Inspection Report Summary
The most recent inspection on June 16, 2025, identified deficiencies related to activities of daily living care and infection control during medication administration. Earlier inspections showed a pattern of citations involving resident care issues such as assistance with daily living activities, medication management, infection control, and environmental maintenance. Several complaint investigations were substantiated, including one with immediate jeopardy in late 2023 related to enteral feeding practices that resulted in a resident’s death, though that issue was addressed with corrective actions. Fines or license suspensions were not listed in the available reports. While deficiencies have recurred over time, recent inspections indicate some corrective actions and partial improvements in compliance.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
28.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
574% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 91
Capacity: 91
Deficiencies: 2
Date: Jun 16, 2025
Visit Reason
This visit was for the investigation of complaints IN00460159, IN00460223, and IN00461609 at Casa of Hobart.
Complaint Details
Complaint IN00460159 was substantiated with federal/state deficiencies cited at F677 and F880. Complaints IN00460223 and IN00461609 had no deficiencies related to the allegations.
Findings
The facility was found deficient related to activities of daily living (ADL) care for dependent residents and infection prevention and control during medication administration. Two residents did not receive showers as scheduled, and a staff member failed to wear gloves when handling medication capsules.
Deficiencies (2)
Failed to ensure activities of daily living (ADLs) were completed for dependent residents related to showers for 2 of 3 residents reviewed (Residents D and B).
Failed to ensure infection control practices were implemented related to opening a medication capsule without gloves during medication administration.
Report Facts
Census: 91
Total Capacity: 91
Medicare Census: 5
Medicaid Census: 70
Other Payor Census: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Falon Wendel | RN, Director of Nursing | Interviewed regarding ADL care and infection control deficiencies; responsible for staff education and corrective actions. |
| LPN 1 | Observed opening medication capsule without gloves during medication administration. | |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding infection control concern; no further information provided. |
| Nurse Consultant | Nurse Consultant | Interviewed regarding shower sheet documentation and concerns. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 13, 2025
Visit Reason
Paper compliance review to the Investigation of Complaints IN00456268, IN00457998, IN00458519, IN00458693, and IN00459297 completed on May 15, 2025.
Complaint Details
Paper compliance review related to multiple complaint investigations was completed and found in compliance.
Findings
Casa of Hobart was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the complaint investigation.
Inspection Report
Re-Inspection
Census: 95
Capacity: 138
Deficiencies: 0
Date: Apr 8, 2025
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey that exited on 03/03/2025.
Findings
At this Emergency Preparedness survey, Casa of Hobart was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. At the Life Safety Code PSR, the facility was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and applicable codes.
Report Facts
Certified beds: 138
Census: 95
Inspection Report
Complaint Investigation
Census: 90
Capacity: 90
Deficiencies: 0
Date: Mar 24, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00455863.
Complaint Details
Complaint IN00455863 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00455863 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 70
Census Payor Type - Other: 16
Inspection Report
Re-Inspection
Census: 87
Capacity: 87
Deficiencies: 0
Date: Mar 12, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on January 29, 2025, including a PSR to the Investigation of Complaints IN00450254, IN00450652, and IN00451800, and was conducted in conjunction with the Investigation of Complaints IN00453904 and IN00454281.
Complaint Details
Complaint IN00450254 - Corrected. Complaint IN00450652 - Corrected. Complaint IN00451800 - Corrected. Complaint IN00453904 - No deficiencies related to the allegations are cited. Complaint IN00454281 - No deficiencies related to the allegations are cited.
Findings
Casa of Hobart was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the PSR to the Recertification and State Licensure Survey and the PSR to the Investigation of Complaints IN00450254, IN00450652, and IN00451800. Complaints IN00450254, IN00450652, and IN00451800 were corrected, and no deficiencies were cited related to complaints IN00453904 and IN00454281.
Report Facts
Census Bed Type: 87
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 72
Census Payor Type - Other: 9
Inspection Report
Complaint Investigation
Census: 87
Capacity: 87
Deficiencies: 0
Date: Mar 12, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00453904 and IN00454281, in conjunction with a Post Survey Revisit to the Recertification and State Licensure Survey and investigation of additional complaints completed on January 29, 2025.
Complaint Details
Complaint IN00453904 and IN00454281 had no deficiencies related to the allegations cited. Complaints IN00450254, IN00450652, and IN00451800 were corrected.
Findings
No deficiencies related to complaints IN00453904 and IN00454281 were cited. Complaints IN00450254, IN00450652, and IN00451800 were corrected. Casa of Hobart was found to be in compliance with relevant federal and state regulations regarding the investigated complaints.
Report Facts
Census: 87
Total Capacity: 87
Medicare Census: 6
Medicaid Census: 72
Other Payor Census: 9
Inspection Report
Life Safety
Census: 91
Capacity: 138
Deficiencies: 13
Date: Mar 3, 2025
Visit Reason
An Emergency Preparedness and Life Safety Code Recertification Survey was conducted to assess compliance with federal and state regulations including emergency preparedness requirements and fire safety codes.
Findings
The facility was found not in compliance with emergency preparedness requirements including failure to annually review and update the Emergency Preparedness Plan, Policies and Procedures, Communication Plan, Training and Testing Program, and conduct required emergency exercises. Life Safety Code deficiencies included missing directional exit signage, lack of kitchen exhaust system inspection documentation, improper appliance placement under kitchen hood, lack of staff training on fire suppression system, incomplete sprinkler system inspection documentation, missing annual backflow preventer test, non-functioning GFCI outlet in memory care pantry, and incomplete fire drill documentation.
Deficiencies (13)
Failed to review and update the Emergency Preparedness Plan at least annually.
Failed to review and update Emergency Preparedness Policies and Procedures at least annually.
Failed to review and update the Emergency Preparedness Communication Plan at least annually.
Failed to review and update the Emergency Preparedness Training and Testing Program at least annually.
Failed to conduct at least two emergency preparedness exercises annually including unannounced staff drills.
Failed to ensure exits in 1 of 5 smoke compartments were marked with directional signage.
Failed to provide documentation of kitchen exhaust system inspection and cleaning.
Failed to provide an approved method for returning cooking appliances to approved design location under kitchen hood extinguishing system.
Failed to ensure staff were instructed in the use of the UL 300 hood fire suppression system in the kitchen.
Failed to provide documentation of sprinkler system inspections and testing for 3 of 4 quarters.
Failed to ensure annual testing of backflow prevention device in sprinkler system piping.
