which she had not wanted to use since the pad would have been wet and unable to be used until dried. They had not offered a bed bath. During an interview on 12/15/23 at 8:28 a.m., Resident J indicated she preferred showers to bed baths and she received bed baths when they were unable to find a shower pad for the mechanical lift. Resident J's record was reviewed on 12/14/23 at 8:55 a.m. The diagnoses included, but were not limited to, diabetes mellitus. An Admission/5-day MDS assessment, dated 11/13/23, indicated an intact cognition, dependent for bed mobility and transfer, maximum assistance was required for showers/bathing. It was somewhat important to choose method of bathing. A Care Plan, dated 11/6/23, indicated assistance was required for ADL's. The interventions included extensive assistance was to be given with bathing/showers. The shower schedule indicated showers were to be completed on Monday and Thursday evenings. The bathing sheets for November 2023 and December 2023 indicated no bathing was completed on November 9 and December 4, 2023, a bed bath was given on November 13, 23, and 30, and December 6 and 11, 2023, and a shower was given on November 17 and 25, 2023. 3. During an interview with Resident N on 12/14/23 at 8:35 a.m., she indicated she had not had a shower or bed bath since she had been placed in Transmission Based Isolation and she tried to wash herself up. Prior to the isolation, she was also not receiving her showers as scheduled and preferred a shower to a bed bath. Resident N's record was reviewed on 12/15/23 at 10:25 a.m. The diagnoses included, but were not limited to, heart failure and positive COVID-19. A Quarterly MDS assessment, dated 10/18/23, indicated an intact cognitive status and was dependent for bathing. The shower schedule, indicated her showers were scheduled for Monday and Thursday evenings. The October 2023 bathing sheets indicated a bed bath was given October 2 and 5. Bathing was completed on October 10th, though the type was not documented. No bathing had been completed on October 12, 16, 19, 23, 26, and 30, 2023. The November 2023 bathing sheets, indicated bathing was completed on November 13, though the type of bathing was not specified. Bed baths were given on November 16, 20, and 30, 2023. There was no bathing completed on November 2, 6, 8, 23, and 27, 2023. The December 2023 bathing sheets, indicated a shower was given on December 4, a bed bath given on December 11, and no bathing was completed on December 7 and 14, 2023. 4. Resident B's closed record was reviewed on 12/13/23 at 3:40 p.m. The diagnoses included, but were not limited to, Parkinson's disease. A Significant Change MDS assessment, dated 7/6/23, indicated a moderately impaired cognitive status and required extensive assistance with bathing. The shower schedule indicated bathing was to be completed on Mondays and Thursdays. The bathing records indicated bathing had been completed on August 17 and 24, 2023. The bathing had not been completed on August 21, 2023. 5. Resident L's record was reviewed on 12/15/23 at 1:42 p.m. The diagnoses included, but were not limited to, non-traumatic intracranial hemorrhage. An admission MDS assessment, dated 11/16/23, indicated an intact cognitive status and was dependent for bathing/showers. The shower schedule indicated the showers were scheduled for Wednesday and Saturday days. The bathing sheets indicated a shower/bathing had not been completed on November 11, 18, 22, and 25 and December 2, 9, and 13, 2023. The Director of Nursing (DON) was informed of the missed bathing on 12/13/23 at 4:30 p.m. No further bathing records were received. This citation relates to Complaints IN00416599, IN00418481, and IN00424119. 3.1-38(a)(2)(A) 3.1-38(a)(2)(C)

Aug 2023 3 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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and interview, the facility failed to implement their written policies and procedures that protected residents after an allegation of abuse, related to a CNA continued to work the rest of the shift after an allegation of abuse was reported by a resident for 1 of 3 residents reviewed for abuse. (Resident B and CNA 2) Finding includes: During an interview on 8/11/23 at 4:37 a.m., Nurse 1 indicated an altercation had occurred between staff members and Resident B on 8/8/23. Resident B accused CNA 2 of throwing water on her. The Director of Nursing (DON) was notified and CNA 2 was removed from the resident's care. CNA 2 had not been sent home and worked the rest of her shift. Cross reference F609 The facility abuse policy, dated 3/2021 and received from the Director of Nursing as current, indicated employees who have been accused of resident abuse shall be suspended of duty immediately until the results of the investigation have been reviewed by the Administrator. This Federal tag relates to Complaint IN00414807. 3.1-28(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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure an allegation of abuse was reported to the Indiana Department of Health (IDOH) and other proper authorities for 1 of 3 residents reviewed for abuse. (Resident B) Finding includes: During an interview on 8/11/23 at 4:37 a.m., Nurse 1 indicated an altercation had occurred between staff members and Resident B on 8/8/23. Resident B had several outbursts of yelling at staff. CNA 2 was in the room and she was in the hallway. She heard something that sounded like an object sliding across the floor like it had been thrown. When she entered the resident's room, Resident B accused CNA 2 of throwing water on her and there was a bath basin on the floor. CNA 2 indicated the resident had thrown water on her. The Director of Nursing (DON) was notified and CNA 2 was removed from the resident's care. The resident was mad and would not let anyone complete care on her. During an observation on 8/11/23 at 4:55 a.m., Resident B was awake, sitting up in bed, the TV was on, and she was doing something on her cell phone. She agreed to be interviewed and indicated a CNA had thrown a glass of water at her earlier in the week. The CNA had not been back in her room to care for her. She notified the Police about the incident and someone from the Police Department had come and spoken to her. During an interview on 8/11/23 at 6:35 a.m., the DON indicated the allegation the CNA had thrown water at the resident was not reported to her. It was reported that there were concerns and the resident was having behaviors. She was aware the Local Police Department had been notified by the resident. During an interview on 8/11/23 at 8:15 a.m., the Executive Director indicated the allegation had not been reported to her. It was reported that the resident threw water on the CNA. The Police Report was reviewed on 8/11/23 at 9:07 a.m. and indicated the Police had arrived on 8/8/23 at 2:39 a.m. The resident had made an allegation a cup of water had been thrown on her by a CNA. She had asked for a glass of water and the CNA had gone to get the water and the resident then activated her call light again due to the need to use the bathroom. The CNA was mad and threw the cup of water at her and it hit her in the face. The bed was observed wet with a few ice cubes observed. Her face and hair were not wet. The chief complaint was listed as abuse and a CNA was abusing her and threw some ice water at her face. During an interview on 8/11/23 at 9:26 a.m., CNA 2 indicated the resident placed her call light on, she answered the light and the resident was rude and said she needed ice water. CNA 2 obtained the ice water and brought it back to her. She then said she needed the bedpan and she was informed that supplies were needed and the CNA left the room to get them. When she returned 5-10 minutes later the resident was cursing and wanted to know what took her so long. The resident then threw the bath basin at her. The CNA stopped what she was doing and informed the resident she would be back and at that time the Resident threw the water at her. The CNA then left the room. During an interview on 8/11/23 at 9:40 a.m., the DON indicated the Nurse and the CNA had written a statement on 8/8/23 and there was nothing in the statement about the CNA throwing water in the resident's face. A signed statement by the DON, dated 8/8/23, indicated the Nurse notified her that the resident had called the Police in regards to a care complaint. It was reported to the nurse by the CNA that the resident threw a wash basin and a cup of water at the CNA. When the Nurse entered the room, the wash basin and water were observed on the floor near the doorway. A signed statement by Nurse 1, dated 8/8/23, indicated at approximately 1:30 a.m., she was in the hallway and heard Resident B yelling. CNA 2 was exiting the room and stated the resident had asked for ice. Nurse 1 entered the room and the resident reported to her the CNA had thrown ice water in her face. The CNA reported the resident had thrown a bath basin and a cup of ice water at her. the resident was screaming that the CNA was liar, she was going to call the Police, and refused any care offered to her by the Nurse. She was screaming at the staff to get out of her room. The DON was notified. Resident B's record was reviewed on 8/11/23 at 7:16 a.m. The diagnoses included, but were not limited to, depression. An admission Minimum Data Set assessment, dated 7/17/23, indicated an intact cognitive status and physical behaviors, verbal behaviors, other behaviors, and rejection of care occurred one to three days. There was no documentation of the incident/allegation that occurred on 8/8/23 in the Progress Notes. A facility abuse policy, dated 3/2021, received from the DON as current, indicated when an alleged or suspected care of mistreatment or abuse was reported the Administrator, DON or designee would immediately notify the State licensing/certification agency (IDOH), the attending Physician, the Resident Representative, and any agencies as required (Adult Protective Services). This Federal tag relates to complaint IN00414807. 3.1-28(c)

