Inspection Reports for
Aperion Care Kokomo
3518 S Lafountain St, Kokomo, IN 46902, United States, IN, 46902
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
32.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
669% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
80
60
40
20
0
Census
Latest occupancy rate
100% occupied
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Routine
Deficiencies: 4
Date: Aug 15, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, notification policies, care planning, medication administration, and respiratory care at Aperion Care Kokomo.
Findings
The facility was found deficient in multiple areas including failure to provide written notification of bed hold policies to residents or representatives, lack of comprehensive care plans for certain medical conditions, medication administration outside ordered parameters, and absence of physician orders specifying oxygen flow rates for residents on oxygen therapy.
Deficiencies (4)
Failed to ensure the resident or resident's representative received written notification of the facility's bed hold policy and reason for transfer/discharge for 1 of 2 residents reviewed for hospitalization.
Failed to develop and implement a comprehensive care plan related to hypertension, heart failure, and anticoagulation therapy for 1 of 20 residents reviewed for care plans.
Failed to ensure a physician's order was followed according to ordered parameters for medication administration for 1 of 5 residents reviewed for quality of care.
Failed to ensure equipment settings for prescribed oxygen flow rates were included in the clinical record for 4 of 5 residents reviewed for respiratory care.
Report Facts
Residents reviewed for care plans: 20
Residents reviewed for quality of care: 5
Residents reviewed for respiratory care: 5
Medication administration dates with out-of-parameter dosing: 7
Oxygen flow rates observed: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Indicated no documentation of bed hold policy notification and care plan deficiencies; provided facility policies |
| Qualified Medication Aide 2 | Qualified Medication Aide (QMA) 2 | Provided information on medication administration practices and documentation |
| Registered Nurse 2 | Registered Nurse (RN) 2 | Indicated physician's order with liter flow needed for oxygen administration |
| Regional Nurse Consultant | Regional Nurse Consultant | Indicated nursing measures for oxygen titration |
| LPN 4 | Licensed Practical Nurse (LPN) 4 | Indicated residents on oxygen should have specific liter flow orders and parameters |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 52
Deficiencies: 0
Date: Jul 2, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00462418.
Complaint Details
Complaint IN00462418 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 4
Medicaid census: 41
Other payor census: 7
Inspection Report
Complaint Investigation
Census: 54
Capacity: 54
Deficiencies: 0
Date: Jun 24, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00461708 at Aperion Care Kokomo.
Complaint Details
Complaint IN00461708 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Medicare census: 4
Medicaid census: 43
Other payor census: 7
Inspection Report
Complaint Investigation
Census: 47
Capacity: 47
Deficiencies: 0
Date: May 6, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00458123 at Aperion Care Kokomo.
Complaint Details
Complaint IN00458123 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00458123 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 47
Total Capacity: 47
Medicare Census: 1
Medicaid Census: 35
Other Payor Census: 11
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 9, 2025
Visit Reason
Paper compliance review related to the Investigation of Complaint IN00447825 and unrelated deficiencies completed on December 3, 2024.
Complaint Details
Investigation of Complaint IN00447825 was reviewed and found to be in compliance.
Findings
Aperion Care Kokomo was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the complaint investigation and unrelated deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 3, 2024
Visit Reason
The inspection was conducted in response to Complaint IN00447825 regarding the facility's handling of a resident's specialized wheelchair and other care concerns.
Complaint Details
Complaint IN00447825 related to the missing specialized wheelchair and care issues for Resident B.
Findings
The facility failed to ensure a resident's specialized wheelchair was properly handled and located after discharge, failed to complete accurate pressure ulcer assessments, and failed to properly anchor an indwelling catheter, resulting in harm or potential harm to the resident.
Deficiencies (3)
Failed to ensure a resident's specialized wheelchair was treated with respect and was unable to be located after discharge.
Failed to ensure staff completed an accurate admission assessment of a resident's pressure ulcer by a licensed nurse qualified to assess pressure wounds.
Failed to ensure staff anchored an indwelling catheter with proper placement into a resident's bladder.
Report Facts
Deficiencies cited: 3
Pressure ulcer measurements: 9
Pressure ulcer measurements: 5.5
Pressure ulcer measurements: 0.2
Pressure ulcer measurements: 2.5
Pressure ulcer measurements: 5
Pressure ulcer measurements: 4.2
Pressure ulcer measurements: 1
Pressure ulcer measurements: 5
Pressure ulcer measurements: 4
Pressure ulcer measurements: 3.5
Indwelling catheter size: 16
Indwelling catheter balloon size: 10
Indwelling catheter size: 12
Indwelling catheter balloon size: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director | Interviewed regarding wheelchair handling and facility policies |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed about resident admission and wheelchair evaluation |
| LPN 12 | Licensed Practical Nurse | Nurse who admitted Resident B and involved in wheelchair placement |
| Director of Nursing | Director of Nursing | Interviewed regarding wound care and staff responsibilities |
| Regional President of Operations | Regional President of Operations | Interviewed regarding catheter care information |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 55
Deficiencies: 3
Date: Dec 3, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00447825, which included federal and state deficiencies related to the allegations as well as unrelated deficiencies.
Complaint Details
Complaint IN00447825 was substantiated with federal and state deficiencies cited at F557, F686, and F690 related to the allegations of mishandling of personal property, inadequate pressure ulcer assessment, and improper catheter placement.
Findings
The facility was found deficient in multiple areas including failure to ensure a resident's specialized wheelchair was treated with respect and was not located after discharge, failure to complete an accurate admission assessment of a pressure ulcer by a licensed nurse, and failure to properly anchor an indwelling catheter causing trauma to the resident's urinary tube.