Failed to ensure GFCI outlet in memory care unit pantry was functioning properly.
Failed to conduct 4 of 12 required fire drills across all shifts in the most recent twelve month period.
Report Facts
Certified beds: 138
Census: 91
Deficiencies cited: 12
Fire drills missing: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zachary Glassburn | Administrator | Named in relation to findings and exit conference |
| Maintenance Director | Interviewed regarding emergency preparedness deficiencies, fire safety findings, and corrective actions |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 91
Deficiencies: 0
Date: Feb 13, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00452874, IN00453120, IN00453220, and IN00453343.
Complaint Details
Complaints IN00452874, IN00453120, IN00453220, and IN00453343 were investigated and found to have no deficiencies related to the allegations.
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 and 410 IAC 16.2-3.1 regarding the investigation of these complaints.
Report Facts
Census SNF/NF: 91
Total Capacity: 91
Medicare Census: 7
Medicaid Census: 66
Other Payor Census: 18
Inspection Report
Recertification
Census: 92
Capacity: 92
Deficiencies: 15
Date: Jan 29, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00450254, IN00450652, and IN00451800.
Complaint Details
This visit included the investigation of Complaints IN00450254, IN00450652, and IN00451800 with multiple deficiencies cited related to these complaints.
Findings
Multiple deficiencies were cited including failure to ensure proper self-administration of medications, resident privacy, grievance handling, notice of transfer, care plan involvement, ADL assistance, quality of care including wound and catheter care, nutrition monitoring, infection control, medication storage, dental services, and environmental maintenance.
Deficiencies (15)
Facility failed to ensure a resident was assessed and had physician's orders to self-administer medications.
Facility failed to ensure resident privacy during assessment of a peg tube in a common area.
Facility failed to file, investigate, and resolve grievances for missing personal items.
Facility failed to notify resident's responsible party in writing related to hospital transfer.
Facility failed to involve resident in decisions about new medications.
Facility failed to ensure ADLs were completed for dependent residents related to showers and eating assistance.
Facility failed to ensure non-pressure skin conditions were monitored and bandages changed, blood pressure parameters followed, and post cataract surgery assessment performed.
Facility failed to ensure pressure ulcer treatments and IV antibiotics were completed and documented as ordered.
Facility failed to ensure resident received necessary foot care related to podiatry visits.
Facility failed to ensure smoking materials were locked and not in residents' rooms and bed halos were in place as ordered.
Facility failed to ensure Foley catheter care was completed per orders and catheter bags/tubing were kept off the floor with enhanced barrier precautions maintained.
Facility failed to ensure fluid restriction was monitored and accounted for dialysis resident.
Facility failed to ensure proper medication storage including pre-filled syringes, unlabeled insulin pens, loose pills, and unattended medication carts.
Facility failed to ensure infection control practices including hand hygiene, enhanced barrier precautions, and proper disposal of lancets and gloves.
Facility failed to keep resident environment clean and in good repair including marred walls, dirty floors, missing toilet paper holders, feces on linens and room dividers, cracked ceiling tiles, non-working call lights, and hot water temperatures above 120 degrees.
Report Facts
Survey dates: 7
Census: 92
Total capacity: 92
Residents with medication orders: 92
Fluid restriction: 1200
Weight: 92
Weight: 112
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Falon Wendel | RN, DON | Signed report and involved in interviews |
| LPN 2 | Named in medication storage and catheter care findings | |
| LPN 1 | Named in infection control and medication administration findings | |
| Restorative CNA 1 | Named in infection control and catheter care findings | |
| Director of Nursing | DON | Interviewed multiple times regarding findings and policies |
| Unit Manager | Interviewed regarding multiple findings including privacy, catheter care, and infection control | |
| Social Service Director | Interviewed regarding grievance and dental care follow-up | |
| Activity Director Katherine | Interviewed regarding activity program for Resident 81 | |
| Wound Nurse | Interviewed and observed regarding wound care and catheter care | |
| Nurse Consultant 1 | Provided policies and education | |
| Nurse Consultant 2 | Provided policies and education |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 14, 2025
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00449105 completed on December 18, 2024.
Complaint Details
Investigation of Complaint IN00449105 completed on December 18, 2024; facility found in compliance.
Findings
Casa of Hobart 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
Census: 87
Capacity: 87
Deficiencies: 3
Date: Dec 18, 2024
Visit Reason
This visit was for the investigation of complaints IN00449081 and IN00449105. Complaint IN00449081 had no deficiencies related to the allegations, while Complaint IN00449105 resulted in federal/state deficiencies cited at F552, F740, and F755.
Complaint Details
Complaint IN00449081 had no deficiencies related to the allegations. Complaint IN00449105 was substantiated with federal/state deficiencies cited at F552, F740, and F755.
Findings
The facility failed to ensure a resident was given the opportunity to participate in treatment decisions related to medication administration, failed to monitor and document ongoing sexual behaviors for a resident, and failed to ensure medications were ordered and available timely including staff awareness of stocked backup medications for residents during medication administration.
Deficiencies (3)
Failed to ensure a resident was given the opportunity to participate in their treatment related to medication administration.
Failed to ensure a resident with ongoing sexual behaviors was monitored and behaviors were documented.
Failed to ensure medications were ordered and available timely, including staff being aware of stocked backup medications for residents during medication administration.
Report Facts
Census: 87
Total Capacity: 87
Medicare Census: 2
Medicaid Census: 68
Other Payor Census: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alisha Boler | RN BSN RNC | Laboratory Director's or Provider/Supplier Representative's signature on the report |
| Director of Nursing | Interviewed regarding medication administration and behavior monitoring deficiencies | |
| LPN 1 | Observed preparing medications and involved in medication administration deficiency | |
| LPN 2 | Interviewed regarding medication availability and behavior monitoring | |
| QMA 1 | Observed preparing medications and interviewed about resident behaviors | |
| Regional Nurse Consultant | Interviewed regarding behavior charting documentation |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 91
Deficiencies: 1
Date: Sep 16, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00442760 regarding federal and state deficiencies related to resident discharge procedures.
Complaint Details
Complaint IN00442760 was substantiated with federal and state deficiencies cited at F622 related to transfer and discharge requirements.
Findings
The facility failed to ensure that a resident-initiated discharge against medical advice (AMA) was properly documented in the resident's medical record, including notification of the physician, documentation of discharge status, and provision of medication information for continuation of care.
Deficiencies (1)
Failure to document resident-initiated discharge and provide appropriate information for continuation of care, including lack of physician notification and medication list at discharge.