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 F0743 (Tag F0743)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to accurately document behaviors, triggers for the behaviors, interventions, and the outcome of the interventions for the behaviors, for 1 of 3 residents reviewed for behaviors. (Resident B) Finding includes: Resident B's record was reviewed on 8/11/23 at 7:16 a.m. The diagnoses included, but were not limited to, depression. An admission Minimum Data Set assessment, dated 7/17/23, indicated an intact cognitive status, and physical behaviors, verbal behaviors, other behaviors, and rejection of care occurred one to three days. A Care Plan, dated 7/11/23 and revised on 8/9/23, indicated behaviors exhibited were refusals of care, medications/treatments, she dictated her care with the staff what she wants/doesn't want and what she will or won't do, demanding of staff when wants/needs could not be accommodated, threatened staff that she will just go home, has made multiple complaints about care, exhibited a rude/unpleasant demeanor, has been manipulative like making a request then refusing and then told others it was never offered, and has had false/unfounded statements. The interventions, dated 7/11/23, were as follows: The resident would be allowed to vent feelings and needs. She was to be approached in a calm and friendly manner. Her needs were to be assessed for food, thirst, toileting, comfort levels, positioning, pain, etc and they would be treated as indicated. Attempts would be made to guide/educate on facility procedures and promote compliance so her wants/needs could be met. The behaviors would be documented per the behavior management program. The staff would explain what they were going to do before initiating the task. The resident would be given as many choices as possible about care and activities. The behavior triggers would be identified and the exposure to the triggers would be reduced. If she was angry and inconsolable, the room was to be left and she was to be re-approached at a later time. The Physician and Psychological Services were to be notified for increased behavioral symptoms. Psychological Services were to be provided as ordered. The Behavior Log indicated the following: - On 7/14/23 there were behaviors of yelling/screaming, pushing, grabbing, pinching, abusive language, threatening behavior, and rejection of care. - On 7/23/23 there was a behavior of abusive language. - On 8/2/23, there were behaviors of yelling, screaming, abusive language, threatening language, and rejections of care. - On 8/8/23, there were behaviors of yelling, screaming, abusive language, and rejection of care. The behaviors were not documentation in the Progress Notes or any other areas of the record that indicated the behaviors occurred, triggers of the behaviors, what was occurring at the time of the behaviors, the interventions attempted and the outcome of the interventions provided. During an interview on 8/11/23 at 12:22 p.m., Social Service 3 acknowledged there was no documentation of the behaviors, the triggers, interventions, and the effectiveness of the interventions other than the Behavior Log. The facility behavior management policy, dated 4/2022 and received from the Executive Director as current, indicated the residents were provided a supportive environment with interventions that are specific to the resident's individualized needs. All altercations would be reviewed by the Interdisciplinary Team, as they were considered worsening behaviors. The Interdisciplinary Team would evaluate the interventions and attempts would be made to determine an underlying cause. 3.1-43(a)(1)

Jun 2023 12 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

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected 1 resident

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2. On 6/12/23 at 9:52 a.m., Resident F was observed in bed. At that time, there were bottles of Combigan 0.2/00.5% ophthalmic solution, Lumigan 0.01% ophthalmic solution, and a bottle of refresh tears sitting on the resident's bedside table. On 6/13/23 at 9:55 a.m., Resident F was observed sitting in his wheelchair watching tv. At that time, there was a bottle of Lantanoprost 0.005% ophthalmic solution with no cap on it and a bottle of Allerflo nasal spray observed on the resident's bedside table. Also observed on the bedside table at that time were the bottles of Combigan, Lumigan and Refresh tears. The record for the resident was reviewed on 6/14/23 at 11:56 a.m. Diagnosis include, but were not limited to, glaucoma (eye condition), stroke, type 2 diabetes, and hyperlipedemia (high cholesterol). The Annual Minimum Data Set (MDS) Quarterly assessment, dated 5/5/23, indicated the resident was cognitively intact. The record lacked any indication a self-medication assessment evaluation, a Physician's Order to self-administer mediations, or a care plan to self-administer medications had been completed. Physician Orders, dated 2/3/23, indicated the following: - Lantanoprost Solution 0.005%, instill 1 drop in the left eye at bedtime. - Timolol Maleate Gel Forming Solution 0.5 %, instill 1 drop in the left eye two times a day. - Brimonidine Tartrate Ophthalmic Solution 0.2 % (Brimonidine Tartrate), instill 1 drop in the left eye every 12 hours. - Carboxymethylcellulose Sod PF Ophthalmic Solution 0.5 % (Carboxymethylcellulose Sodium (Ophth), instill 1 drop in both eyes every 6 hours as needed. Interview with LPN 1 on 6/14/23 at 11:50 a.m., indicated she administered eye drops for resident F that come from her medication cart. She did not administer any medication that the resident had at his bedside. Interview with the Director of Nursing (DON) on 6/15/23 at 1:13 p.m., indicated they did not have a self medication assessment evaluation form on file for this resident. This Federal tag relates to Complaint IN00410203. 3.1-7(a)(2) Based on observation, record review, and interview, the facility failed to ensure a self-medication administration assessment was completed for residents with medications at the bedside for 2 of 2 random observations. (Residents H and F) Findings include: 1. On 6/12/23 at 11:33 a.m., Resident H was observed lying in her bed. There was a Symbicort inhaler on her bedside table. On 6/12/23 at 2:56 p.m., the inhaler was observed still on her bedside table The record for Resident H was reviewed on 6/15/23 at 9:09 a.m. Diagnoses included, but were not limited to cellulitis, dementia and neoplasm of the brain. The admission Minimum Data Set (MDS) assessment, dated 5/26/23, indicated the resident had moderate cognitive deficits and required a total of 2 staff assistance for bed mobility and transfers. A Physician's Order, dated 5/20/23, indicated to give Symbicort Inhalation 2 puffs, twice daily. There was no self-medication administration assessment, care plan or Physician order to self administer medications. Interview with QMA 2 on 6/12/23 at 2:56 p.m., indicated she was not sure if the resident was able to self administer medications, but she would look into it. There was no additional information provided.

