Inspection Reports for Greenfield Healthcare Center
200 GREEN MEADOWS DR, IN, 46140
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 102
Capacity: 102
Deficiencies: 0
Jan 31, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00451699.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00451699 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 3
Medicaid census: 79
Other payor census: 20
Inspection Report
Life Safety
Census: 110
Capacity: 163
Deficiencies: 3
Jan 2, 2025
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 related regulations.
Findings
The facility was found not in compliance with Life Safety Code requirements, including failure to ensure therapy room doors had positive latching mechanisms, incomplete annual inspection and testing of all fire door assemblies, and improper storage of liquid oxygen containers in resident rooms without required fire barriers and self-closing doors.
Severity Breakdown
SS=E: 1
SS=F: 1
SS=A: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 1 therapy room doors were equipped with a positive latching mechanism to resist passage of smoke. | SS=E |
| Failed to ensure annual inspection and testing of all fire door assemblies were completed, missing inspection of fire doors at indoor oxygen storage and transfilling rooms. | SS=F |
| Failed to protect 2 resident rooms from use of liquid oxygen containers without required fire barriers and self-closing doors. | SS=A |
Report Facts
Certified beds: 163
Census: 110
Liquid oxygen containers: 2
Fire door inspection date: Sep 9, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrew Clark | Executive Director | Named in relation to findings and exit conference |
| Maintenance Director | Interviewed and involved in findings related to fire door inspections and therapy room door |
Inspection Report
Life Safety
Deficiencies: 0
Jan 2, 2025
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey conducted on 01/02/25.
Findings
Greenfield Healthcare Center was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Annual Inspection
Census: 108
Capacity: 108
Deficiencies: 3
Dec 10, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the investigation of three complaints (IN00444183, IN00445714, and IN00446124).
Findings
No deficiencies were cited related to the complaints investigated. Deficiencies were found related to care plan timing and revision, activities meeting resident interests, and catheter care.
Complaint Details
Complaints IN00444183, IN00445714, and IN00446124 were investigated with no deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 2
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to include a resident and a resident's representative in care plan conferences for 2 of 5 residents reviewed. | SS=D |
| Failed to provide weekend activities as preferred for 2 of 4 residents reviewed for activities, potentially affecting 19 residents on the Reflections 1 Unit. | SS=E |
| Failed to ensure Resident 36's indwelling urinary catheter drainage bag remained free of contact with the floor while in bed. | SS=D |
Report Facts
Residents present: 108
Total licensed capacity: 108
Residents affected by care plan deficiency: 2
Residents affected by activities deficiency: 2
Residents potentially affected by activities deficiency: 19
Residents reviewed for catheter care: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrew Clark | Executive Director | Signed the report and provided policy information |
| Social Services Director 2 | Social Services Director | Responsible for coordinating care plan meetings and interviewed regarding care plan deficiencies |
| Unit Manager 4 | Unit Manager | Managed Reflections units and interviewed regarding activities deficiencies |
| Qualified Medication Aide 5 | QMA | Interviewed regarding weekend activities |
| Certified Nursing Assistant 6 | CNA | Interviewed regarding weekend activities |
| Certified Nursing Assistant 7 | CNA | Interviewed regarding weekend activities and catheter care |
Inspection Report
Annual Inspection
Deficiencies: 0
Dec 10, 2024
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Greenfield Healthcare Center 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 Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 120
Capacity: 120
Deficiencies: 1
Sep 5, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00437844, IN00439505, IN00442010, and IN00442065 at Greenfield Healthcare Center.
Findings
The facility was found to have a deficiency related to misappropriation of medication involving one resident (Resident C). Registered Nurse 2 admitted to taking narcotic medication intended for Resident C on multiple occasions. Other complaints investigated showed no deficiencies.
