Inspection Reports for Hamilton Pointe Health and Rehabilitation Center
IN, 47630
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 25, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a pattern of deficiencies primarily involving safety and accident prevention, food service sanitation, infection control, and timely physician orders for resident care. Notable issues included failure to prevent resident falls resulting in injury, inadequate food handling practices, and delays in physician orders for pressure wound treatment. Several complaint investigations were substantiated with deficiencies, while many others were unsubstantiated or corrected upon reinspection. The facility appears to have addressed prior deficiencies over time, with the most recent inspections showing compliance and no new citations.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
22.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
431% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
66% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Deficiencies: 1
Dec 16, 2025
Visit Reason
The inspection was conducted to evaluate compliance with medical record documentation standards, specifically to ensure accurate clinical records were maintained for residents with wounds.
Findings
The facility failed to ensure accurate clinical records for one of three residents reviewed for wounds, documenting a wound on the wrong extremity repeatedly. The wound nurse acknowledged the initial documentation error, which was perpetuated in subsequent notes, and the facility policy on documentation was reviewed.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure accurate clinical records were in place for 1 of 3 residents reviewed for wounds; wound to left extremity was documented as right extremity. | Level of Harm - Minimal harm or potential for actual harm |
Inspection Report
Deficiencies: 1
Oct 17, 2025
Visit Reason
The inspection was conducted to evaluate compliance with pharmaceutical services requirements, specifically ensuring medications were securely stored and residents' privacy rights were protected.
Findings
The facility failed to ensure medications were kept secure in a locked cart and residents' privacy was protected during medication administration, as observed with an unlocked medication cart and exposed resident information on a computer screen.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Medications were not kept secure and stored in a locked cart; residents' privacy rights were not protected during medication administration. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Number of pills observed: 6
Date of medication storage policy revision: Apr 6, 2024
Date of medication administration policy revision: Nov 11, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 2 | Observed leaving medication cart unlocked and acknowledged policy requirements | |
| Administrator | Provided current medication storage and administration policies |
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 5, 2025
Visit Reason
The inspection was conducted to investigate complaints related to failure to use Enhanced Barrier Precautions (EBP) for a resident with a wound and lack of physician orders for ostomy care for another resident.
Findings
The facility failed to ensure Enhanced Barrier Precautions were used during incontinence and wound care for Resident C, and no physician orders were in place for the care of Resident D's colostomy despite care plans indicating ostomy care needs.
Complaint Details
This citation relates to Intake 2597338. The complaint investigation found failures in infection control practices and documentation/orders for ostomy care.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure Enhanced Barrier Precautions were used for a resident with a wound during incontinence and wound care. | Level of Harm - Minimal harm or potential for actual harm |
| No physician orders in place for the care of a resident's colostomy despite care plans and interventions. | Level of Harm - Minimal harm or potential for actual harm |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding expectations for Enhanced Barrier Precautions and provided current policies on EBP and ostomy care. |
| RN 2 | Registered Nurse | Indicated that normally orders are in place for colostomy care and nursing documentation when changing ostomy bags. |
| Qualified Medication Aide 1 | Qualified Medication Aide | Failed to don Enhanced Barrier Precautions during incontinence care for Resident C. |
| Qualified Medication Aide 2 | Qualified Medication Aide | Failed to don Enhanced Barrier Precautions during incontinence care for Resident C and brought the Wound Nurse who also failed to don EBP supplies. |
| Wound Nurse | Wound Nurse | Failed to don Enhanced Barrier Precautions while providing wound care to Resident C. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 6, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to failure to notify residents' families about changes in residents' physical conditions and incidents such as falls and seizures.
Findings
The facility failed to notify the families of two residents about significant changes: Resident F's family was not informed of a fall and subsequent mental status change until the family visited, and Resident M's family was not notified after seizure activity. The facility's policy requires notification of such changes, which was not followed.
Complaint Details
This citation relates to complaint 2567193. The complaint involved failure to notify family members about changes in residents' conditions, specifically falls and seizure activity.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to notify residents' families of changes in physical condition and incidents such as falls and seizures for 2 of 3 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for notification: 3
Residents affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN 7 | Registered Nurse | Composed nursing progress note regarding Resident F's fall and admitted failure to notify family promptly. |
| Director of Nursing | Indicated that staff should notify family and physician after seizure activity. | |
| Administrator | Provided current policy Notification of Change dated August 2024. |
Inspection Report
Complaint Investigation
Deficiencies: 10
Aug 6, 2025
Visit Reason
The inspection was conducted based on complaints related to medication self-administration, notification of changes, care plan development, catheter care, infection control, and kitchen sanitation.
Findings
The facility failed to ensure proper assessments for medication self-administration, timely family notification of resident changes, development and revision of care plans, appropriate catheter size and care, infection prevention protocols including PPE use, dishwasher temperature compliance, and pest control in the kitchen.
