Deficiencies (last 4 years)
Deficiencies (over 4 years)
37.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
793% worse than Indiana average
Indiana average: 4.2 deficiencies/year
Deficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
91% occupied
Based on a June 2025 inspection.
Occupancy rate over time
Inspection Report
Deficiencies: 3
Date: Sep 16, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, and assistance with activities of daily living at Hammond-Whiting Care Center.
Findings
The facility failed to ensure residents were fully informed about their medications, did not provide adequate assistance with activities of daily living for a dependent resident, and failed to administer medications as ordered, resulting in missed doses and delayed treatment.
Deficiencies (3)
F 0552: The facility failed to ensure a resident was informed about the medication she received during medication administration, resulting in the resident not understanding the importance of taking the medication fully.
F 0677: The facility failed to provide assistance with bathing for a dependent resident, who had not received a bath or shower for multiple consecutive days without documented refusals.
F 0684: The facility failed to administer medications as ordered for a resident, resulting in missed doses of antibiotic and antianxiety medications due to lack of proper orders and follow-up.
Report Facts
Missed doses of Vancomycin: 4
Dates without bath/shower: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding medication administration and bathing assistance deficiencies |
| RN 1 | Observed administering medication without informing resident | |
| LPN 1 | Observed administering medication without informing resident |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 0
Date: Jun 12, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00460279.
Complaint Details
Complaint IN00460279 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 73
Census by Payor Type: 73
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 11, 2025
Visit Reason
Paper compliance review to the Investigation of Complaint IN00458244 completed on May 6, 2025.
Complaint Details
Investigation of Complaint IN00458244 completed on May 6, 2025; facility found in compliance.
Findings
Hammond-Whiting Care 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.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 6, 2025
Visit Reason
The inspection was conducted in response to Complaint IN00458244 regarding pressure ulcer care and wound treatment at the facility.
Complaint Details
This citation relates to Complaint IN00458244.
Findings
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for 2 of 3 residents reviewed. There were also failures in maintaining accurate clinical records related to conflicting wound treatment orders for 1 resident and failure to ensure correct Personal Protective Equipment (PPE) use by staff during wound care for 1 resident.
Deficiencies (3)
F 0686: The facility failed to ensure wound treatment was completed and heels were floated as ordered for 2 of 3 residents reviewed for pressure-related skin conditions.
F 0842: The facility failed to maintain clinical records that were complete and accurately documented related to conflicting orders for wound treatments for 1 of 3 residents reviewed.
F 0880: The facility failed to ensure correct Personal Protective Equipment (PPE) was used by a staff member when providing care during a wound treatment for 1 of 3 residents observed.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Inspection Report
Complaint Investigation
Census: 67
Capacity: 67
Deficiencies: 3
Date: May 6, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00458244 regarding pressure ulcer care and related allegations at Hammond-Whiting Care Center.
Complaint Details
Complaint IN00458244 was substantiated with federal/state deficiencies cited related to pressure ulcer care and infection control.
Findings
The facility was found deficient in ensuring wound treatments were completed and heels were off-loaded as ordered for residents with pressure ulcers. Additionally, clinical records had conflicting wound treatment orders, and staff failed to use correct PPE during wound care for a resident under Enhanced Barrier Precautions.
Deficiencies (3)
Failed to ensure wound treatment was completed and heels were floated as ordered for 2 of 3 residents reviewed for pressure-related skin conditions.
Failed to maintain clinical records that were complete and accurately documented related to conflicting orders for wound treatments for 1 of 3 residents reviewed for pressure.
Failed to ensure correct Personal Protective Equipment (PPE) was used by a staff member when providing care during a wound treatment for a resident in Enhanced Barrier Precautions.
Report Facts
Census: 67
Total Capacity: 67
Medicare residents: 7
Medicaid residents: 57
Other payor residents: 3
Inspection Report
Complaint Investigation
Census: 63
Capacity: 63
Deficiencies: 0
Date: Apr 23, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00457994.
Complaint Details
Complaint IN00457994 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census SNF/NF beds: 63
Census total residents: 63
Census Medicare residents: 6
Census Medicaid residents: 53
Census other payor residents: 4
Inspection Report
Complaint Investigation
Census: 66
Capacity: 66
Deficiencies: 0
Date: Apr 11, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00452461.
Complaint Details
Complaint IN00452461 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 4
Medicaid census: 56
Other payor census: 6
Inspection Report
Re-Inspection
Census: 67
Capacity: 67
Deficiencies: 0
Date: Dec 2, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on October 7, 2024, including the PSR to the Investigation of Complaint IN00440581 completed on October 7, 2024.
Complaint Details
Complaint IN00440581 was investigated and found to be corrected.
Findings
Hammond-Whiting Care 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 Recertification and State Licensure Survey and the PSR to the Investigation of Complaint IN00440581.
Report Facts
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 55
Census Payor Type - Private: 6
Census Payor Type - Other: 3
Inspection Report
Follow-Up
Census: 70
Capacity: 80
Deficiencies: 0
Date: Nov 20, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 10/16/24.
Findings
The facility was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 483.73, and with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Report Facts
Certified beds: 80
Census: 70
Inspection Report
Life Safety
Census: 70
Capacity: 80
Deficiencies: 15
Date: Oct 16, 2024
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health to assess compliance with emergency preparedness and life safety requirements.
Findings
The facility was found not in compliance with emergency preparedness training, testing requirements, emergency power system maintenance, fire safety, sprinkler system maintenance, fire alarm system maintenance, corridor door smoke resistance, fire drills, maintenance of fire doors, electrical safety including power cords and extension cords, and oxygen transfilling safety. Deficiencies could affect all residents, staff, and visitors.
Deficiencies (15)
Failed to conduct annual training for the Emergency Preparedness Program and maintain documentation of training and staff knowledge.