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

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

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2. On 6/12/23 at 10:11 a.m., a locked wheelchair was observed blocking the entrance into Resident J's room. The resident indicated the wheelchair was in place related to another resident wandering in her room at night and stealing her snacks. The record for Resident J was reviewed on 6/14/23 at 8:45 a.m. Diagnoses included, but were not limited to, anemia (low iron), depression, type 2 diabetes, heart failure, and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS) assessment, dated 5/1/23, indicated the resident was cognitively intact. Interview with CNA 3 on 6/13/23 at 3:01 p.m., indicated another resident had wandered into Resident J's room and took the resident's snacks. The resident had asked for the wheelchair to block her door. Interview with LPN 1 on 6/14/23 at 9:37 a.m., indicated she had no issues getting into the resident's room and if there were an emergency, she could remove the chair in seconds. The wheelchair was placed there due to someone going in her room and removing her snacks. Interview with the Director of Nursing (DON), on 6/14/23 at 9:41 a.m., indicated she was unaware a wheelchair was placed in front of the resident's door or her allegation of snacks being taken, as nothing was reported by floor staff. She would speak to the resident and place a stop sign intervention instead to see if that worked. The DON removed the locked wheelchair, indicating the resident was not completely bedbound and does get up sometimes. A grievance, dated 6/14/23, indicated the resident's concern related to a co-resident entering her room and taking her snacks. The grievance was signed by Social Services on 6/14/23. Interview with the Administrator on 6/15/23 at 11:30 a.m., indicated she was unaware a resident had complained to staff that someone wandered into her room and stole her snacks until the day before. The staff should have notified her right away so a grievance could have been completed instead of just putting a wheelchair in her doorway to prevent anyone from wandering into her room. A facility policy titled, Resident Concerns and Grievances and received as current, indicated, . A concern/grievance of any kind is documented on a Report of Concern Form . The Executive Director/Grievance Official is responsible for overseeing the grievance process and will collaborate with state and federal agencies, as necessary. The Executive Director/Grievance Official will report allegations of neglect, abuse, and/or misappropriation of resident property, by anyone providing services on behalf of the facility as required by the regulations and law of the state by which the facility is located . This Federal tag relates to Complaint IN00410203. 3.1-11(a) Based on record review, and interview, the facility failed to report, investigate the root cause, and resolve resident grievances for 2 of 2 residents reviewed for grievances. (Residents D and J) Findings include: 1. The record for Resident D was reviewed on 6/14/22 at 2:54 p.m. Diagnoses included, but were not limited to, Parkinson's Disease, dementia with behavioral disturbance, and major depressive disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 4/21/23, indicated the resident was mildly cognitively impaired and required extensive assist x 1 for personal hygiene and bathing. A Grievance form, dated 5/2/23, indicated the resident had not received her shower on 5/1/23. The findings indicated the resident's family had her shower day mixed up and the resident was given a shower on 5/3/23. A Grievance form, dated 5/3/23, indicated the resident's showers were not given consistently per the resident's daughter. The findings indicted the resident had not received her shower on the scheduled day and the shower was provided on the following day shift. A Grievance form, dated 5/26/23, indicated the resident's family voiced ongoing concerns with the resident not receiving showers. The family asked if they could assist the resident with showering when they visited. The findings indicated the resident had been given a shower on 5/25/23. A Grievance form, dated 6/6/23, indicated the resident had again not received a shower in over a week per her daughter. She was also requesting follow up on directions so she could assist the resident with a shower when visiting. The findings indicated a shower was provided by staff and family was provided follow up for future showers. Interview with the Executive Director and the Administrator on 6/15/23 at 10:15 a.m., indicated they had been staffing challenged on second shift and getting scheduled showers done on that shift had been an issue. The grievances had the same repeated concern. They offered to switch the resident's showers to day shift but the family wanted to keep them on second shift so they could assist at times when they were visiting. Some showers had been missed and they had been completed the following day shift.

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to ensure showers were provided as scheduled for a dependent resident for 1 of 11 residents reviewed for activities of daily living (ADL) care. (Resident L) Finding includes: On 6/12/23 at 1:01 p.m., Resident L indicated he wasn't getting his scheduled showers, he hadn't been showered in over a week. The resident's record was reviewed on 6/14/23 at 12:14 p.m. Diagnoses included, but were not limited to, Muscular Sclerosis and Diabetes Mellitus. The Annual Minimum Data Set assessment, dated 5/4/23, indicated the resident was cognitively intact, and required extensive assistance of 2 for bed mobility and transfers. The shower schedule indicated the resident was to be showered on Wednesday and Saturday evenings. Shower sheets for the past 30 days indicated the resident had a bed bath on 5/6/23. The Point of Care charting (used by CNAs) indicated the resident got a shower on 5/25/23 and 6/7/23. There was no additional documentation. Interview with CNA 1 on 6/14/23 at 2:25 p.m., indicated she was the only CNA on the hall that day. She was able to give 1 of the 4 scheduled showers. She indicated it was impossible to give all the showers when working alone. Interview with the Administrator and Executive Director on 6/15/23 at 10:14 a.m., indicated they would look into it. There was no additional information provided. This Federal tag relates to Complaint IN00410203. 3.1-38(a)(3)