Complaint Details
The complaint investigation included issues related to medication self-administration, family notification failures, incomplete care plans, catheter care errors, infection control breaches, and kitchen sanitation problems.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to ensure an assessment was completed for a resident who self-administered medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify residents' families of changes in condition and falls for 2 of 3 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement complete care plans for residents, including palliative care and fall interventions. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to revise a resident's care plan to reflect current fall interventions. | Level of Harm - Minimal harm or potential for actual harm |
| Resident with indwelling urinary catheter received wrong size catheter. | Level of Harm - Minimal harm or potential for actual harm |
| Dishwasher temperatures were below required levels and food was prepared under unsanitary conditions. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure accurate documentation for residents related to catheter size and hospice care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure proper infection control protocols including PPE use, catheter bag placement, and glucometer disinfection. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to designate a qualified infection preventionist with required certification and time dedication. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain a pest control program; gnats and flies observed in kitchen areas. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Dishwasher temperature readings below required levels: 130
Dishwasher temperature readings below required levels: 165
Catheter sizes: 16
Catheter sizes: 18
Balloon size: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN 7 | Registered Nurse | Named in family notification finding for Resident F |
| LPN 9 | Licensed Practical Nurse | Named in medication self-administration finding for Resident 13 |
| Director of Nursing | Director of Nursing | Provided policies and interviews related to care plans, infection control, and complaint findings |
| Administrator | Administrator | Provided policies and interviews related to complaint findings |
| MDS Coordinator 11 | MDS Coordinator | Interviewed regarding care plan deficiencies |
| LPN 21 | Licensed Practical Nurse | Observed changing catheter and wound dressing |
| RN 3 | Registered Nurse | Interviewed regarding catheter size and infection control |
| CNA 6 | Certified Nursing Assistant | Observed providing care without PPE |
| CNA 10 | Certified Nursing Assistant | Observed providing care without PPE |
| Kitchen Manager | Kitchen Manager | Interviewed regarding kitchen sanitation and dishwasher temperatures |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 141
Deficiencies: 0
Jun 25, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00461760.
Findings
No deficiencies related to the allegations in Complaint IN00461760 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00461760 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 93
Total Capacity: 141
Inspection Report
Complaint Investigation
Census: 88
Capacity: 133
Deficiencies: 0
May 22, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00459203 and IN00459604.
Findings
No deficiencies related to the allegations in complaints IN00459203 and IN00459604 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00459203 and IN00459604 were investigated with no deficiencies cited related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 72
Census Bed Type - SNF: 16
Census Bed Type - Residential: 45
Total Capacity: 133
Census Payor Type - Medicare: 12
Census Payor Type - Medicaid: 58
Census Payor Type - Other: 18
Total Census: 88
Inspection Report
Re-Inspection
Census: 146
Deficiencies: 0
May 8, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00456869 and IN00456718 completed on April 10, 2025.
Findings
Hamilton Pointe Health And Rehab 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 IN00456869 and IN00456718. Both complaints were corrected.
Complaint Details
Investigation of Complaint IN00456869 and IN00456718; both complaints were corrected.
Report Facts
Census Bed Type Total: 146
Census Payor Type Total: 97
SNF/NF Beds: 75
SNF Beds: 22
Residential Beds: 49
Medicare Residents: 14
Medicaid Residents: 60
Other Payor Residents: 23
Inspection Report
Complaint Investigation
Census: 96
Capacity: 146
Deficiencies: 2
Apr 10, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00456632, IN00456718, and IN00456869 regarding safety and accident prevention at the facility.
Findings
The facility failed to ensure adequate safety measures to prevent accidents for 2 of 3 residents reviewed, resulting in serious injury including hospitalization and subarachnoid hemorrhage for Resident C. Additionally, the facility failed to report a major accident involving Resident C as required by state regulations. Another resident, Resident B, experienced a fall from a mechanical lift due to improper transfer procedures.
Complaint Details
Complaint IN00456632 had no deficiencies related to allegations. Complaint IN00456718 had deficiencies cited at F689 related to accident hazards and supervision. Complaint IN00456869 had deficiencies cited at F689 and F9999 related to accident prevention and failure to report major accidents. Resident C suffered a fall resulting in subarachnoid hemorrhage and hospitalization. Resident B fell from a mechanical lift due to improper transfer technique.
Severity Breakdown
SS=G: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure adequate safety measures to prevent accidents for 2 of 3 residents reviewed, resulting in hospitalization and subarachnoid hemorrhage for Resident C. | SS=G |
| Failed to report a major accident involving Resident C to the state within required timeframe. | — |
Report Facts
Census Bed Type - Total: 146
Census Payor Type - Total: 96
Survey dates: 3
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Cates | Administrator | Signed report and involved in facility management |
| CNA 2 | Named in interview regarding failure to follow two-person assist protocol for Resident C | |
| Therapy 1 | Provided therapy notes and care plan information for Resident C | |
| Assistant Director Of Nursing | ADON | Provided policies and interviews regarding transfer procedures and accident reporting |
| Director Of Nursing | DON | Attended Fall IDT meeting and provided information on transfer incident |
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 10, 2025
Visit Reason
The inspection was conducted to investigate complaints related to safety and accident prevention at Hamilton Pointe Health and Rehab, focusing on incidents involving resident falls and the facility's compliance with safety protocols.
Findings
The facility failed to ensure adequate safety measures to prevent accidents for two residents, resulting in actual harm including hospitalization and a subarachnoid hemorrhage. Deficiencies included inadequate supervision during transfers and use of mechanical lifts, failure to follow care plans for assistance levels, and lapses in communication among staff.
Complaint Details
This citation relates to Complaints IN00456718 and IN00456869. The investigation found substantiated issues with supervision and safety protocols leading to falls and injuries for Residents B and C.