Failed to conduct exercises to test the emergency plan at least twice per year including unannounced staff drills.
Failed to implement emergency power system requirements including missing monthly load and weekly exercise testing of the generator.
Failed to ensure documentation for preventative maintenance of 48 battery operated smoke alarms in resident rooms was complete.
Failed to maintain fire alarm system to assure accurate time and date information.
Failed to maintain sprinkler system inspections and testing including missing monthly gauge and valve inspections and weekly inspections.
Failed to ensure 1 of 20 resident room doors completely resisted passage of smoke due to a circular penetration in the door.
Failed to conduct fire drills on each shift for 2 of 4 quarters.
Failed to maintain annual testing of 1 rolling fire door; missing documentation of pass/fail status.
Failed to maintain complete written record of monthly generator load testing for 4 of 12 months and weekly inspection for 14 of 52 weeks.
Failed to maintain documentation of a four hour run test for the emergency generator within the last 36 months.
Used 3 power cords daisy chained together as a substitute for fixed wiring in the Executive Director's office.
One flexible power cord was unsecured and dangling at a high height in the Executive Director's office.
Used an extension cord as a substitute for fixed wiring for permanent use in the Activities office.
Failed to ensure oxygen transfilling occurred in a designated area separated by a 1-hour fire barrier; door was propped open during transfilling due to insufficient space.
Report Facts
Certified beds: 80
Census: 70
Battery operated smoke alarms: 48
Resident room doors inspected: 20
Fire drills missing: 3
Monthly generator load tests missing: 4
Weekly generator inspections missing: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tamela Jones | Maintenance Director | Named in multiple findings related to emergency preparedness, maintenance, and safety compliance |
Inspection Report
Complaint Investigation
Deficiencies: 15
Date: Oct 7, 2024
Visit Reason
The inspection was conducted based on complaints regarding resident care, medication administration, infection control, and facility conditions.
Complaint Details
The inspection was complaint-driven, addressing issues such as resident care, medication errors, infection control, and facility sanitation. The complaint number IN00440581 is referenced in relation to psychotropic medication management.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs, incomplete care plans, inadequate assistance with activities of daily living, improper medication administration, insufficient pressure ulcer care, incorrect oxygen flow rates, incomplete dialysis assessments, lack of RN coverage, inadequate psychosocial visits for isolated residents, failure to implement gradual dose reductions for psychotropic medications, improper medication storage and labeling, failure to follow menus for pureed diets, unsanitary kitchen conditions, and lapses in infection control practices.
Deficiencies (15)
F 0558: The facility failed to ensure call lights were placed within reach of 1 resident reviewed for accommodation of needs.
F 0657: The facility failed to ensure care plans were held and families invited for 2 of 19 residents reviewed.
F 0677: The facility failed to provide timely assistance with meals and facial hair removal for 2 of 7 residents reviewed for ADLs.
F 0679: The facility failed to provide a personalized activity program for 1 cognitively impaired resident in isolation.
F 0684: The facility failed to ensure insulin was administered as ordered and bruising was assessed for residents reviewed.
F 0695: The facility failed to ensure oxygen was administered at the correct flow rate for 1 resident reviewed.
F 0698: The facility failed to complete post dialysis assessments for 1 resident reviewed for dialysis.
F 0727: The facility failed to ensure a Registered Nurse worked 8 consecutive hours for 1 of 14 days reviewed.
F 0745: The facility failed to provide ongoing psychosocial visits for 1 resident in prolonged isolation.
F 0758: The facility failed to implement gradual dose reductions of psychotropic medications for 2 residents reviewed.
F 0761: The facility failed to label and store medication appropriately related to unlabeled bulk medications in medication rooms and carts.
F 0803: The facility failed to ensure the menu was followed as written related to pureed diets for residents receiving pureed diets.
F 0812: The facility failed to ensure food was served and prepared under sanitary conditions in the main kitchen.
F 0880: The facility failed to ensure infection control guidelines were implemented related to improper PPE use and missed antiseptic baths for 1 resident.
F 0921: The facility failed to maintain kitchen areas in a functional and sanitary manner related to dirty floors, dried food spillage, and dust accumulation.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Days without RN coverage: 1
Residents affected: 1
Residents affected: 2
Medication bottles unlabeled: 2
Residents affected: 7
Kitchen sanitation issues: 1
Residents affected: 1
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 7, 2024
Visit Reason
The inspection was conducted due to a complaint (IN00440581) regarding the facility's failure to implement gradual dose reductions (GDR) of psychotropic medications for residents.
Complaint Details
The citation relates to Complaint IN00440581 regarding failure to implement gradual dose reductions of psychotropic medications as required.
Findings
The facility failed to ensure gradual dose reductions of psychotropic medications were implemented for 2 of 5 residents reviewed. Both residents continued to receive the original medication doses despite orders to reduce them, and there was no documentation that the reductions were declined by physicians.
Deficiencies (2)
F 0758: The facility did not implement gradual dose reductions of psychotropic medications for Resident B, who continued to receive 25 mg of Seroquel despite an order to reduce to 12.5 mg. There was no documentation that the physician declined the reduction.
F 0758: The facility did not implement gradual dose reductions of psychotropic medications for Resident C, who continued to receive 0.5 mg of Ativan despite an order to reduce to 0.25 mg. There was no documentation that the physician declined the reduction.
Report Facts
Residents reviewed for unnecessary medications: 5
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Consultant | Interviewed regarding failure to implement gradual dose reductions |
Inspection Report
Recertification
Census: 67
Capacity: 67
Deficiencies: 17
Date: Oct 7, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey including the Investigation of Complaints IN00440532, IN00440581, IN00441219, and IN00442579.
Complaint Details
Complaint IN00440532 - No deficiencies related to the allegations are cited. Complaint IN00440581 - Federal/State deficiencies related to the allegations are cited at F758. Complaint IN00441219 - No deficiencies related to the allegations are cited. Complaint IN00442579 - No deficiencies related to the allegations are cited.