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

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3. Interview with Resident D on 6/12/23 at 9:55 a.m., indicated her legs and feet had dry skin. Staff had not put any lotion on her legs. She was observed with dry flaky skin to both legs and ankles and she had a small dry scabbed area on her left shin. On 6/14/23 at 11:13 a.m., the resident was observed seated in her wheelchair in her room. Dry flaky skin was observed to both lower extremities. The record for Resident D was reviewed on 6/14/22 at 2:54 p.m. Diagnoses included, but were not limited to, Parkinson's Disease, dementia with behavioral disturbance, and major depressive disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 4/21/23, indicated the resident was mildly cognitively impaired and required extensive assist of 1 staff for personal hygiene and bathing. The Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated 6/2023, indicated the resident received Lasix (a diuretic medication) 40 mg (milligrams) twice daily. There was lack of any treatment for the dry flaky skin to the resident's lower extremities. The Weekly Nursing Summary, dated 6/12/23, indicated the resident's skin was warm and dry and there were no current concerns. Interview with the DON on 6/15/23 at 12:41 p.m., indicated the resident's legs were dry and she would obtain orders for lotion. 3.1-37(a) 2. On 6/12/23 at 2:14 p.m., Resident 5 was observed lying in bed. The resident had multiple purple discolorations to both arms. The resident also had a bandage to his right elbow. The bandage was not dated or initialed for when it was applied. The resident indicated his elbow was cut on the strap from the transfer lift and the nurse had applied the bandage. On 6/14/23 at 9:20 a.m., Resident 4 was observed lying in bed. There were multiple purple discolorations observed to both his arms as well as the undated bandage to his right elbow. Record review for Resident 5 was completed on 6/15/23 at 9:24 a.m. Diagnoses included, but were not limited to, atrial fibrillation, heart failure, and hypertension. The Annual Minimum Data Set (MDS) assessment, dated 5/17/23, indicated the resident was moderately cognitively impaired. The resident required an extensive 2+ person assist for bed mobility, transfers, toilet use, and personal hygiene. The resident had received an anticoagulant (prevent blood clots) medication. A Care Plan, dated 8/30/21, indicated the resident was at risk for abnormal bleeding secondary to anticoagulant therapy for atrial fibrillation. An intervention included to inspect the skin during care for bruising or increased bruising and to notify the nurse of abnormal findings. The June 2023 Physician's Order Summary (POS) indicated an order for Eliquis (anticoagulant) 2.5 mg (milligrams) twice a day for atrial fibrillation. There was no documentation to indicate the discolorations had been assessed or monitored. There was no documentation to indicate why the bandage was on the resident's elbow or any treatment orders in place for the bandage. Interview with the Director of Nursing (DON) on 6/15/23 at 12:58 p.m., indicated the wound nurse was unaware of the resident's bandage on his elbow. She couldn't provide any documentation related to the assessment, monitoring, or treatment orders for the discolorations or the bandage. Based on observation, record review, and interview, the facility failed to ensure skin discolorations were assessed and monitored, a treatment order for a bandage was in place, and a treatment was in place for dry and flaky legs for 3 of 7 residents reviewed for non-pressure skin conditions. (Residents H, 5 and D) Findings include: 1. On 6/12/23 at 11:33 a.m., Resident H was observed lying in her bed. There was a dark purplish discoloration on her left forearm and left thigh. The resident indicated she did not know what happened to the areas. On 6/13/23 at 10:09 a.m., the resident was again observed in bed and the discoloration to her left forearm and left thigh were visible. The record for Resident H was reviewed on 6/15/23 at 9:09 a.m. Diagnoses included, but were not limited to cellulitis, dementia and neoplasm of the brain. The admission Minimum Data Set (MDS) assessment, dated 5/26/23, indicated the resident had moderate cognitive deficits and required total 2 staff assistance for bed mobility and transfers. A Medication Care Plan indicated the resident was at increased risk of bruising and bleeding related to antiplatelet and aspirin use. Interventions included to observe for abnormal signs of bleeding such as increased frequency of bruising and increased size of bruising. Document findings and notify the Physician. There was no documentation or monitoring of the discolorations in the resident's record. On 6/15/23 at 10:20 a.m., the Executive Director was made aware there was no documentation or monitoring of the discolorations. There was no additional information provided.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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Based on observation, record review and interview, the facility failed to ensure a resident's positioning was maintained related to a hand splint not applied as ordered for 1 of 2 residents reviewed for positioning/ mobility. (Resident 74) Finding includes: On 6/12/23 at 10:12 a.m., Resident 74 was observed in bed, there was no hand splint on her right hand. She was again observed in her room on 6/12/23 at 11:16 a.m., 6/14/23 at 9:25 a.m., 6/15/23 at 8:50 a.m., and 11:12 a.m., 6/16/23 at 9:41 a.m. and 10:21 a.m., with no hand splint on her right hand. The resident's record was reviewed on 6/16/23 at 10:08 a.m. Diagnoses included, but were not limited to, chronic pain syndrome and hypertension. A Quarterly Minimum Data Set assessment, dated 4/4/23, indicated the resident was cognitively intact and required extensive assistance of two staff for bed mobility and transfers. A Physician's Order, dated 1/13/23, indicated to wear a splint to the right hand at all times, to be removed for skin checks each shift. The June 2023 Medication Administration Record indicated the right hand splint was applied every shift, every day in June. There was no documentation to indicate the resident refused or removed the splint. Interview with the resident on 6/16/23 at 10:21 a.m., indicated sometimes the staff would put the splint on and sometimes they wouldn't. She indicated she did not know where the splint was currently. Interview with Executive Director on 6/16/23 at 11:40 a.m., indicated the resident would sometimes remove the splint and she would look into the concern. There was no additional information provided. 3.1-42(a)(2)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and interview, the facility failed to provide supervision and follow protocols related to random observations of residents transferred by a Hoyer lift (suspension lift to reposition and transfer into a chair or bed) for 2 of 2 Hoyer transfers observed. (Residents B and 151) Findings include: 1. During a random observation on 6/14/23 at 9:30 a.m., CNA 2 was observed in Resident's B's room to transfer him from his bed to his wheelchair via a Hoyer lift. CNA 2 was the only staff member in the room completing the transfer. On 6/14/23 at 9:42 a.m., CNA 2 left the resident's room and the resident was sitting in his wheelchair. Record review for Resident B was completed on 6/13/23 at 2:00 p.m. Diagnoses included, but were not limited to, stroke, hemiplegia, end stage renal disease, and respiratory failure. The admission Minimum Data Set (MDS) assessment, dated 4/17/23, indicated the resident was cognitively impaired. The resident required a total 2+ person assist for transfers. The resident had an impairment on one side of his upper and lower extremities for a functional limitation in range of motion. A Care Plan, dated 4/21/23, indicated the resident needed assistance with activities of daily living. An intervention included the resident required a total assistance of 2 staff for transfers. 2. During a random observation on 6/14/23 at 9:54 a.m., CNA 2 was observed getting Resident 151 out of bed via a Hoyer lift. CNA 2 was the only staff member in the room completing the transfer. On 6/14/23 at 9:59 a.m., CNA 2 left Resident 151's room. The resident was sitting in his wheelchair. Record Review for Resident 151 was completed on 6/14/23 at 9:50 a.m. Diagnoses included, but were not limited to, stroke, hemiplegia, and dementia. The Annual MDS assessment, dated 5/12/23, indicated the resident was cognitively impaired. The resident required an extensive 2+ assist for transfers. The resident had an impairment on one side of his upper and lower extremities for functional limitation in range of motion. A Care Plan, dated 4/6/23 and revised 5/15/23, indicated the resident needed assistance with activities of daily living. An intervention included the resident required an extensive 2 staff assistance with transfers. Interview with CNA 2 on 6/14/23 at 9:59 a.m., indicated she had gotten both Resident B and Resident 151 out of bed and into their wheelchairs by herself via the Hoyer lift. There were 2 aides and 1 nurse working the hall that day. She indicated normally there was only 1 aide that worked the hall, so she was use to getting residents up by herself. She didn't ask the other aide or the nurse for help. Interview with the DON (Director of Nursing) on 6/14/23 at 10:07 a.m., indicated the staff are supposed to use 2 staff members when they transfer residents via a Hoyer lift. The CNA should have asked for assistance before transferring the residents by herself with the Hoyer lift. A policy titled, Safe Resident Handling/Transfer and received as current from the facility on 6/14/23, indicated, .10. Two staff members must be utilized when transferring residents with a mechanical lift . 