Severity Breakdown
Level of Harm - Actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure adequate safety measures to prevent accidents for residents requiring assistance with transfers and toileting, resulting in falls and injury. | Level of Harm - Actual harm |
Report Facts
Residents affected: 2
Dates of incidents: Resident C fall on 2/24/25; Resident B fall on 3/30/25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Therapy 1 | Therapist | Provided therapy notes and care plan information regarding Resident C's assistance needs |
| Assistant Director Of Nursing | ADON | Interviewed regarding staff awareness and policy on resident transfers and safety |
| Case Manager | Interviewed regarding Resident C's care plan changes after fall | |
| CNA 3 | Certified Nursing Assistant | Provided written statement about Resident B's fall from mechanical lift |
| LPN 2 | Licensed Practical Nurse | Provided written statement about Resident B's fall from mechanical lift |
| CNA 4 | Certified Nursing Assistant | Indicated two staff required when using mechanical lift |
| CNA 5 | Certified Nursing Assistant | Indicated two staff required when using mechanical lift |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 7, 2025
Visit Reason
Paper compliance review related to the Investigation of Nursing Home Complaints IN00453228 and IN00453974 ending February 27, 2025.
Findings
Hamilton Pointe Health and Rehab 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 nursing home complaints.
Complaint Details
Investigation of Nursing Home Complaint IN00453228 and IN00453974; paper compliance review found facility in compliance.
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 27, 2025
Visit Reason
The inspection was conducted in response to complaints IN00453228 and IN00453974 regarding food service safety and infection control practices at Hamilton Pointe Health and Rehab.
Findings
The facility was found to have deficiencies in food service safety, including unsanitary food handling practices and contaminated surfaces, and in infection prevention and control, including failure to properly don personal protective equipment (PPE) when entering isolation rooms.
Complaint Details
This citation relates to Complaint IN00453228 and IN00453974.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure food was served in a sanitary manner; gloves were not changed, bare hands touched plates, fingers were licked, and floors were soiled in the kitchen and during meal service. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure infection control practices were maintained; PPE was not worn properly or at all when entering isolation rooms on 3 of 7 halls observed. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Number of plates prepared: 6
Number of halls observed for PPE compliance: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Aide 2 | Observed improperly handling food and gloves during food preparation. | |
| Dietary Aide 3 | Observed touching plates with bare fingers and improper food handling. | |
| Dietary Aide 4 | Observed plating lunch with bare fingers touching plates. | |
| Dietary Aide 5 | Observed licking fingers to separate meal tickets. | |
| Dietary Aide 6 | Provided information on proper glove use during food prep. | |
| Director of Nursing | DON | Provided policies on food handling, kitchen cleaning, infection prevention and control, and PPE use. |
| Activity Staff 2 | Observed entering isolation room without donning PPE. | |
| CNA 2 | Observed donning gloves, N95 mask, and gown but did not tie gown at neck. | |
| CNA 3 | Observed entering isolation room without PPE. | |
| CNA 6 | Observed entering isolation room without PPE. | |
| RN 2 | Observed entering isolation room without PPE. |
Inspection Report
Complaint Investigation
Census: 98
Capacity: 146
Deficiencies: 3
Feb 25, 2025
Visit Reason
This visit was for the investigation of multiple nursing home and residential complaints (IN00452314, IN00453974, IN00452718, IN00453228, IN00452493). The survey dates were February 25, 26, and 27, 2025.
Findings
The facility was found to have deficiencies related to food service sanitation and infection prevention and control practices, including failure to maintain sanitary food handling and improper use of personal protective equipment (PPE) in isolation rooms. Some complaints had no deficiencies cited, while others had federal/state deficiencies related to food safety and infection control.
Complaint Details
The investigation included Nursing Home Complaints IN00452314, IN00453974, IN00452718, IN00453228, and IN00452493 and Residential Complaints IN00452493, IN00453228, IN00453974. Complaints IN00452314, IN00452718, and IN00452493 had no deficiencies related to the allegations. Complaints IN00453974 and IN00453228 had federal/state deficiencies cited related to food safety and infection control.
Severity Breakdown
SS=D: 1
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure food was served in a sanitary manner; gloves were not changed, bare hands touched plates, fingers were licked, floors soiled in kitchen and meal service. | SS=D |
| Failed to ensure infection control practices were maintained and PPE was worn entering isolation rooms for 3 of 7 halls observed. | SS=E |
| Failed to ensure food was served in a sanitary manner in accordance with professional standards for food service safety. | — |
Report Facts
Census Bed Type - SNF/NF: 74
Census Bed Type - SNF: 24
Census Bed Type - Residential: 48
Total Census: 146
Census Payor Type - Medicare: 12
Census Payor Type - Medicaid: 60
Census Payor Type - Other: 26
Total Census Payor: 98
Residential Census: 74
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Cates | Administrator | Signed the report as facility administrator |
| Dietary Aide 2 | Observed failing to change gloves and touching food and surfaces improperly during food preparation | |
| Dietary Aide 3 | Observed touching plates with bare fingers during meal preparation | |
| Dietary Aide 4 | Observed touching plates with bare fingers during meal plating | |
| Dietary Aide 5 | Observed licking fingers to separate meal tickets | |
| Dietary Aide 6 | Provided information about glove use during food prep | |
| Dietary Manager | Provided information about kitchen cleaning schedule | |
| Director of Nursing | DON | Provided policies on food handling, infection control, PPE use, and kitchen cleaning |
| Activity Staff 2 | Observed entering isolation room without PPE | |
| CNA 6 | Observed entering isolation room without PPE | |
| CNA 2 | Observed donning PPE improperly before entering isolation room | |
| CNA 3 | Observed entering isolation room without PPE | |
| RN 2 | Observed entering isolation room without PPE |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 21, 2025
Visit Reason
Paper compliance review to the Investigation of Complaint IN00448583 ending December 10, 2024.