Findings
The facility was found deficient in multiple areas including reasonable accommodations, notification of transfer, care plan meetings, ADL care, activity programming, medication administration, pressure ulcer treatment, oxygen therapy, dialysis assessments, RN staffing, social services, psychotropic medication management, medication labeling and storage, menu compliance, infection control, and kitchen sanitation.
Deficiencies (17)
Failed to ensure call lights were placed within reach of the resident for 1 of 1 resident reviewed for accommodation of needs.
Failed to ensure the resident's Responsible Party was notified in writing related to a transfer to the hospital for 1 of 1 resident reviewed.
Failed to ensure residents' care plans were held and families were invited to attend care plan meetings for 2 of 19 residents reviewed.
Failed to ensure dependent residents received assistance with activities of daily living related to meal assistance and removal of facial hair for 2 of 7 residents reviewed.
Failed to provide a personalized activity program for a cognitively impaired and dependent resident related to ongoing stimulation and one to one visits.
Failed to ensure insulin was administered as ordered and held per insulin parameters for 2 of 5 residents reviewed for unnecessary medications; failed to assess and monitor bruising for 1 of 6 residents reviewed for skin conditions.
Failed to ensure necessary treatment and services were provided to promote healing of pressure ulcers related to use of pressure reducing devices for 1 of 3 residents reviewed.
Failed to ensure oxygen was at the correct flow rate for 1 of 1 resident reviewed for oxygen.
Failed to complete a post dialysis assessment for 1 of 1 resident reviewed for dialysis.
Failed to ensure a Registered Nurse worked 8 consecutive hours in the facility for 1 of 14 days reviewed.
Failed to provide ongoing psychosocial visits for a resident in indefinite isolation for 1 of 3 residents reviewed for isolation.
Failed to ensure gradual dose reductions of psychotropic medications were implemented for 2 of 5 residents reviewed for unnecessary medications.
Failed to label and store medication appropriately related to storing unlabeled bulk medication for 1 of 2 medication rooms and 1 of 2 medication carts observed.
Failed to ensure the menu was followed as written related to pureed diets.
Failed to ensure food was served and prepared under sanitary conditions related to dried food spillage, scoops in bins, and food not labeled.
Failed to ensure infection control guidelines were in place and implemented related to improper use of PPE, staff not knowing isolation reasons, and not completing antiseptic bath as ordered for 1 of 9 residents reviewed.
Failed to ensure kitchen areas were maintained in a functional and sanitary manner related to dirty floor tile, dried food spillage, and dust accumulation on pipes.
Report Facts
Census: 67
Total Capacity: 67
Medicare Census: 4
Medicaid Census: 56
Private Pay Census: 3
Other Payor Census: 4
Insulin doses not signed: 11
Insulin doses given below threshold: 3
RN coverage days missed: 1
Psychotropic medication GDR not implemented: 2
Unlabeled medication bottles: 4
Kitchen sanitation audit frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tamela Jones | Executive Director | Signed report |
| QMA 1 | Mentioned in relation to unlabeled medications and PPE use | |
| LPN 1 | Mentioned in relation to dialysis assessments and oxygen therapy | |
| LPN 2 | Mentioned in relation to medication storage | |
| LPN 3 | Mentioned in relation to isolation precautions | |
| Interim Administrator | Interviewed regarding multiple findings including RN staffing, infection control, and medication administration | |
| Dietary Food Manager | Interviewed regarding menu compliance and kitchen sanitation | |
| Social Service Director | Interviewed regarding psychosocial visits and transfer notification | |
| Nurse Consultant | Interviewed regarding psychotropic medication management and dialysis communication |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 8, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00434673 completed on June 6, 2024.
Complaint Details
Investigation of Complaint IN00434673 completed on June 6, 2024; facility found in compliance.
Findings
Hammond-Whiting Care 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.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 6, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to concerns about skin condition assessments and fall prevention measures at the facility.
Complaint Details
This citation relates to Complaint IN00434673.
Findings
The facility failed to properly assess and monitor areas of skin discoloration and scabbing for 2 of 3 residents reviewed for skin conditions. Additionally, the facility failed to ensure preventative fall measures were in place for 1 of 3 residents reviewed for accidents.
Deficiencies (2)
F 0684: The facility failed to ensure areas of skin discoloration and scabbing were assessed and monitored for 2 of 3 residents reviewed for skin conditions non-pressure related. Documentation and physician orders for monitoring were lacking.
F 0689: The facility failed to ensure preventative fall measures were in place for a resident at risk for falls. The resident's bed was not kept in a low position as required by the care plan.
Report Facts
Residents reviewed for skin conditions: 3
Residents reviewed for accidents: 3
Fall Risk Evaluation score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding awareness of resident conditions and care plan compliance |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 66
Deficiencies: 2
Date: Jun 6, 2024
Visit Reason
This visit was for the investigation of complaints IN00431585, IN00433143, and IN00434673. Complaints IN00431585 and IN00433143 had no deficiencies related to the allegations cited. Complaint IN00434673 resulted in federal/state deficiencies cited at F684 and F689.
Complaint Details
Complaint IN00434673 was substantiated with federal/state deficiencies cited at F684 (Quality of Care) and F689 (Free of Accident Hazards/Supervision/Devices). Complaints IN00431585 and IN00433143 had no deficiencies related to the allegations cited.
Findings
The facility failed to ensure areas of skin discoloration and scabbing were assessed and monitored for 2 of 3 residents reviewed for skin conditions non-pressure related. Additionally, the facility failed to ensure preventative fall measures were in place for 1 of 3 residents reviewed for accidents.
Deficiencies (2)
Failed to ensure areas of skin discoloration and scabbing were assessed and monitored for 2 of 3 residents reviewed for skin conditions non-pressure related.