3.1-45(a)(2)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and interview, the facility failed to ensure a resident with a urinary tract infection (UTI) received the necessary treatment and services related to completing an ordered laboratory test timely for 1 of 2 residents reviewed for urinary tract infections. (Resident K) Finding includes: On 6/12/23 from 2:23 p.m. through 2:36 p.m., Resident K was observed lying in her bed. The resident was repetitively yelling out I need help. Where am I going to go? Somebody help me. Where will I go? The Unit Manager entered the room and spoke to the resident. Upon exiting the room, the resident again began repetitively yelling out. The record for Resident K was reviewed on 6/16/23 at 9:21 a.m. Diagnoses included, but were not limited to, Alzheimer's Disease, hypertension, and atrial fibrillation. A Psych Services Progress Note, dated 6/1/23, indicated the resident was experiencing worsening behaviors and anxiety. A medication change was made, and a urinalysis (UA, urine test) was ordered. A Progress Note, dated 6/2/23, indicated the urine sample was obtained and placed in the refrigerator for pick up. A Progress Note, dated 6/3/23, indicated the urine sample was available for lab pickup. A Progress Note, dated 6/5/23 at 1:32 p.m., indicated the urine sample that was collected on 6/2/23 had not been picked up by the lab until 6/5/23. The lab was unable to use the specimen because it was too old. A Progress Note, dated 6/5/23 at 2:22 p.m., indicated a new urine sample was obtained and placed in the refrigerator for pick up. A Progress Note, dated 6/6/23 at 2:17 p.m., indicated the UA results had been received and sent to the Physician. A urine culture, dated 6/6/23, indicated the urine was positive for > (greater than) 100,000 Escherichia coli and >100,000 proteus mirabilis (bacteria). A Nurse Practitioner Note, dated 6/9/23, indicated she had seen the resident today for an abnormal urinalysis. The urine culture was positive for E. coli (Escherichia coli, a bacteria), the resident was diagnosed with a UTI and started on Macrobid (an antibiotic) 100 mg (milligrams) twice a day for 7 days. Interview with the Director of Nursing (DON) on 6/16/23 at 11:33 a.m., indicated the UA had been ordered for a Friday, 6/2/23. Lab services did not regularly pick up on weekends, so the sample wasn't picked up until Monday 6/5/23. By then, the sample was too old and a new sample was collected the same day. No antibiotics were started until 6/9/23 because the Physician was waiting for the urine culture to be complete. She indicated she would need to come up with a better process for labs that were ordered on the weekend. This Federal tag relates to Complaint IN00408785. 3.1-41(a)(2)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and interview, the facility failed to provide proper respiratory care and services related to not changing nebulizer (machine that turns liquid medications into a mist to be inhaled) masks timely and not completing nebulizer treatment assessments as ordered for 1 of 3 residents reviewed for oxygen. (Resident B) Finding includes: On 6/12/23 at 10:33 a.m., a nebulizer mask was observed in a bag laying on Resident B's bed. The mask was dated 5/27. On 6/13/23 at 10:24 a.m., Resident B was observed lying in bed. A nebulizer mask was in a bag on the resident's wheelchair. The mask was dated 5/27. Record review for Resident B was completed on 6/13/23 at 2:00 p.m. Diagnoses included, but were not limited to, stroke, hemiplegia, end stage renal disease, and respiratory failure. The admission Minimum Data Set (MDS) assessment, dated 4/17/23, indicated the resident was cognitively impaired. The resident had received oxygen therapy. A Care Plan, dated 4/21/23, indicated the resident was at risk for respiratory distress related to respiratory failure. An intervention included for vital signs and oxygen saturation as ordered and as indicated. The June 2023 Physician's Order Summary (POS) indicated orders for the following: - albuterol sulfate (used to prevent and treat wheezing and shortness of breath caused by breathing problems) inhalation nebulizer solution; 3 ml (milliliters) inhaled via nebulizer two times a day - document the pulse, respiratory rate, breath sounds, oxygen saturation and minutes before and after nebulizer treatments - change nebulizer tubing weekly The June 2023 Medication Administration Record (MAR) had the order to document the pulse, respiratory rate, breath sounds, oxygen saturation and minutes before the nebulizer treatments. The MAR had check marks it was completed but there was no documentation of the vital sign results. Interview with the Director of Nursing (DON) on 6/13/23 at 2:10 p.m., indicated the nebulizer masks were supposed to be changed weekly. Interview with the DON on 6/15/23 at 12:58 p.m., indicated the nebulizer assessment order was not put in correctly. The MAR should have had values for the vital signs instead of only check marks when it was completed. This Federal tag relates to Complaint IN00408169. 3.1-47(a)(6)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure residents were free from unnecessary psychoactive medications related to administration of an anti-anxiety medication as ordered and antipsychotic medication use for 1 of 5 residents reviewed for unnecessary medications and 1 of 2 residents reviewed for behavior/ emotional care. (Residents D and K) Findings include: 1. The record for Resident D was reviewed on 6/14/22 at 2:54 p.m. Diagnoses included, but were not limited to, Parkinson's Disease, dementia with behavioral disturbance, and major depressive disorder. The resident was admitted to the facility on [DATE]. The Quarterly MDS (Minimum Data Set) assessment, dated 4/21/23, indicated the resident had not had any behaviors. She received antipsychotic and antidepressant medications. A Progress Note, dated 1/20/23, indicated the resident's family was requesting she be started on Abilify (aripiprazole, an antipsychotic medication) as she would have hallucinations without the medication. The Physician was notified of the family's request. A Psych Services Progress Note, dated 1/23/23, indicated there was no reported new or worsening psychiatric behaviors, no reports of delusions, hallucinations, or paranoia. They spoke with the resident's daughter regarding the resident's medications. She indicated the resident had received medication for hallucinations where she had previously resided, and they had discontinued her Abilify abruptly without tapering. Psych Services explained they would prescribe a different medication for the hallucinations. The resident's daughter was in agreement and Nuplazid (an antipsychotic medication) 34 mg (milligrams) daily was ordered. An IDT (interdisciplinary team) Note, dated 1/25/23, indicated the Physician in house would review the resident. The resident was started on a new medication and the Physician and family were in agreement with the plan of care. A Physician's Order, dated 1/25/23, indicated an order for Abilify 10 mg at bedtime. The 6/2023 Medication Administration Record (MAR), indicated the resident had received the Abilify medication as ordered. A Psych Services Progress Note, dated 6/8/23, indicated the Abilify had previously been reduced and discontinued at a previous facility. The medication had been resumed by the POA (power of attorney, responsible party) and the PCP (primary care provider). There was lack of any documented hallucinations or behaviors for January 2023. There was lack of documentation from the Physician of the clinical reasoning as to why the Abilify had been started on 1/25/23. Interview with the Director of Nursing (DON) on 6/15/23 at 1:48 p.m., indicated the resident's family had indicated the resident was on Abilify for years at her previous facility and then it was abruptly discontinued. They requested the Physician restart it and he had. She was unable to provide any further documentation of any behaviors, or any progress note from the Physician. 2. On 6/12/23 from 2:23 p.m. through 2:36 p.m., Resident K was observed lying in her bed. The resident was repetitively yelling out I need help. Where am I going to go? Somebody help me. Where will I go? The Unit Manager entered the room and spoke to the resident. Upon exiting the room, the resident again began repetitively yelling out. The record for Resident K was reviewed on 6/16/23 at 9:21 a.m. Diagnoses included, but were not limited to, Alzheimer's Disease, hypertension, and atrial fibrillation. A Psych Services Progress Note, dated 6/1/23, indicated the resident was experiencing worsening behaviors and anxiety. Xanax (an anti-anxiety medication) 0.25 milligrams (mg) twice daily was discontinued and clonazepam (an anti-anxiety medication) 0.25 mg twice a day for 14 days was started. A Physician's Order, dated 6/1/23, indicated clonazepam 0.25 mg twice daily for 14 days. The MAR, dated 6/2023, indicated the resident had not received the clonazepam medication as ordered on the following dates and times: - 6/2/23 6:00 a.m. - 6/3/23 6:00 a.m. Dosage different than entry. Clarification needed from pharmacy. - 6/3/23 6:00 p.m. Awaiting med (medication) from pharmacy. - 6/4/23 6:00 a.m. - 6/4/23 6:00 p.m. Med (medication) not available. - 6/5/23 6:00 p.m. Medicine did not arrive from pharmacy. - 6/6/23 6:00 a.m. A Psych Services Progress Note, dated 6/8/23, indicated .Spoke with nursing staff regarding behaviors since medication change. Reported the new medication was started late due to issues with delivery from the pharmacy. Therefore, the resident has been having the same yelling and screaming episodes . Interview with the DON on 6/16/23 at 11:33 a.m., indicated the resident had not received the clonazepam as ordered. She was unsure why the medication had not arrived from the pharmacy timely. 3.1-48(a)(6)

