CARDINAL NURSING AND REHABILITATION CENTER
For profit - Corporation
144 Beds
AMERICAN SENIOR COMMUNITIES
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
66/100
#20 of 505 in IN
Photo by Cardinal Nursing and Rehabilitation
Photo by Cardinal Nursing and Rehabilitation
Photo by Cardinal Nursing and Rehabilitation
1 / 10 photos
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Cardinal Nursing and Rehabilitation Center has a Trust Grade of C+, which indicates it is slightly above average in quality but not exceptional. It ranks #20 out of 505 facilities in Indiana, placing it in the top half, and #1 out of 18 in St. Joseph County, meaning it is the best option locally. The facility's trend is improving, having reduced its issues from two in 2024 to none in 2025, although it still reported a concerning $12,649 in fines, which is higher than 82% of Indiana facilities. Staffing is average with a turnover rate of 36%, which is lower than the state average, and it has more RN coverage than many others, suggesting a good level of care. However, there are serious concerns as a Qualified Medication Aide was observed pushing a resident to the ground, resulting in fractures, and the facility failed to ensure proper pain management for that resident. Additionally, food safety practices have been noted as inadequate, with items not being properly labeled or sealed, posing potential risks to residents.
- Trust Score
- C+
- In Indiana
- #20/505
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 36% turnover. Near Indiana's 48% average. Typical for the industry.
- Penalties ✓ Good
- $12,649 in fines. Lower than most Indiana facilities. Relatively clean record.
- Skilled Nurses ○ Average
- Each resident gets 41 minutes of Registered Nurse (RN) attention daily — about average for Indiana. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 19 deficiencies on record. Higher than average. Multiple issues found across inspections.
66/100
Top 3%
Review needed
2 → 0 violations
★★★★★
5.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★★
5.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 2 issues
2025: 0 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (36%)
12 points below Indiana average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
Staff Turnover: 36%
10pts below Indiana avg (46%)
Typical for the industry
Federal Fines: $12,649
Below median ($33,413)
Minor penalties assessed
Chain: AMERICAN SENIOR COMMUNITIES
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 19 deficiencies on record
1 life-threatening 1 actual harm
Jun 2024
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation and interview the facility failed to store and prepare food in a sanitary manner in 1 of 1 kitchens and 1 of 2 nourishment pantries. This deficient practice had the potential to a...
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Based on observation and interview the facility failed to store and prepare food in a sanitary manner in 1 of 1 kitchens and 1 of 2 nourishment pantries. This deficient practice had the potential to affect 58 residents who food from the kitchen and/or pantry.
Finding includes:
During a tour of the kitchen with [NAME] 2 on 6/9/24 at 9:02 A.M., the following was observed:
-Uncovered coffee filters were stored on the lower shelf of a table right next to a trash can for the hand washing sink.
-Dead bugs and dirt were noted in the light fixtures in the dry storage area and in the food prep areas of the kitchen.
-Metal wire racks in the dry storage area were dusty and had rust and grime on them.
-A fan and filter in the walk-in refrigerator were black with dust and dirt.
-The knife storage rack was grimy and dusty.
-Walls in the food preparation area were dirty with a build up of brown and black grime.
During an interview on 6/11/24 at 9:17 A.M., the Dietary Supervisor indicated maintenance was working on replacing the light fixtures covers. She agreed the walls and the knife storage unit were dirty and should be cleaned.
During an interview on 6/11/24 at 2:25 P.M., the Executive Director (ED_she indicated the facility did not have a policy regarding kitchen sanitation and cleaning of the kitchen but she did provide a copy of the cleaning schedule.
During an observation of the 1st floor nutrition pantry with the Dietary Supervisor on 6/13/24 at 9:13 A.M., there was an employee's purse on the counter. The Dietary Supervisor indicated the purse should not be stored in the nutrition pantry.
During an interview on 6/13/24 at 10:56 A.M., the ED indicated they did not have a policy that specifically covered the nutrition kitchen pantry
3.1-21(i)(1)(3)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to maintain the cleanliness of resident's personal refrigerators, for 2 of 3 personal refrigerators that were observed. (Residen...
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Based on observation, interview, and record review, the facility failed to maintain the cleanliness of resident's personal refrigerators, for 2 of 3 personal refrigerators that were observed. (Resident 42 & 24)
Findings include:
1. An observation of Resident 42's refrigerator was completed on 6/10/2024 at 9:13 A.M and on 6/11/2024 at 11: 16 A.M. with the Director of Nursing (DON). The following was observed:
- 7 undated peanut butter and jelly sandwiches without expiration dates
- A dark brown, sticky solution covering the bottom of the refrigerator
- A heavy amount of ice build-up on freezer compartment
During an interview on 6/10/2024 at 9:14 A.M., Resident 42 indicated he used his refrigerator for snacks and drinks.
2. An observation of Resident 24's refrigerator was completed on 6/10/2024 at 10:30 A.M and on 6/11/2024 at 11: 16 A.M. with the DON. The following was observed:
- A foul odor was detected when the refrigerator door was opened
- A small, clear container labeled ground turkey and with an expiration date of 6/4/2024
- 2 opened diet cokes without opened dates
- A thick red substance was inside on the bottom, sides, and condiment holder
- Food crumbs throughout the inside of refrigerator and along the seal of the door.
- A large amount of ice build up on freezer
During an interview with the DON on 6/11/2024 at 11:18 A.M, she indicated there should not be expired food in resident's personal refrigerators and all refrigerators should be clean and maintained without an ice buildup.
During an interview on 6/12/2024 at 2:54 P.M., the Housekeeping Supervisor indicated housekeeping was responsible for cleaning personal refrigerators in residential rooms.
On 6/11/2024 at 12:52 P.M., the ED (Executive Director) provided a policy, dated 7/2015, titled, Cleaning Refrigerators. The ED identified it as the policy currently used by the facility. The policy indicated, .The refrigerators will be kept clean. Spills and leaks will be wiped up . 2. Remove shelves, drawers and other removable parts. Clean and sanitize. 3. Wash walls and base with warm detergent
3.1-19(f)
Dec 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 1 of 3 residents reviewed for resident rights ...
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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 1 of 3 residents reviewed for resident rights and dignity, were treated in a manner that respected the resident's dignity, when the resident was photographed without permission by a facility employee (Resident B).
Findings include:
On 12/12/23 at 12:30 P.M., Resident B was observed in her room sitting in a wheelchair near the bed. The resident was well groomed and in appropriate casual wear. During an interview at that time, Resident B, stood from the wheelchair and transferred herself to her bed without difficulty. The resident indicated that she and Employee 2 had become close friends and that she felt like a granddaughter to her. She indicated sometime in June or July of 2023; she sent a text to Employee 2 requesting that she bring a bag of popcorn to her room from a facility activity. Resident B indicated she fell asleep in her room before Employee 2 delivered the popcorn and that she later sent her a text that showed Resident B sleeping in her bed wearing a night shirt. The resident indicated she was uncovered in the picture and that her legs and upper thighs were exposed. Resident B indicated she did not like the way she looked in the picture and that she did not think the employee should have taken her picture without permission even though they were friends.Resident B indicated she reported the incident to the local Ombudsman around 11/25/23 and gave the Ombudsman permission to notify the facility on 12/4/23. When asked why she did not report the incident to the State Agency, facility Administrator, or Ombudsman earlier, she indicated she didn't know, that the picture did not cause distress, but she didn't like the way she looked in the picture and did not feel Employee 2 should have taken her picture.
12/12/23 at 2:25 P.M., during an interview with the Executive Director, she indicated on 12/04/23 at 1:01 P.M., she was notified by the local Ombudsman that Resident B reported that Employee 2 took a photo of her while she was sleeping in her bed in her room, and without her permission. The Executive Director indicated she immediately notified the State Agency, local police department, Medical Director, began an investigation, and suspended Employee 2 pending an investigation. The Executive Director indicated it was against facility policy for employees to photograph residents without the residents' permission.
On 12/13/23 at 10:30 A.M., Resident B's clinical record was reviewed. Resident B was admitted to the facility on [DATE]. The resident's most resent Minimum Data Set (MDS) was a quarterly assessment, dated 9/26/23. The MDS indicated the resident was cognitively intact, with current diagnosis that included diabetes, hypertension, anemia, and depression. Resident B required limited assistance for transfers, dressing, and personal hygiene.