Report Facts
Census SNF/NF beds: 91
Census total residents: 91
Medicare residents: 8
Medicaid residents: 69
Other payor residents: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dilane D Knights | Administrator | Signed the report and plan of correction |
| LPN 1 | Nurse on duty at time of resident discharge AMA, involved in documentation issues | |
| Unit Manager 2 | Allegedly responsible for documenting discharge but denied interaction with resident | |
| Director of Nursing | DON | Interviewed regarding lack of documentation and notification of AMA discharge |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 16, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00442760 completed on September 16, 2024.
Complaint Details
Investigation of Complaint IN00442760; paper compliance review completed and found in compliance.
Findings
Casa of Hobart 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 complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 13, 2024
Visit Reason
The visit was conducted as a paper compliance review related to the investigation of complaints IN00438030, IN00438757, IN00439881, and IN00440433.
Complaint Details
The complaint investigation was completed on August 15, 2024, and the facility was found to be in compliance.
Findings
Casa of Hobart 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
Census: 93
Deficiencies: 7
Date: Aug 15, 2024
Visit Reason
This visit was for the investigation of multiple complaints (IN00438030, IN00438757, IN00438809, IN00439721, IN00439881, IN00440433, and IN00440984) at Casa of Hobart.
Complaint Details
This visit was triggered by complaints IN00438030, IN00438757, IN00438809, IN00439721, IN00439881, IN00440433, and IN00440984. Several complaints were substantiated with deficiencies cited at tags F677, F684, F842, F689, and others. Some complaints had no deficiencies related to the allegations.
Findings
The facility was found deficient in several areas including failure to maintain resident dignity related to uncovered foley catheter drainage bags, failure to ensure proper self-administration medication orders, delayed incontinence care, incomplete treatment of non-pressure skin conditions, inadequate fall interventions, improper placement of urinary catheter drainage bags, and incomplete clinical documentation related to insulin administration.
Deficiencies (7)
Failed to ensure each resident's dignity was maintained related to foley catheter drainage bags not being covered for 1 of 2 residents with urinary catheters (Resident H).
Failed to ensure a Physician's Order for self administration of medications and an assessment to self-administer medications was completed for 1 of 1 resident reviewed (Resident B).
Failed to ensure residents dependent on staff for ADLs received timely assistance with incontinence care for 1 of 3 residents (Resident G).
Failed to ensure treatments were completed as ordered for non-pressure skin conditions for 1 of 3 residents (Resident G).
Failed to ensure fall interventions were in place for a resident with a history of falls related to bed height for 1 of 3 residents (Resident H).
Failed to ensure urinary catheter drainage bags were not placed on the floor for 1 of 2 residents reviewed for urinary catheters (Resident F).
Failed to ensure clinical records were complete and accurately documented related to insulin administration for 1 of 3 residents reviewed (Resident L).
Report Facts
Census: 93
Medicare Census: 4
Medicaid Census: 71
Other Payor Census: 8
Deficiency Completion Dates: Aug 28, 2024
Deficiency Completion Dates: Sep 4, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alisha Boler | RN BSN RNC | Laboratory Director or Provider/Supplier Representative who signed the report |
| Nurse Consultant 1 | Interviewed regarding foley catheter dignity bag and catheter drainage bag placement | |
| LPN 1 | Observed leaving medication unattended and interviewed about self-administration order | |
| LPN 2 | Observed providing incontinence care and interviewed about dressing | |
| CNA 1 | Provided incontinence care and interviewed about resident care | |
| CNA 2 | Interviewed about bed height and fall interventions | |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies and corrective actions |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 30, 2024
Visit Reason
Paper compliance review to the Investigation of Complaints IN00432283 and IN00434490 completed on May 29, 2024.
Complaint Details
The visit was related to complaint investigations IN00432283 and IN00434490. The facility was found to be in compliance.
Findings
Casa of Hobart 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 complaint investigation.
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 4
Date: Jul 2, 2024
Visit Reason
This visit was for the investigation of multiple complaints alleging abuse, neglect, and other regulatory violations at Casa of Hobart.
Complaint Details
The investigation involved complaints IN00435972, IN00437067, IN00437072, IN00437100, IN00437119, IN00437347, IN00437524, and IN437564. Some complaints had no deficiencies related to allegations, while others resulted in citations at F609, F689, and F690.
Findings
The facility was found deficient in multiple areas including failure to report allegations of abuse timely, inadequate fall prevention interventions, improper urinary catheter care, and failure to use appropriate personal protective equipment for residents under enhanced barrier precautions.
Deficiencies (4)
Failure to ensure employees reported allegations of abuse by an employee toward residents of the Memory Care Unit.
Failure to ensure care planned interventions to prevent falls were in place related to anti-roll brakes not initiated timely for a resident.
Failure to ensure a resident admitted with a urinary catheter had correct assessment, physician orders, and documented reason; urinary catheter care was incomplete.
Failure to ensure correct Personal Protective Equipment (PPE) was used by staff when providing care to a resident in Enhanced Barrier Precautions.
Report Facts
Census: 92
Medicare residents: 2
Medicaid residents: 73
Other residents: 17
Residents affected by abuse reporting deficiency: 18
Residents affected by PPE deficiency: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dilane Knights | Administrator | Administrator was notified of abuse allegations for the first time during investigation. |
| Employee 7 | Employee alleged to have abused residents on Memory Care Unit. | |
| Terminated Employee 6 | Reported abuse allegations against Employee 7 and described retaliation. | |
| RN 8 | Registered Nurse | Observed not using correct PPE when providing care to resident in Enhanced Barrier Precautions. |
| Director of Nursing | DON | Interviewed regarding abuse reporting, fall prevention, catheter care, and PPE use. |
| LPN 1 | Licensed Practical Nurse | Admission nurse who failed to document urinary catheter on admission assessment. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 2, 2024
Visit Reason
Paper compliance review was conducted for the investigation of multiple complaints (IN00437067, IN00437100, IN00437119, IN00437524, and IN437564).
Complaint Details
The visit was related to complaint investigations with multiple complaint IDs reviewed. The facility was found in compliance.
Findings
Casa of Hobart 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
Census: 85
Capacity: 86
Deficiencies: 5
Date: May 29, 2024
Visit Reason
This visit was for the investigation of complaints IN00431805, IN00432283, and IN00434490.