CONCERN (E) 📢 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 F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

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Based on observation, record review and interview, the facility failed to ensure there was adequate nursing staff available to meet the residents' needs related to receiving scheduled showers for 1 of 9 units reviewed for staffing. (Unit 3A) Finding includes: On 6/14/23, the 3A unit was observed continuously from 10:15 to 11:40 a.m. The was one QMA and one CNA on the unit. There were 24 residents on the unit. There was no additional staff on the unit. The shower book indicated there were four residents scheduled to receive a shower that day on day shift. Interview with QMA 1 on 6/14/23 at 2:00 p.m., indicated there was only one CNA that day. There were sometimes two CNAs, or a split that would work two units. She indicated they would offer residents bed baths instead of showers when they were short staffed. Interview with CNA 1 on 5/14/23 at 2:25 p.m., indicated she was only able to give one of the four scheduled residents a shower that day. When working alone it was impossible to give all four showers during a shift. Interview with the Executive Director and the Administrator on 6/15/23 at 10:14 a.m., indicated when there was a call off or staffing shortage, the clinical supervisors should assist. They would look into the staffing on 3A the previous day. There was no additional information provided. This Federal tag relates to Complaints IN00408785 and IN00410203. 3.1-17(b)

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications were labeled correctly related to eye drops, nasal sprays, and insulin with no labels and insulin in use that was expired for 3 of 5 medication carts observed. (3D, 2D, and 1A Medication Carts) Findings include: 1. On [DATE] at 10:26 a.m., the 3D Medication Cart was observed with QMA 3. Resident 149's insulin glargine 100 unit/milliter (mL) vial was labeled with an expiration date of [DATE]. QMA 3 indicated the resident was still receiving the medication nightly and the medication should have been disposed of on [DATE]. 2. On [DATE] at 2:05 p.m., the 2D Medication Cart was observed with LPN 1. The following medications were found in the cart: a. There was Aller-flo nasal spray, Refresh Tears, Combigan (eye drops), and a Novolog insulin vial opened on [DATE] in a drawer with no label. b. Resident 153's had two vials of Lantus insulin 100 unit/mL vial that were opened on [DATE] and [DATE]. She had a Humalog 100 unit/mL vial that was opened on [DATE]. c. Resident 21's Humalog insulin vial was opened on [DATE]. d. Resident 118's Humalog insulin vial was opened on [DATE]. LPN 1 indicated each bottle should have an appropriate label with the name of medication, name of resident, and instructions for use. The insulin vials were only good for 28 days after opening so they should have been disposed of prior to [DATE]. 3. On [DATE] at 3:35 p.m., the 1A Medication Cart was observed with QMA 4. An unlabeled vial of insulin lispro 100 unit/mL was observed with an opened date of [DATE]. QMA 4 indicated the medication was expired 28 days after opening. Interview with the Director of Nursing on [DATE] at 2:01 p.m., indicated the insulin medications should have been disposed of after 28 days or the manufacturer's recommendations and all medications should have had appropriate labels in the medication carts. 3.1-25(j) 3.1-25(o)