Findings
Hamilton Pointe Health and Rehab 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
Investigation of Complaint IN00448583 was reviewed and found to be in compliance.
Inspection Report
Complaint Investigation
Census: 156
Capacity: 156
Deficiencies: 1
Dec 10, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00448583 regarding federal and state deficiencies related to admission physician orders for immediate care.
Findings
The facility failed to ensure that a newly admitted resident had immediate physician orders for pressure wound treatments upon admission. Orders for wound treatments were not recorded until three days after admission, despite the resident having multiple pressure wounds on admission.
Complaint Details
Complaint IN00448583 was substantiated with federal and state deficiencies cited at F635 related to admission physician orders for immediate care.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a newly admitted resident had immediate orders for pressure wounds. | SS=D |
Report Facts
Census total: 156
Licensed capacity: 156
Survey dates: 2
Medicare residents: 12
Medicaid residents: 58
Other payor residents: 31
Pressure wound treatment delay: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Cates | Administrator | Signed the report |
| RN 2 | Interviewed and indicated wound treatments should have been placed on admit | |
| RN 3 | Interviewed and indicated triage should be called for orders if no orders sent on admit | |
| DON | Provided current admission orders policy |
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 10, 2024
Visit Reason
The inspection was conducted due to a complaint (IN00448583) regarding the facility's failure to provide immediate doctor's orders for pressure wound care for a newly admitted resident.
Findings
The facility failed to ensure that Resident B, admitted in June 2024 with multiple pressure wounds, had immediate physician orders for wound treatments upon admission. Orders were not recorded until several days after admission, and wound measurements were missing from the initial report.
Complaint Details
This citation relates to Complaint IN00448583. The complaint was substantiated as the facility did not have immediate wound treatment orders for Resident B upon admission.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide doctor's orders for the resident's immediate care at the time of admission related to pressure wounds. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Number of residents reviewed for pressure wounds: 3
Number of administrations for Daptomycin intravenous solution: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN 2 | Indicated Resident B came to the facility with pressure wounds and that wound treatments should have been placed on admit. | |
| RN 3 | Indicated if pressure wounds are found on initial admit skin assessment and no orders were sent, triage should be faxed or called for orders. | |
| Director of Nursing (DON) | Provided the current admission orders policy and explained requirements for physician orders on admission. |
Inspection Report
Follow-Up
Census: 103
Capacity: 115
Deficiencies: 0
Jul 19, 2024
Visit Reason
This Post Survey Review (PSR) was conducted as a follow-up to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 06/25/2024.
Findings
The facility was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, as well as with the Life Safety Code requirements including fire safety and sprinkler systems. No deficiencies were cited during this follow-up survey.
Report Facts
Certified beds: 115
Census: 103
Inspection Report
Re-Inspection
Census: 103
Capacity: 153
Deficiencies: 0
Jul 18, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on June 5, 2024, and was conducted in conjunction with the PSR to the Investigation of Complaint IN00435563 completed on June 5, 2024.
Findings
Hamilton Pointe Health and Rehab 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.
Complaint Details
Investigation of Complaint IN00435563 was included in this visit; no deficiencies were cited indicating compliance.
Report Facts
Census Bed Type - SNF/NF: 79
Census Bed Type - SNF: 24
Census Bed Type - Residential: 50
Census Payor Type - Medicare: 15
Census Payor Type - Medicaid: 61
Census Payor Type - Other: 27
Inspection Report
Re-Inspection
Census: 103
Capacity: 153
Deficiencies: 0
Jul 18, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00435563 completed on June 5, 2024, conducted in conjunction with a PSR to the Recertification and State Licensure Survey and State Residential Licensure Survey completed on June 5, 2024.
Findings
Hamilton Pointe Health and Rehab 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 IN00435563. The complaint was corrected.
Complaint Details
Complaint IN00435563 was investigated and found to be corrected.
Report Facts
Census Bed Type - SNF/NF: 79
Census Bed Type - SNF: 24
Census Bed Type - Residential: 50
Census Payor Type - Medicare: 15
Census Payor Type - Medicaid: 91
Census Payor Type - Other: 27
Inspection Report
Life Safety
Census: 90
Capacity: 115
Deficiencies: 2
Jun 25, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with emergency preparedness and fire safety regulations.
Findings
The facility was found not in compliance with emergency preparedness requirements due to failure to maintain a current documented facility-based and community-based risk assessment reviewed within the past twelve months. Additionally, the facility failed to provide a complete facility-specific written fire safety plan that accurately identifies all life safety systems, including the location of smoke barriers.
Severity Breakdown
SS=F: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to maintain an emergency preparedness plan based on a documented, facility-based and community-based risk assessment reviewed within the most recent twelve month period. | SS=F |
| Failed to provide a complete facility-specific written fire safety plan that identifies where smoke barriers are located in the facility. | SS=F |
Report Facts
Certified beds: 115
Census: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Cates | Administrator | Named as facility administrator during exit conference |
| Director of Plant Operations | Present during record review and interview regarding emergency preparedness and fire safety plan deficiencies |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 20
Jun 5, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey in conjunction with the Investigation of Complaint IN00435563.