Complaint Details
This visit was triggered by complaints IN00431805, IN00432283, and IN00434490. Complaint IN00431805 had no deficiencies related to the allegations. Complaints IN00432283 and IN00434490 had federal/state deficiencies cited related to respect and dignity, ADL care, quality of care, accident hazards, and infection control.
Findings
The facility was found deficient in multiple areas including failure to assist a resident to the bathroom upon request, failure to provide timely incontinent care, inadequate investigation of a fracture after a fall, failure to implement fall prevention interventions, and failure to follow infection control protocols including proper use of enhanced barrier precautions.
Deficiencies (5)
Failed to ensure a resident was treated with respect and dignity related to not assisting the resident to the bathroom upon request.
Failed to ensure a resident who required maximum to dependent care received incontinent care in a timely manner.
Failed to ensure a resident received treatment and care in accordance with professional standards related to a fracture after a fall not investigated thoroughly.
Failed to ensure care planned interventions to prevent injuries due to a fall were in place, including floor mats and anti-roll brakes on wheelchair, and failed to complete a urinalysis after a fall.
Failed to ensure correct Personal Protective Equipment (PPE) was used by staff when providing care to a resident in Enhanced Barrier Precautions and failed to remove soiled gloves before touching clean surfaces.
Report Facts
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 65
Census Payor Type - Other: 19
Total Census: 85
Total Capacity: 86
Deficiency Severity - SS=D: 4
Deficiency Severity - SS=E: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dilane Knights | Administrator | Named as facility administrator and interviewed regarding investigation of fracture and infection control |
| CNA 1 | Mentioned in relation to failure to assist resident timely and improper PPE use | |
| Wound Nurse | Mentioned in relation to failure to assist resident timely and improper PPE use | |
| Director of Nursing | Director of Nursing | Interviewed regarding resident care, investigation of fracture, and infection control practices |
Inspection Report
Re-Inspection
Census: 90
Capacity: 90
Deficiencies: 0
Date: May 22, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00430302 and IN00430628 completed on March 27, 2024.
Complaint Details
This visit was related to complaints IN00430302 and IN00430628, both of which were corrected.
Findings
Casa of Hobart was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Investigation of Complaints IN00430302 and IN00430628.
Report Facts
Census SNF/NF beds: 90
Census total residents: 90
Census Medicare residents: 2
Census Medicaid residents: 66
Census other payor residents: 22
Inspection Report
Complaint Investigation
Census: 96
Capacity: 96
Deficiencies: 3
Date: Mar 27, 2024
Visit Reason
The visit was conducted for the investigation of four complaints (IN00429937, IN00430114, IN00430302, and IN00430628) regarding the facility's compliance with regulatory requirements.
Complaint Details
The investigation was triggered by complaints IN00429937, IN00430114, IN00430302, and IN00430628. Complaints IN00429937 and IN00430114 had no deficiencies related to the allegations. Complaints IN00430302 and IN00430628 resulted in cited deficiencies related to medication self-administration and pressure ulcer care and notification.
Findings
The facility was found deficient in ensuring proper physician orders and assessments for resident self-administration of medications, timely notification of resident condition changes to responsible parties, and adequate treatment and monitoring of pressure ulcers. Two residents developed facility-acquired pressure ulcers, including one with a rapidly declining unstageable pressure ulcer consistent with a Kennedy Terminal Ulcer. The facility implemented corrective actions including staff education, audits, and quality assurance monitoring.
Deficiencies (3)
Failure to ensure a resident had Physician's Orders and an assessment to self-administer medication.
Failure to notify resident's Responsible Party of a significant change in condition related to pressure sores.
Failure to provide care consistent with professional standards to prevent and treat pressure ulcers, resulting in facility-acquired pressure ulcers.
Report Facts
Census: 96
Total Capacity: 96
Medicare Census: 8
Medicaid Census: 66
Other Payor Census: 22
Deficiency Severity SS=D: 2
Deficiency Severity SS=G: 1
Pressure Ulcer Size: 15
Pressure Ulcer Size: 10
Pressure Ulcer Size: 0.8
Pressure Ulcer Size: 0.5
Inspection Report
Complaint Investigation
Census: 92
Capacity: 92
Deficiencies: 0
Date: Jan 31, 2024
Visit Reason
This visit was for the investigation of complaints IN00426522 and IN00426603, conducted in conjunction with the post survey revisit to the investigation of complaint IN00421764.
Complaint Details
Complaint IN00426522 - No deficiencies related to the allegations are cited. Complaint IN00426603 - No deficiencies related to the allegations are cited. Complaint IN00421764 - Corrected.
Findings
No deficiencies related to the allegations in complaints IN00426522 and IN00426603 were cited. Complaint IN00421764 was corrected. The facility was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census SNF/NF: 92
Total Capacity: 92
Census Payor Type Medicare: 8
Census Payor Type Medicaid: 58
Census Payor Type Other: 26
Inspection Report
Re-Inspection
Census: 92
Capacity: 92
Deficiencies: 0
Date: Jan 31, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00421764 and was conducted in conjunction with the Investigation of Complaints IN00426522 and IN00426603.
Complaint Details
Complaint IN00421764 was corrected. Complaints IN00426522 and IN00426603 had no deficiencies related to the allegations.
Findings
Casa of Hobart was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the PSR to the Investigation of Complaint IN00421764. Complaints IN00426522 and IN00426603 had no deficiencies related to the allegations cited.
Report Facts
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 58
Census Payor Type - Other: 26
Inspection Report
Complaint Investigation
Census: 95
Capacity: 138
Deficiencies: 0
Date: Jan 24, 2024
Visit Reason
An investigation of Complaint Number IN00426597 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Complaint Details
Complaint IN00426597 was investigated and found to have no deficiencies related to the allegation.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and applicable fire safety codes.
Report Facts
Facility capacity: 138
Census: 95
Inspection Report
Life Safety
Census: 85
Capacity: 138
Deficiencies: 0
Date: Jan 8, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted to verify compliance with fire safety and licensure requirements.
Findings
The facility was found in compliance with the Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. All resident-accessible areas and facility service areas were fully sprinklered.
Inspection Report
Re-Inspection
Census: 85
Capacity: 85
Deficiencies: 0
Date: Dec 12, 2023
Visit Reason
This visit was for the Post Survey Revisit (PSR) to the Recertification and State Licensure Survey and a PSR to the Investigation of Complaints IN00415423 and IN00417794 completed on 2023-11-02. It was also in conjunction with the Investigation of Complaints IN00421764 and IN00422865.