On 12/13/23 at 11:00 A.M., the Executive Director provided Incident #1189. The report indicated on 12/4/23 at 1:01 P.M., the Executive Director was, . made aware that in June 2023, a staff member took a picture of Resident B without her consent .12/4/23 Employee was immediately suspended pending further investigation .12/9/23 Investigation completed .Appropriate disciplinary action rendered to the staff member [Employee 2]
On 12/12/23 at 2:46 P.M., the Executive Director provided the current facility policy titled, Resident Rights, dated 7/23. The policy indicated, .All staff members recognize the rights of residents at all times .to enable personal dignity, well being
On 12/13/23 at 11:49 A.M., the Executive Director provided an undated document titled,Policy Reminder: Mandatory In-Service ALL LOCATIONS Resident's Rights, Privacy, Photographs, Cell Phone Usage and Investigation Cooperation .Resident Rights Except for photographs or recordings taken with advance written consent of an alert and oriented resident, and as obtained only by the Executive Director (ED) .photographing residents at anytime is a violation of resident's rights and privacy .Residents have rights designed to ensure dignity and self-respect .
This concern relates to complaint IN00423238.
3.1-3(a)(u)(3)
Nov 2023
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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to notify the attending physician for a change in condition for 1 of 1...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to notify the attending physician for a change in condition for 1 of 1 resident reviewed for change in condition. (Resident B)
Findings include:
During a record review, conducted 11/7/2023 at 10:12 A.M., the 5- day admission Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had an intact cognition. She was independent for mobility and self-care. Active diagnoses included but were not limited to: chronic obstructive pulmonary disease, anxiety, atrial fibrillation, and cardiac pacemaker. She used oxygen as needed. She took a daily anticoagulant.
Physician orders included, but were not limited to:
-10/24/2023 Oxygen at l liter per nasal cannula as needed
-10/23/2023 Cardizem 180 milligrams (mg) oral once a day
-10/20/2023 Eliquis 2.5 mg oral twice a day
A care plan problem, dated 10/24/2023, included, but was not limited to: resident is at risk for alteration in cardiac function related to pacemaker. The goal was for the resident to be free from signs of malfunction. Interventions included, but were not limited to, medications as ordered and observe for symptoms of weakness, shortness of breath, cyanosis, and dizziness.
A progress note by RN 2, dated 11/5/2023 at 9:47 P.M., included, but was not limited to: resident complaining her heart is going fast. Pulse 112 B/P- 140/68. Resident has had all her scheduled medication at this point. Refused NTG (nitroglycerin) since she denies chest pain. States I don't have anxiety, but clearly trembling. Refused transport to hospital.
An investigation interview done by the DON with RN 2, on 11/06/2023 at 12:54 P.M., included, but was not limited to: the resident came to the nurses desk to report that her heart was racing. The RN offered the resident a chair to sit and did an assessment consisting of a biox, pulse, and respirations. The RN offered the resident a nitroglycerin tablet but the res refused. The RN also offered to call for an ambulance but the resident refused. The RN then went to care for another resident's IV and a CNA reported to the RN that the res had sat herself on the floor. The resident then ambulated independently back to her room and offered no other complaints.
During an interview with Resident B, on 11/8/2023 at 10:37 A.M., she indicated she walked down to the nurses desk and asked the nurse if she could take her pulse and BP. The nurse did not take her BP or pulse and told her she would be fine its just anxiety. The resident sat down on the floor and the nurse continued to say that it was her anxiety. Then the nurse got up and went down the hall and punched in the code to go on break. Resident continued to sit on the floor for about 45 minutes. After time passed and she felt better she got up without assist and went back to her room. She maintains that the nurse did not do any assessment other than the checking her oxygen level. The nurse did not offer to call an ambulance or her physician. Another resident, that was sitting in the hall during this occurrence, told her she should go to the hospital, but she declined.
During a phone interview with RN 2, on 11/9/2023 at 9:35 A.M., she indicated the resident said her heart was beating fast. She went into nurse mode, took vitals, Biox (oxygen level) was 99% but admitted she didn't put it in the note She checked recent meds and what she had that might be effective. Offered an as needed dose of nitroglycerin but the resident stated she was not having chest pain and refused it. Resident B was alert and oriented. Someone else asked Resident B if she wanted to go to the hospital and she denied wanting to go to the hospital. Vitals included pulse, blood pressure (BP) using a manual BP cuff. The resident was sitting in her rollater in front of the nurses station and she was unsure when the resident ended up sitting on the floor. RN 2 indicated that the resident got herself up off of the floor independently. She denied filling out an event or observation form. The RN indicated that she did take the BP contrary to what the resident said. The resident was trembling and seemed anxious but denied feeling anxious. She hesitated to notify the physician. The RN did not take an apical pulse but did a radial and the Biox. It seemed that the resident sitting on the floor was an anxiety type of thing. The RN did not look at all of her diagnoses and so she could not say that it was a change in condition as she did not know the resident well. At the time I thought I was making the correct decision. She did not show any indication that she was having chest pain or an acute cardiac event and did not state she was having chest pain. Offered the nitroglycerin because that was the only cardiac as needed medication ordered and that is when she denied the chest pain.
She indicated if there was a resident with any complaint her process would be as follows: I would check the medications to see if there was something to offer, and look at their diagnoses. She would look at their code status. Based on her assessment and if the resident was in pain, she would ask if they wanted to go to the hospital, or anything life threatening especially if they were a full code, she would call the physician.
During an interview with DON on 11/9/2023 at 9:54 A.M. indicated if she was the nurse, she would have called the on call provider.
A current policy provided by the DON on 11/8/2023 at 2:10 P.M., titled, Resident Change of Condition Policy and revised on 11/2018, included, but was not limited to: .It is the policy of this facility that all changes in resident condition will be communicated to the physician
This concern relates to complaint IN00421418.
3.1-5(a)(2)
Jun 2023
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
On 6/14/2023 at 10:47 A.M., the Director of Nursing provided a policy titled, Advanced Directives, revised 2/2023, and indicated the policy was the one currently used by the facility. The policy indic...
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On 6/14/2023 at 10:47 A.M., the Director of Nursing provided a policy titled, Advanced Directives, revised 2/2023, and indicated the policy was the one currently used by the facility. The policy indicated .if a resident has a valid Advanced Directive, the facility's care will reflect the resident's wishes as expressed in the Directive, in accordance with state law .Information about any Advanced Directives already in place will be gathered as part of the admission process. Executed Advanced Directives will be documented in the medical record. Advanced Directives which reflect medical care and treatment will be documented in a physician's order .Advanced Directives will be reviewed quarterly during care plan conference and as needed upon change in condition The POST (physician's orders for scope of treatment) is a physician's order based on resident's individual goals and treatments for medical treatment .the POST will be reviewed by the facility interdisciplinary team during the quarterly care planning conference, anytime there is a significant change in the resident's condition and at anytime the resident or legally recognized health care decision maker requests it .at any time, a resident or legally recognized health care decision making can revoke the POST form or change his/her mind about treatment preferences by verbalizing or given a written advance directive, or after consultation with physician or advanced practice nurse, a new POST form .All discussions about revising or revoking the POST form should be documented in the resident's medical record
3.1-4(5)
Based on observation, interview and record review, the facility failed to ensure the signed advance directive was updated in the plan of care and physician order for 1 of 25 residents reviewed for advanced directives. (Resident 20)
Finding includes:
A record review was completed on 6/14/2023 at 2:40 P.M. Diagnoses included, but were not limited to: cerebral infarction and hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side.
A Physician Orders For Scope of Treatment (POST), dated 5/12/2023, indicated do not attempt resuscitation.
A Physician Order, dated 4/5/2022, indicated full code.
A Care Plan, dated 2/19/2020, indicated resident/legal representative prefers a full code status.
During an interview on 6/14/2023 at 10:30 A.M., the Director of Nursing indicated they obtain a code status upon admission, readmission, and revisit during a quarterly care conference. The resient was a do not resuscitate and the order and care plan should have been updated when it was changed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a notification of change in Medicare covered services was pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a notification of change in Medicare covered services was provided for 1 of 3 residents reviewed for Medicare services. (Resident 64)
Finding includes:
The clinical record for Resident 64 was reviewed on 6/14/2023 at 11:00 A.M. Resident 64 was admitted to the facility on [DATE] and was receiving Medicare Part A Services. Review of the record indicated the resident's last covered Medicare Part A services day was 2/16/2023.
The clinical record for Resident 64, reviewed on 6/13/2023 at 1:17 P.M., indicated the resident was admitted to the facility on [DATE] with diagnoses included, but not limited to: hemiparesis and hemiplegia related to subarachnoid hemorrhage, diabetes mellitus, depression, and dysphagia. The resident was receiving Medicare Part A skilled services when she was admitted , and her last covered Medicare day was 2/16/2023.
The facility Business office provided documentation that a skilled care ABN (Advanced Beneficiary Notice of Non-Coverage form and a NOMNC (Notice of Medicare Non-Coverage) form were not issued to Resident 64. Resident 64 chose to remain a resident of the facility after 2/16/2023.
During an interview with the Business Office Manager (BOM), on 6/13/2023 at 10:30 A.M., she indicated she could not locate the forms for Resident 64 and both forms should have been provided to the resident.