Deficiencies (3)
Failed to ensure a resident's specialized wheelchair was treated with respect and was unable to be located after discharge.
Failed to ensure staff completed an accurate admission assessment of a resident's pressure ulcer by a licensed nurse qualified to assess pressure wounds.
Failed to ensure staff anchored an indwelling catheter with proper placement into a resident's bladder, causing trauma.
Report Facts
Census: 55
Total Capacity: 55
Medicare Census: 4
Medicaid Census: 36
Other Payor Census: 15
Pressure ulcer wound measurements: 9
Pressure ulcer wound measurements: 5.5
Pressure ulcer wound measurements: 0.2
Pressure ulcer wound measurements: 2.5
Pressure ulcer wound measurements: 5
Pressure ulcer wound measurements: 4.2
Pressure ulcer wound measurements: 1
Pressure ulcer wound measurements: 5
Pressure ulcer wound measurements: 4
Pressure ulcer wound measurements: 3.5
Indwelling catheter size: 16
Indwelling catheter size: 12
Balloon size: 10
Balloon size: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sherry Morgan | RN | Laboratory Director's or Provider/Supplier Representative's signature on report |
| LPN 12 | Licensed Practical Nurse | Nurse who admitted Resident B to the facility on 7/12/24 |
| Executive Director | Interviewed regarding wheelchair and facility policies | |
| Assistant Director of Nursing | Interviewed regarding Resident B's admission and call light | |
| Director of Nursing | Interviewed regarding wound care and staff changes | |
| Regional Vice President of Operations | Interviewed regarding catheter placement and facility operations |
Inspection Report
Follow-Up
Census: 55
Capacity: 105
Deficiencies: 2
Date: Dec 2, 2024
Visit Reason
This was a Post Survey Revisit (PSR) to the Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey conducted on 10/01/24, to verify correction of previously cited deficiencies.
Findings
The facility was found in substantial compliance with Emergency Preparedness Requirements and Life Safety Code. However, deficiencies were cited for failure to ensure staff demonstrated knowledge of emergency preparedness policies and procedures, and failure to provide a complete written Fire Safety Plan addressing all required elements.
Deficiencies (2)
Failed to ensure staff were trained and could demonstrate knowledge of emergency preparedness policies and procedures.
Failed to provide a complete written Fire Safety Plan according to LSC 19.7, missing evacuation of smoke compartments and preparation of floors/buildings for evacuation.
Report Facts
Certified beds: 105
Census: 55
Date of compliance: Dec 16, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Markia Baker | Administrator | Named in relation to findings and exit conference |
Inspection Report
Routine
Census: 55
Capacity: 105
Deficiencies: 18
Date: Oct 1, 2024
Visit Reason
Routine Emergency Preparedness and Life Safety Code Recertification survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Emergency Preparedness requirements including failure to maintain a complete Emergency Preparedness Plan, conduct annual training, maintain documentation of drills, and maintain emergency power system testing. Life Safety Code deficiencies included obstructed egress corridors, uneven exit discharge walkways, hazardous storage areas, lack of access to cooktop shutoff, corroded sprinkler heads, unsealed smoke barrier penetrations, missing fire safety plan, incomplete fire drills, improper smoking area maintenance, missing smoke door inspections, untested electrical receptacles, and improper use of power strips.
Deficiencies (18)
Failed to maintain an Emergency Preparedness Plan based on all-hazards risk assessment.
Failed to conduct annual Emergency Preparedness Program training for all staff.
Failed to analyze and document Emergency Preparedness drills and exercises.
Failed to implement emergency power system testing and maintenance per NFPA 110 and Life Safety Code.
Failed to maintain means of egress corridors free of obstructions.
Exit discharge walkway was uneven and not unobstructed.
Hazardous storage areas not protected by self-closing or latching doors.
Staff lacked access to cooktop shutoff switch; kitchen cooking equipment not maintained per fire extinguishing system requirements.
Failed to maintain sprinkler system including missing monthly inspections and corroded sprinkler heads.
Unsealed penetrations in smoke barrier walls compromising smoke resistance.
Failed to maintain electrical terminals and main power switches in safe condition; exposed copper terminals due to missing light bulbs.
Failed to provide and maintain written Fire Safety Plan available to supervisory personnel; plan lacked specific facility information.
Failed to conduct quarterly fire drills on each shift for multiple quarters.
Smoking area not maintained with proper disposal containers; cigarette butts found on ground.
Failed to routinely inspect and maintain smoke barrier doors and oxygen room fire door.
Failed to test non-hospital grade electrical receptacles in resident rooms annually.
Power strip used as substitute for fixed wiring to power high current equipment.
Failed to ensure emergency generator had reliable fuel source and conducted required weekly and monthly testing.
Report Facts
Certified beds: 105
Census: 55
Fire drills missing: 5
Resident sleeping rooms: 45
Smoke barrier doors: 11
Sprinkler heads corroded: 2
Unsealed smoke barrier penetrations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deana Jordan Collins | Regional Nurse Consultant | Signed report and participated in exit conference |
| Maintenance Director | Interviewed multiple times regarding deficiencies and corrective actions | |
| Director of Nursing | Interviewed multiple times regarding deficiencies and corrective actions | |
| Assistant Director of Nursing | Interviewed multiple times regarding deficiencies and corrective actions | |
| Administrator | Participated in exit conference and corrective action planning | |
| Dietary Manager | Interviewed regarding kitchen equipment maintenance |
Inspection Report
Routine
Deficiencies: 7
Date: Sep 23, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including resident rights, care planning, respiratory care, staffing, pharmaceutical services, medication storage, and food service quality.
