Inspection Reports for
Manderley Health Care Center
806 S BUCKEYE ST, OSGOOD, IN, 47037
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
17.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
324% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
72% occupied
Based on a March 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 21, 2025
Visit Reason
The inspection was conducted in response to Complaint 1814346 regarding food handling practices and pest control issues at the facility.
Complaint Details
This citation relates to Complaint 1814346. The complaint involved concerns about food handling and pest control, specifically the presence of gnats in the kitchen and food storage areas.
Findings
The facility failed to follow appropriate food handling guidelines including food storage, open dating, and protecting food from gnats. The facility also failed to maintain an effective pest control program, resulting in a persistent gnat infestation in the kitchen and food storage areas.
Deficiencies (2)
F 0812: The facility failed to procure food from approved sources and properly store, prepare, and serve food. Observations included undated opened food items, food on the floor, and uncovered meat with gnats present.
F 0925: The facility failed to maintain an effective pest control program to prevent and eliminate gnats. Multiple gnats were observed in the kitchen and dry food storage areas despite pest control efforts.
Report Facts
Residents affected: 47
Gnats observed: 50
Gnats on coffee machine buttons: 15
Gnats on trash can lid: 7
Gnats on cereal bag: 5
Gnats on cheese can: 3
Inspection Report
Re-Inspection
Census: 51
Capacity: 71
Deficiencies: 1
Date: Mar 18, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted to verify compliance with fire safety and licensure requirements.
Findings
The facility was found in compliance with the Life Safety Code requirements during this revisit. However, a deficiency related to HVAC compliance with NFPA 101 was noted, with an annual waiver request in place.
Deficiencies (1)
HVAC heating, ventilation, and air conditioning shall comply with 9.2 and be installed according to manufacturer's specifications; this requirement was not met as evidenced by the annual waiver request.
Report Facts
Facility capacity: 71
Census: 51
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 4, 2025
Visit Reason
The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Manderley Health Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 52
Capacity: 71
Deficiencies: 9
Date: Feb 12, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal regulations.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements, with multiple deficiencies noted including obstructed exit discharge, missing 'No Exit' signage, improper cooking appliance placement, corridor doors not latching, HVAC return air system issues, inadequate fire drill scheduling, smoking policy violations, unsecured power cords, and incomplete maintenance documentation for electrical equipment.
Deficiencies (9)
Failed to ensure 1 of 5 exit discharges was free of obstructions; a significant gap in concrete at exit discharge.
Failed to ensure 1 of 1 courtyard doors was posted with a 'No Exit' sign.
Failed to provide an approved method for returning 1 of 1 kitchen hood extinguishing system cooking appliances to approved design location.
Failed to ensure 2 of over 30 corridor doors had no impediment to closing and latching into the door frame.
Failed to ensure 1 of 4 egress corridors were not used as a portion of a return air system/plenum for HVAC ductwork.
Failed to conduct quarterly fire drills on unexpected days and at unexpected times under varying conditions.
Failed enforcement of non-smoking policies; smoking observed within 8 feet of the building.
Failed to ensure 1 power strip in room 304 was secured and not dangling from the wall behind the TV.
Failed to conduct required maintenance and maintain complete documentation of inspections for Patient Care Related Electrical Equipment (PCREE).
Report Facts
Certified beds: 71
Census: 52
Exit discharges: 5
Corridor doors: 30
Fire drills: 12
Fire drills near month end: 8
Residents potentially affected by exit obstruction: 8
Residents potentially affected by missing no exit sign: 15
Staff potentially affected by cooking appliance issue: 6
Staff potentially affected by corridor door issue: 4
Residents potentially affected by smoking violation: 15
Residents potentially affected by power strip issue: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Monica Ogden | LHFA | Facility representative signing the report and plan of correction. |
| Maintenance Supervisor | Interviewed during observations and findings related to exit discharge, signage, cooking appliances, corridor doors, HVAC, and power strip issues. | |
| Administrator | Interviewed during observations and findings; involved in exit conferences and education. | |
| Maintenance Director | Named in corrective actions and education related to multiple deficiencies including exit discharge, signage, cooking appliances, corridor doors, HVAC, smoking policy, power strips, and electrical equipment maintenance. | |
| Dietary Manager | Educated regarding cooking appliance deficiency. |
Inspection Report
Annual Inspection
Census: 47
Capacity: 47
Deficiencies: 8
Date: Jan 31, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from January 27 to January 31, 2025.
Findings
The facility was found deficient in multiple areas including resident dignity during meal service, privacy breaches with medication carts, failure to follow medication hold parameters, delayed treatment of urinary tract infection, improper medication storage, failure to obtain timely lab tests, unsanitary food storage, and inadequate infection control related to urinary catheter care.