Failed to ensure preventative fall measures were in place for a resident at risk for falls.
Report Facts
Census: 66
Total Capacity: 66
Fall Risk Evaluation Score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding awareness of resident bruises and fall precautions |
Inspection Report
Re-Inspection
Census: 65
Capacity: 80
Deficiencies: 0
Date: Apr 3, 2024
Visit Reason
A 2nd Post Survey Revisit (PSR) was conducted for the investigation of Complaint Number IN00427505 that exited on 02/01/24 to verify correction of previous deficiencies.
Complaint Details
Complaint IN00427505 was corrected as of this survey.
Findings
At this Life Safety Code PSR, Hammond-Whiting Care Center was found in compliance with Medicare/Medicaid participation requirements and the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code. The facility was fully sprinklered with a fire alarm system and hard wired smoke detection in all required areas.
Report Facts
Facility capacity: 80
Census: 65
Inspection Report
Re-Inspection
Census: 64
Capacity: 80
Deficiencies: 1
Date: Mar 20, 2024
Visit Reason
This was a Post Survey Revisit (PSR) to the investigation of Complaint Number IN00427505 that exited on 02/01/24, conducted to verify compliance with fire safety and life safety code requirements.
Complaint Details
This visit was a Post Survey Revisit to Complaint IN00427505. The complaint was found Not Corrected as of this survey date.
Findings
The facility was found not in compliance with fire safety requirements related to the sprinkler system being out of service and failure to ensure staff were properly trained on fire watch procedures. One of five staff interviewed was not properly trained, and the facility failed to implement proper corrective action from the prior citation.
Deficiencies (1)
Failed to ensure 1 of 5 staff interviewed were properly trained on fire watch procedures as required by NFPA 25, 15.5.2.
Report Facts
Facility capacity: 80
Census: 64
Staff interviewed: 5
Compliance date: Mar 22, 2024
Inspection Report
Re-Inspection
Census: 65
Capacity: 80
Deficiencies: 0
Date: Mar 15, 2024
Visit Reason
A 2nd Post Survey Revisit (PSR) was conducted following a previous Life Safety Code survey to verify compliance with fire safety regulations.
Findings
At this Life Safety Code PSR, Hammond-Whiting Care Center was found in compliance with Medicare/Medicaid participation requirements and the 2012 edition of the National Fire Protection Association Life Safety Code.
Report Facts
Facility capacity: 80
Census: 65
Inspection Report
Follow-Up
Census: 68
Capacity: 80
Deficiencies: 2
Date: Feb 2, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 12/18/23 was performed to verify correction of previously cited deficiencies.
Findings
The facility was found not in compliance with Life Safety Code requirements related to smoke barrier doors and electrical equipment use. Deficiencies included a set of smoke barrier doors failing to close properly and a power strip being used improperly to power high current equipment. Corrective actions were planned and implemented with ongoing monitoring.
Deficiencies (2)
Failed to ensure 1 of 2 sets of smoke barrier doors would restrict the movement of smoke for at least 20 minutes due to a coordinating device not working properly, leaving a gap approximately one inch.
Failed to ensure 1 of 1 power strips were not used as a substitute for fixed wiring to provide power equipment with a high current draw.
Report Facts
Facility capacity: 80
Census: 68
Residents potentially affected: 20
Residents potentially affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nellie Alexander | RN RDCS | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Maintenance Director | Interviewed regarding smoke barrier door and power strip deficiencies | |
| Maintenance Technician #1 | Interviewed and observed during facility tour regarding deficiencies | |
| Executive Director | Involved in corrective actions and exit conference | |
| Regional Director | Involved in exit conference |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 80
Deficiencies: 1
Date: Feb 1, 2024
Visit Reason
An investigation of Complaint Number IN00427505 was conducted by the Indiana Department of Health related to a fire safety allegation involving the sprinkler system being out of service.
Complaint Details
Complaint Number IN00427505 was substantiated with a federal/state deficiency cited at K354 related to failure to conduct fire watch during sprinkler system outage.
Findings
The facility failed to conduct a required fire watch during a sprinkler system outage lasting more than 10 hours, and staff assigned to fire watch had other duties, violating NFPA 25 and Life Safety Code requirements. No residents were affected by this deficiency.
Deficiencies (1)
Failed to conduct 1 of 1 required fire watches during sprinkler system outage exceeding 10 hours, and staff assigned to fire watch had other facility responsibilities.
Report Facts
Sprinkler outage duration (hours): 14
Facility capacity: 80
Census: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Coralette Bowling | Executive Director | Signed report and responsible for compliance in Plan of Correction |
| Maintenance Director | Interviewed regarding fire watch duties and sprinkler outage |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 9, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey and the Investigation of Complaint IN00417083 completed on December 1, 2023.
Complaint Details
Investigation of Complaint IN00417083 was completed.
Findings
Hammond-Whiting Care 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 Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 67
Capacity: 80
Deficiencies: 7
Date: Dec 18, 2023
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) to assess compliance with fire safety and life safety code requirements.
Findings
The facility was found not in compliance with several Life Safety Code requirements including corridor width obstruction, exit discharge blockage, kitchen cooking equipment maintenance, smoke barrier door functionality, emergency generator fuel source reliability, generator transfer time, and improper use of power strips. Corrective actions and monitoring plans were established for each deficiency.
Deficiencies (7)
Service corridor width was obstructed by carts reducing clear width to approximately 38 inches, less than the required 44 inches.
Exit discharge from the North Hall was blocked by a parked car in the fire lane.
Kitchen commercial cooking equipment hood system tank showed significant rust and lacked documentation of hydrostatic testing or corrosion limits compliance.
Smoke barrier doors between main lobby and north hall corridor did not close completely due to lack of coordinating device and door getting caught on metal rabbet.
Emergency generator lacked a letter from the natural gas provider confirming reliable fuel source.