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation and interview, the facility failed to follow proper sanitation and food handling practices related to the high temperature dish machine not reaching appropriate rinse temperature and use of expired sanitizer test strips for 1 of 1 kitchens. This had the potential to affect 170 residents who received food from the kitchen. (The Main Kitchen) Findings include: 1. On 6/14/23 at 9:40 a.m., the Dietary Food Manager (DFM) was observed wiping down a preparation counter with a sanitizer solution. At the time, a sanitizer test strip was used to test the solution. The test strips expired on 6/30/22. The strip did not have a readily discernable color change. The DFM brought another package of test strips to test the solution, which had expired on 3/1/22. The strip did not have a readily discernable color change. Interview with the DFM at the time indicated he would send someone out to purchase sanitizer test strips that were not expired. The Sanitation Bucket Log for the month of June 2023, received from the Executive Director on 6/15/23 at 3:51 p.m., indicated three buckets in the morning and three buckets in the evening were checked for correct sanitation levels. There were no sanitation levels written, only check marked that it was completed. The instructions indicated to hold the strip still in the water for 10 seconds and the correct sanitation level was between 150-400 parts per million (ppm). 2. On 6/14/23 at 9:46 a.m., the dishwasher machine was observed to be in use. The dishwasher was a high temperature dishwasher. The wash cycle reached 160 degrees Fahrenheit and the final rinse reached 160 degrees Fahrenheit. The U.S. Department of Health and Human Services, Public Health Services, Food and Drug Administration Food Code indicates the following standard for proper sanitation temperatures: High Temperature Dishwasher (heat sanitization): Wash - 150-165 degrees F; Final Rinse - 180 degrees F; Interview with the DFM at the time indicated the rinse cycle should reach 180 for final rinse for high temperature dishwasher and the temperature logs indicated the same parameters. He would have to shut down the dishwasher and have the service company assess and fix the machine. A follow-up interview on 6/15/23 at 3:45 p.m. with the DFM indicated the service company had assessed the dishwasher and the booster was not working properly, so they had to order a part to fix the problem. They would continue to use their other dishwasher in the meantime to sanitize dishware. 3.1-21(i)(3)

Apr 2023 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

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Based on observation, record review and interview, the facility failed to ensure a resident received necessary treatment and services related to incorrect wound treatments and heel protectors not applied as ordered for 1 of 3 residents reviewed for wound treatment. (Resident C) Finding includes: On 4/13/23 at 10:27 a.m., RN 1 was observed changing the dressings to Resident C's feet. After removal of the old dressings, the RN washed the wounds on the right lateral foot and left toes with wound wash and a sterile gauze. She asked the resident if he was having any pain. The resident indicated his heels hurt. The nurse indicated he needed some heel cushions. She then applied bacitracin (antibiotic) ointment to the wound on the right foot and the left toes, applied a sterile gauze over the areas, and then wrapped both feet in Kerlix gauze. The resident's heels were not offloaded from the mattress with a pillow nor was he wearing heel protectors, which were lying on the floor in the room. The resident's record was reviewed on 4/13/23 at 9:25 a.m. The diagnoses included, but were not limited to, hemiparesis and hemiplegia following a stroke and diabetes mellitus. A Quarterly Minimum Data Set assessment, dated 1/27/23, indicated a moderate cognitive impairment, required extensive staff assistance for bed mobility, and was dependant on staff for transfers A Physician's Order, dated 3/16/23, indicated the right foot wound was to be cleansed with wound wash, patted dry, and calcium alginate was to be applied to the wound bed. The area was to be covered with a border dressing daily. A Physician's Order, dated 4/11/23, indicated the left toes were to be cleansed with wound wash, bacitracin ointment was to be applied and the areas were to be covered with a dry dressing daily. A Physician's Order, dated 1/23/23, indicated heel protectors were to be applied as tolerated every shift. An interview with RN 1, on 4/13/23 at 9:25 a.m., indicated she had provided the incorrect treatment to the right foot and would redo the treatment. She also indicated she was not aware the heel protectors were there, but was going to check his heels again. This Federal tag relates to Complaint IN00401416. 3.1-37

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 F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to ensure a resident's pain medication was administered as ordered for 1 of 3 residents reviewed for pain. (Resident C) Finding includes: Resident C's record was reviewed on 4/13/23 at 9:25 a.m. Diagnoses included, but were not limited to, hemiparesis and hemiplegia following a stroke and diabetes mellitus. The Quarterly Minimum Data Set assessment, dated 1/27/23, indicated the resident had moderate cognitive impairment, required extensive staff assistance for bed mobility, was dependent on staff for transfers, and received scheduled and as needed pain medications. A Physician's Order, dated 12/16/22, indicated to give Norco (an opioid pain medication) 10/325 milligrams (mg) twice daily for chronic pain. A Physician's Order, dated 2/20/23, indicated to give Norco 10/325 mg every 24 hours as needed for breakthrough pain. A Physician's Order, dated 8/26/22, indicated to give Tylenol 650 mg every 4 hours as needed for mild pain. The February 2023 Medication Administration Record (MAR), indicated the resident had not received the scheduled dose of Norco on 2/6/23 in the morning and in the evening. The morning dose of the Norco had not been administered on 2/7/23. The March 2023 MAR indicated the resident had not received the scheduled Norco dose in the morning and evening on 3/3/23 and the morning dose of Norco had not been administered on 3/4/23. Electronic MAR notes,dated 2/6/23, indicated the Norco was not available. The notes dated 3/3/23 indicated the Norco had not been delivered by the Pharmacy. The note dated 3/4/23 indicated the Norco was on order. Interview with the Administrator, on 4/13/23, indicated she did not know why the Norco was not available and had no other additional information about the Norco. This Federal tag relates to Complaint IN00401416. 3.1-37(a)