Deficiencies (8)
Failed to treat a resident in a dignified manner during meal service by standing over the resident instead of sitting next to them.
Failed to maintain resident records in a private manner with medication cart screens left unattended and resident information visible.
Failed to follow physician's orders related to hold parameters for medications for 2 residents.
Failed to treat a urinary tract infection in a timely manner for 1 resident.
Failed to store medications appropriately; medication cart left unlocked and unattended.
Failed to obtain a blood test and urinalysis timely for 1 resident.
Failed to store foods in a sanitary manner; unlabeled and outdated foods found in kitchen.
Failed to follow infection control guidelines related to urinary catheter care; catheter bag was on the floor and staff failed to don gown when required.
Report Facts
Census: 47
Total Capacity: 47
Deficiencies cited: 8
Audit frequency: 5
Audit duration: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Monica Ogden | Laboratory Director/Facility Administrator | Signed the report and involved in plan of correction |
| RN 3 | Observed leaving medication cart unlocked and unattended | |
| CNA 6 | Certified Nurse Aide | Observed treating resident without dignity during meal service |
| CNA 4 | Certified Nurse Aide | Interviewed about proper meal assistance procedures |
| QMA 8 | Qualified Medication Aide | Interviewed about medication cart privacy practices |
| RN 2 | Registered Nurse | Interviewed about medication hold parameters and lab specimen collection |
| CNA 9 | Certified Nurse Aide | Observed providing urinary catheter care without proper gown use |
| CNA 10 | Certified Nurse Aide | Observed assisting with urinary catheter care without donning gown |
| Cook 5 | Cook | Interviewed about expired food items in kitchen |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Jan 31, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity during meal service, confidentiality of resident records, medication administration errors, timely treatment of urinary tract infections, medication storage, laboratory services, food storage, and infection control practices related to urinary catheter care.
Deficiencies (8)
F 0550: The facility failed to treat a resident in a dignified manner during a meal service for 1 of 2 dining observations.
F 0583: The facility failed to maintain resident records in a private manner related to information visible on a computer screen and on top of a medication cart for 2 of 6 observations.
F 0684: The facility failed to follow physician's orders related to hold parameters for medications for 2 of 15 residents reviewed for Quality of Care.
F 0690: The facility failed to treat a Urinary Tract Infection in a timely manner for 1 of 2 residents reviewed for UTIs.
F 0761: The facility failed to store medications appropriately for 1 of 2 medication carts reviewed; the 100-Hall Medication Cart was unlocked and left unattended.
F 0770: The facility failed to obtain a blood test and a urinalysis timely for 1 of 5 residents reviewed for laboratory services.
F 0812: The facility failed to store foods in a sanitary manner related to unlabeled and outdated foods for 1 of 3 kitchen observations.
F 0880: The facility failed to follow infection control guidelines related to urinary catheter care for 1 of 2 residents reviewed for infection control.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 45
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 3 | Observed leaving medication cart unlocked and unattended | |
| CNA 6 | Certified Nurse Aide | Failed to treat resident with dignity during meal service |
| CNA 4 | Certified Nurse Aide | Described proper meal assistance technique |
| DON | Director of Nursing | Provided policies and interviews regarding deficiencies |
| RN 2 | Interviewed about medication administration and lab specimen handling | |
| QMA 8 | Qualified Medication Aide | Interviewed about medication cart confidentiality |
| CNA 9 | Certified Nurse Aide | Observed performing urinary catheter care without proper gown use by assisting CNA |
| CNA 10 | Certified Nurse Aide | Entered room to assist with urinary catheter care without donning gown |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 51
Deficiencies: 0
Date: Nov 14, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00447188.
Complaint Details
Complaint IN00447188 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00447188 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Report Facts
Census SNF/NF beds: 51
Census total residents: 51
Census Medicare residents: 2
Census Medicaid residents: 42
Census other payor residents: 7
Inspection Report
Re-Inspection
Census: 50
Capacity: 71
Deficiencies: 1
Date: May 30, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and Life Safety Code survey previously conducted on 04/15/2024 by the Indiana State Department of Health.
Findings
At this Emergency Preparedness survey, the facility was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. At the Life Safety Code survey, the facility was found in compliance with applicable fire safety codes and regulations, except for an HVAC deficiency which had an annual waiver requested.
Deficiencies (1)
HVAC heating, ventilation, and air conditioning did not comply with manufacturer's specifications as required by NFPA 101.