Generator transfer time from normal power to emergency power exceeded 10 seconds on monthly tests with no annual confirmation process documented.
Power strip was used to supply power to a refrigerator in a resident room, which is not permitted as a substitute for fixed wiring.
Report Facts
Certified beds: 80
Census: 67
Service corridor carts: 5
Residents potentially affected: 20
Residents potentially affected: 12
Residents potentially affected: 20
Generator load test frequency: 12
Generator exercise duration: 30
Generator exercise interval: 20
Generator full test interval: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Ready | Regional Vice President | Signed report as provider/supplier representative |
| Maintenance Director | Interviewed and involved in observations and corrective actions for multiple deficiencies | |
| Interim Administrator | Interviewed and involved in exit conference discussions | |
| Executive Director | Responsible for corrective action implementation and monitoring |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 1, 2023
Visit Reason
The inspection was conducted in response to Complaint IN00417083 regarding concerns about residents not receiving adequate assistance with activities of daily living, specifically shaving and bathing.
Complaint Details
This citation relates to Complaint IN00417083.
Findings
The facility failed to ensure dependent residents received assistance with activities of daily living related to shaving and bathing for 2 of 6 residents reviewed. Observations and record reviews showed residents did not consistently receive the required showers or facial hair removal.
Deficiencies (1)
F 0677: The facility failed to provide care and assistance for activities of daily living, including bathing and shaving, for dependent residents. Two residents reviewed did not consistently receive showers twice weekly or facial hair removal as required.
Report Facts
Residents reviewed for ADL assistance: 6
Residents affected: 2
Shower frequency documented: 2
Shower frequency missed weeks: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Consultant | Interviewed regarding shower frequency for Resident B | |
| Director of Nursing | Interviewed regarding facial hair removal for Resident C |
Inspection Report
Recertification
Census: 69
Capacity: 69
Deficiencies: 10
Date: Dec 1, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00417083 and IN00417627.
Complaint Details
Complaint IN00417083 resulted in federal/state deficiencies related to the allegations cited at F677. Complaint IN00417627 had no deficiencies related to the allegations.
Findings
The facility was found deficient in multiple areas including failure to notify families of medication changes, inadequate assistance with activities of daily living, failure to assess and monitor skin conditions and falls, lack of vision and dental services, improper pressure ulcer care, incorrect tube feeding management, oxygen flow rate errors, incomplete dialysis post-assessments, and environmental maintenance issues.
Deficiencies (10)
Failed to promptly notify resident's family of medication changes for 2 residents.
Failed to ensure dependent residents received assistance with activities of daily living related to shaving and bathing.
Failed to assess and monitor areas of bruising, scratches, sutures, glued lacerations, and neurological checks after falls for multiple residents.
Failed to ensure residents had access to vision and hearing services.
Failed to ensure pressure reducing measures were in use for a resident with a deep tissue injury.
Failed to ensure tube feeding was infusing at the correct time and proper tube feeding placement checks and flushes were completed prior to medication administration.
Failed to ensure oxygen was at the correct flow rate for a resident.
Failed to complete post dialysis assessment for a resident receiving dialysis.
Failed to ensure residents received routine dental services.
Failed to maintain a safe, functional, sanitary, and comfortable environment due to marred walls, marred door frames, discolored floors, rusted and missing toilet bolts, dirty and broken floor baseboards, missing pieces from an air conditioner, and uncovered wash basins in multi-resident rooms.
Report Facts
Survey dates: 5
Census: 69
Total Capacity: 69
Medicare Census: 7
Medicaid Census: 51
Other Payor Census: 11
Tube feeding infusion hours: 18
Tube feeding infusion rate: 75
Oxygen flow rate ordered: 3
Oxygen flow rate observed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Thompson | Executive Director | Signed Plan of Correction and correspondence |
| Brenda Buroker | Director of Long-Term Care, Indiana State Department of Public Health | Recipient of Plan of Correction correspondence |
Inspection Report
Complaint Investigation
Deficiencies: 10
Date: Dec 1, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to notify families of medication changes, inadequate assistance with activities of daily living, failure to assess and monitor skin conditions and falls, lack of access to vision and dental services, improper pressure ulcer care, improper tube feeding administration, incorrect oxygen flow rate, and environmental cleanliness and repair issues.
Complaint Details
The investigation was complaint-related, focusing on medication notification failures, inadequate ADL assistance, skin and fall assessments, vision and dental care access, pressure ulcer care, tube feeding administration, oxygen therapy, dialysis care, and environmental conditions.
Findings
The facility was found deficient in multiple areas including failure to notify families of medication changes for residents, inadequate assistance with bathing and shaving, failure to assess and monitor bruising and falls, lack of access to vision and dental services, failure to provide pressure ulcer care, improper tube feeding procedures, incorrect oxygen flow rate, failure to complete post dialysis assessments, and environmental cleanliness and maintenance issues.
Deficiencies (10)
F 0580: The facility failed to promptly notify the resident's family of medication changes for 2 of 2 residents reviewed.
F 0677: The facility failed to ensure dependent residents received assistance with activities of daily living related to shaving and bathing for 2 of 6 residents reviewed.
F 0684: The facility failed to ensure areas of bruising, scratches, sutures, and glued lacerations were assessed and monitored for 3 of 4 residents reviewed for skin conditions and failed to complete neurological checks and fall follow-up documentation for 2 of 3 residents reviewed for falls.
F 0685: The facility failed to ensure residents had access to receive services for impaired vision for 2 of 3 residents reviewed.
F 0686: The facility failed to ensure pressure reducing measures were in use for a resident with a deep tissue injury for 1 of 1 resident reviewed.
F 0693: The facility failed to ensure a tube feeding was infusing at the correct time and failed to ensure tube feeding placement was checked and a water flush was completed prior to administering gastrostomy tube medications for 2 of 2 residents reviewed.