Findings
The facility was found deficient in multiple areas including resident privacy, medication self-administration assessments, accuracy of MDS assessments, comprehensive care planning, nutrition and weight monitoring, quality of care related to narcotic administration, fall prevention and post-fall assessments, pain management, nurse staffing postings, medication administration errors, food safety and temperature control, infection prevention and control, pest control, staff licensure, and reporting of injuries of unknown source.
Complaint Details
Complaint IN00435563 - Federal deficiencies related to the allegations are cited at F684 and F9999.
Severity Breakdown
SS=E: 6
SS=D: 6
SS=C: 1
Deficiencies (20)
| Description | Severity |
|---|---|
| Facility failed to ensure privacy of residents during medication administration and room entry. | SS=E |
| Facility failed to ensure residents who self-administer medications were properly assessed. | SS=E |
| Facility failed to ensure accuracy of MDS assessments for unnecessary medications. | SS=D |
| Facility failed to develop and implement comprehensive care plans consistent with resident rights and needs. | SS=D |
| Facility failed to ensure physician orders were followed for nutrition and weight monitoring. | SS=D |
| Facility failed to provide care by thorough assessment prior to narcotic administration and accurate care plans for resuscitative measures. | SS=D |
| Facility failed to ensure post fall assessments were completed and care plans updated to prevent falls. | SS=D |
| Facility failed to ensure pain management consistent with professional standards, care plans, and resident preferences. | SS=D |
| Facility failed to post accurate nurse staffing sheets daily. | SS=C |
| Facility failed to maintain medication error rate below 5%, with observed medication administration errors. | SS=D |
| Facility failed to ensure accurate documentation of blood glucose readings and post-fall assessments. | SS=D |
| Facility failed to ensure food was served at palatable temperatures. | SS=E |
| Facility failed to store and prepare food under sanitary conditions, including uncovered food and expired items. | SS=E |
| Facility failed to maintain resident records that were complete, accurate, and readily accessible. | SS=D |
| Facility failed to establish and maintain an infection prevention and control program to prevent transmission of infections. | SS=E |
| Facility failed to report an injury of unknown source to the Indiana Department of Health. | — |
| Facility failed to conduct fire and disaster drills every six months in conjunction with the local fire department. | — |
| Facility failed to maintain current and valid licenses for Qualified Medication Aides. | — |
| Facility failed to ensure medications were given as ordered by the physician. | — |
| Facility failed to ensure medications were labeled correctly and had open dates on medication carts. | — |
Report Facts
Survey dates: May 28, 29, 30, 31, June 3, 4, 5, 2024
Census: 53
Medication error rate: 12
Number of medication errors: 3
Number of shifts worked: 5
Number of fire drills: 12
Weight loss percentage: 10.65
Number of falls: 7
Number of gnats observed: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 19 | Licensed Practical Nurse | Named in medication administration errors and insulin administration observation |
| RN 31 | Registered Nurse | Provided guidance on medication administration and privacy |
| QMA 23 | Qualified Medication Aide | Named in privacy and hand hygiene findings |
| Administrator | Provided policy and interview responses related to multiple findings | |
| DON | Director of Nursing | Provided policy and interview responses related to multiple findings |
| Medical Records employee | Provided policies and information related to documentation and food safety | |
| Dietary Manager | Provided kitchen tour and food safety observations | |
| RN 57 | Registered Nurse | Observed and interviewed related to medication and privacy findings |
| Regional Clinical Nurse 9 | Provided interview related to narcotic monitoring and care plans | |
| Medical Records employee | Provided policies on leftovers and glove usage | |
| HR Director | Responsible for licensure compliance |
Inspection Report
Complaint Investigation
Census: 141
Deficiencies: 2
Jun 5, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00435563, conducted in conjunction with the Recertification and State Licensure Survey and State Residential Licensure Survey.
Findings
The facility failed to provide thorough assessment and appropriate care planning related to narcotic medication administration and resuscitative measures for one resident (Resident P). Additionally, the facility failed to report an injury of unknown source for another resident (Resident D) to the Indiana Department of Health as required.
Complaint Details
Complaint IN00435563 was substantiated with federal deficiencies cited at F684 and F9999 related to the allegations.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide care by thorough assessment prior to narcotic medication administration and implementation of a person-centered care plan for narcotics, and inaccurate resuscitative care plan for Resident P. | SS=D |
| Failed to report an injury of unknown source to the Indiana Department of Health for Resident D. | — |
Report Facts
Survey dates: 9
Census Bed Type - Total residents: 141
Census Payor Type - Total residents: 88
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Cates | Administrator | Signed the report. |
| LPN 45 | Mentioned in relation to Resident P's medication administration and incident on 4/23/24. | |
| Regional Clinical Nurse 9 | Interviewed regarding respiratory distress recognition and care plan accuracy for Resident P. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 5, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to concerns about the facility's care and medication administration practices for Resident P, specifically regarding narcotic medication assessment, care planning, and resuscitative measures.
Findings
The facility failed to provide thorough assessment prior to narcotic medication administration and did not implement a person-centered care plan for narcotic use. The care plan inaccurately reflected resuscitative measures for Resident P, who experienced respiratory distress and ultimately stopped breathing without CPR being initiated. The facility lacked a policy for monitoring adverse side effects of narcotic medications.