Findings
The facility was found deficient in multiple areas including failure to honor resident financial rights, incomplete care plan revisions, incorrect oxygen administration, insufficient RN coverage, medication availability issues, improper medication storage, and failure to serve food at proper temperature and follow puree recipes.
Deficiencies (7)
Failed to ensure a resident was able to receive personal funds when requested.
Failed to ensure a care plan was reviewed and revised as appropriate for a resident.
Failed to administer oxygen at the correct flow rate as ordered by the physician for residents.
Failed to ensure a Registered Nurse was in the facility at least 8 consecutive hours a day, 7 days a week for 5 days reviewed.
Failed to ensure medications were available and a resident received scheduled medication as ordered.
Failed to ensure eye drops were dated when opened and medication drawers were free of loose unidentified medications.
Failed to ensure food was served at the proper temperature, menus were followed, or residents were offered substitutions of nutritional value, and puree recipes were followed.
Report Facts
Days without RN coverage: 5
Medication missed days: 7
Medication delivery count: 14
Oxygen flow rate ordered: 3
Oxygen flow rate observed: 2
Food temperature: 118.9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| QMA 3 | Indicated medication was not available and eye drops should have had open dates | |
| Director of Nursing | DON | Provided information on RN coverage, medication issues, and policies |
| Assistant Director of Nursing | ADON | Indicated oxygen flow rate should be as ordered |
| Corporate Business Office Manager | Discussed resident fund management issues | |
| Dietary Manager | DM | Tested food temperature and discussed puree recipe adherence |
| LPN 6 | Indicated oxygen should have been at 3 LPM per physician's order |
Inspection Report
Annual Inspection
Census: 52
Capacity: 52
Deficiencies: 7
Date: Sep 23, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00443390.
Complaint Details
Complaint IN00443390 was investigated and no deficiencies related to the allegations were cited.
Findings
The facility was found deficient in several areas including management of personal funds, care plan revisions, oxygen administration, RN staffing coverage, medication availability, medication storage, and food service quality. Complaint allegations were not substantiated.
Deficiencies (7)
Failed to ensure a resident was able to receive personal funds when requested.
Failed to ensure a care plan was reviewed and revised as appropriate for a resident.
Failed to administer oxygen at the correct flow rate as ordered by the physician for 2 residents.
Failed to ensure a Registered Nurse was in the facility at least 8 consecutive hours a day, 7 days a week for 5 days reviewed.
Failed to ensure medications were available and a resident received scheduled medication as ordered.
Failed to ensure eye drops were dated when opened and medication drawers were free of loose unidentified medications.
Failed to ensure food was served at the proper temperature, menus were followed, substitutions honored, and puree recipes followed.
Report Facts
Census: 52
Total Capacity: 52
Survey Dates: 2024-09-16 to 2024-09-23
Oxygen flow rate ordered: 3
Oxygen flow rate observed: 2
Medication missed days: 7
Eye drops count: 2
Loose medications: 6
Food temperature: 118.9
Food temperature required: 145
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Markia Baker | Administrator | Named as facility administrator on report |
| Corporate Business Office Manager | Involved in personal funds management deficiency | |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan and oxygen administration deficiencies |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding oxygen administration deficiency |
| Scheduler | Interviewed regarding RN staffing deficiency | |
| Qualified Medication Assistant 3 | Interviewed regarding medication availability and storage deficiencies | |
| Dietary Manager | Dietary Manager | Interviewed regarding food service deficiencies |
| Cook 4 | Named in food preparation deficiency | |
| Cook 5 | Named in food preparation deficiency | |
| LPN 6 | Interviewed regarding oxygen administration deficiency |
Inspection Report
Renewal
Deficiencies: 0
Date: Sep 23, 2024
Visit Reason
The inspection was conducted as a paper compliance review for the Recertification and State Licensure survey.
Findings
Aperion Care Kokomo was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 51
Capacity: 51
Deficiencies: 0
Date: Jun 25, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00436059.
Complaint Details
Complaint IN00436059 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the complaint investigation.
Report Facts
Census Bed Type: 51
Medicare Census: 5
Medicaid Census: 35
Other Payor Census: 11
Inspection Report
Complaint Investigation
Census: 44
Capacity: 44
Deficiencies: 0
Date: Apr 17, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00428969 and IN00432351.
Complaint Details
Investigation of complaints IN00428969 and IN00432351 found no deficiencies related to the allegations; both complaints were not substantiated.
Findings
No deficiencies related to the allegations in complaints IN00428969 and IN00432351 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 44
Total Capacity: 44
Medicare Census: 3
Medicaid Census: 32
Other Payor Census: 9
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 5, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00425889 completed on January 24, 2024.
Complaint Details
Investigation of Complaint IN00425889 completed on January 24, 2024; facility found in compliance.
Findings
Aperion Care Kokomo was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 24, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of resident mistreatment, verbal aggression, and misappropriation of resident property at Aperion Care Kokomo.
Complaint Details
The complaint involved multiple allegations against LPN 2 for verbal aggression, use of profanity, disrespectful treatment of residents, and failure to respond appropriately to resident requests. LPN 2 was given verbal and written warnings and ultimately terminated. Additionally, CNA 3 was found to have taken money from residents improperly and was terminated. The complaint is identified as IN00425889.
Findings
The facility failed to ensure residents were treated with respect and dignity by a staff member, resulting in verbal aggression and disrespectful behavior towards multiple residents. Additionally, the facility failed to protect residents from theft, as a staff member was found to have taken resident money improperly. Corrective actions included staff termination and training.