Complaint Details
Complaint IN00415423 was corrected. Complaint IN00417794 was corrected. Complaint IN00421764 had Federal/State deficiencies cited at F693. Complaint IN00422865 had no deficiencies related to the allegations.
Findings
The visit resulted in a Partially Extended Survey with Substandard Quality of Care and Immediate Jeopardy. Complaints IN00415423 and IN00417794 were corrected. Complaint IN00421764 had Federal/State deficiencies cited at F693. Complaint IN00422865 had no deficiencies related to the allegations. Casa of Hobart was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey and the PSR to the Investigation of Complaints IN00415423 and IN00417794.
Report Facts
Census SNF/NF: 85
Total Capacity: 85
Medicare Census: 4
Medicaid Census: 63
Other Payor Census: 18
Inspection Report
Complaint Investigation
Census: 85
Capacity: 85
Deficiencies: 1
Date: Dec 11, 2023
Visit Reason
This visit was for the investigation of complaints IN00421764 and IN00422865, resulting in a Partially Extended Survey due to Substandard Quality of Care with Immediate Jeopardy. It was conducted in conjunction with Post Survey Revisits to previous complaints and recertification surveys.
Complaint Details
Complaint IN00421764 was substantiated with federal/state deficiencies cited at F693 related to the allegations. Complaint IN00422865 had no deficiencies related to the allegations. Complaints IN00415423 and IN00417794 were corrected.
Findings
The facility failed to ensure a moderately impaired resident was not lying flat while receiving enteral tube feeding, which led to labored breathing, projectile vomiting, aspiration, unresponsiveness, intubation, and death. Immediate jeopardy was identified and later removed after staff education and corrective actions, but noncompliance remained at a lower severity level.
Deficiencies (1)
Failed to implement measures to ensure a resident was not lying flat during enteral tube feeding, leading to severe complications and death.
Report Facts
Census: 85
Total Capacity: 85
Medicare Census: 4
Medicaid Census: 63
Other Payor Census: 18
Tube feeding rate: 50
Audit frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosa McGowen | Vice President of Operations | Notified of immediate jeopardy and involved in investigation |
| RN 1 | Registered Nurse | Nurse on duty who observed resident lying flat during feeding and raised head of bed |
| CNA 1 | Certified Nursing Assistant | Responded to resident's mother call, raised head of bed, assisted during emergency |
| LPN 2 | Licensed Practical Nurse | Assisted with suctioning resident during emergency |
| Admissions Director | Manager on duty who observed resident lying flat during feeding and notified RN 1 | |
| Director of Nursing | DON | Interviewed regarding CNA 2's lack of involvement during incident |
| CNA 2 | Certified Nursing Assistant | Did not enter resident's room during incident and expressed discomfort with infection status |
Inspection Report
Life Safety
Census: 94
Capacity: 138
Deficiencies: 8
Date: Nov 16, 2023
Visit Reason
The survey was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 standards.
Findings
The facility was found not in compliance with several Life Safety Code requirements including deficiencies in kitchen fire suppression system inspection, fire alarm system maintenance, sprinkler system installation and maintenance, and corridor door integrity.
Deficiencies (8)
Failed to ensure semiannual inspection of kitchen fire suppression system was conducted.
Failed to maintain fire alarm system with accurate time and date and failed to document semiannual visual inspections.
Failed to provide complete sprinkler coverage in one smoke compartment (walk-in freezer).
Failed to maintain ceiling construction around sprinkler heads; missing or dislodged escutcheon plates.
Failed to maintain sprinkler system; dry sprinkler system failed air leakage test and no documentation of repair.
Failed to provide documentation of quarterly sprinkler system inspections for 2 of 4 quarters in 2023.
Failed to maintain monthly/weekly inspections of wet and dry pipe sprinkler system gauges and valves for several months.
Failed to ensure corridor door resisted passage of smoke; door to physical therapy gym had a hole compromising integrity.
Report Facts
Certified beds: 138
Census: 94
Residents potentially affected: 15
Residents potentially affected: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Pazera | Laboratory Director or Provider/Supplier Representative | Signed the report. |
| Maintenance Director | Involved in inspection findings and interviews regarding fire alarm, sprinkler, and kitchen suppression system deficiencies. | |
| VP of Operations | Involved in inspection findings and interviews regarding fire alarm, sprinkler, and kitchen suppression system deficiencies. | |
| Administrator | Participated in exit conference and plan of correction discussions. |
Inspection Report
Recertification
Census: 94
Capacity: 94
Deficiencies: 16
Date: Nov 2, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey including the Investigation of Complaints IN00415423, IN00417326, IN00417794, and IN00417955.
Complaint Details
This visit included the Investigation of Complaints IN00415423, IN00417326, IN00417794, and IN00417955. Deficiencies related to complaints IN00415423 and IN00417794 were cited. Complaints IN00417326 and IN00417955 had no deficiencies related to the allegations.
Findings
The facility was found deficient in multiple areas including medication self-administration orders, notification of changes to responsible parties, care plan participation, ADL assistance, vision and hearing services, pressure ulcer treatment, oxygen humidification maintenance, pain management, medication labeling and storage, dental services, food safety and sanitation, resident record completeness, quality assurance program implementation, infection control, and environmental maintenance.
Deficiencies (16)
Failed to ensure residents had Physician's Orders and assessments for self-administration of medications for 2 residents.
Failed to notify resident's Responsible Party of medication changes for 1 resident.
Failed to notify resident's Responsible Party in writing related to hospital transfer for 2 residents.
Failed to ensure residents were invited to attend and participate in care planning conferences for 3 residents.
Failed to provide assistance with activities of daily living related to shaving for 1 resident.
Failed to ensure residents were able to see audiologist and optometrist regularly and follow up completed for 2 residents.
Failed to ensure residents with pressure ulcers received necessary treatment and weekly wound measurements for 5 residents.
Failed to ensure oxygen humidification canisters were changed weekly for 1 resident.
Failed to ensure pain medications were available when requested, side effects monitored, and medication signed out for 2 residents.
Failed to ensure medications were labeled correctly related to inhalers and antacid bottle for 1 medication cart.
Failed to ensure residents were seen by the dentist for routine dental services for 2 residents.
Failed to store food under sanitary conditions related to outdated food, dirty griddle and ovens, and improperly stored lids in the main kitchen.
Failed to maintain clinical records complete and accurately documented related to monitoring food consumption for 1 resident.
Failed to identify unresolved quality deficiencies and implement corrective actions through the QAA process related to pressure ulcers.