Complaint Details
This citation relates to complaint IN00435563.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide care by thorough assessment of a resident prior to narcotic medication administration and implementation of a person centered care plan for the use of narcotics, and a care plan that reflected accurate resuscitative measures. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication administration times: 5
Oxygen saturation levels: 68
Oxygen saturation levels: 89
Survey completion date: Jun 5, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 45 | Administered bedtime medications to Resident P and reported on medication administration and resident condition. | |
| Regional Clinical Nurse 9 | Provided interviews regarding respiratory distress recognition and care plan inaccuracies. |
Inspection Report
Routine
Deficiencies: 12
Jun 5, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, medication management, care planning, fall prevention, infection control, and food safety.
Findings
The facility was found deficient in multiple areas including failure to ensure resident privacy, incomplete assessments for self-administration of medications, inaccurate Minimum Data Set (MDS) assessments, failure to follow physician orders, inadequate pain management, incomplete post-fall assessments, medication administration errors, improper food temperature and handling, unsanitary kitchen conditions, incomplete staffing records, and presence of pests.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 11
Level of Harm - Potential for minimal harm: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to ensure the privacy of residents was respected; staff did not knock on doors when entering and left doors open during insulin administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to assess residents for ability to self-administer medications; medications were found in rooms without proper orders or assessments. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to complete accurate Minimum Data Set (MDS) assessments for residents regarding medication use. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to follow physician orders for nutrition and weight monitoring; missing weights and missed nutritional supplement administrations. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate treatment and care according to orders, including inaccurate care plans and lack of monitoring for narcotic side effects resulting in overdose. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure post-fall assessments were completed and care plans updated to prevent falls. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide safe, appropriate pain management consistent with professional standards, care plans, and resident preferences. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to post accurate nurse staffing information daily; staffing sheets lacked designation of actual shift hours worked for multiple shifts. | Level of Harm - Potential for minimal harm |
| Failure to ensure food was served at palatable temperatures; food was served lukewarm below recommended temperatures. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to store and prepare food under sanitary conditions; uncovered food, expired food not discarded, improper glove use, and unsanitary kitchen conditions observed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure accurate documentation of blood glucose readings and post-fall assessments. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide and implement an infection prevention and control program; uncovered resident care items and failure to sanitize hands when required. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 12
Number of falls: 7
Weight loss percentage: 10.65
Food temperature: 116
Number of gnats observed: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN 57 | Registered Nurse | Observed entering rooms without knocking and leaving medications in rooms without proper orders. |
| QMA 23 | Qualified Medication Aide | Observed entering rooms without knocking and failing to sanitize hands when required. |
| LPN 19 | Licensed Practical Nurse | Observed administering insulin incorrectly and medication administration errors. |
| RN 31 | Registered Nurse | Provided guidance on privacy, medication administration, and infection control. |
| DON | Director of Nursing | Provided policies and interviews regarding multiple deficiencies. |
| MDS Coordinator 89 | Indicated errors in MDS assessments. | |
| Unit Manager | Provided information on medication policies and weight monitoring. | |
| Regional Clinical Nurse | Provided interviews regarding pain management and care plans. | |
| Therapy Supervisor | Indicated therapy provided heat treatment and requirements for orders. | |
| CNA 77 | Certified Nurse Aide | Indicated toothbrushes should be covered and not on floor. |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 158
Deficiencies: 0
Mar 12, 2024
Visit Reason
This visit was conducted for the investigation of Nursing Home Complaint IN00428866, which included the investigation of a residential complaint with the same number.
Findings
No deficiencies related to the allegations in Complaint IN00428866 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00428866 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type Total Capacity: 158
Census Payor Type Total: 103
Census Bed Type SNF/NF: 21
Census Bed Type SNF: 82
Census Bed Type Residential: 55
Census Payor Type Medicare: 16
Census Payor Type Medicaid: 63
Census Payor Type Other: 24
Inspection Report
Complaint Investigation
Census: 104
Capacity: 115
Deficiencies: 0
Feb 21, 2024
Visit Reason
An investigation of Complaint Number IN00428258 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
No Federal/State deficiency related to the allegation was cited. The facility was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and applicable codes.
Complaint Details
Complaint Number IN00428258 was investigated and found to have no deficiencies related to the allegation.
Report Facts
Facility capacity: 115
Census: 104
Inspection Report
Complaint Investigation
Census: 104
Capacity: 155
Deficiencies: 0
Feb 19, 2024
Visit Reason
This visit was conducted for the Investigation of Complaint IN00428371 and included a Covid 19 Focused Infection Control Survey.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation and Covid 19 survey.
Complaint Details
Complaint IN00428371 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 78
Census SNF beds: 26
Census Residential beds: 51
Total licensed capacity: 155
Census Medicare residents: 14
Census Medicaid residents: 65
Census Other payor residents: 25
Total census: 104
Inspection Report
Annual Inspection
Deficiencies: 0
Feb 19, 2024
Visit Reason
The inspection was conducted as an annual survey to assess the facility's compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 101
Capacity: 154
Deficiencies: 0
Nov 14, 2023
Visit Reason
This visit was conducted for the investigation of two complaints, IN00421099 and IN00420974.
Findings
No deficiencies related to the allegations in either complaint were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00421099 and Complaint IN00420974 were investigated; no deficiencies related to the allegations were cited for either complaint.