Complaint Details
Complaint IN00439505 was substantiated with federal/state deficiencies cited related to medication misappropriation. Complaints IN00437844, IN00442010, and IN00442065 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure misappropriation of residents' medication did not occur for 1 of 3 residents reviewed for medication administration (Resident C). | SS=D |
Report Facts
Resident census: 120
Total licensed capacity: 120
Medicare residents: 4
Medicaid residents: 98
Other payor residents: 18
Medication discrepancies: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN 2 | Registered Nurse | Admitted to taking Resident C's narcotic pain medication on multiple occasions |
| QMA 3 | Qualified Medication Aide | Reported narcotic count errors to Director of Nursing |
| Executive Director | Executive Director | Interviewed regarding notification and actions taken after medication discrepancies were found |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 23, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00423037 completed on June 26, 2024.
Findings
Greenfield Healthcare Center 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.
Complaint Details
Investigation of Complaint IN00423037 completed on June 26, 2024; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 122
Capacity: 122
Deficiencies: 1
Jun 26, 2024
Visit Reason
This visit was for the investigation of multiple complaints (IN00435677, IN00427026, IN00426858, IN00426147, IN00425521, and IN00423037). Deficiencies related to complaint IN00423037 were cited.
Findings
The facility failed to provide medications as ordered by the physician for 1 of 3 residents reviewed (Resident C). The medications were available but not administered upon admission. Corrective actions included education of staff and audits of new admissions medication orders.
Complaint Details
Complaint IN00423037 was substantiated with federal/state deficiencies cited at F-755 related to medication administration failures. Other complaints investigated had no deficiencies related to allegations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide medications as ordered by the physician for Resident C upon admission. | SS=D |
Report Facts
Census: 122
Total Capacity: 122
Medicare Residents: 9
Medicaid Residents: 92
Other Residents: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrew Clark | Executive Director | Signed report and provided Emergency Pharmacy Service and Emergency kit policy |
Inspection Report
Re-Inspection
Census: 120
Capacity: 163
Deficiencies: 0
Nov 29, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 10/03/23 was performed by the Indiana Department of Health.
Findings
At this PSR Life Safety Code survey, Greenfield Healthcare Center was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. All resident areas and facility service areas were properly sprinkled except for four outside storage sheds.
Report Facts
Facility capacity: 163
Census: 120
Inspection Report
Complaint Investigation
Census: 125
Capacity: 125
Deficiencies: 0
Oct 19, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00418286, IN00418534, and IN00418673.
Findings
No deficiencies related to the allegations were cited for any of the three complaints. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaints IN00418286, IN00418534, and IN00418673 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 125
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 97
Census Payor Type - Other: 25
Inspection Report
Life Safety
Census: 120
Capacity: 163
Deficiencies: 6
Oct 3, 2023
Visit Reason
The visit 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 related NFPA 101 Life Safety Code requirements.
Findings
The facility was found not in compliance with Life Safety Code requirements including issues with delayed egress locking mechanisms, exit signage, hazardous area door self-closing devices, kitchen hood drip trays, sprinkler system maintenance, and corridor door smoke resistance. Corrective actions were planned or underway for all deficiencies.
Severity Breakdown
SS=E: 5
SS=F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure 1 of over 6 delayed egress locking arrangements released the lock within 15 seconds as required. | SS=E |
| Failed to ensure 1 of 3 courtyard doors was not mistaken as a facility exit due to missing 'NO EXIT' signage. | SS=E |
| Failed to ensure corridor doors to 5 of over 10 hazardous rooms had self-closing devices. | SS=E |
| Failed to install the kitchen range hood drip tray on the left side as required by NFPA 96. | SS=E |
| Failed to perform a full hydrostatic flush on 1 of 2 automatic sprinkler piping systems as required by NFPA 25. | SS=F |
| Failed to ensure 1 of over 60 corridor doors resisted the passage of smoke; door to resident room 329 missing latching device and had a hole. | SS=E |
Report Facts
Certified beds: 163
Census: 120
Delayed egress locking arrangements: 6
Courtyard doors: 3
Hazardous rooms: 10
Hazardous rooms with deficient doors: 5
Staff and visitors potentially affected: 6
Corridor doors evaluated: 60
Residents potentially affected: 15
Residents potentially affected: 8
Residents potentially affected: 20
Residents potentially affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrew Clark | Executive Director | Named as Executive Director present at exit conference and involved in corrective action education |
| Maintenance Director | Named as present during observations, acknowledged deficiencies, and involved in corrective actions and education | |
| Maintenance Supervisor | Responsible for monthly inspections and reporting to QA/QAPI committee | |
| Maintenance Assistant | Involved in education and corrective actions related to locking mechanisms and door inspections |
Inspection Report
Renewal
Deficiencies: 0
Sep 13, 2023
Visit Reason
The inspection was conducted as a paper compliance review for the Recertification and State Licensure of Greenfield Healthcare Center.