Failed to provide a sanitary and comfortable environment to prevent infections related to disinfecting mattress after blood spill, hand hygiene, and storage of wash basins.
Failed to maintain a sanitary, safe, and homelike environment related to greasy kitchen pipes, rusty equipment, dirty floors, marred walls, scuffed doors and floors, cracked tile, and missing window blinds in kitchen and hallways.
Report Facts
Residents: 94
Medicare residents: 20
Medicaid residents: 61
Other payor residents: 13
Pressure ulcer measurements: 9
Pressure ulcer measurements: 7.5
Pressure ulcer measurements: 1
Pressure ulcer measurements: 4.5
Pressure ulcer measurements: 6
Pressure ulcer measurements: 6.5
Pressure ulcer measurements: 3.5
Pressure ulcer measurements: 1.7
Pressure ulcer measurements: 1.4
Pressure ulcer measurements: 1.3
Pressure ulcer measurements: 3
Oxycodone pills: 30
Oxycodone pills remaining: 16
Oxycodone pills administered: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosa McGowen | VP of Operations | Signed report cover page |
| Nurse Consultant 1 | Interviewed regarding medication orders, care planning, wound care, and infection control | |
| Nurse Consultant 2 | Interviewed regarding medication administration, wound care, and lab monitoring | |
| Director of Nursing | DON | Responsible for audits and QAPI activities |
| Administrator | Interviewed regarding QAPI and facility operations | |
| Social Service Director | Interviewed regarding care planning and dental services | |
| Cook 1 | Interviewed regarding kitchen sanitation | |
| Dietary Food Manager | Interviewed regarding food safety and sanitation | |
| Director of Environmental Services | Interviewed regarding environmental maintenance | |
| Director of Maintenance | Interviewed regarding environmental maintenance | |
| Wound Nurse | Observed and interviewed regarding wound care treatments | |
| LPN 1 | Observed medication administration without hand hygiene | |
| LPN 2 | Observed medication cart and interviewed regarding medication labeling |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 3, 2023
Visit Reason
Paper compliance review to the Investigation of Complaints IN00411679, IN00412121, and IN00412151 completed on July 6, 2023.
Complaint Details
The visit was related to complaint investigations IN00411679, IN00412121, and IN00412151. The facility was found to be in compliance.
Findings
Casa of Hobart 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 complaint investigation.
Inspection Report
Complaint Investigation
Census: 96
Capacity: 96
Deficiencies: 0
Date: Jul 31, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00413109, IN00413329, and IN00413726.
Complaint Details
Complaints IN00413109, IN00413329, and IN00413726 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00413109, IN00413329, and IN00413726 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census SNF/NF: 96
Total Capacity: 96
Census Payor Type - Medicare: 9
Census Payor Type - Medicaid: 71
Census Payor Type - Other: 16
Inspection Report
Complaint Investigation
Census: 94
Capacity: 94
Deficiencies: 5
Date: Jul 5, 2023
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00409415, IN00410185, IN00411679, IN00412121, and IN00412151) regarding care and facility conditions at Casa of Hobart.
Complaint Details
The investigation was triggered by complaints IN00409415, IN00410185, IN00411679, IN00412121, and IN00412151. Complaints IN00409415 and IN00410185 had no deficiencies related to allegations. Complaints IN00411679, IN00412121, and IN00412151 had federal/state deficiencies cited.
Findings
The facility was found deficient in multiple areas including failure to provide adequate ADL care for dependent residents, inadequate treatment and prevention of pressure ulcers, improper catheter care, lack of gastrostomy tube site care orders, and environmental cleanliness and maintenance issues. Several residents were affected by these deficiencies, and corrective actions were planned and implemented.
Deficiencies (5)
Failed to provide ADL assistance related to showers and nail care for 3 of 3 residents reviewed.
Failed to ensure weekly wound measurements were completed for 1 of 3 residents with pressure ulcers.
Failed to ensure appropriate treatment and services for residents with Foley catheters, including catheter drainage bag placement and timely catheter care orders for 2 of 3 residents.
Failed to obtain gastrostomy tube site care orders for cleansing for 1 of 3 residents with gastrostomy tubes.
Failed to provide a safe, functional, sanitary, and comfortable environment related to marred walls, hard water stains on faucets, lifting tiles, trash cans without garbage bags, dirty floors, and loose trim for 2 of 5 units.
Report Facts
Census: 94
Total Capacity: 94
Medicare Census: 15
Medicaid Census: 69
Other Payor Census: 10
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Craig Clemons | Administrator | Signed the report |
| Director of Nursing | Director of Nursing | Interviewed regarding ADL care, wound care, catheter care, and gastrostomy tube care deficiencies |
| CNA 1 | Interviewed regarding wound dressing changes | |
| Maintenance Supervisor | Interviewed regarding environmental maintenance issues |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 19, 2023
Visit Reason
Paper compliance review to the Investigation of Complaints IN00399022, IN00399243, IN00399594, IN00403395, IN00403601, IN00404937, IN00405500, and IN00406294 completed on April 19, 2023.
Complaint Details
Investigation of multiple complaints as listed was completed with paper compliance found.
Findings
Casa of Hobart was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the complaint investigation.
Inspection Report
Complaint Investigation
Census: 96
Capacity: 96
Deficiencies: 8
Date: Apr 18, 2023
Visit Reason
This visit was for the investigation of multiple complaints related to the facility.
Complaint Details
This visit was triggered by multiple complaints (IN00399022, IN00399243, IN00399594, IN00403395, IN00403601, IN00404937, IN00405500, IN00405595, IN00406294). Several complaints were substantiated with federal/state deficiencies cited at various tags including F550, F609, F624, F684, F686, F690, F692, F804. One complaint (IN00405595) had no deficiencies related to the allegations.
Findings
The facility was found deficient in multiple areas including residents' rights, reporting of alleged violations, preparation for safe discharge, quality of care, treatment of pressure ulcers, bowel/bladder incontinence, nutrition/hydration status, and food safety. Specific failures included failure to ensure residents had the opportunity to vote, timely reporting of abuse allegations, proper medication education at discharge, neurological checks after falls, following physician orders for pressure ulcers, timely treatment of urinary tract infections, fluid restriction monitoring, and documentation of food temperatures.
Deficiencies (8)
Failed to ensure registered voters had the opportunity to vote in the last general election.
Failed to ensure an allegation of physical abuse was reported timely to the State Survey Agency.