Report Facts
Census Bed Type Total: 154
Census Payor Type Total: 101
Census by Bed Type: 83
Census by Bed Type: 18
Census by Bed Type: 53
Census by Payor Type: 14
Census by Payor Type: 58
Census by Payor Type: 29
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 2, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00415372 ending August 29, 2023.
Findings
Hamilton Pointe Health and Rehab 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 Investigation of Complaint IN00415372 Survey.
Complaint Details
Investigation of Complaint IN00415372; paper compliance review found facility in compliance.
Inspection Report
Complaint Investigation
Deficiencies: 2
Aug 29, 2023
Visit Reason
The inspection was conducted in response to complaints regarding the facility's provision of dialysis care and medication administration for residents requiring dialysis services.
Findings
The facility failed to provide necessary dialysis care and services for 2 residents, including missing post dialysis assessments and failure to administer medications as ordered according to blood pressure parameters. Documentation and nursing protocols were not consistently followed.
Complaint Details
This Federal tag relates to Complaints IN00415372.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to complete post dialysis assessments for Resident B on 8/12 and 8/26. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to administer Midodrine medication as ordered for Resident C on multiple dates in July and August due to blood pressure parameters not being met or lack of documentation. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Dates medication not given as ordered: 5
Dates medication not given as ordered: 8
Dialysis frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Indicated post dialysis assessments were not done and medication was not always given per physician orders | |
| LPN 1 | Provided facility protocol for dialysis assessments and medication administration parameters | |
| Assistant Director of Nursing | Provided current policies on dialysis and medication administration |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 151
Deficiencies: 2
Aug 28, 2023
Visit Reason
This visit was for the investigation of Complaint IN00415372 regarding dialysis services at the facility.
Findings
The facility failed to ensure necessary dialysis care and medication administration for 2 residents. Post dialysis assessments were not completed for Resident B, and Resident C did not receive medications as ordered according to blood pressure parameters.
Complaint Details
Complaint IN00415372 was investigated with federal/state deficiencies cited at F698 related to dialysis care and medication administration.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to complete post dialysis assessments for Resident B on specified dates. | SS=D |
| Failure to administer Midodrine medication as ordered for Resident C based on blood pressure parameters. | SS=D |
Report Facts
Census total residents: 99
Total licensed capacity: 151
Dialysis residents reviewed: 2
Medication doses held: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Cates | Administrator | Signed the report |
| RN 1 | Provided information about missed post dialysis assessments and medication administration | |
| LPN 1 | Provided information on facility protocol for dialysis assessments and medication parameters | |
| Assistant Director of Nursing | Provided current policies on dialysis and medication administration |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 157
Deficiencies: 0
Aug 15, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00414871.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00414871 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - Total Capacity: 157
Census Payor Type - Census: 103
Inspection Report
Complaint Investigation
Census: 100
Capacity: 151
Deficiencies: 0
Jul 6, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00411193.
Findings
No deficiencies related to the allegations in Complaint IN00411193 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00411193 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 82
Census Bed Type - SNF: 18
Census Bed Type - Residential: 51
Census Bed Type - Total: 151
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 70
Census Payor Type - Other: 25
Census Payor Type - Total: 100
Inspection Report
Complaint Investigation
Census: 99
Capacity: 153
Deficiencies: 0
Mar 30, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00405087, IN00403784, IN00398199, and IN00396831 at Hamilton Pointe Health and Rehab.
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.
Complaint Details
Complaints IN00405087, IN00403784, IN00398199, and IN00396831 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF beds: 22
Census SNF/NF beds: 77
Census Residential beds: 54
Total licensed capacity: 153
Census Medicare residents: 16
Census Medicaid residents: 61
Census Other payor residents: 22
Total census: 99
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 30, 2022
Visit Reason
The inspection was conducted for the Recertification, State Licensure, and Investigation of Complaint IN00387822, including paper compliance to the State Residential Survey completed on November 22, 2022.
Findings
Hamilton Pointe Health and Rehab was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the Recertification, State Licensure, and Investigation of Complaint IN00387822 survey.
Complaint Details
Complaint IN00387822 was investigated and found to be corrected.
Inspection Report
Life Safety
Census: 93
Capacity: 115
Deficiencies: 0
Dec 29, 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 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
The facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements for Medicare and Medicaid participating providers and suppliers. The facility is a one-story, fully sprinklered Type V (111) construction with a fire alarm system and hard wired smoke detectors in corridors and resident sleeping rooms.
Report Facts
Certified beds: 115
Census: 93
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 12
Nov 22, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Complaints IN00391521, IN00387822, and IN00383534. The visit included a State Residential Licensure Survey.
Findings
The facility was substantiated for complaints IN00391521, IN00387822, and IN00383534. Deficiencies were cited related to notification of changes, transfer/discharge notice, bed hold notice, care plan revisions, pressure ulcer care, accident prevention, respiratory care, dialysis care, psychotropic medication management, radiology services, infection control, and medication administration.
Complaint Details
Complaint IN00391521 - Substantiated with no deficiencies cited. Complaint IN00387822 - Substantiated with deficiencies cited at F580 and F776. Complaint IN00383534 - Substantiated with no deficiencies cited.