The BOM indicated the facility policy was to follow the requirements of both forms per CMS (Centers for Medicare and Medicaid Services). The form instructions for the NOMNC form indicated a completed copy was to be delivered to the resident and/or their representative 2 calendar days prior to Medicare covered services ending. The form instructions for the ABN indicated it was to be issued in advance of a shift from Medicare covered items and/or services to expected non-coverage of items or services.
3.1-4(f)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to protect a residents right to be free from verbal abuse for 1 of 1 resident reviewed for abuse. (Resident C)
Finding includes:
Review of a f...
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Based on record review and interview, the facility failed to protect a residents right to be free from verbal abuse for 1 of 1 resident reviewed for abuse. (Resident C)
Finding includes:
Review of a facility reported incident, on 6/11/2023 indicated Resident C reported a staff person to be verbally abusive to her. The report indicated the identified employee was suspended pending an investigation, alert and oriented residents were interviewed to determine any concerns with staff they might have, the identified employee received Customer service education and the progressive discipline policy was followed. Resident C was to be monitored for any psychosocial concerns regarding the event.
There was no specific information regarding the event on the facility reported incident. However, review of the incident investigation, provided upon request on 6/14/2023 indicated the following:
On 6/8/2023, two activity aides (Employee 15 and 16) had transported Resident C on the facility bus to an outside physician's office for an appointment. During the bus ride to the appointment, Employee 16 had been driving the bus and Employee 15 was sitting with the resident on the bus. Resident C had been complaining about the bumpy road during the trip. Once the bus arrived at the medical office building, Employee 15 assisted Resident C to the building and discovered they were at the wrong entrance/address. According to Employee 15, Resident C and Employee 16 started speaking to each other, in a raised voice and arguing. Employee 16 then stated to Resident C I brought your a-- to the right place. I'm tired of your f------ yelling at me. Employee 16 also called Resident C a b----.
During an interview with Employee 15, on 6/14/2023 at 3:57 P.M. she confirmed the other Act Aide called Resident C a b---- and said also told Resident C that she had brought her a-- to the right place and told the resident she was tired of her f------ yelling at her. Employee 15 indicated she did not do anything immediately as she did not want to get in the middle of it but she did consider it mental abuse and she reported the incident to the Administrator immediately when she returned from the outing. Resident 15 indicated she pushed Resident C into the doctor's office immediately after arriving at the correct entrance and she and Employee 16 drove back to the facility. Employee 15 indicated she had been in-serviced regarding the facility's abuse policy and was able to verbalize the resident was to be removed from any abusive situation and any abuse was to be reported to the Administrator immediately.
Review of an Employee Communication Form and interview with the Director of Nursing, on 6/14/2023 at 3:15 P.M. she indicated Employee 16 was terminated for Disruptive Behavior on 6/8/2023. The form indicated the employee used Inappropriate Verbage and her workplace conduct was no in accordance with customer service expectations and she was argumentative with resident. The form was completed on 6/13/2023. The Director of Nursing indicated the employee had some previous disciplinary reports and she was terminated after this incident.
The facility's Abuse, Prohibition, Reporting and Investigation policy, provided by the Administrator upon entrance to the facility on 6/12/2023, included the following: .It is the policy of [name of company]to provide each resident with an environment that is free from abuse .[name of company] will not permit residents to be subjected to abuse by anyone, including employees .Verbal Abuse - The use of oral, written, and/or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within hearing distance .This includes any episode of staff to resident .Resident Abuse - Staff member, volunteer, or visitor: 1. The resident (s) involved in the incident will be protected and/or removed from the situation immediately. 2. Any individual who witnesses abuse, or has suspicion of abuse, shall immediately notify the chart nurse of the unit, which the resident resides and to the Executive Director (Administrator)
This Federal tag relates to complaint IN00407225.
3.1-27(b)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure showers were provided for 1 out of 3 Residents reviewed for activities of daily living. (Resident 50)
Finding includes:
During an in...
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Based on interview and record review, the facility failed to ensure showers were provided for 1 out of 3 Residents reviewed for activities of daily living. (Resident 50)
Finding includes:
During an interview on 6/13/2023 at 9:11 A.M., Resident 50 indicated he preferred to take a shower but does not get one.
During an interview on 6/14/2023 at 1:28 P.M., Resident 50 indicated he did not have a shower this week.
During an interview on 6/16/2023 at 1:41 P.M., the resident indicated he had not received a shower this week.
A record review was completed on 6/15/2023 at 2:00 P.M. Diagnoses included, but were not limited to: neoplasm of the brain, Diabetes Mellitus, anxiety and depression.
A Quarterly Minimum Data Set (MDS) Assessment, dated 5/22/2023, indicated physical help in part of bathing activity.
A Preference for Customary Routine and Activities, dated 4/11/2023, indicated he would like twice a week shower in the P.M. and that it was very important to him to choose between tub bath, shower, and bed/sponge bath.
A Care Plan, dated 4/9/2023, indicated resident required assistance with activities of daily living (ADL's) with an intervention to assist with bathing as needed per residents' preference. Offer showers two times a week and partial bath in between.
During an interview on 6/15/2023 at 3:53 P.M., the Director of Nursing indicated they have a shower schedule posted at the nurse's station, it is the only location where the resident showers are posted. The staff document the showers on the shower sheet and chart in the progress notes of any refusals. She indicated that he was not on the shower schedule, and she could not find any documentation indicating he got a shower or of any refusals. No shower sheets were located for month of May and June. He should have been getting two showers a week per his preference.
On 6/16/2023 at 12:00 P.M., the Director of Nursing indicated that they have no policy on showers.
3.1-38(2)(A)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
2. A record review was completed on 6/14/2023 at 2:40 P.M., for Resident 20. Diagnoses included, but were not limited to: cerebral infarction and hemiplegia and hemiparesis following nontraumatic intr...
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2. A record review was completed on 6/14/2023 at 2:40 P.M., for Resident 20. Diagnoses included, but were not limited to: cerebral infarction and hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side.
During an observation, on 6/13/2023 at 10:17 A.M., Resident 20 was in bed and had long, jagged fingernails with a dark substance under them.
During an observation, on 6/14/2023 at 9:04 A.M., the resident was in bed fingernails long, jagged with brown substance under the nails.
During an observation, on 6/16/2023 at 2:34 P.M., the resident was in bed and had long, jagged fingernails with brown substance under them.
A Quarterly Minimum Data Set (MDS) assessment, dated 5/24/2023, indicated that he is total dependent for bathing with one assist.
A Care Plan, dated 2/9/2020, indicated resident requires assistance with activities of daily living (ADL's), assist with dressing, grooming, and hygiene as needed.
During an interview, on 6/14/2023 at 3:21 P.M., certified nurse aide (CNA) 5 indicated when she gives a shower she washes the entire body, wash hair, brush residents' teeth, and inspects the skin for redness.
During an interview, on 6/15/2023 at 10:17 A.M., CNA 7 indicated when she gives a shower, she will assist with washing the body and their hair, brush the teeth and shave them if needed.
During an interview, on 6/15/2023 at 10:21 A.M., CNA 6 indicated when she gives a shower she washes the whole body, hair, shaves them and clips toe and fingernails, dries them off and assist with dressing.
On 6/16/2023 at 12:00 P.M. the Director of Nursing indicated she does not have a policy on nail care
or showers.
Based on observation, record review and interviews, the facility failed to ensure Activities of daily living assistance was provided for 2 of 4 residents reviewed. (Resident 20 and 53)
Findings include:
1. Resident 53 was observed on 6/12/2023, 6/13/2023 and 6/14/2023 dressed in the common areas and/or at an activity. Her hair was observed to be unkept in appearance and greasy.
The clinical record for Resident 53, reviewed on 6/19/23 at 9:16 A.M., indicated the resident had diagnoses included but not limited to: hypertension, chronic kidney disease hyperlipidemia, obesity, insomnia, adjustment disorder with depressed mood, dementia, and major depressive disorder, recurrent,
The most recent MDS (Minimum Data Set) assessment for Resident 53, completed on 5/11/2023 for a quarterly review, indicated the resident was severely cognitively impaired and required extensive assist of one for toileting, bathing, dressing, and limited assist of one for personal hygiene.
The annual MDS assessment, completed on 4/12/2023, indicated it was very important for the resident to choose between a bath/shower/bed bath on the preferences section of the assessment.
The current care plan regarding preferences indicated the resident was to be showered twice a week in the mornings.
The documentation in the resident's clinical record regarding showering and/or bathing from 5/19/2023 - 6/19/2023, indicated the resident was only documented to have received a shower on 5/31/2023 at 8:37 A.M. The Point of care documentation for bathing from 4/19/2023 - 5/18/2023 indicated the resident only received 3 showers and 1 complete bed bath. Finally, the charting form 4/1/2023 - 4/19/2023 indicated there were no showers documented.