Findings
Greenfield Healthcare Center 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 for Recertification and State Licensure.
Inspection Report
Annual Inspection
Census: 115
Capacity: 115
Deficiencies: 6
Sep 6, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted over multiple days in September 2023.
Findings
The facility was found deficient in several areas including failure to conduct timely care plan meetings and develop care plans for self-administration of medications, lack of ongoing activity programs on the memory care unit, failure to secure smoking materials properly, failure to follow up on pharmacy recommendations for medication regimen reviews, food safety violations related to dating and storage of food, and ineffective pest control resulting in ants in a resident's room.
Severity Breakdown
SS=D: 4
SS=E: 1
SS=F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to have a care plan meeting and develop a care plan for self-administration of medications for 2 of 6 residents reviewed for care planning. | SS=D |
| Failed to provide an ongoing activity program on the memory care unit for 7 of 9 residents reviewed for activities. | SS=E |
| Failed to ensure smoking materials were kept in a secure location for 1 of 3 residents reviewed for smoking. | SS=D |
| Failed to follow-up with pharmacy recommendations and provide rationale for declining gradual dose reduction for 2 of 5 residents reviewed for unnecessary medications. | SS=D |
| Failed to ensure food was dated, out of date food was removed, and a storage scoop was not stored inside of a container with food affecting 112 of 115 residents. | SS=F |
| Failed to maintain an effective pest control program related to mitigation efforts to minimize ants for 1 of 2 residents reviewed for environment. | SS=D |
Report Facts
Census Bed Type: 115
Residents reviewed for care planning: 6
Residents reviewed for activities: 9
Residents reviewed for smoking: 3
Residents reviewed for medication regimen: 5
Residents affected by food safety: 112
Residents reviewed for pest control: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrew Clark | Executive Director | Signed the report and plan of correction |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 17, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of complaints IN00408249 and IN00411999, as well as an unrelated deficiency.
Findings
Greenfield Healthcare Center 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.
Complaint Details
The visit was related to complaint investigations IN00408249 and IN00411999. The facility was found to be in compliance.
Inspection Report
Complaint Investigation
Census: 120
Capacity: 120
Deficiencies: 3
Jul 7, 2023
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00403838, IN00408249, IN00409754, IN00411601, and IN00411999) concerning the facility.
Findings
The investigation identified deficiencies related to call light accessibility for one resident, failure to thoroughly investigate allegations of misappropriation of resident funds for two residents, and failure to ensure proper monitoring and documentation of weight loss and meal intake for one resident. Some complaints had no deficiencies cited, while others resulted in federal/state deficiencies.
Complaint Details
The visit was complaint-related involving multiple complaints. Some complaints had no deficiencies cited (IN00403838, IN00409754, IN00411999). Deficiencies related to complaints were cited at F692 (nutrition/weight loss), F610 and F689 (investigation of misappropriation), and F558 (call light accessibility).
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 7 residents reviewed for call light accessibility had their call light within reach. | SS=D |
| Facility failed to complete a thorough investigation of an allegation of misappropriation of resident funds for 2 of 6 residents reviewed. | SS=D |
| Facility failed to ensure 1 of 6 residents with weight loss had notification to the attending physician, weekly weight monitoring, and routinely documented meal intakes. | SS=D |
Report Facts
Census: 120
Total Capacity: 120
Medicare Census: 4
Medicaid Census: 102
Other Payor Census: 14
Weight loss: 11.54
Meal intake documentation: 45.9
Electronic fund transfers: 6
Inspection Report
Re-Inspection
Census: 126
Capacity: 126
Deficiencies: 0
Mar 28, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of multiple complaints completed earlier in February 2023.