Failed to ensure a resident was provided education related to medication use prior to discharge.
Failed to ensure neurological checks were initiated following a fall and timely treatment was completed related to leg edema.
Failed to ensure residents with pressure ulcers received necessary treatment and services related to following updated Physician's Orders.
Failed to ensure residents with urinary tract infections received prompt treatment.
Failed to ensure fluid restriction was followed per Physician's Orders related to fluid intake monitoring not documented.
Failed to ensure food temperatures were documented for meals observed.
Report Facts
Census: 96
Total Capacity: 96
Registered voters affected: 25
Deficiency counts: 8
Missed antibiotic doses: 4
Fluid restriction: 1500
Fluid intake per shift: 780
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Craig Clemons | Administrator | Signed report on page 1 |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 24, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00398016 completed on December 29, 2022.
Complaint Details
Investigation of Complaint IN00398016 completed; facility found in compliance.
Findings
Casa of Hobart 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 complaint investigation.
Inspection Report
Complaint Investigation
Census: 85
Capacity: 85
Deficiencies: 1
Date: Dec 29, 2022
Visit Reason
This visit was conducted for the investigation of Complaints IN00397867 and IN00398016. Complaint IN00397867 was substantiated with no deficiencies cited, while Complaint IN00398016 was substantiated with federal/state deficiencies cited related to food temperature.
Complaint Details
Complaint IN00397867 was substantiated with no deficiencies cited. Complaint IN00398016 was substantiated with federal/state deficiencies cited related to food temperature under 135 degrees and cold meals reported by residents.
Findings
The facility failed to serve one of one observed meals at a safe and appetizing temperature, with food temperatures under 135 degrees and five of seven residents interviewed indicating the food was cold. The issue was linked to a burst sprinkler pipe in the kitchen, requiring meals to be prepared offsite and delivered in heated containers, but the Sterno containers used to keep food hot were not functioning properly.
Deficiencies (1)
Failed to serve food at a safe and appetizing temperature; food temperatures were under 135 degrees and residents reported cold meals.
Report Facts
Residents interviewed indicating cold food: 5
Residents interviewed: 7
Food temperature: 110.8
Food temperature: 90.3
Census: 85
Total capacity: 85
Medicare census: 12
Medicaid census: 64
Other payor census: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katherine Bakrevski | Administrator | Signed the report. |
| Regional Vice President | Interviewed regarding the sprinkler pipe burst and food preparation issues. | |
| Director of Nursing | Present during observation of food service. | |
| Assistant Director of Nursing | Present during observation of food service. | |
| Dietary Manager | Interviewed about food temperature checks and handling. | |
| Cook 1 | Observed preparing and serving food; did not check food temperatures prior to serving. | |
| Cook 2 | Observed preparing and serving food; indicated Sterno flames had gone out. |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 92
Deficiencies: 0
Date: Dec 8, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00396111 and IN00396453.
Complaint Details
Complaint IN00396111 - Substantiated with no deficiencies cited. Complaint IN00396453 - Unsubstantiated due to lack of evidence.
Findings
Complaint IN00396111 was substantiated but no deficiencies related to the allegations were cited. Complaint IN00396453 was unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 92
Census Payor Type - Medicare: 10
Census Payor Type - Medicaid: 67
Census Payor Type - Other: 15
Inspection Report
Life Safety
Census: 92
Capacity: 138
Deficiencies: 0
Date: Dec 8, 2022
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted to assess compliance with fire safety and licensure requirements.
Findings
The facility was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and applicable codes. The facility is fully sprinklered in all resident access areas and service areas.
Inspection Report
Annual Inspection
Census: 93
Capacity: 138
Deficiencies: 3
Date: Nov 14, 2022
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal regulations.
Findings
The facility was found in compliance with Emergency Preparedness Requirements. However, deficiencies were found related to Life Safety Code including unsealed penetrations in smoke barrier walls, lack of fire damper inspections within required intervals, and missing weekly generator inspection documentation.
Deficiencies (3)
Failed to ensure penetrations through smoke barrier walls were properly sealed to maintain smoke resistance.
Failed to ensure fire dampers were inspected and maintained at least every four years as required.
Failed to maintain written records of weekly generator inspections for 17 of 52 weeks.
Report Facts
Certified beds: 138
Census: 93
Weeks missing generator inspection records: 17
Fire dampers observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosa McGowen | RVP | Signed the report |
| Administrator | Participated in observations and exit conference | |
| Maintenance Director | Confirmed deficiencies and participated in observations and exit conference |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 28, 2022
Visit Reason
Paper compliance review to the Investigation of Complaint IN00391678 completed on October 28, 2022.
Complaint Details
Investigation of Complaint IN00391678; paper compliance review found facility in compliance.
Findings
Casa of Hobart 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 complaint investigation.
Inspection Report
Re-Inspection
Census: 90
Capacity: 90
Deficiencies: 1
Date: Oct 28, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 9/27/22, including PSRs to the Investigation of Complaints IN00387879 and IN00390783, and was conducted in conjunction with investigations of Complaints IN00391530, IN00391678, and IN00392052.
Complaint Details
Complaint IN00387879 - Corrected. Complaint IN00390783 - Corrected. Complaint IN00391530 - Substantiated with no deficiencies cited. Complaint IN00391678 - Substantiated with deficiencies cited at F624. Complaint IN00392052 - Substantiated with no deficiencies cited.
Findings
Casa of Hobart was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the PSR to the Recertification and State Licensure Survey and the PSR to the Investigation of Complaints IN00387879 and IN00390783. Some complaints were substantiated with deficiencies cited at F624, while others were corrected or had no deficiencies related to allegations.
Deficiencies (1)
Federal/state deficiencies related to complaint IN00391678 cited at F624
Report Facts
Census SNF/NF beds: 90
Total census: 90
Medicare census: 7
Medicaid census: 72
Inspection Report
Complaint Investigation
Census: 90
Capacity: 90
Deficiencies: 1
Date: Oct 27, 2022
Visit Reason
This visit was for the investigation of complaints IN00391530, IN00391678, and IN00392052, conducted in conjunction with post survey revisits to prior surveys completed on 9/27/22.
Complaint Details
Complaint IN00391678 was substantiated with federal/state deficiencies cited at F624 related to safe and orderly transfer/discharge. Complaints IN00391530 and IN00392052 were substantiated but no deficiencies were cited. Complaints IN00387879 and IN00390783 were corrected.