Copies of additional Shower Report forms for Resident 53 were provided on 6/14/2023 at 2:00 P.M. by the Administrator. The forms indicated the resident had received a shower on the following dates: 4/3/2023, 4/6/2023, 4/10/2023, 4/13/2023, 4/17/2023, 4/20/2023, 4/27/2023, 5/1/2023, 5/4/2023, 5/8/2023, 5/15/2023, 5/18/2023, 5/25/2023, 5/29/2023, 6/1/2023, and 6/8/2023. The shower form on 4/3/2023 and 4/6/2023 were not signed by the aide or the nurse and did not indicate the time the shower was given and if a shampoo, nail care, was given. The form on 4/10/23, 4/27/2023, 5/4/2023, 5/8/2023, 5/15/2023, 5/18/2023, 5/25/2023, 5/29/2023, 6/1/2023 and 6/8/2023 were all signed by the same nurse, LPN 1, not signed by the aide completing the showering and only indicated shower given, not shampoo.
Review of the April 2023 schedule and interview with the Director of Nursing, on 6/19/2023 at 11:40 A.M., indicated on several of the days Employee 1, an LPN, had signed an incomplete shower report, she was not on the working schedule for the day. The Director of Nursing indicated she did know why LPN 1 was not on the schedule on the days she had signed the shower report forms but she was going to look into the discrepancy. She indicated the aides were not good about documenting correctly in the Point of Care electronic record. No further information regarding the showers and/or shower forms was provided during the survey.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure antibiotic medications were administered as di...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure antibiotic medications were administered as directed by the physician's orders and anti- coagulant medication was resumed timely for 1 of 3 residents reviewed. (Resident C)
Findings include:
The record for Resident C, reviewed on 6/14/2023 at 11:01 A.M., indicated Resident C was admitted with diagnoses included, but not limited to: acute embolism and thrombosis of right lower extremity, thrombocytopenia, repeated falls, muscle weakness, unsteadiness on feet and osteomyelitis of vertebra -cervical and thoracic region.
The resident was hospitalized [DATE] - 4/11/2023 for a septic arthritic left hip joint and on 6/8/2023 for an acute deep vein thrombosis.
Review of the hospital discharge records for Resident C, completed on 4/11/2023 indicated the resident was to receive enoxaparin (an anticoagulant) .3 ml (mililiter) via subcutaneous injections every 12 hours for 21 days. In addition, the resident was to receive the antibiotic, Vancomycin 1 gram via intravenous route every 12 hours for 6 weeks.
Review of the medication administration record (MAR) for April and May 2023 for Resident C indicated she received the enoxaparin injections from 4/11/2023 through 5/2/2023. The resident had received the Vancomycin infusions but missed one dose on 4/18/2023, 4/19/2023, 4/21/2023, 4/25/2023 and 4/29/2023. The resident missed both doses on 4/20/2023. After 5/2/2023 the resident had no physician's orders for any type of blood thinning medication.
During an interview with the Director of Nursing, on 6/19/2023 at 1:46 P.M., she indicated on 4/20/2023 the vancomycin was put on hold due to staff waiting on dosing from the pharmacy based on laboratory results and on 4/25/2023 the resident had been out of building with her family for the morning dose and was given the evening dose when she returned. The Director of Nursing indicated she could not account for the other 4 missing doses.
Review of acute care records for Resident C, dated 6/8/2023 indicated the resident presented to the emergency room with overt nonpitting edema to the right lower extremity with associated tenderness below the knee. The resident was diagnosed with an acute DVT (deep vein thrombosis of the deep femoral vein on the right side. The hospital notes emphasized the resident had not been on anticoagulant for several weeks. The resident had reported to the acute care physician she thought the anticoagulation medication had been stopped the first week in May 2023.
Review of physician progress notes, dated 5/26/2023 and 6/5/2023, indicated the resident's current medication list included enoxaparin injections, even though the order was discontinued on 5/2/2023. The note also listed Assessment issues including Acute embolism and thrombosis of left femoral vein: continue Xarelto, monitor extremities for changes in color, temperature and peripheral pulse. and Muscle weakness (generalized) Pt (patient) is immobile. Continue Lovenox (brand name for enoxaparin)
During an interview with the physician on 6/19/23 at 11:56 A.M., he indicated he used a Scribe system for writing his notes which accounted for the way certain things were typed on the notes. He indicated acute orders from the hospital orthopedic team and/or hospitalists take presidence over routine orders and often resident's blood thinners were held prior to surgical procedures. He indicated while the resident would not be prescribed Lovenox injections at the same time as oral Xarelto medications, she should have been on a blood thinner. He indicated Resident C did have an IVF (intravenous filter) due to her history of blood clots, but she should also have been on Xarelto indefinitely. He indicated the whole clinical team was responsible for reviewing the resident's chart and ensuring her medication regimen was complete and accurate. He indicated no one from the facility had notified him of the need to reorder Xarelto.
The facility policy and procedure, titled, Resident Change of Condition provided by the Regional Nurse Consultant on 6/19/2023 at 2:29 P.M., included instructions for reporting Non-urgent Medical Change.
The facility policy and procedure, titled, Physician Services provided by the Regional Nurse Consultant on 6/19/2023 at 2:29 P.M., included the following: .The Physician must document a review of the resident's total program of care, including the resident's current condition, progress and problems in maintaining or improving their physical, mental, and psychosocial well-being and decisions about the continues (sic) appropriateness of the resident's current medical regimen
This Federal tag relates to complaint IN00407225 and IN00410341.
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
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation and record review, the facility failed to ensure physicians orders to prevent the development of pressure ulcers was implemented for 1 of 3 residents reviewed. (Resident 33)
Findi...
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Based on observation and record review, the facility failed to ensure physicians orders to prevent the development of pressure ulcers was implemented for 1 of 3 residents reviewed. (Resident 33)
Finding includes:
A record review was completed on 6/14/2023 at 11:55 A.M. for Resident 33. Diagnoses included, but were not limited to: acute and chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease.
During an observation, on 6/12/2023 at 12:41 P.M., resident was lying in bed supine with her legs crosses at the ankles, heels not floated, no prevalon boots on or ear protectors on the oxygen tubing.
During an observation, on 6/13/2023 at 10:03 A.M., resident was lying supine in bed, heels not floated, no prevalon boots on and no ear protectors on the oxygen tubing.
During an observation, on 6/14/2023 resident was lying supine in bed, heels not floated, no prevalon boots on and no ear protectors on the oxygen tubing.
A Physician Order, dated 2/24/2023, indicated prevlon [sic] boots to be worn at all times except during patient care.
A Physician Order, dated 2/24/2023, indicated to encourage to float heel when in bed.
A Physician Order, dated 4/7/2023, indicated ear protectors to oxygen tubing and check placement every shift.
A Care Plan, dated 11/11/2022, indicated at risk for skin breakdown with interventions to encourage to float heel and prevlon [sic]boots to be worn at all times except during patient care.
During an interview, on 6/14/2023 at 11:16 A.M., the Director of Nursing indicated she is not wearing prevalon boots or ear protectors on the oxygen tubing or floating her heels. She does have orders for them and should have been wearing them. She was unable to find documentation of refusals in the progress notes or the treatment record. She would expect her staff to document refusals and inform management or doctor of refusals and discontinue them.
On 6/16/2023 at 12:00 P.M., the Director of Nursing indicated she does not have a policy on physician orders.
3.1-40
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
3. A record review was completed for Resident 1 on 6/14/2023 at 10:00 A.M.
The most recent MDS (mimimum data set), assessment, dated 4/4/2023, indicated severe cognitive impairment. Diagnoses include...
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3. A record review was completed for Resident 1 on 6/14/2023 at 10:00 A.M.
The most recent MDS (mimimum data set), assessment, dated 4/4/2023, indicated severe cognitive impairment. Diagnoses included, but not limited to: chronic obstructive pulmonary disease, schizophrenia, palliative care for respiratory failure.
Medications included but not limited to: Oxygen at 3 liters per nasal cannula as needed.
During an observation on 6/14/2023 at 10:00 A.M., resident was dressed in bed with the head of the bed elevated.
Oxygen was on at 3 liters/via nasal cannula. Tubing was not dated; humidification bottle not dated.
During an observation on 6/15/2023 at 9:41 A.M., resident was in bed with oxygen on at 3 liter via nasal cannula. The tubing and humidification bottle were not dated.
During an interview on 6/15/2023 at 9:57, Employee 1 indicated the resident should have an order to change all oxygen equipment on Sundays. A order for oxygen supply changes was not found in the clinical record.
During an observation on 6/16/2023 at 9:18 A.M., Resident was resting in bed with oxygen on at 3 liters via nasal cannula. No oxygen signage was on the door.