Deficiencies (2)
Facility failed to ensure residents were treated with respect and dignity by a staff member for 4 of 8 residents reviewed.
Facility failed to protect a resident from theft related to a staff member not returning change after picking up food.
Report Facts
Residents reviewed for respect and dignity: 8
Residents affected by disrespect: 4
Residents reviewed for misappropriation: 2
Residents affected by theft: 2
Money given by Resident C: 50
Money CNA 3 admitted to keeping: 10
Money given by Resident K: 4
Change not returned to Resident K: 0.65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 2 | Licensed Practical Nurse | Named in multiple findings of verbal aggression, disrespect, and use of profanity towards residents; terminated for misconduct. |
| CNA 3 | Certified Nursing Assistant | Named in findings related to theft of resident money; admitted to keeping gas money; terminated for violating company policy. |
| Executive Director | Executive Director | Provided statements and documentation regarding corrective actions and investigation outcomes. |
| Director of Nursing | Director of Nursing | Present during termination phone call with LPN 2. |
| Human Resources Director | Human Resources Director | Present during termination phone call with LPN 2. |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 2
Date: Jan 24, 2024
Visit Reason
The visit was conducted for the investigation of Complaint IN00425889 regarding allegations of resident rights violations and misappropriation of property.
Complaint Details
Complaint IN00425889 was substantiated with findings of verbal abuse, use of profanity, and disrespectful treatment by LPN 2 towards residents, as well as substantiated theft by CNA 3 involving resident funds. LPN 2 was terminated for misconduct and CNA 3 was terminated for misappropriation of resident money.
Findings
The facility was found to have failed to ensure residents were treated with respect and dignity by a staff member, and failed to protect residents from misappropriation of property by staff. Several incidents involving staff verbal abuse, profanity, and theft of resident money were substantiated, resulting in staff terminations and corrective actions.
Deficiencies (2)
Failure to ensure residents were treated with respect and dignity by a staff member for 4 of 8 residents reviewed.
Failure to ensure a resident was free from theft related to a staff member not returning change after picking up food for her.
Report Facts
Census: 42
Medicare residents: 4
Medicaid residents: 29
Other residents: 9
Residents reviewed for respect and dignity: 8
Residents involved in respect and dignity deficiency: 4
Residents reviewed for misappropriation: 2
Amount of money involved in theft: 10
Amount reimbursed to resident: 10
Number of residents interviewed for monitoring: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 2 | Licensed Practical Nurse | Named in multiple findings of verbal abuse, disrespect, and use of profanity towards residents; terminated for misconduct |
| CNA 3 | Certified Nursing Assistant | Named in findings of misappropriation of resident money; terminated for violating company policy |
| Jeff Attinger | RVP of Operations | Signed the report |
Inspection Report
Re-Inspection
Census: 48
Capacity: 48
Deficiencies: 0
Date: Nov 27, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00418301 completed on September 29, 2023, conducted in conjunction with the PSR to the Recertification and State Licensure survey completed on July 28, 2023.
Complaint Details
Complaint IN00418301 was investigated and found to be corrected.
Findings
Aperion Care Kokomo was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the Investigation of Complaint IN00418301, which was corrected.
Report Facts
Census: 48
Total Capacity: 48
Medicare Census: 4
Medicaid Census: 33
Other Payor Census: 11
Inspection Report
Re-Inspection
Census: 48
Capacity: 48
Deficiencies: 0
Date: Nov 27, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure survey completed on July 28, 2023, conducted in conjunction with the PSR to the Investigation of Complaint IN00418301 completed on September 29, 2023.
Complaint Details
Complaint IN00418301 was investigated and found to be corrected.
Findings
Aperion Care Kokomo was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the Recertification and State Licensure survey. The complaint IN00418301 was corrected.
Report Facts
Census SNF/NF: 48
Total Capacity: 48
Census Payor Type Medicare: 4
Census Payor Type Medicaid: 33
Census Payor Type Other: 11
Inspection Report
Complaint Investigation
Census: 50
Capacity: 50
Deficiencies: 0
Date: Oct 20, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00418807.
Complaint Details
Complaint IN00418807 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00418807 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Medicare census: 3
Medicaid census: 35
Other payor census: 12
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 19, 2023
Visit Reason
The document reports on paper compliance to the Post Survey Revisit (PSR) conducted on 09/25/23 for the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey conducted on 08/18/23.
Findings
Aperion Care Kokomo was found in compliance with Medicare/Medicaid Emergency Preparedness Requirements and Life Safety Code from Fire requirements, including the 2012 Edition of the NFPA 101 Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Sep 29, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of mental and verbal abuse, intimidation, and improper discharge of a resident by the previous Executive Director (ED) at the facility.
Complaint Details
The complaint involved allegations that the previous Executive Director verbally and mentally abused Resident B, intimidated staff and residents, and improperly discharged Resident B against her wishes. The investigation confirmed the allegations, leading to the termination of the previous ED. Resident B was offered to return to the facility after the incident.
Findings
The facility failed to ensure a resident was free from mental and verbal abuse and intimidation by the previous ED, failed to ensure staff intervened during the abuse, and failed to provide required 72-hour psychosocial follow-up after the incident. The previous ED acted unprofessionally, intimidating staff and residents, leading to a resident being discharged against her wishes. The previous ED was terminated following the investigation.
Deficiencies (4)
Failed to protect a resident from mental and verbal abuse and intimidation by the Executive Director.
Failed to ensure staff intervened while a resident was being mentally and verbally abused and intimidated.
Failed to provide 72-hour psychosocial follow-up for a resident after abuse.