F 0695: The facility failed to ensure oxygen was at the correct flow rate for 1 of 2 residents reviewed for oxygen.
F 0698: The facility failed to complete a post dialysis assessment for 1 of 1 resident reviewed for dialysis.
F 0791: The facility failed to ensure residents received routine dental services for 1 of 4 residents reviewed.
F 0921: The facility failed to ensure the residents' environment was clean and in good repair related to marred walls, marred door frames, discolored floors, rusted and missing toilet bolts, dirty and broken floor baseboards, missing pieces from an air conditioner, and wash basins not contained in a multi resident room on 2 of 2 units.
Report Facts
Medication changes not notified: 2
Residents reviewed for ADL assistance: 6
Residents reviewed for skin conditions: 4
Residents reviewed for vision and hearing: 3
Residents reviewed for pressure ulcers: 1
Residents reviewed for tube feeding: 2
Residents reviewed for oxygen therapy: 2
Residents reviewed for dialysis: 1
Residents reviewed for dental services: 4
Units inspected for environmental issues: 2
Inspection Report
Re-Inspection
Census: 67
Capacity: 67
Deficiencies: 0
Date: Sep 22, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00414236 completed on August 9, 2023.
Complaint Details
Complaint IN00414236 was investigated and found to be corrected.
Findings
Hammond-Whiting Care 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 IN00414236. The complaint was corrected.
Report Facts
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 51
Census Payor Type - Other: 8
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Aug 9, 2023
Visit Reason
The inspection was conducted in response to Complaint IN00414236, which raised concerns about resident dignity during meals, intrafacility transfers without proper notification, resident-to-resident abuse, incomplete medical records, and equipment safety.
Complaint Details
This Federal tag relates to Complaint IN00414236. The complaint involved issues of resident dignity, intrafacility transfer notifications, resident-to-resident abuse, record keeping, and equipment safety.
Findings
The facility was found deficient in multiple areas including failure to assist residents with meal intake timely, lack of written notification for room transfers, failure to prevent resident-to-resident physical abuse resulting in injury, incomplete and inaccurate resident records, and failure to ensure glucometers were properly calibrated.
Deficiencies (5)
F 0557: The facility failed to ensure residents were treated with dignity by not assisting two residents with meal intake in a timely manner during an observed lunch meal.
F 0559: The facility failed to provide written notice to residents or their representatives regarding intrafacility transfers for three residents, including reasons and approvals for the moves.
F 0600: The facility failed to protect a resident from physical abuse by a roommate, resulting in bilateral nasal bone fractures and facial hematoma.
F 0842: The facility failed to maintain complete and accurate resident records related to behavior and intrafacility transfers for two residents.
F 0908: The facility failed to ensure glucometers were calibrated properly, with no calibration checks documented for the month of July for one of two units.
Report Facts
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 2
Residents affected: 8
Date of incident: Jun 23, 2023
Date of survey: Aug 9, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Notified resident's sister about room transfer and observed resident standing over roommate |
| QMA 3 | Qualified Medication Aide | Assisted residents C and D with meals during observed lunch |
| Social Service Director | Interviewed regarding intrafacility transfers and resident requests |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 63
Deficiencies: 5
Date: Aug 9, 2023
Visit Reason
This visit was for the Investigation of Complaints IN00413363 and IN00414236. Complaint IN00413363 had no deficiencies related to the allegations, while Complaint IN00414236 resulted in federal/state deficiencies cited at F557, F559, F842, and F908.
Complaint Details
Complaint IN00413363 had no deficiencies related to the allegations. Complaint IN00414236 was substantiated with federal/state deficiencies cited at F557, F559, F842, and F908.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity during meal assistance, failure to notify residents or responsible parties in writing about room transfers, failure to ensure residents were free from physical abuse related to a resident-to-resident altercation causing injury, incomplete and inaccurate resident records related to behavior and transfers, and failure to maintain glucometers in safe operating condition due to lack of calibration.
Deficiencies (5)
Failed to ensure residents were treated with dignity related to not assisting residents who required assistance with meal intake in a timely manner for 2 of 8 residents during 1 meal observed.
Failed to ensure residents and/or their Responsible Party were notified in writing of an intrafacility transfer, the reason for the transfer, and the approval of the transfer for 3 of 3 residents reviewed.
Failed to ensure a resident was free from physical abuse related to a resident-to-resident altercation resulting in injuries including bilateral non-displaced nasal bone fractures and facial hematoma for 1 of 1 resident to resident altercations reviewed.
Failed to ensure a resident's record was complete and accurate related to a resident's behavior which resulted in an intrafacility transfer for 2 of 9 resident records reviewed.
Failed to ensure resident care equipment was in safe operating condition related to glucometers not calibrated for 1 of 2 units where 8 residents received glucometer testing.
Report Facts
Census: 63
Total Capacity: 63
Residents receiving glucometer testing: 8
Dates of survey: 2023-08-08 to 2023-08-09
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Observed resident standing over roommate and made decision to move resident for safety |
| QMA 3 | Qualified Medication Aide | Assisted residents with meals during observed meal |
| Social Service Director | Social Service Director | Interviewed regarding room transfers and resident safety concerns |
| Executive Director | Executive Director | Notified of resident altercation and responsible for compliance with plan of correction |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 21, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to concerns about safe and orderly resident discharges and completeness of clinical records.
Complaint Details
This Federal tag relates to Complaint IN00410149 for discharge deficiencies and Complaint IN00407586 for incomplete clinical records.
Findings
The facility failed to ensure safe and orderly discharges for 3 residents due to lack of documented home health information, follow-up physician appointments, and wound treatment instructions. Additionally, the facility failed to maintain complete and accurate clinical records for a resident with a skin injury.
Deficiencies (2)
F 0624: The facility failed to prepare residents for a safe transfer or discharge by not documenting home health agency contact information, follow-up physician appointments, and wound care instructions for 3 residents discharged home.