During a 2nd interview, on 6/16/2023 at 9:18 A.M., with Employee 1 he indicated that tubing and humidification bottles should be dated, and that staff is responsible for chaning oxygen tubing and bottles on Sundays. Hospice managed oxygen therapy for this resident but that staff in the facility should change out oxygen supplies on Sundays as the ordered. She indicated if not directed in the physician order the oxygen supply changes should default to Sundays and there should be signage on the door.
On 6/16/2023 at 1:20 P.M., Employee 16 presented a copy of the Oxygen Therapy and Devices policy. The policy indicated .for some people with certain health conditions whose lung function is impaired, the amount of oxygen that is obtained through normal breathing is not enough. Therefore, they require supplemental amounts to maintain normal body function oxygen must be ordered by physician, No smoking signs need to be affixed to front and back of doors per OSHA, practice standard precautions, gather equipment (liquid, cylinder, concentrator and humidity if applicable, apply device at appropriate flow, place oxygen signs and document in patient file .Oxygen nasal cannula to be changed out weekly and as needed and place in labeled bag when not in use
3.1-47(a)(6)
2. During an observation on 6/12/2023 at 12:40 P.M., Resident 33's oxygen concentrator filter was covered with white/gray colored lint.
During an observation on 6/13/2023 at 10:04 A.M., the concentrator was covered with white/gray colored lint.
During an observation on 6/14/2023 at 8:53 A.M., lint continued to be covering the filter.
A record review was completed on 6/14/2023 at 11:55 A.M. Diagnoses included, but were not limited to: acute chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease.
A Physician Order, dated 4/7/2023, indicated to change the oxygen tubing and humidity, clean concentrator and filter once a day on Monday.
During an interview on 6/14/2023 at 1:08 P.M., the Director of Nursing indicated that there was lint on the filter but needed to contact filter company on the maintenance of the filter.
On 6/16/2023 at 1:20 P.M., the Regional [NAME] President of Operation (RVPO) provided maintenance on the filter for the concentrator titled, Provider Maintenance, undated. The routine maintenance indicated .The external air intake gross particle filter is located on the back of the unit. You can easily remove it by hand. Instruct the patient to clean this filter weekly
On 6/16/2023 at 1:22 P.M. the Regional [NAME] President of Operation (RVPO) indicated that the filter should have been cleaned weekly.
On 6/16/2023 at 1:20 P.M. the Regional [NAME] President of Operations provided a policy titled, Oxygen Therapy Devices , undated, and indicated the policy was the one currently used by the facility. The policy indicated . Oxygen Safety 1) No smoking signs need to be affixed to front and back of doors (OSHA regulations), Oxygen Devices 1) Nasal cannula e. Change out weekly and PRN, f. place in a labeled bag when not in use
Based on observation, record review and interviews, the facility failed to ensure respiratory equipment was maintained per professional standards for 3 of 3 residents reviewed for respiratory care. (Resident 44, 33 and 1 )
Findings include:
1. Resident 44 was observed on 6/12/2023 during the initial tour of the facility, lying in bed, holding his oxygen tubing and nasal cannula in his hands. The resident's oxygen tubing, which was connected to a concentrator was not dated and there was no plastic storage bag observed in the room.
On 6/13/23 at 10:07 A.M., Resident 44 was observed seated in his wheelchair with oxygen per a nasal cannula connected to a portable oxygen tank. The tubing was not dated.
On 6/16/23 at 9:30 A.M., Resident 44 was observed lying in bed. The resident was not wearing oxygen at the time. The oxygen tubing was hanging off the back of his wheelchair, connected to a portable oxygen tank. There was no storage bag noted and the oxygen tubing was not dated.
A record review was completed on 6/16/23 for Resident 44. Diagnoses included, but not limited to: dementia, Wernicke's encephalopathy, severe protein-calorie malnutrition, chronic obstructive pulmonary disease, lack of coordination, repeated falls, constipation, chronic pain, generalized anxiety disorder, major depressive disorder, hyperkalemia, dysphagia, cognitive communication and alcohol dependence with delirium withdrawal, nicotine dependence, osteoarthritis.
During an observation and interview of resident 44, with the DON, on 6/16/2023 at 10:58 A.M., she indicated oxygen tubing and/or a storage bag should have date on it and tubing was to be changed every week. She indicated the nurses usually wrote the date with a permanent marker when they changed the oxygen tubing.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observations and interviews, the facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents by 1 of 2 medication carts, 1 of 3 treatment carts...
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Based on observations and interviews, the facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents by 1 of 2 medication carts, 1 of 3 treatment carts.
Findings include:
1. During a medication observation, on 6/14/2023, at 8:20 A.M., Qualified Medication Aide (QMA) 8 left the medication cart unlocked while she was in a resident's room. The medication cart was not in view of the QMA. QMA 8 indicated she should have locked the cart before entering the resident's room.
2. During a medication observation, on 6/14/2023 at 2:45 P.M., Licensed Practical Nurse (LPN) 9 walked away from the medication cart without locking it. It was not in view of the LPN. LPN 9 indicated he should have locked the medication cart before walking away.
3. On 6/15/2023 at 8:08 A.M., during an observation and interview with QMA 17, the treatment cart was unlocked in the unit's resident lounge with treatment medications and supplies. QMA 17 indicated the cart should be locked.
4. During a medication observation, on 6/15/2023 at 11:56 A.M., Registered Nurse (RN) 11 pre-poured metoclopramide 10 mg 1 tab oral every 6 hours, a medication for Resident 10, and left it in the resident's room on the nightstand while she went back to the nurse's desk. The resident was sitting in his wheelchair in the room at the time. During an interview at the time RN 10 indicated she should not have left the medication in the resident's room unattended.
During an interview, on 6/15/2023 at 1:23 P.M., the Director of Nursing indicated medication and treatment carts should be locked when unattended and medications should not be left in a resident's room unattended.
A current policy titled, Storage and Expiration Dating of Medication, Biologicals and revised on 7/21/2022, provided by the corporate nurse consultant, on 6/19/2023 at 10:13 A.M. The policy indicated, .Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors
A current policy titled, General Dose Preparation and Medication Administration and revised on 1/1/2022, was provided by the corporate nurse consultant, on 6/19/2023 at 11:04 A.M. The policy indicated, .Facility staff should not leave medications or chemicals unattended
3.1-25(m)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure food items in the freezer were dated/labeled and sealed securely after opening and failed to ensure used by dates on foods. This defic...
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Based on observation and interview, the facility failed to ensure food items in the freezer were dated/labeled and sealed securely after opening and failed to ensure used by dates on foods. This deficient practice had the potential to affect 62 of 64 residents who received meals out of the kitchen.
Findings include:
On 6/12/23 at 9:28 A.M., during on observation and kitchen tour with the dietary manager, the following was oberserved:
- In the pantry of the main kitchen, graham cracker crumbs were in an open bag with no date on the bag indicating when opened.
- In the cooler, an open half gallon of milk and a carton of Half and Half had no open date.
- In the freezer, two open tubs of ice cream had no open dates. Italian sausage, pork loin chops, beef cubed patties were found to be undated and unsealed.
On 6/15/23 at 12:30 P.M., the Regional Nurse Consultant provided a policy titled, Food Storage, revised 5/23 and indicated the policy was the one currently used by the facility. The policy indicated .frozen foods, should be covered or wrapped tightly, labeled and dated with the date the item is being placed in the freezer. Frozen food items should be used within 1 year of this date to maintain quality dry storage, all foods should be covered or wrapped tightly, labeled and dated refrigerated, ready-to-eat, potentially hazardous foods purchased from approved vendors shall be clearly marked with the date the original container is opened and the date by which the food shall be consumed or discarded
3.1-21 (3)
Jan 2023
5 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to protect a resident's right to be free from physical a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to protect a resident's right to be free from physical abuse when a Qualified Medication Aide (QMA) pushed a resident to the ground, resulting in a fracture to the intertrochanter (hip) and radius (arm) for 1 of 3 residents reviewed for abuse. (Resident D)
The immediate jeopardy began, on 12/29/22 at 7:30 P.M., when Resident D was observed being pushed to the ground by Qualified Medication Aide T, on the facility's video surveillance system. The Administrator was notified of the immediate jeopardy on 1/25/23 at 4:45 P.M.
Finding includes:
On 1/24/23 at 4:05 P.M., the Executive Director (ED) provided a recorded video dated 12/29/22, of the area near and around the first floor 2 E Nurses Station. The Video indicated Resident D was at the Nurses Station attempting to approach the Medication Cart. QMA T was observed talking to the resident and pointing to the medication cart. When Resident D approached the medication cart again, QMA T pushed the resident causing him to fall to the floor. QMA T was then observed getting the resident up to his feet and escorted him back to his room with the aide of a walker, an assessment was not performed at that time. Resident D was observed limping with difficulty walking.