Failed to ensure facility-initiated transfer or discharge aligned with resident's goals and preferences; resident was told to leave by the Executive Director.
Report Facts
Date of incident: Sep 20, 2023
Date of survey completion: Sep 29, 2023
Resident's Brief Interview for Mental Status score: 11
Resident's Mini Mental State Examination score: 28
Resident's Dementia Assessment score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident B | Resident | Subject of abuse and improper discharge by previous Executive Director. |
| Previous Executive Director | Executive Director | Alleged and confirmed to have verbally and mentally abused Resident B and intimidated staff; terminated after investigation. |
| Interim Executive Director | Interim Executive Director | Spoke with Resident B after incident and offered her to return to the facility; provided investigation information. |
| Business Office Manager | Business Office Manager | Provided information about previous ED and resident's husband living arrangements. |
| CNA 7 | Certified Nursing Assistant | Witnessed yelling by previous ED and intimidation; did not intervene due to fear. |
| CNA 8 | Certified Nursing Assistant | Witnessed previous ED yelling at Resident B and instructed to get boxes; felt intimidated. |
| CNA 10 | Certified Nursing Assistant | Witnessed previous ED yelling at CNAs; confused by aggressive behavior. |
| LPN 9 | Licensed Practical Nurse | Reported previous ED yelling and upset behavior. |
| ADON | Assistant Director of Nursing | Witnessed previous ED yelling and aggressive behavior; involved in incident with Resident B. |
| DON | Director of Nursing | Witnessed previous ED behavior and involved in incident with Resident B. |
| Floor Tech 12 | Floor Technician | Observed previous ED instructing staff to get boxes for Resident B. |
| Social Service Director | Social Service Director | Did not perform required psychosocial assessment after abuse allegation. |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 48
Deficiencies: 2
Date: Sep 29, 2023
Visit Reason
Investigation of Complaints IN00416939 and IN00418301. Complaint IN00416939 found no deficiencies; Complaint IN00418301 cited federal/state deficiencies related to abuse and improper discharge.
Complaint Details
Complaint IN00418301 substantiated with federal/state deficiencies cited at F600 (abuse) and F622 (transfer and discharge). Complaint IN00416939 found no deficiencies related to allegations.
Findings
The facility failed to ensure a resident was free from mental and verbal abuse and intimidation by the previous Executive Director (ED), who also improperly instructed the resident to leave the facility. The resident was verbally abused, intimidated, and discharged against her will but returned the next day with no adverse outcomes. The previous ED was terminated due to these actions.
Deficiencies (2)
Failed to ensure a resident was free from mental and verbal abuse and intimidation by the Executive Director, and failed to provide 72-hour psychosocial follow-up after abuse.
Failed to ensure facility-initiated transfer or discharge was in alignment with resident's goals and preferences; resident was told to leave by the Executive Director.
Report Facts
Census SNF/NF beds: 48
Census Medicare residents: 5
Census Medicaid residents: 35
Census Other residents: 8
Deficiency completion date: Oct 20, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Attinger | RVP of Operations | Signed report as provider/supplier representative |
| Previous Executive Director | Named in findings for verbal and mental abuse, intimidation, and improper discharge of Resident B | |
| Interim Executive Director | Spoke with Resident B and offered return to facility; provided plan of correction information | |
| CNA 7 | Certified Nursing Assistant | Witnessed verbal abuse incident and reported intimidation by previous ED |
| CNA 8 | Certified Nursing Assistant | Witnessed verbal abuse incident and assisted resident with packing belongings |
| CNA 10 | Certified Nursing Assistant | Witnessed verbal abuse incident and reported previous ED's aggressive behavior |
| ADON | Assistant Director of Nursing | Witnessed verbal abuse and aggressive behavior by previous ED |
| DON | Director of Nursing | Witnessed verbal abuse and aggressive behavior by previous ED |
| Social Service Director | Involved in post-incident resident interview and noted lack of psychosocial assessment | |
| Qualified Medication Aide 6 | Reported previous ED delivering boxes to resident's room | |
| Floor Tech 12 | Observed previous ED instructing staff to get boxes for resident |
Inspection Report
Re-Inspection
Census: 48
Capacity: 105
Deficiencies: 3
Date: Sep 25, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey originally conducted on 08/16/23 to verify correction of previous deficiencies.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements, Life Safety Code requirements including evacuation and relocation plan, fire safety plan adherence, and oxygen transfilling signage. Deficiencies included incomplete staff training on emergency preparedness and fire safety plans, failure to immediately contact fire department during fire conditions, and lack of proper signage in the oxygen storage/transfer room.
Deficiencies (3)
Failed to conduct annual training for the Emergency Preparedness Program; incomplete staff training sign-in sheet with only 29 of 63 employees trained by completion date.
Failed to follow written fire safety plan including immediate contact of fire department upon fire condition; incomplete staff training on fire safety plan by completion date.
Failed to provide proper signage indicating oxygen transfilling is occurring in the oxygen storage/transfer room.
Report Facts
Certified beds: 105
Census: 48
Employees listed on EPP training sign-in sheet: 63
Employees signed on EPP training sign-in sheet: 29
Residents potentially affected by oxygen signage deficiency: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Attinger | RVP of Operations | Signed report as provider/supplier representative |
| Director of Nursing | Interviewed regarding incomplete emergency preparedness training and fire safety plan training | |
| Maintenance Director | Interviewed regarding incomplete emergency preparedness training and fire safety plan training; involved in oxygen room signage observation | |
| Maintenance Supervisor | Interviewed regarding oxygen storage/transfer room signage |
Inspection Report
Life Safety
Census: 73
Capacity: 105
Deficiencies: 25
Date: Aug 18, 2023
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted due to regulatory compliance and an Immediate Jeopardy related to fire safety.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code standards, including deficiencies in emergency preparedness plan updates, fire safety plan execution, fire alarm system maintenance, fire drills, combustible decorations, corridor door integrity, electrical safety, generator testing, and oxygen storage.