Severity Breakdown
SS=D: 9
SS=E: 2
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to notify resident's family timely of a delay in STAT X-Ray order following a fall resulting in hip fracture. | SS=D |
| Failed to provide transfer/discharge notice to residents upon transfer to ER for 2 residents. | SS=D |
| Failed to provide bed hold notice to residents upon transfer to ER for 2 residents. | SS=D |
| Failed to revise comprehensive care plans timely for nutrition, advanced directives, and care planning for 4 residents. | SS=E |
| Failed to provide care consistent with professional standards to prevent pressure ulcers; resident developed stage II pressure ulcer. | SS=D |
| Failed to ensure proper supervision to prevent accident hazards; resident had box cutter in possession and medication cart was unlocked. | SS=D |
| Failed to change oxygen tubing weekly for 2 residents receiving oxygen therapy. | SS=D |
| Failed to ensure weights were taken as ordered for a resident receiving dialysis. | SS=D |
| Failed to provide contraindications for gradual dose reduction trials for residents on psychotropic medications for 2 residents. | SS=D |
| Failed to obtain STAT radiology services timely for a resident with recent hip replacement and fall. | SS=D |
| Failed to properly prevent and/or contain COVID-19 for 3 residents and failed to maintain infection control during perineal care for 1 resident. | SS=E |
| Failed to ensure infection control practices during medication administration; staff handled medications with bare hands. | — |
Report Facts
Survey dates: 2022-11-14 to 2022-11-22
Facility census: 48
STAT X-Ray delay: 18
Pressure ulcer size: 1
Pressure ulcer size: 0.5
Pressure ulcer size: 0.1
Weight measurements: 104
Weight measurements: 132.4
Dialysis weights: 211.2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Cates | Administrator | Signed the report |
| DON | Director of Nursing | Provided interviews and information on multiple findings including radiology, infection control, care plans, and policies |
| LPN 1 | Licensed Practical Nurse | Observed handling medications with bare hands |
| CNA 6 | Certified Nurse Aide | Observed providing incontinence care and call light placement; interviewed about care practices |
| QMA 15 | Qualified Medication Aide | Observed providing incontinence care |
| LPN 9 | Licensed Practical Nurse | Interviewed about oxygen tubing change frequency |
| RN 1 | Registered Nurse | Interviewed about dialysis weight orders |
| CNA 17 | Certified Nurse Aide | Observed near medication cart |
| QMA 15 | Qualified Medication Aide | Observed locking medication cart |
Inspection Report
Complaint Investigation
Deficiencies: 11
Nov 22, 2022
Visit Reason
The inspection was conducted as a complaint investigation related to failure to notify a resident's family about a delay in STAT X-Ray orders following a fall, failure to provide transfer/discharge and bed hold notices, failure to revise care plans, failure to prevent pressure ulcers, failure to ensure proper supervision to prevent accidents, failure to provide safe respiratory care, failure to provide appropriate dialysis care, failure to provide timely approved X-ray services, and failure to implement an infection prevention and control program.
Findings
The facility was found deficient in multiple areas including failure to notify family timely about treatment changes, failure to provide required transfer and bed hold notices for hospitalizations, failure to update care plans for nutrition, advanced directives, and infections, failure to prevent pressure ulcers due to inadequate repositioning and call light accessibility, failure to supervise residents to prevent hazards such as possession of a box cutter and unlocked medication cart, failure to change oxygen tubing weekly, failure to obtain resident weights as ordered for dialysis, failure to obtain STAT X-rays timely due to mobile radiology service delays, and failure to properly implement infection control measures including PPE use and glove changes during care.
Complaint Details
This Federal tag relates to Complaint IN00387822.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to notify a resident's family related to the need to alter treatment in 1 of 4 residents reviewed for falls, including delay in STAT X-Ray order following a fall resulting in hip fracture. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide timely notification to residents and representatives before transfer or discharge, including appeal rights, for 2 of 6 residents reviewed for hospitalizations. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide bed hold notice to residents upon transfer to the ER for 2 of 6 residents reviewed for hospitalizations. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to revise comprehensive care plans for nutrition, advanced directives, and care planning for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing in 1 of 2 residents reviewed for pressure ulcers. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure proper supervision to prevent accident hazards for 1 of 5 residents reviewed for accidents, including possession of a box cutter and unlocked medication cart. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure safety of residents during oxygen therapy by not changing oxygen tubing weekly for 2 of 2 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure necessary dialysis care and services were provided, including failure to obtain weights as ordered for 1 of 1 resident reviewed for dialysis. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide timely, approved X-ray services or have an agreement with an approved provider to obtain them for 1 of 1 resident needing STAT X-Ray procedures. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to properly prevent and/or contain COVID-19 for 3 of 33 residents reviewed for infection control and 1 of 6 residents observed for care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide contraindications for gradual dose reduction trials for residents on psychotropic medications for 2 of 5 residents reviewed for unnecessary medications. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 6 | Certified Nurse Aide | Named in pressure ulcer and supervision findings |
| DON | Director of Nursing | Provided interviews and policies related to multiple deficiencies |
| LPN 11 | Licensed Practical Nurse | Indicated oxygen tubing change frequency |
| RN 1 | Registered Nurse | Indicated responsibility for weights and MAR entry |
| CNA 17 | Certified Nurse Aide | Observed near unlocked medication cart |
| QMA 15 | Qualified Medication Aide | Observed providing care and locking medication cart |
| LPN 7 | Licensed Practical Nurse | Indicated medication cart locking policy |
| CNA 1 | Certified Nurse Aide | Observed and interviewed regarding PPE use |
| IP | Infection Preventionist Nurse | Interviewed regarding infection control practices |
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