On 1/25/23 at 11:47 A.M., during an interview, conducted with Resident D's responsible party, he indicated Resident D was pushed down real hard by a male nurse. He indicated the facility told him the resident fell and he requested to see a video but was told by the facility they did not have a video of the fall. The Responsible party indicated he was notified of Resident D's fall on 12/30/22 in the morning and was told they were sending the resident to the hospital for pain from a fall. The Responsible Party never notified him there was abuse until after the resident returned to the facility from the hospital.
On 1/25/23 at 12:03 P.M., during an interview, conducted with a local police detective, they indicated the facility reported an incident that occurred on 12/29/22 at the facility to the police department and on 12/30/22 at an unknown time, the Detective indicated the facility provided a video related to the incident. The Detective indicated they observed Resident D near the Nurse's Station and was thrown to the ground by QMA T. The resident was sent to the hospital where they discovered a broken hip and arm.
On 1/25/23 at 12:30 P.M., during an observation of Resident D, the resident was observed sitting on the edge of his bed eating lunch utilizing the over bed table. Resident D had a brace to his right forearm and 2 healing incisions both approximately 3 cm (centimeters) long to the right hip. In an interview, conducted at that time, the resident indicated he went to the nurses station one evening, he was not able to recall the date, for something more to eat. The resident indicated the nurse pointed back to the refrigerator behind the nurses station so he thought the nurse wanted him to go get a snack from the refrigerator. Resident D indicated when he opened the door the nurse jumped up and took him out of the Nurse's Station and threw him onto the floor and that's when his leg and arm broke. The resident indicated he couldn't move, was crying, and hurt bad while the nurse was telling him to get back to his room. Resident D indicated he could not move, so the nurse got him up and hand hauled him to his room and threw him in his bed. The resident indicated all he could do was cry.
On 1/25/23 at 2:00 P.M., the clinical record for Resident D was reviewed. Resident D was admitted on [DATE] with diagnoses included but not limited to: alcohol withdrawal related seizures, alcohol induced chronic pancreatitis, Wenicke's encephalopathy, diabetes and acute respiratory failure with hypoxia.
An admission Minimum Data Set (MDS) dated [DATE], indicated Resident D was severely cognitively impaired and demonstrated verbal behaviors directed at others 1-3 days during the assessment period. Resident D required limited assistance with bed mobility, was independent with transfers, walking in his room and corridors, locomotion on and off the unit, and dressing. He required supervision with eating and limited assistance with toilet use and personal hygiene.
On 1/25/23 at 3:00 P.M., during an interview, conducted with the Director of Nursing (DON), she indicated she received a call from Licensed Practical Nurse (LPN) L that Resident D had a fall without injuries but was in intense pain. The DON indicated LPN L told her that QMA T indicated he had made a mistake and that was an odd thing to say. The DON indicated she notified the ED on 12/29/22 at about 7:50 P.M., to report the fall and that LPN L had indicated QMA T had made a mistake and told the ED there was something missing in LPN L's report. The DON indicated she asked the ED if she should go to the facility, but was not directed to do so. The DON indicated she did not receive any notifications regarding Resident D until the following morning on 12/30/22 at 6:50 A.M. when the X-Ray technician notified her that Resident D had sustained a fracture to his right hip. The DON indicated she should have gone into the facility when she received the call from LPN L about the resident's fall and the comment made by QMA T indicating he had made a mistake.
On 1/25/23 at 3:07 P.M., during an interview, conducted with the ED she indicated she received a call from the DON indicating Resident D had sustained a fall and there was some concern about what had happened. The ED indicated she called the facility and spoke with LPN L and had QMA T removed from the facility pending an investigation. The ED indicated she was notified of Resident D's hip fracture on 12/30/22 at 6:50 A.M., when it was reported to the DON.
A Radiology report, dated 12/30/22 at 7:32 A.M., indicated Resident D had a displaced intertrochanteric fracture of the proximal right femur.
A Local Police Report, dated 12/30/22 at 4:00 P.M., indicated .viewed the facility video and could see [Resident D] grab the medication cart and start to open the drawers looking for medication. At this time QMA T stood up and walked over and grabbed the cart and told the resident he could not get in the cart. QMA T starts to pull the cart away from the resident and the resident grabbed the cart and pulled it out of the QMA's hands and started going through the drawers again. At this time QMA T is seen putting hands up to stop the resident, but the resident keeps trying to get in the cart. AMA T then grabs [Resident D] by both of his arms and pulls the resident away from the cart at which the resident stumbles to the counter and catches himself. Then [QMA T] is seen to walk over and push the resident causing the resident to fall to the floor. QMA T is seen trying to help the resident back up at which the resident falls again because he can not get his balance. Resident finally gets up with the help of [QMA T] and another nurse comes out after everything happened
A emergency room Physician's Report, dated 12/30/22 at 3:03 P.M., indicated .[Resident D] arrived presented to ED [Emergency Department] from [local long term care facility] for evaluation of right hip and right shoulder pain. Patient provides little to no history. Patient states that someone beat his ass .was thrown into a wall. EMS [Emergency Medical Services] state the[ facility] staff state the patient fell at some point yesterday which was unwitnessed between the hours of 2 PM [2:00 P.M.] and 10 PM [10:00 P.M.]. No other history is provided. Patient states that nothing has been tried for relief. When asked to rate his pain he states just put me down man! Knock me out! The ER report further indicated the resident had a right intertrochanteric fracture and an intra-articular right radius fracture.
On 1/26/23 at 2:30 P.M., during an interview, conducted with LPN L, he indicated on 12/29/22 around 7:30 P.M., he was working in another area of the building when QMA T came to get him saying he needed some help. LPN L indicated QMA T took him to Resident D's room to have the resident assessed because he had fallen. LPN L indicated when he assessed the resident he was found to be in pain but the remainder of the assessment was negative and the resident stoped complaining of pain within 15 minutes of the assessment. LPN L indicated he asked QMA T what happened and the QMA indicated the resident was reaching for the med cart and he pushed the resident away and he fell. LPN L indicated he attempted to notify the Nurse Practicioner (NP) 4 times but the NP never answered the calls. LPN L indicated he notified the ED and the DON immediately and the ED instructed him to remove QMA T from the facility immediately pending an investigation, which he did.
A policy, titled Abuse Prohibition, Reporting, and Investigating dated 1/23 was provided by the DON on 1/24/23 at 11:15 A.M. The policy indicated .It is the policy to provide each resident with an environment that is free from abuse .will not permit residents to be subjected to abuse by anyone, including employees .Physical abuse- A willful act against a resident by .staff member
The immediate jeopardy was removed and corrected, on 12/30/23, when the facility staff was; in-serviced regarding their abuse policy and behavior management, an emergency Resident Council meeting was held, resident and staff interviews were completed, a house wide skin sweep was completed for uninterviewable residents, employee files were reviewed for abuse training upon hire, audits were implimented regarding monthly staff abuse policy in-services, and signage regarding staff burn and abuse and how to report to each.
This Federal tag relates to complaint IN00399801.
3.1-27(a)(1)
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0697
(Tag F0697)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure pain management was in place for a resident wh...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure pain management was in place for a resident who sustained injuries following an altercation with a facility Qualified Medication Aide (QMA) when the resident was pushed to the ground and sustained a fracture to the hip and arm. (Resident D)
Finding includes:
On 1/24/23 at 4:05 P.M., the Executive Director (ED) provided a recorded video dated 12/29/22, of the area near and around the first floor 2 E Nurses Station. The Video indicated Resident D was at the Nurses Station attempting to approach the Medication Cart. QMA T was observed talking to the resident and pointing to the medication cart. When Resident D approached the medication cart again, QMA T pushed the resident causing him to fall to the floor. QMA T was then observed getting the resident up to his feet and escorted him back to his room with the aide of a walker, an assessment was not performed at that time. Resident D was observed limping with difficulty walking.
On 1/25/23 at 12:30 P.M., during an observation of Resident D, the resident was observed sitting on the edge of his bed eating lunch utilizing the over bed table. Resident D had a brace to his right forearm and 2 healing incisions both approximately 3 cm (centimeters) long to the right hip. In an interview, conducted at that time, the resident indicated he went to the nurses station one evening, he was not able to recall the date, for something more to eat. The resident indicated the nurse pointed back to the refrigerator behind the nurses station so he thought the nurse wanted him to go get a snack from the refrigerator. Resident D indicated when he opened the door the nurse jumped up and took him out of the Nurse's Station and threw him onto the floor and that's when his leg and arm broke. The resident indicated he couldn't move, was crying, and hurt bad while the nurse was telling him to get back to his room. Resident D indicated he could not move, so the nurse got him up and hand hauled him to his room and threw him in his bed. The resident indicated all he could do was cry.
On 1/25/23 at 2:00 P.M., the clinical record for Resident D was reviewed. Resident D was admitted on [DATE] with diagnoses included, but not limited to: alcohol withdrawal related seizures, alcohol induced chronic pancreatitis, Wenicke's encephalopathy, diabetes and acute respiratory failure with hypoxia.