Nov 2022 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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview, the facility failed to thoroughly assess pressure ulcers and failed to provide treatment to a pressure ulcer in a timely manner, for 2 of 3 residents reviewed for pressure ulcers. (Residents B and D) Findings include: 1. Resident B's closed record was reviewed on 11/2/22 at 9:16 a.m. The diagnoses included, but were not limited to, diabetes mellitus. An admission Minimum Data Set (MDS) assessment, dated 7/8/22, indicated an intact cognitive status, required minimal assistance with bed mobility and transfers, had one stage 2 (partial thickness of skin loss) and two unstageable (unable to determine the depth) pressure ulcers on admission into the facility. A Care plan, revised on 8/23/22, indicated there were pressure ulcers present. The interventions included wound treatment as ordered and the pressure ulcers were to be assessed and documented. A Nurse's Progress Note, dated 7/1/22 at 12:44 a.m., late entry date of 7/4/22, indicated an unstageable area on the right outer foot, which measured 2.0 cm (centimeters) by 1.0 cm., depth was unable to be obtained and Venelex ointment (a [NAME]/castor oil ointment) was to be used. A Physician's Order, dated 7/2/22 and discontinued on 9/6/22, indicated Venelex ointment was to be applied twice a day. There were no further assessments of the unstageable area on the right outer foot. A Nurse's Progress Note, dated 7/20/22 at 9:40 p.m., indicated an open area was found on the right heel. The area was cleaned and a dry dressing was applied A Nurse's Progress Note, dated 7/20/22 at 9:50 p.m., indicated the Physician was notified of the right heel open area and orders were obtained. A Physician's Order, dated 7/21/22, indicated to cleanse the right heel, then apply calcium alginate (wound treatment) and cover the area with a dressing every evening. There was no assessment that indicated the size, depth, and description of the pressure ulcer on the right heel when the heel was first observed. A Wound Nurse Practitioner's Progress Note, dated 7/27/22, indicated the pressure wounds on the sacrum, left elbow, and spine were assessed. there was no assessment of the right heel. There were no assessments of the right heel wound from 7/20/22 to 8/10/22. A Wound Nurse Practitioner's Progress Note, dated 8/10/22, indicated the right heel was a new area, and measured 4.25 cm by 4.96 cm, was 100% eschar or slough, was unstageable, and the pressure ulcer was to be cleansed daily with a betadine dressing. During an interview on 11/2/22 at 2:56 p.m. with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the DON acknowledged there were no follow up assessments for the right outer foot area and the right heel had not been thoroughly assessed. 2. During an observation with the DON on 11/2/22 at 9:42 a.m., Resident D was lying on a low air loss bed and his right leg was elevated on a pillow. The second and middle toes of the right foot had dark areas and there was an orange color of betadine noted on the areas. Resident D's record was reviewed on 11/3/22 at 12:38 p.m. The diagnoses included, but were not limited to, diabetes mellitus. An Annual MDS assessment, dated 9/5/22, indicated a moderately impaired cognitive status, required extensive assistance of two for bed mobility and was dependent on two for transfers. There was one stage 2 pressure area on and one unstageable area after admission. A Care Plan, dated 10/12/22, indicated an impaired skin integrity on the right middle toe. The interventions included the area was to be assessed, the skin condition documented, and the wound would be treated as ordered by the Physician. A Wound Nurse Practitioner's Progress Note, dated 10/12/22, indicated area on the right middle toe was new. The measurements were 0.71 cm by 0.78 cm. There was 0.13 cm of redness and 0.15 cm of black tissue. The treatment indicated skin prep (barrier) was to be applied twice a day. A Wound Nurse Practitioner's Progress Note, dated 10/18/22, indicated the area on the right middle toe was 1.70 cm by 1.22 cm. There was 0.79 cm of redness, 0.7 cm of black tissue, and 0.15 cm of yellow tissue. The depth could not be measured. A betadine treatment was to be completed three times a day. A Wound Nurse Practitioner's Progress Note, dated 10/25/22, indicated the area on the right middle toe was 2.37 cm by 1.46 cm. There was 1.14 cm of redness, 0.61 cm of black tissue, and 0.11 cm of yellow tissue. The depth could not be measured. The wound status was stable. The betadine treatment was to be completed three times a day. A Wound Nurse Practitioner's Progress Note, dated 11/1/22, indicated the area on the right middle toe was 2.37 cm by 1.46 cm. There was 1.14 cm of redness, 0.61 cm black tissue, and 0.11 cm of yellow tissue. The depth could not be measured. The wound was stable. The betadine treatment was to be completed three times a day. The Medication and Treatment Administration Records, dated 10/2022, indicated the treatment for the right middle toe had not been transcribed on the records and a treatment had not been completed from 10/12/22 through 10/31/22. The Medication and Treatment Administration Records, dated 11/2022, indicated the treatment was transcribed and initiated on 11/1/22. During an interview on 11/3/22 at 2:58 p.m. the DON indicated the first treatment for the middle toe was initiated on 11/1/22. A facility pressure ulcer policy, dated 4/2018 and received from the Executive Director as current, indicated the Nurse was to describe and document a full assessment of a pressure sore, which included, the location, stage, length, width, depth, the presence of drainage or necrotic tissue. The Physician would order the wound treatments and dressings. During resident visits, the Physician was to evaluate and document the progress of the wound healing. This Federal tag relates to Complaint IN00393386. 3.1-40(a)(2)

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

"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
• No fines on record. Clean compliance history, better than most Indiana facilities.

Concerns

• 50 deficiencies on record. Higher than average. Multiple issues found across inspections.
• Grade D (40/100). Below average facility with significant concerns.

Bottom line: Trust Score of 40/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Saint Anthony's CMS Rating?

CMS assigns SAINT ANTHONY an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Indiana, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Saint Anthony Staffed?

CMS rates SAINT ANTHONY's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 51%, compared to the Indiana average of 46%.

What Have Inspectors Found at Saint Anthony?

State health inspectors documented 50 deficiencies at SAINT ANTHONY during 2022 to 2025. These included: 49 with potential for harm and 1 minor or isolated issues.

Who Owns and Operates Saint Anthony?

SAINT ANTHONY 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 MAJESTIC CARE, a chain that manages multiple nursing homes. With 189 certified beds and approximately 172 residents (about 91% occupancy), it is a mid-sized facility located in CROWN POINT, Indiana.

How Does Saint Anthony Compare to Other Indiana Nursing Homes?

Compared to the 100 nursing homes in Indiana, SAINT ANTHONY's overall rating (1 stars) is below the state average of 3.1, staff turnover (51%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Saint Anthony?

Based on this facility's data, families visiting should ask: "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?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.

Is Saint Anthony Safe?

Based on CMS inspection data, SAINT ANTHONY has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Indiana. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Saint Anthony Stick Around?

SAINT ANTHONY has a staff turnover rate of 51%, which is about average for Indiana nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Saint Anthony Ever Fined?

SAINT ANTHONY has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Saint Anthony on Any Federal Watch List?

SAINT ANTHONY 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.

Facility Details

Beds: 189
Avg. Residents: 172
Occupancy: 91.2%
Ownership: For profit - Corporation
Chain: MAJESTIC CARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
50 Deficiencies: -10
Final Score: 40/100

Nearby Alternatives

LOWELL HEALTHCARE 4-star REHABILITATION CENTER AT HARTS... 3-star CEDAR CREEK HEALTH CAMPUS 3-star

View all in CROWN POINT →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 155214