Deficiencies (25)
Failed to review and update the Emergency Preparedness Plan (EPP) at least annually.
Failed to review and update the Emergency Preparedness Plan (EPP) Policies and Procedures at least annually.
Failed to ensure Emergency Preparedness Plan (EPP) subsistence needs policies and procedures did not have conflicting policies.
Failed to ensure Emergency Preparedness Plan (EPP) include non-conflicting information for safe evacuation from the LTC facility.
Failed to review and update the Emergency Preparedness Plan (EPP) Communication program at least annually.
Failed to review and update the Emergency Preparedness Plan (EPP) Training and Testing program at least annually.
Failed to implement emergency power system inspection, testing, and maintenance requirements; generator missing monthly load testing documentation and natural gas reliability letter.
Failed to maintain latching hardware on 3 of 8 smoke barrier doors.
Failed to ensure at least 50 of 50 Packaged Terminal Air Conditioner (PTAC) units were maintained in a safe operational condition; dirty or clogged air filters.
Failed to ensure 2 of 10 delayed egress locking arrangements were installed in accordance with code requirements.
Failed to ensure 139 DEG 'Bell Style' heat detectors were removed from the fire alarm system.
Failed to ensure staff were instructed in the use of the UL 300 hood system in the kitchen.
Failed to maintain fire alarm system in accordance with NFPA 70 and NFPA 72; presence of non-tied heat detectors.
Failed to provide complete fire watch policy including notification to Indiana Department of Health.
Failed to inspect 2 of over 20 portable fire extinguishers monthly.
Failed to ensure corridor doors resist passage of smoke and close properly; holes in doors and privacy curtains blocking doors.
Failed to ensure access and working space was maintained in 1 of 1 electrical panel in the mechanical room; storage blocking panel.
Failed to ensure hospital-grade electrical receptacles testing form showed each receptacle was tested and results documented.
Failed to maintain natural gas emergency generator testing documentation for 36-month continuous run and fuel reliability letter.
Failed to segregate and mark empty oxygen cylinders from full cylinders in storage.
Failed to post sign indicating oxygen transfilling is occurring in liquid oxygen storage/transfer room.
Failed to follow written fire safety plan during actual fire resulting in Immediate Jeopardy due to delayed fire alarm activation and resident evacuation.
Failed to provide complete and non-conflicting written emergency fire safety plan incorporating all required elements.
Failed to ensure fire drills included simulation of emergency fire conditions.
Failed to maintain smoking areas by disposing cigarette butts in metal or noncombustible containers with self-closing covers.
Report Facts
Certified beds: 105
Census: 73
Deficiencies cited: 29
Fire drills missing emergency simulation: 12
Smoke barrier doors with faulty latching: 3
PTAC units inspected: 50
Delayed egress locks deficient: 2
Battery operated smoke alarms tested monthly: 50
Corridor doors with holes: 4
Corridor doors blocked by privacy curtains: 3
Electrical receptacles with exposed wiring: 2
Fire extinguishers missed monthly inspection: 2
Oxygen cylinders improperly segregated: 15
Cigarette butts improperly disposed: 30
Inspection Report
Routine
Deficiencies: 13
Date: Jul 28, 2023
Visit Reason
The inspection was conducted to evaluate compliance with Medicare and Medicaid regulations, including beneficiary notification, resident transfer notifications, care planning, medication administration, nutrition monitoring, pain management, dialysis care, pharmacy reviews, medication storage, dental services, arbitration agreements, immunizations, and environmental safety.
Findings
The facility was found deficient in multiple areas including failure to issue Medicare Part A beneficiary notices, failure to notify family and ombudsman of resident transfers, lack of initial care plan meetings, delayed administration of anti-anxiety medication, failure to recognize and report significant weight changes, lack of pain medication availability, inadequate monitoring of fluid restrictions for dialysis patients, unaddressed pharmacy recommendations, improper medication storage, failure to assess resident dental service preferences, improper handling of arbitration agreements, missing consents for influenza vaccinations, and environmental safety issues such as damaged walls, ceiling tiles, debris, and unsafe outdoor concrete.
Deficiencies (13)
Failed to ensure residents with Medicare Part A services ending were issued Skilled Nursing Facility Advance Beneficiary Notices of Non-coverage for 2 of 3 residents reviewed.
Failed to notify family and Ombudsman before transfer or discharge for 1 of 3 residents reviewed for hospitalization.
Failed to ensure an initial care plan meeting was held for a cognitively intact resident for 1 of 1 resident reviewed.
Failed to ensure residents were given anti-anxiety medication as scheduled for 1 of 5 residents reviewed.
Failed to recognize and notify the physician of significant weight gain or loss for 4 of 5 residents reviewed for nutrition.
Failed to ensure a resident's PRN pain medication was available and to notify the physician when it was not available for 1 of 1 resident reviewed.
Failed to ensure residents were monitored for fluid restriction for 1 of 1 resident reviewed for dialysis.
Failed to ensure a pharmacy recommendation was addressed by the physician for 1 of 5 residents reviewed for unnecessary medications.
Failed to ensure medications were stored properly in locked compartments and labeled for 1 of 2 medication rooms reviewed.
Failed to ensure a resident's preference to obtain dental services was assessed for 1 of 1 resident reviewed.