F 0842: The facility failed to safeguard resident-identifiable information and maintain complete medical records related to a scratch on a resident's nose, with no documentation or assessment recorded.
Report Facts
Residents affected: 3
Residents affected: 1
Inspection Report
Complaint Investigation
Census: 62
Capacity: 62
Deficiencies: 2
Date: Jun 21, 2023
Visit Reason
This visit was conducted for the investigation of three complaints (IN00403028, IN00407586, and IN00410149) regarding the facility's compliance with state and federal regulations.
Complaint Details
Complaint IN00403028 had no deficiencies related to the allegations. Complaint IN00407586 and IN00410149 had federal/state deficiencies cited at F842 and F624 respectively.
Findings
The facility was found deficient in ensuring safe and orderly discharge preparation for residents, with lack of documented home health information, follow-up physician appointments, and wound treatments for 3 residents discharged home. Additionally, the facility failed to maintain complete and accurate clinical records related to a resident's non-pressure skin injury. Some complaints had no deficiencies cited, while others resulted in federal/state deficiencies.
Deficiencies (2)
Failed to ensure residents' discharges to home were safe and orderly, related to lack of documented home health information, follow-up Physician appointments and wound treatments for 3 of 3 residents reviewed for discharges (Residents D, E, and F).
Failed to ensure clinical records were complete and accurately documented related to a scratch on a resident's nose for 1 of 3 residents reviewed for non-pressure related skin conditions (Resident C).
Report Facts
Census: 62
Total Capacity: 62
Medicare Census: 8
Medicaid Census: 47
Other Payor Census: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Verna Meacham | Executive Director | Signed the report |
| Social Service Director | Interviewed regarding discharge planning and home health services | |
| Director of Nursing | Interviewed regarding discharge instructions and clinical documentation | |
| Assistant Director of Nursing | Interviewed regarding assessment and documentation of resident's skin injury |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 21, 2023
Visit Reason
Paper compliance review to the Investigation of Complaints IN00407586 and IN00410149 completed on June 21, 2023.
Complaint Details
Investigation of Complaints IN00407586 and IN00410149; paper compliance review completed with findings of compliance.
Findings
Hammond-Whiting Care 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.
Inspection Report
Life Safety
Deficiencies: 0
Date: Feb 1, 2023
Visit Reason
The visit was a Life Safety Code Recertification and State Licensure Survey conducted to assess compliance with fire safety and health care occupancy regulations.
Findings
Hammond-Whiting Care Center was found in compliance with the 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
Life Safety
Census: 59
Capacity: 80
Deficiencies: 10
Date: Dec 8, 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 on 12/08/2022.
Findings
The facility was found in compliance with Emergency Preparedness requirements but was not in compliance with Life Safety Code requirements, including issues with corridor egress obstructions, exit signage illumination, fire alarm system maintenance, fire watch policy completeness, sprinkler system installation and maintenance, portable fire extinguisher inspections, and essential electrical system testing.
Deficiencies (10)
Failed to ensure 1 of 4 corridor means of egresses were continuously maintained free of obstructions due to PPE carts without wheels blocking the corridor.
Failed to ensure 1 of 10 exit signs were continuously illuminated; South Hall exit sign was not illuminated.
Failed to maintain the fire alarm system with accurate time and date information; fire alarm control panel showed incorrect date/time.
Failed to ensure smoke detector sensitivity testing was fully documented and completed as required.
Failed to provide a complete fire watch policy including proper notification procedures to the Indiana Department of Health.
Failed to ensure only one type of sprinkler head was installed in 1 of 4 smoke compartments; mixed quick response and standard sprinklers found.
Failed to perform a full hydrostatic flush on 1 of 2 automatic sprinkler piping systems as required by NFPA 25.
Failed to provide correct written policies for sprinkler system out-of-service procedures including notification and fire watch requirements.
Failed to inspect 1 of 2 portable fire extinguishers in the kitchen monthly; missing documentation for past 12 months.
Failed to maintain Emergency Power Standby System testing documentation for a required 4-hour load test within the last 36 months.
Report Facts
Deficiencies cited: 10
Facility capacity: 80
Census: 59
Compliance dates: Jan 7, 2023
Sprinkler system flush scheduled: May 1, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Verna Meacham | Executive Director | Named in relation to findings and exit conferences. |
| Maintenance Director | Mentioned multiple times in relation to findings and corrective actions but no full name provided. |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 55
Deficiencies: 0
Date: Dec 6, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00395962.
Complaint Details
Complaint IN00395962 - Substantiated. No deficiencies related to the allegations are cited.
Findings
The complaint IN00395962 was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Medicare residents: 9
Medicaid residents: 42
Other residents: 4
Inspection Report
Annual Inspection
Census: 57
Capacity: 57
Deficiencies: 16
Date: Oct 25, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey including the Investigation of Complaints IN00386810, IN00388294, IN00389608, and IN00392720.
Complaint Details
Complaints IN00386810, IN00388294, IN00389608, and IN00392720 were substantiated with related federal/state deficiencies cited.
Findings
The facility was found to have multiple deficiencies including failure to maintain resident dignity, incomplete treatment and medication administration, inadequate activities for cognitively impaired residents, environmental cleanliness issues, and medication errors.
Deficiencies (16)
Failure to ensure residents' dignity related to uncovered foley catheter bags and residents wearing hospital gowns throughout the day.
Failure to provide assistance with activities of daily living including personal hygiene, oral care, nail care, and shaving for dependent residents.
Failure to provide quarterly statements for resident personal funds.
Failure to ensure ongoing activities were in place for cognitively dependent residents.
Failure to ensure treatments were completed as ordered and monitoring initiated for elevated blood pressures for residents reviewed for skin conditions and hospitalization.