An admission Minimum Data Set (MDS) dated [DATE], indicated Resident D was severely cognitively impaired and demonstrated verbal behaviors directed at others 1-3 days during the assessment period. Resident D required limited assistance with bed mobility, was independent with transfers, walking in his room and corridors, locomotion on and off the unit, and dressing. He required supervision with eating and limited assistance with toilet use and personal hygiene.
Review of Resident D's Progress Notes, indicated on 12/29/22 at 8:57 P.M., .QMA reported resident had a fall with complaints of pain. I [Licence Practical Nurse (LPN) L] assessed resident rang of motion and resident was in intense pain .
12/29/22 at 9:35 P.M., .spoke with resident He complained of pain in his hip. A STAT X RAY was ordered.
12/30/22 at 6:44 A.M., [Resident D] has been in pain, yelling out and on the call light most of the night d/t [due to] right leg having s/s [signs and symptoms] of a fracture from a fall. Noted to be externally rotated, and swollen at the hip ball joint area. Given him PRN [as needed] Butal-Acetam-Caff (primary use to relieve symptoms of tension headaches) at 0030 [10:30 P.M] which did not help much. PRN Loazepam (an antianxiety medication) 0.25 ml given at 0202 [2:02 A.M.] which did help and had been comfortable until [mobile unit X Ray] came to do his x-ray.
12/30/22 at 7:21 A.M., Resident noted with severe pain, calling out in pain. Per report .R [right] leg noted with external rotation, unable to move leg and screaming out when touched and moved .
Review of physicians orders indicate Resident D's orders included, but were not limited to: Loazepam 0.25 ml 2 times a day for anxiety disorder, from 7:00 A.M. to 11:00 A.M., and from 7:00 P.M, to 11:00 P.M., dated 12/20/22, Tylenol 650 mg, for pain every 6 hours as needed, dated 12/13/22, Butalbital-acetaminophen-caff 50-300-40 mg for headache every 6 hours as needed, dated 12/20/22.
Review of Resident D's Medication Administration Record (MAR) indicated the resident did not received Loazepam 0.25 ml as ordered on 1/29/22 sometime between 7:00 P.M. and 11:00 P.M. Reason/Comments on the MAR indicated the medication was not administered because the medication was unavailable. Resident D received Loazepam 0.5 ml on 1/30/22 at 2:04 A.M. with the Reason/Comment documented as .yelling out d/t pain. The MAR indicated Butalbital-acetaminophen-caff 50-300-40 mg capsule was given one time on 1/30/22 at 12:31 A.M. No documentation for Reason/Comment was noted. No other pain medications or interventions were documented to address the resident's pain.
On 1/25/23 at 3:00 P.M., during an interview, conducted with the Director of Nursing (DON), she indicated she received a call from Licensed Practical Nurse (LPN) L that Resident D had a fall without injuries but was in intense pain. The DON indicated she did not receive any notifications regarding Resident D until the following morning on 12/30/22 at 6:50 A.M. when the X-Ray technician notified her that Resident D had sustained a fracture to his right hip. The DON indicated no one called her about the resident's pain level in the night but that they should have addressed his pain better and the Nurse Practitioner should have been notified of the pain but was not.
A policy, titled Pain Management, dated 10/20 was provided by the DON on 1/27/23 at 11:30 A.M. and indicated it was the current facility policy. The policy indicated, .It is the policy .to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well being, including pain management .Pain medications will be prescribed and given based upon the intensity of the pain .The physician will be notified [for] unrelieved or worsening pain .
This Federal tag relates to complaint IN00399801.
3.1-37(a)
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's responsible party was notified in a timely mano...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's responsible party was notified in a timely manor of an allegation of physical abuse and also failed to provide notification in advance of obtaining an X-ray, for 1 of 3 residents reviewed for notification, (Resident D).
Finding includes:
On 1/24/23 at 4:05 P.M., the Executive Director (ED) provided a recorded video dated 12/29/22 at 7:30 P.M., of the area near and around the first floor 2 E Nurses Station. The Video indicated Resident D was at the Nurses Station attempting to approach the Medication Cart. QMA T was observed talking to the resident and pointing to the medication cart. When Resident D approached the medication cart again, QMA T pushed the resident causing him to fall to the floor. QMA T was then observed getting the resident up to his feet and escorted him back to his room with the aide of a walker, an assessment was not performed at that time. Resident D was observed limping with difficulty walking.
On 1/25/23 at 2:00 P.M., the clinical record for Resident D was reviewed. Resident D was admitted on [DATE] with diagnoses included, but not limited to: alcohol withdrawal related seizures, alcohol induced chronic pancreatitis, Wenicke's encephalopathy, diabetes and acute respiratory failure with hypoxia.
An admission Minimum Data Set (MDS) dated [DATE], indicated Resident D was severely cognitively impaired and demonstrated verbal behaviors directed at others 1-3 days during the assessment period. Resident D required limited assistance with bed mobility, was independent with transfers, walking in his room and corridors, locomotion on and off the unit, and dressing. He required supervision with eating and limited assistance with toilet use and personal hygiene.
A Significant Change Minimum Data Set, dated [DATE], indicated Resident D was moderately cognitively impaired and demonstrated verbal behaviors directed at others 1-3 days during the assessment period. Resident D required extensive assistance of 2 people with bed mobility, transfers, and toileting, and extensive assistance of 1 person for locomotion on and off the unit, dressing, and personal hygiene. The resident required a wheelchair for mobility. Diagnoses included but were not limited to hip fracture and other fracture (arm).
A review of a Physician's Telephone Order dated 12/29/22 indicated orders for STAT (statim, immediate) X-ray of bilateral hips.
A Radiology report, dated 12/30/22 at 7:32 A.M., indicated Resident D had a displaced intertrochanteric fracture of the proximal right femur.
Resident D's progress notes indicated on 12/29/23 at 8:57 P.M., QMA reported resident had a fall with complaints of pain. I [Licensed Practical Nurse L] assessed resident .DNS [Director of Nursing Services] was called. ED [Executive Director] was notified. NP [Nurse Practitioner] was notified via voice message.
On 12/29/22 at 9:35 P.M., .STAT X RAY was ordered.
On 12/30/22 at 7:39 A.M., [Ambulance] arrive to transfer resident to [local] ER [emergency room] and are currently in route to hosp. [hospital] DNS and resident father informed .
On 1/25/23 at 11:47 A.M., during an interview, with Resident D's responsible party, he indicated he was notified in the morning of 1/30/23 that Resident D had a fall the previous evening and that an X-ray was obtained by the facility showing the resident fractured his femur and was being transported to a local hospital. Resident D's responsible party indicated he was not notified of an allegation of abuse until the resident returned to the facility after his hospitalization.
On 1/25/23 at 3:00 P.M., during an interview, conducted with the Director of Nursing (DON), she indicated she received a call from Licensed Practical Nurse (LPN) L that Resident D had a fall without injuries but was in intense pain. The DON indicated she notified the ED on 12/29/22 at about 7:50 P.M., to report the fall. The DON indicated on 12/30/22 at 6:50 A.M., the X-Ray technician notified her that Resident D had sustained a fracture to his right hip. The DON indicated the Resident D's responsible party was notified of the fractured hip and transport to the hospital on 1/30/22 at 7:39 A.M. The DON indicated the resident's responsible party should have been notified at the time of the fall and when the order for the X-ray was obtained.
A policy titled Resident Change of Condition Policy, dated 11/28 was provided by the DON on 1/24/23 at 11:30 A.M., indicating it was the current policy, indicated, .It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party .The responsible party will be notified that there has been a change in the resident's condition and what steps are being taken .
This Federal tag relates to complaint IN00399801.
3.1-5(a)(1)(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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, the facility failed to ensure an allegation of abuse that resulted in serious bodily injury w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, the facility failed to ensure an allegation of abuse that resulted in serious bodily injury was reported to the State Agency (SA) in a timely manner for 1 resident, (Resident D).
Finding includes:
On 1/24/23 at 4:05 P.M., the Executive Director (ED) provided a recorded video dated 12/29/22 at around 7:30 P.M., of the area near and around the first floor 2 E Nurses Station. The Video indicated Resident D was at the Nurses Station attempting to approach the Medication Cart. QMA T was observed talking to the resident and pointing to the medication cart. When Resident D approached the medication cart again, QMA T pushed the resident causing him to fall to the floor. QMA T was then observed getting the resident up to his feet and escorted him back to his room with the aide of a walker, an assessment was not performed at that time. Resident D was observed limping with difficulty walking.