Findings
Greenfield Healthcare Center 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 of the complaints.
Complaint Details
The visit was related to investigations of complaints IN00395378, IN00396482, IN00396440, IN00397427, IN00398226, and IN00401246, all of which were corrected.
Report Facts
Census Bed Type: 126
Total Census: 126
Payor Type - Medicare: 4
Payor Type - Medicaid: 104
Payor Type - Other: 18
Inspection Report
Re-Inspection
Census: 126
Capacity: 126
Deficiencies: 0
Mar 28, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00401246 completed on 2/13/23, conducted in conjunction with PSRs to other complaint investigations completed on 2/7/23.
Findings
Greenfield Healthcare Center 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 Complaint IN00401246.
Complaint Details
This visit was related to multiple complaint investigations (IN00395378, IN00396482, IN00396440, IN00397427, IN00398226, and IN00401246) which were corrected as of this revisit.
Report Facts
Census Bed Type: 126
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 104
Census Payor Type - Other: 18
Inspection Report
Complaint Investigation
Census: 131
Capacity: 131
Deficiencies: 4
Feb 7, 2023
Visit Reason
This visit was for the investigation of multiple complaints (IN00395378, IN00396020, IN00396482, IN00396440, IN00397427, IN00398226, and IN00399996) at Greenfield Healthcare Center.
Findings
The facility was found to have several deficiencies including failure to ensure call light accessibility for a resident, inadequate bathing and hair care documentation and provision, failure to complete post-fall assessments and interventions, and delayed meal service. Some complaints were substantiated with related federal/state deficiencies cited, while others were unsubstantiated due to lack of evidence.
Complaint Details
Complaints IN00395378, IN00396482, IN00396440, IN00397427, and IN00398226 were substantiated with related deficiencies cited. Complaints IN00396020 and IN00399996 were unsubstantiated due to lack of evidence.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure a call light was within reach of Resident J for accommodation of needs. | SS=D |
| Failed to document type of bathing provided and failed to complete hair care for residents J and K. | SS=D |
| Failed to complete assessment and develop post-fall interventions after Resident H's fall. | SS=D |
| Failed to serve lunch timely for residents K, J, and E. | SS=D |
Report Facts
Census: 131
Total Capacity: 131
Medicare Census: 6
Medicaid Census: 100
Other Payor Census: 25
Inspection Report
Complaint Investigation
Census: 129
Capacity: 129
Deficiencies: 1
Feb 7, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00401246, which was substantiated with a federal/state deficiency cited at F600.
Findings
The facility failed to protect a resident's right to be free from physical abuse by another resident, resulting in a fall and hip fracture requiring hospitalization for 1 of 5 residents reviewed for abuse. The incident involved Resident T striking Resident S with a folding chair, causing Resident S to fall and break his hip. Resident T was placed on 1:1 supervision and transferred to a geriatric psychiatric facility for evaluation and treatment.
Complaint Details
Complaint IN00401246 was substantiated. The abuse involved Resident T physically assaulting Resident S with a folding chair on 2-7-23, resulting in Resident S's fall and hip fracture. The facility intervened immediately, notified appropriate parties, and Resident T was transferred for psychiatric evaluation. The facility conducted interviews and assessments of other residents and educated staff on abuse policies.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to protect a resident's right to be free from physical abuse by another resident, resulting in a fall and hip fracture requiring hospitalization. | SS=G |
Report Facts
Census: 129
Total Capacity: 129
Survey Dates: 3
Medicare Residents: 8
Medicaid Residents: 99
Other Payor Residents: 22
Inspection Report
Complaint Investigation
Census: 134
Capacity: 134
Deficiencies: 0
Jan 20, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00399347.