Failed to ensure residents understood arbitration agreements and that electronic signatures were only applied if residents agreed for 2 of 3 residents reviewed.
Failed to ensure residents who received influenza vaccines signed consents and education for 3 of 5 residents reviewed.
Failed to ensure the nursing home environment was safe, clean, and well maintained including walls, ceilings, floors, and outdoor areas for multiple rooms, halls, and the smoking area.
Report Facts
Residents reviewed for beneficiary notification: 3
Residents reviewed for hospitalization notification: 3
Residents reviewed for care plan meetings: 1
Residents reviewed for quality of care medication: 5
Residents reviewed for nutrition: 5
Residents reviewed for pain management: 1
Residents reviewed for dialysis care: 1
Residents reviewed for unnecessary medications: 5
Medication rooms reviewed: 2
Residents reviewed for dental services: 1
Residents reviewed for arbitration agreements: 3
Residents reviewed for immunizations: 5
Rooms observed for environment: 8
Halls observed for environment: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Indicated Social Worker was new and unsure if SNF ABN forms were completed | |
| Director of Nursing | DON | Indicated no documentation of family or Ombudsman notification; discussed medication and weight monitoring issues; explained pain medication delay; noted unaddressed pharmacy recommendations |
| Social Services Director | SSD | Indicated no initial care plan meeting held with Resident 102; explained dental consent process |
| LPN 3 | Indicated Resident 48 had continuous enteral feeding; Resident 40 fluid restriction unclear | |
| Admissions Director | Explained arbitration agreement electronic signature process and resident discussions | |
| Administrator | Indicated no policy on arbitration agreements; explained plant chemical container ownership; discussed environmental issues | |
| Maintenance Director | Discussed ceiling tile and door painting issues; noted water condensation and uneven concrete |
Inspection Report
Annual Inspection
Census: 46
Capacity: 46
Deficiencies: 14
Date: Jul 28, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from July 23 to July 28, 2023.
Findings
The facility was found deficient in multiple areas including Medicare beneficiary notification, transfer/discharge notifications, care plan meetings, medication administration, nutrition monitoring, pain management, dialysis monitoring, drug regimen review, medication storage, dental services, arbitration agreements, immunization consents, environmental conditions, and employee health screenings.
Deficiencies (14)
Failed to ensure residents with Medicare Part A services ending were issued Skilled Nursing Facility Advance Beneficiary Notices of Non-coverage (SNF ABNs).
Failed to notify family and Ombudsman for a resident hospitalized and transferred to another facility.
Failed to ensure an initial care plan meeting was held for a cognitively intact resident.
Failed to ensure residents were given anti-anxiety medication as scheduled.
Failed to recognize and notify the physician of significant weight gain or loss for residents.
Failed to ensure a resident's PRN pain medication was available and physician notified when unavailable.
Failed to ensure residents on dialysis were monitored for fluid restriction.
Failed to ensure pharmacy recommendations were addressed by the physician.
Failed to ensure medications were stored properly in medication rooms.
Failed to ensure a resident's preference for dental services was assessed and dental services arranged.
Failed to ensure residents understood arbitration agreements and that electronic signatures were only obtained if agreement was given.
Failed to ensure residents who received influenza vaccines signed consents and education forms.
Failed to maintain a safe, functional, sanitary, and comfortable environment including repair of walls, ceilings, floors, and removal of hazardous chemicals.
Failed to ensure new employees received required physical exams, TB testing, and annual risk assessments.
Report Facts
Census: 46
Total Capacity: 46
Survey Dates: 2023-07-23 to 2023-07-28
Weight Gain Resident 40: 25.22
Weight Gain Resident 48: 34.87
Weight Loss Resident 8: 6.1
Weight Loss Resident 9: 7.6
Brown Stains on Ceiling Tiles: 11
Days without oxycodone: 3
Audit Frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paula Carroll | Administrator | Signed report and involved in interviews |
| Business Office Manager | Mentioned in relation to Medicare beneficiary notification deficiency and arbitration agreement | |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including medication administration, care plans, and pharmacy recommendations |
| Social Services Director | Social Services Director | Interviewed regarding care plan meetings, transfer notifications, and dental services |
| Admissions Director | Admissions Director | Interviewed regarding arbitration agreements and dental consents |
| Maintenance Director | Maintenance Director | Interviewed regarding environmental deficiencies |
| LPN 3 | Licensed Practical Nurse | Mentioned in relation to medication administration and employee health screening deficiencies |
| LPN 4 | Licensed Practical Nurse | Mentioned in relation to employee health screening deficiencies |
| CNA 5 | Certified Nursing Assistant | Mentioned in relation to employee health screening deficiencies |
| LPN 6 | Licensed Practical Nurse | Mentioned in relation to employee health screening deficiencies |
| CNA 7 | Certified Nursing Assistant | Mentioned in relation to employee health screening deficiencies |
| CNA 8 | Certified Nursing Assistant | Mentioned in relation to employee health screening deficiencies |
| CNA 9 | Certified Nursing Assistant | Mentioned in relation to employee health screening deficiencies |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 52
Deficiencies: 0
Date: Jun 27, 2023
Visit Reason
This visit was for the investigation of Complaint IN00410606.
Complaint Details
Complaint IN00410606 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Report Facts
Census: 52
Total Capacity: 52
Payor Type Census: 1
Payor Type Census: 43
Payor Type Census: 8
Inspection Report
Complaint Investigation
Census: 53
Capacity: 53
Deficiencies: 0
Date: May 4, 2023
Visit Reason
This visit was conducted for the investigation of multiple complaints identified as IN00402872, IN00402962, IN00403648, IN00404808, and IN00406824.