On 1/25/23 at 12:03 P.M., during an interview, conducted with a local police detective, they indicated the facility reported an incident that occurred on 12/29/22 at the facility to the police department and on 12/30/22 at an unknown time, the Detective indicated the facility provided a video related to the incident. The Detective indicated they observed Resident D near the Nurse's Station and was thrown to the ground by QMA T. The resident was sent to the hospital where they discovered a broken hip and arm.
On 1/25/23 at 12:30 P.M., during an observation of Resident D, the resident was observed sitting on the edge of his bed eating lunch utilizing the over bed table. Resident D had a brace to his right forearm and 2 healing incisions both approximately 3 cm (centimeters) long to the right hip. In an interview, conducted at that time, the resident indicated he went to the nurses station one evening, he was not able to recall the date, for something more to eat. The resident indicated the nurse pointed back to the refrigerator behind the nurses station so he thought the nurse wanted him to go get a snack from the refrigerator. Resident D indicated when he opened the door the nurse jumped up and took him out of the Nurse's Station and threw him onto the floor and that's when his leg and arm broke. The resident indicated he couldn't move, was crying, and hurt bad while the nurse was telling him to get back to his room. Resident D indicated he could not move, so the nurse got him up and hand hauled him to his room and threw him in his bed. The resident indicated all he could do was cry.
On 1/25/23 at 2:00 P.M., the clinical record for Resident D was reviewed. Resident D was admitted on [DATE] with diagnoses included but not limited to: alcohol withdrawal related seizures, alcohol induced chronic pancreatitis, Wenicke's encephalopathy, diabetes and acute respiratory failure with hypoxia.
An admission Minimum Data Set (MDS) dated [DATE], indicated Resident D was severely cognitively impaired and demonstrated verbal behaviors directed at others 1-3 days during the assessment period. Resident D required limited assistance with bed mobility, was independent with transfers, walking in his room and corridors, locomotion on and off the unit, and dressing. He required supervision with eating and limited assistance with toilet use and personal hygiene.
A Significant Change Minimum Data Set, dated [DATE], indicated Resident D was moderately cognitively impaired and demonstrated verbal behaviors directed at others 1-3 days during the assessment period. Resident D required extensive assistance of 2 people with bed mobility, transfers, and toileting, and extensive assistance of 1 person for locomotion on and off the unit, dressing, and personal hygiene. The resident required a wheelchair for mobility. Diagnoses included but were not limited to hip fracture and other fracture (arm).
An Incident Report Number: 117, with a report date of 12/30/22 at 8:02 P.M., was provided by the ED on 1/25/23 at 2:09 P.M. The report indicated an incident date of 12/29/22 at 7:30 P.M., indicating, . the resident approached the Nurses Station and Medication Cart demanding medications. As staff member attempted to redirect resident, the resident became increasingly agitated and persistent, pulling med cart and trying to open. Staff member continued to redirect resulting in a physical altercation with resident falling to floor. Staff member contacted Nurse for assessment .Moble X-ray was completed on morning of 12/30 indicating a Right hip fracture . New orders received to send to ER for further evaluation and treatment .
On 1/25/23 at 3:00 P.M., during an interview, conducted with the Director of Nursing (DON), she indicated she received a call from Licensed Practical Nurse (LPN) L that Resident D had a fall without injuries but was in intense pain. The DON indicated LPN L told her that QMA T indicated he had made a mistake and that was an odd thing to say. The DON indicated she notified the ED on 12/29/22 at about 7:50 P.M., to report the fall and that LPN L had indicated QMA T had made a mistake and told the ED there was something missing in LPN L's report. The DON indicated she asked the ED if she should go to the facility, but was not directed to do so. The DON indicated she did not receive any notifications regarding Resident D until the following morning on 12/30/22 at 6:50 A.M. when the X-Ray technician notified her that Resident D had sustained a fracture to his right hip. The DON indicated she should have gone into the facility when she received the call from LPN L about the resident's fall and the comment made by QMA T indicating he had made a mistake.
On 1/25/23 at 3:07 P.M., during an interview, conducted with the ED, she indicated she received a call from the DON indicating Resident D had sustained a fall and there was some concern about what had happened. The ED indicated she called the facility and spoke with LPN L and had QMA T removed from the facility pending an investigation. The ED indicated she was notified of Resident D's hip fracture on 12/30/22 at 6:50 A.M., when it was reported to the DON. The ED indicated the State Agency was was notified of the allegation of abuse on 1/30/22 at 8:02 P.M., and that the State Agency should have been notified sooner.
A policy, titled Abuse Prohibition, Reporting, and Investigating dated 1/23 was provided by the DON on 1/24/23 at 11:15 A.M. The policy indicated, .Resident Abuse-Staff member .An incident report will be initiated within 2 hours of the allegation, following the guidelines for 'Unusual Occurrence Reporting' via ISDH [Indiana State Department of Health] gateway portal .
This Federal tag relates to complaint IN00399801.
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
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure 1 of 3 residents reviewed for Activities of Daily Living an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure 1 of 3 residents reviewed for Activities of Daily Living and neglect, received showers as scheduled, (Resident B).
Findings include:
On 1/27/22 at 1:00 P.M., the clinical record for Resident B was reviewed. Resident B was most recently admitted on [DATE] with diagnoses that included, but were not limited to: hemiplegia and hemiparesis following a stroke, chronic obstructive pulmonary disease, diabetes, stage 4 chronic kidney disease, and muscle weakness.
Review of the most recent Minimum Data Set (MDS) dated [DATE] for significant change indicated Resident B had moderate cognitive impairment, demonstrated no behaviors, was totally dependent on staff for bathing, and indicated daily preference for choosing between tub bath, shower, bed bath and sponge bath were very important to her.
Review of Resident B's Care Plans included but were not limited to;
Activites, most recently revised on 10/20/22, that indicated resident preferences while in the facility was to choose between a shower, bed bath, sponge bath, or tub bath, and that the resident prefers to bath more than twice a week in the A.M.
ADL (activities of daily living) care, most recently revised on 7/28/21, indicated the resident required assistance with ADLs including assist with bathing as needed per resident preference. Offer showers two times per week, partial bath in between.
Review of Resident B's Shower Report Sheet from 8/29/22 to 11/11/22, indicated the resident's documentation regarding showers or baths were as follows:
9/29/22 Refused Shower
9/15/22 Refused Shower
9/26/22 Partial Bed Bath Given
9/27/22 Complete Bed Bath Given
10/20/22 Refused Shower, attempted 2 times
10/25/22 Refused Shower
There was no other document regarding Resident B's bathing or showering at the facility.
On 1/27/23 at 1:30 P.M., during an interview with the Director of Nursing, she indicated residents at the facility were supposed to be showered 2 times per week or per preference. The Director of Nursing indicated Resident D should have been offered showers more than 2 times weekly due to her preferences and when showers were not given, the reason should have been documented. The Director of Nursing indicated the only records of showers or refusals were provided and noted above.
This Federal tag relates to complaint IN00392986.
3.1-38(a)(2)(A)
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 36% turnover. Below Indiana's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 1 harm violation(s). Review inspection reports carefully.
- • 19 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $12,649 in fines. Above average for Indiana. Some compliance problems on record.
Bottom line: Mixed indicators with Trust Score of 66/100. Visit in person and ask pointed questions.
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About This Facility
What is Cardinal's CMS Rating?
CMS assigns CARDINAL NURSING AND REHABILITATION CENTER an overall rating of 5 out of 5 stars, which is considered much above average nationally. Within Indiana, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Cardinal Staffed?
CMS rates CARDINAL NURSING AND REHABILITATION CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 36%, compared to the Indiana average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Cardinal?
State health inspectors documented 19 deficiencies at CARDINAL NURSING AND REHABILITATION CENTER during 2023 to 2024. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 17 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Cardinal?
CARDINAL NURSING AND REHABILITATION CENTER 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 AMERICAN SENIOR COMMUNITIES, a chain that manages multiple nursing homes. With 144 certified beds and approximately 59 residents (about 41% occupancy), it is a mid-sized facility located in SOUTH BEND, Indiana.
How Does Cardinal Compare to Other Indiana Nursing Homes?
Compared to the 100 nursing homes in Indiana, CARDINAL NURSING AND REHABILITATION CENTER's overall rating (5 stars) is above the state average of 3.1, staff turnover (36%) is significantly lower than the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Cardinal?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "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 facility's Immediate Jeopardy citations.
Is Cardinal Safe?
Based on CMS inspection data, CARDINAL NURSING AND REHABILITATION CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 5-star overall rating and ranks #1 of 100 nursing homes in Indiana. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Cardinal Stick Around?
CARDINAL NURSING AND REHABILITATION CENTER has a staff turnover rate of 36%, 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 Cardinal Ever Fined?
CARDINAL NURSING AND REHABILITATION CENTER has been fined $12,649 across 1 penalty action. This is below the Indiana average of $33,205. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Cardinal on Any Federal Watch List?
CARDINAL NURSING AND REHABILITATION CENTER 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.