Findings
The complaint IN00399347 was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00399347 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Census SNF/NF: 134
Census Medicare: 8
Census Medicaid: 108
Census Other: 18
Total Census: 134
Inspection Report
Complaint Investigation
Census: 123
Capacity: 123
Deficiencies: 0
Nov 17, 2022
Visit Reason
This visit was conducted for the investigation of Complaints IN00394401 and IN00394971.
Findings
Both complaints were substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant federal and state regulations regarding the complaints.
Complaint Details
Complaint IN00394401 - Substantiated with no deficiencies cited. Complaint IN00394971 - Substantiated with no deficiencies cited.
Report Facts
Census SNF/NF beds: 123
Census Medicare residents: 3
Census Medicaid residents: 103
Census Other residents: 17
Inspection Report
Life Safety
Census: 126
Capacity: 163
Deficiencies: 0
Oct 11, 2022
Visit Reason
A Post Survey Revisit (PSR) the Life Safety Code Recertification and State Licensure Survey conducted on 08/24/22 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR Life Safety Code survey, Greenfield Healthcare Center was found in compliance 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. All areas where residents have customary access were sprinkled and all areas providing facility services were sprinkled except for four outside sheds used for storage.
Report Facts
Facility capacity: 163
Census: 126
Inspection Report
Complaint Investigation
Census: 130
Capacity: 130
Deficiencies: 0
Sep 28, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00390262.
Findings
The complaint IN00390262 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00390262 was investigated and found unsubstantiated due to lack of evidence.
Report Facts
Medicare census: 9
Medicaid census: 104
Other payor census: 17
Inspection Report
Re-Inspection
Census: 129
Capacity: 129
Deficiencies: 0
Sep 15, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on July 26, 2022, including a PSR to the Investigation of Complaint IN00384162 completed on July 26, 2022.
Findings
Greenfield Healthcare 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 Complaint IN00384162.
Complaint Details
Complaint IN00384162 was investigated and found to be corrected.
Report Facts
Census SNF/NF: 129
Medicare Census: 9
Medicaid Census: 102
Other Payor Census: 18
Inspection Report
Life Safety
Census: 126
Capacity: 163
Deficiencies: 14
Aug 24, 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 not in compliance with several Life Safety Code requirements including issues with smoke barrier door latching, exit door accessibility, hazardous area door self-closing devices, sprinkler system maintenance, portable fire extinguisher placement, corridor door latching and smoke resistance, electrical safety including GFCI protection, fire drill scheduling, fire door annual inspections, electrical receptacle testing, power cord usage, and oxygen transfilling room ventilation.
Severity Breakdown
SS=E: 11
SS=F: 3
SS=C: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to maintain latching hardware on 1 of 2 smoke barrier doors near Physicians Lounge on TCU Hall. | SS=E |
| Failed to ensure all exterior exit doors were readily accessible and able to open on first try, including exit door near Generator on Brookshire Hall. | SS=E |
| Failed to ensure corridor doors to 3 hazardous rooms had self-closing devices. | SS=E |
| Failed to maintain sprinkler system ceiling escutcheons properly covering sprinkler heads. | SS=E |
| Failed to maintain sprinkler system inspection and testing in accordance with NFPA 25; incomplete weekly gauge and valve checks on dry system. | SS=F |
| Failed to ensure sprinkler heads in laundry area were free of dust and loading. | SS=E |
| Failed to ensure portable fire extinguisher was properly installed in 2nd floor attic area. | SS=E |
| Failed to ensure corridor doors had no impediment to closing and latching and resist passage of smoke; multiple corridor doors had issues including a door knob falling off. | SS=E |
| Failed to provide ground fault circuit interrupter (GFCI) protection in 3 wet locations including pantry sink on TCU Hall and water machines near nurse stations. | SS=E |
| Failed to conduct quarterly fire drills on unexpected days and times under varying conditions; missing documentation of fire drills or orientation training on each shift for 4th quarter 2021. | SS=C |
| Failed to ensure annual inspection and testing documentation for 10 of 12 fire door assemblies. | SS=F |
| Failed to ensure documentation of electrical outlet receptacle testing at resident rooms was available and completed annually. | SS=F |
| Failed to ensure power cord daisy chains were not used as a substitute for fixed wiring; power strip plugged into another power strip in Physicians Lounge. | SS=E |
| Failed to ensure oxygen transfilling room had properly working mechanical ventilation. | SS=E |
Report Facts
Certified beds: 163
Census: 126
Deficiencies cited: 15
Residents potentially affected: 25
Residents potentially affected: 20
Residents potentially affected: 40
Residents potentially affected: 6
Residents potentially affected: 15
Staff potentially affected: 6
Staff potentially affected: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in multiple findings including door latching, sprinkler maintenance, fire extinguisher placement, electrical safety, and oxygen room ventilation | |
| Executive Director | Present at exit conference acknowledging findings |
Inspection Report
Annual Inspection
Census: 123
Capacity: 123
Deficiencies: 15
Jul 26, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00384162 and IN00385211.