Findings
The facility failed to provide a safe discharge for a resident with a court-appointed guardian who was deemed not capable of decision making. The resident left the facility against medical advice (AMA) despite staff attempts to prevent her from leaving, and the facility did not notify police or EMS. The guardian was informed but was told the facility could not restrain the resident. The resident was later detained by EMS and police at her destination.
Deficiencies (1)
Failed to provide a safe discharge for a resident with a court-appointed guardian who was not capable of decision making.
Report Facts
Census: 90
Total Capacity: 90
Medicare Census: 7
Medicaid Census: 72
Other Payor Census: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katherine Bakrevski | Administrator | Signed the report |
| Social Service Director | Involved in discharge process and communication with guardian | |
| Assistant Director of Nursing (ADON) | Notified about resident leaving AMA and communicated with physician | |
| Director of Nursing (DON) | Notified by phone during incident |
Inspection Report
Recertification
Census: 97
Capacity: 97
Deficiencies: 16
Date: Sep 27, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey. This visit included the Investigation of Complaints IN00387879 and IN00390783.
Complaint Details
Complaint IN00387879 - Substantiated. Federal/State deficiencies related to the allegations are cited at F880 and F921. Complaint IN00390783 - Substantiated. Federal/State deficiencies related to the allegations are cited at F684 and F689.
Findings
The facility was found deficient in multiple areas including medication administration, resident self-administration of medications, honoring resident preferences, timely assessments, assistance with activities of daily living, quality of care including fall follow-up and wound care, nutrition and hydration, pain management, infection control, and environmental sanitation. Several residents had substantiated complaints related to these deficiencies.
Deficiencies (16)
Facility failed to ensure residents had Physician's Orders for self-administration of medications and assessments for 1 of 1 residents reviewed.
Facility failed to honor a resident's preference related to the number of showers per week for 1 of 1 residents reviewed.
Facility failed to complete a Quarterly Minimum Data Set (MDS) assessment timely for 1 of 27 residents reviewed.
Facility failed to ensure the Minimum Data Set (MDS) comprehensive assessment was accurately coded related to range of motion and enteral feeding for 2 of 27 MDS assessments reviewed.
Facility failed to ensure a resident with a significant change in diagnoses and/or psychotropic medication received a new Level 1 PASARR for 1 of 1 residents reviewed.
Facility failed to ensure dependent residents were provided assistance with activities of daily living related to nail care and shaving for 2 of 5 residents reviewed.
Facility failed to ensure residents were sent out for evaluation timely after a fall and fall follow up was completed for 2 of 4 residents reviewed for falls. Also failed to ensure bruising and excoriation were assessed and monitored, treatments completed as ordered, and weekly skin assessments with measurements were completed for 6 of 7 residents reviewed for skin conditions.
Facility failed to ensure indwelling foley catheter tubing was kept off the floor and catheter care was signed out as completed for a resident with a urinary tract infection for 1 of 1 residents reviewed for catheters.
Facility failed to ensure insulin was administered as ordered by the physician for 1 of 5 residents reviewed for unnecessary medications.
Facility failed to ensure a gradual dose reduction was attempted for 1 of 7 residents reviewed for unnecessary psychotropic medications.
Facility failed to post in a timely manner the daily staffing sheet indicating how many staff were working and the facility census.
Facility failed to ensure food was served and stored under sanitary conditions related to dirty food equipment, uncovered food, and food not labeled and dated for 1 of 1 kitchens.
Facility failed to ensure infection control guidelines were in place and implemented, including proper PPE use, hand hygiene after glove removal, and proper storage of linens and equipment in resident bathrooms.
Facility failed to ensure behavioral health services were obtained for 1 of 3 residents reviewed for mood and behavior.
Facility failed to ensure residents' medical records included documentation that education on benefits and risks of COVID-19 vaccination was provided and why vaccine was not administered for 2 of 5 residents reviewed for COVID-19 vaccinations.
Facility failed to ensure residents' environment and kitchen area was clean and in good repair related to dirty floors, marred walls and doors, food build up on baseboards, lime build up on pipes, dirty floor tile, rusty hinges, dusty ceiling vents, and odors in kitchen and resident lanes.
Report Facts
Census: 97
Survey dates: 6
Deficiencies cited: 15
Weight: 322
Weight loss: 11.1
Weight: 168
Weight loss: 11.6
Weight: 116
Weight loss: 7.6
Insulin doses: 5
Medication administration missing: 4
Medication administration missing: 2
Medication administration missing: 7
Staffing sheet dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Certified Nursing Assistant | Observed not wearing proper PPE in isolation room |
| CNA 4 | Certified Nursing Assistant | Observed not wearing proper PPE in isolation room |
| LPN 1 | Licensed Practical Nurse | Observed not wearing proper PPE in isolation room |
| QMA 1 | Qualified Medication Aide | No record of annual inservice training for 2021 |
| Director of Nursing | Director of Nursing | Multiple interviews regarding deficiencies and corrective actions |
Inspection Report
Re-Inspection
Census: 97
Capacity: 97
Deficiencies: 0
Date: Aug 9, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00378660, IN00379466, IN00380446, IN00382277, IN00382310 completed on 6/17/22, and was in conjunction with the Investigation of Complaint IN00384890.
Complaint Details
Complaints IN00378660, IN00379466, IN00380446, IN00382277, and IN00382310 were corrected. Complaint IN00384890 was substantiated with no deficiencies cited related to the allegations.
Findings
The facility was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the PSR to the investigations. Complaints IN00378660, IN00379466, IN00380446, IN00382277, and IN00382310 were corrected. Complaint IN00384890 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Census SNF/NF: 97
Total Capacity: 97
Medicare Census: 12
Medicaid Census: 61
Other Payor Census: 24
Inspection Report
Complaint Investigation
Census: 97
Capacity: 97
Deficiencies: 0
Date: Aug 9, 2022
Visit Reason
The visit was conducted for the investigation of Complaint IN00384890 and in conjunction with a Post Survey Revisit to the Investigation of Complaints IN00378660, IN00379466, IN00380446, IN00382277, and IN00382310.
Complaint Details
Complaint IN00384890 was substantiated with no deficiencies cited. Complaints IN00378660, IN00379466, IN00380446, IN00382277, and IN00382310 were corrected.
Findings
Complaint IN00384890 was substantiated but no deficiencies related to the allegations were cited. All other complaints investigated were corrected. Casa of Hobart was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 97
Census Payor Type - Medicare: 12
Census Payor Type - Medicaid: 61
Census Payor Type - Other: 24
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