Complaint Details
Complaints IN00402872, IN00402962, IN00403648, IN00404808, and IN00406824 were investigated and no deficiencies related to the allegations were found.
Findings
No deficiencies related to the allegations in any of the complaints were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B.
Report Facts
Census SNF/NF beds: 53
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 42
Census Payor Type - Other: 9
Inspection Report
Complaint Investigation
Census: 62
Capacity: 62
Deficiencies: 0
Date: Jan 30, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00399827.
Complaint Details
Complaint IN00399827 was substantiated; however, no deficiencies related to the allegations were cited.
Findings
The complaint was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census bed type: 62
Medicare census: 11
Medicaid census: 36
Other payor census: 15
Inspection Report
Complaint Investigation
Census: 61
Capacity: 61
Deficiencies: 0
Date: Jan 4, 2023
Visit Reason
This visit was conducted for the investigation of three complaints: IN00395301, IN00396855, and IN00397824.
Complaint Details
Complaint IN00395301 - Unsubstantiated due to lack of evidence. Complaint IN00396855 - Unsubstantiated due to lack of evidence. Complaint IN00397824 - Substantiated. No deficiencies related to the allegations were cited.
Findings
Two complaints (IN00395301 and IN00396855) were unsubstantiated due to lack of evidence, while the third complaint (IN00397824) was substantiated but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census SNF/NF beds: 61
Total census: 61
Medicare census: 9
Medicaid census: 39
Other payor census: 13
Inspection Report
Follow-Up
Census: 57
Capacity: 105
Deficiencies: 0
Date: Oct 17, 2022
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 08/23/22 by the Indiana Department of Health.
Findings
At this Post Survey Revisit, Aperion Care Kokomo was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 483.73, and with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Report Facts
Certified beds: 105
Census: 57
Inspection Report
Complaint Investigation
Census: 59
Capacity: 59
Deficiencies: 0
Date: Oct 7, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00390231.
Complaint Details
Complaint IN00390231 - Substantiated. No deficiencies related to the allegations were cited.
Findings
Complaint IN00390231 was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census bed type: 59
Census payor type - Medicare: 3
Census payor type - Medicaid: 44
Census payor type - Other: 12
Inspection Report
Complaint Investigation
Census: 55
Capacity: 55
Deficiencies: 0
Date: Sep 7, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00386507 and IN00386859.
Complaint Details
Complaint IN00386507 - Substantiated with no deficiencies cited. Complaint IN00386859 - Substantiated with no deficiencies cited.
Findings
Both complaints IN00386507 and IN00386859 were substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census SNF/NF beds: 55
Census total beds: 55
Census Medicare residents: 2
Census Medicaid residents: 39
Census other payor residents: 14
Census total residents: 55
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 29, 2022
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on July 13, 2022.
Findings
Aperion Care Kokomo was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Recertification and State Licensure Survey.
Inspection Report
Routine
Census: 57
Capacity: 105
Deficiencies: 20
Date: Aug 23, 2022
Visit Reason
Routine Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health in accordance with federal regulations.
Findings
The facility was found in substantial compliance with Emergency Preparedness Requirements but had multiple deficiencies related to emergency preparedness plan review, life safety code violations including door latch issues, corridor obstructions, fire alarm and sprinkler system maintenance, portable fire extinguisher inspections, electrical receptacle testing, improper use of power strips, oxygen cylinder storage, and smoking area maintenance.
Deficiencies (20)
Failed to develop and maintain an emergency preparedness plan reviewed and updated at least annually.
Failed to develop and maintain emergency preparedness policies and procedures reviewed and updated at least annually.
Failed to develop and maintain an emergency preparedness communication plan reviewed and updated at least annually.
Failed to develop and maintain an emergency preparedness training and testing program reviewed and updated at least annually.
Kitchen door had an independent deadbolt in addition to door handle latch, requiring more than one operation to open.
Corridor obstruction by non-wheeled equipment (3-drawer chest) reducing clear corridor width below required minimum.
Means of egress obstructed by a scale in corridor.
Exit door near resident room #129 was magnetically locked with keypad code not posted.
Exterior overhang at main entrance constructed of wood and not sprinkled underneath.
Corridor door to hazardous storage room lacked self-closing device.
Fire alarm system sensitivity testing documentation not available.
Sprinkler system internal pipe inspection documentation not available.
Fire hydrant inspection failed due to frozen valve; no documentation of repair provided.
Portable fire extinguishers missing monthly inspection tags for July 2022.
Resident room doors (9 of 49) failed to fully close and latch into the frame.
Barrier doors (3 of 6) failed to fully close leaving gaps allowing smoke passage.
Smoking area container was not an approved metal container with self-closing cover device.
Small oxygen cylinder was not properly secured in the nurses station medication room.
Nonhospital-grade electrical receptacles at resident rooms were not fully tested for polarity and retention.
Power strip used improperly in Harmony Hall nurses station.
Report Facts
Certified beds: 105
Current census: 57
Residents affected by corridor obstruction: 12
Residents affected by door latch issues: 40
Residents affected by barrier door gaps: 32
Residents affected by oxygen cylinder storage: 24
Residents affected by power strip misuse: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Attinger | RVP of Operations | Named as facility representative signing report |
| Maintenance Director | Interviewed and acknowledged multiple deficiencies including door latch issues, corridor obstructions, fire alarm and sprinkler system maintenance, oxygen storage, and power strip misuse | |
| Administrator-in-Training | Interviewed and acknowledged multiple deficiencies and participated in exit conference |
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