Failure to ensure treatments were completed as ordered and treatment orders obtained for residents with pressure ulcers.
Failure to ensure residents with limited range of motion had splints and/or anticontracture devices applied as ordered.
Failure to ensure adaptive equipment was provided as ordered and meal consumption monitored for a resident with nutritional risk.
Failure to ensure a resident dependent on enteral tube feedings received adequate nutrition and head of bed was raised during feedings.
Failure to ensure oxygen was set at the correct flow rate for residents reviewed for oxygen use.
Failure to post daily nurse staffing information accurately and timely.
Failure to ensure pharmacy services provided timely medications related to admission medications.
Failure to ensure residents' drug regimens were free from unnecessary medications.
Failure to ensure AIMS scales were completed for residents receiving psychotropic medications.
Medication error rate exceeded 5% with errors including improper timing and administration of medications.
Failure to ensure a safe, functional, sanitary, and comfortable environment related to stained floor tiles, marred walls and doors, stained privacy curtains, and urine odors on two units.
Report Facts
Census: 57
Total Capacity: 57
Medication error rate: 10.71
Medication administration opportunities: 28
Medication errors observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Named in medication error finding and tube feeding care | |
| LPN 3 | Named in medication error finding for insulin pen administration | |
| QMA 1 | Named in medication error finding for medication administration | |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple findings including dignity, treatments, oxygen, medication administration, and staffing |
| Nurse Consultant | Interviewed regarding wound care and medication administration | |
| Maintenance Supervisor | Interviewed regarding environmental deficiencies | |
| Activity Director | Interviewed regarding activities for cognitively impaired residents |
Inspection Report
Renewal
Deficiencies: 0
Date: Oct 25, 2022
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey and the Investigation of Complaints IN00386810, IN00388294, IN00389608, and IN00392720.
Findings
Hammond-Whiting Care 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 Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Deficiencies: 16
Date: Oct 25, 2022
Visit Reason
The inspection was conducted based on complaints and allegations related to resident dignity, personal funds management, assistance with activities of daily living, ongoing activities for cognitively dependent residents, treatment and care for skin conditions, pressure ulcer care, range of motion care, nutrition, tube feeding care, oxygen therapy, staffing information posting, pharmaceutical services, medication administration, unnecessary medications, and environmental cleanliness.
Complaint Details
The deficiencies relate to multiple complaints including IN00388294, IN00389608, IN00386810, and IN00392720.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, failure to provide quarterly personal funds statements, inadequate assistance with activities of daily living, lack of ongoing activities for cognitively dependent residents, incomplete treatment and monitoring of skin conditions and pressure ulcers, failure to apply splints and anticontracture devices as ordered, inadequate nutritional support and adaptive equipment, improper tube feeding care, incorrect oxygen flow rates, failure to post daily staffing information, delayed medication delivery, medication administration errors, failure to complete AIMS scales for psychotropic medications, and environmental cleanliness issues such as stained floors, marred walls, stained curtains, and improper storage of bedpans and wash basins.
Deficiencies (16)
F 0550: The facility failed to ensure residents' dignity was maintained related to uncovered foley catheter bags and residents wearing hospital gowns while in bed for 3 of 5 residents reviewed.
F 0568: The facility failed to provide quarterly personal funds statements for 1 of 1 resident reviewed.
F 0677: The facility failed to provide assistance with activities of daily living including personal hygiene, oral care, nail care, and shaving for 3 of 5 residents reviewed.
F 0679: The facility failed to ensure ongoing activities were in place for cognitively dependent residents for 2 of 2 residents reviewed.
F 0684: The facility failed to ensure treatments were completed as ordered and monitoring was initiated for elevated blood pressures for 3 of 5 residents reviewed for skin conditions and hospitalization.
F 0686: The facility failed to ensure treatments were completed as ordered and treatment orders were obtained for 4 of 5 residents reviewed for pressure ulcers.
F 0688: The facility failed to ensure residents with limited range of motion had splints and anticontracture devices applied as ordered for 3 of 3 residents reviewed.
F 0692: The facility failed to ensure adaptive equipment was provided and meal consumption monitored for 1 of 2 residents reviewed for nutrition.
F 0693: The facility failed to ensure a resident dependent on enteral tube feedings received adequate nutrition and the head of the bed was raised while feedings were infusing.
F 0695: The facility failed to ensure oxygen was set at the correct flow rate for 2 of 3 residents reviewed for oxygen therapy.
F 0732: The facility failed to post daily nurse staffing information indicating staff numbers and facility census.
F 0755: The facility failed to ensure medications were obtained timely from the pharmacy related to admission medications for 1 of 3 residents reviewed for hospitalization.
F 0757: The facility failed to ensure medications were administered as ordered by the physician for 1 of 7 residents reviewed for unnecessary medications.
F 0758: The facility failed to ensure AIMS scales were completed for 2 of 7 residents reviewed for unnecessary medications.
F 0759: The facility failed to ensure a medication error rate less than 5%, with 3 errors observed during 28 medication administration opportunities.
F 0921: The facility failed to ensure the residents' environment was clean and in good repair related to stained floor tiles, marred walls and doors, stained privacy curtains, and urine odors on 2 units.
Report Facts
Medication error rate: 10.71
Resident weight loss: 17.1
Pressure ulcer measurements: 2
Medication doses missed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding multiple findings including dignity, treatments, oxygen therapy, medication errors, and staffing. | |
| Business Office Manager | Interviewed regarding personal funds statements. | |
| Nurse Consultant | Interviewed regarding medication administration and AIMS scales. | |
| LPN 1 | Observed medication administration and interviewed regarding splint and feeding assistance. | |
| QMA 1 | Observed medication administration and interviewed regarding medication timing. | |
| Activity Director | Interviewed regarding activities for cognitively dependent residents. | |
| Maintenance Supervisor | Interviewed regarding environmental cleanliness and repairs. |
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