Findings
The facility was found deficient in multiple areas including resident accommodations, self-determination, grievance handling, PASRR screening, care plan updates, ADL care, medication management, infection control, and activity provision for cognitively impaired residents.
Complaint Details
Complaint IN00384162 was substantiated with related Federal/State deficiencies cited. Complaint IN00385211 was unsubstantiated due to lack of evidence.
Severity Breakdown
SS=D: 11
SS=E: 3
SS=G: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to accommodate resident needs by providing a comfortable environment and usable call lights for residents 95 and 64. | SS=D |
| Failed to ensure resident shower preferences were followed for Resident 35. | SS=D |
| Failed to timely complete and document grievance for Resident 96. | SS=D |
| Failed to ensure PASRR Level I screening was completed timely for Resident 93. | SS=D |
| Failed to update care plans related to aggressive behaviors and fall interventions for Residents 14 and 44. | SS=D |
| Failed to provide nail care and assist with showers for Residents 2 and G. | SS=D |
| Failed to schedule specialist appointment for Resident H and monitor blood sugars for Resident 46 as ordered. | SS=D |
| Failed to provide adequate supervision and fall prevention interventions for Residents 44, 48, 118, 119, and 520. | SS=G |
| Failed to monitor nutrition and hydration status including weight loss, supplement consumption, and fluid intake for Residents G, C, and H. | SS=D |
| Failed to monitor intravenous peripheral site for Resident 90. | SS=D |
| Failed to perform pre and post dialysis assessments for Resident 3. | SS=D |
| Failed to ensure activities were provided to cognitively impaired residents (Residents C, 14, 44, 57, and 84). | SS=E |
| Failed to promote safe medication storage including locking medication carts, removing loose medications, labeling insulin, and securing narcotics. | SS=E |
| Failed to promote infection control by improper handling of soiled linen and uncovered soiled linen containers. | SS=D |
| Failed to maintain complete and accurate documentation of resident meal intake for Resident B. | SS=D |
Report Facts
Survey dates: July 19, 20, 21, 22, 25, 26, 2022
Census: 123
Total capacity: 123
Weight loss percentage: 11.65
Weight loss percentage: 6.6
Loose pills: 17
Loose pills: 11
Loose pills: 5
Loose pills: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Gunter | RN Division IP / Clinical | Named in infection control root cause analysis and plan of correction |
| Nichol Cardwell | RN, Regional Director of Clinical Operations | Named in infection control root cause analysis and plan of correction |
| David Mlodecki | Regional Director of Operations | Named in infection control root cause analysis and plan of correction |
| Andrew Clark | Executive Director | Named in infection control root cause analysis and plan of correction |
| Tim Vickery | LPN Infection Preventionist | Named in infection control root cause analysis and plan of correction |
| Dr. Pragnesh Radadiya | MD Medical Director | Named in infection control root cause analysis and plan of correction |
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