Report Facts
Certified beds: 71
Census: 43
Census: 50
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 17, 2024
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Manderley Health Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 50
Capacity: 71
Deficiencies: 7
Date: Apr 15, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal regulations and state law.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies were identified related to fire alarm system testing and maintenance, sprinkler system maintenance, corridor wall construction, HVAC system use of egress corridors as return air plenums, improper use of power strips, and combustible materials stored too close to oxygen storage.
Deficiencies (7)
Failed to maintain 1 of 1 fire alarm systems with required semi-annual visual inspections and accurate time information.
Failed to replace sprinkler heads showing rust/corrosion in multiple locations and failed to maintain spare sprinkler heads properly.
Failed to maintain ceiling construction in 2 locations in shower room 1 affecting sprinkler operation.
Failed to ensure corridor walls in 2 of 5 smoke compartments were constructed to resist the transfer of smoke.
Failed to ensure 4 of 4 egress corridors were not used as a portion of a return air system/plenum for HVAC ductwork.
Failed to ensure 1 of 1 power strips in room 204 was not used as a substitute for fixed wiring.
Failed to ensure a minimum distance of at least 20 feet separated combustible materials from oxygen storage equipment in 1 of 1 oxygen storage areas.
Report Facts
Certified beds: 71
Census: 50
Deficiencies cited: 7
Completion dates: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed regarding fire alarm system inspection, sprinkler heads, corridor wall penetrations, HVAC system, and power strip usage | |
| Maintenance Director | Performed audits, education, and corrective actions related to fire alarm system, sprinkler system, corridor walls, HVAC waiver, power strips, and oxygen storage | |
| Administrator | Participated in exit conference and education regarding deficiencies and corrective actions |
Inspection Report
Annual Inspection
Census: 45
Capacity: 45
Deficiencies: 7
Date: Mar 8, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from March 4 to March 8, 2024.
Findings
The facility was found deficient in multiple areas including failure to maintain resident privacy, failure to follow physician orders for medication and lab tests, failure to monitor nutrition and hydration adequately, failure to provide safe food preparation and serving, and failure to maintain functioning resident call systems.
Deficiencies (7)
Failed to maintain resident records in a private manner with records left unattended and visible for 3 residents.
Failed to follow physician's orders related to hold parameters for blood pressure medication for 1 resident.
Failed to address and monitor weight loss concerns and fluid intake for 3 residents.
Failed to follow physician's order related to medication reduction for 1 resident.
Failed to follow physician's orders to obtain blood tests for 1 resident.
Failed to prepare and serve food in a safe and sanitary manner for 2 dining observations, including undercooked meatloaf and inadequate hand sanitation by staff.
Failed to provide a functioning call light for 1 resident.
Report Facts
Survey dates: 5
Census: 45
Total capacity: 45
Residents affected by privacy deficiency: 3
Residents reviewed for quality of care: 15
Residents reviewed for nutrition and hydration: 5
Residents reviewed for pharmacy services: 5
Residents reviewed for laboratory services: 5
Residents reviewed for call light function: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Monica Ogden | LNHA | Signed plan of correction |
| Carla Poynter | Director of Nursing | Signed report and provided policies |
Inspection Report
Routine
Census: 45
Deficiencies: 7
Date: Mar 8, 2024
Visit Reason
Routine inspection survey conducted to assess compliance with healthcare regulations and standards at Manderley Health Care Center.
Findings
The facility was found to have multiple deficiencies including failure to maintain resident record confidentiality, failure to follow physician's medication orders, inadequate monitoring of fluid intake and weight loss, failure to obtain ordered laboratory tests, unsafe food preparation and serving practices, and a non-functioning call light system for a resident.
Deficiencies (7)
F 0583: The facility failed to maintain resident records in a private manner related to records left unattended on the nurse's station counter and a computer screen left open with visible resident information for 3 of 45 residents.
F 0684: The facility failed to follow physician's orders related to hold parameters for a blood pressure medication for 1 of 15 residents reviewed for quality of care (Resident 27).
F 0692: The facility failed to address and monitor weight loss concerns in a timely manner and monitor fluid intake for 3 of 5 residents reviewed for nutrition and hydration.
F 0755: The facility failed to follow a physician's order related to medication reduction for 1 of 5 residents reviewed for pharmacy services (Resident 25).
F 0770: The facility failed to follow the physician's orders to obtain blood tests for 1 of 5 residents reviewed for laboratory services (Resident 12).
F 0812: The facility failed to prepare and serve food in a safe and sanitary manner for 2 of 3 dining observations, including serving undercooked meatloaf and improper hand hygiene by staff.
F 0919: The facility failed to provide a functioning call light for 1 of 16 residents reviewed for functioning call lights (Resident 26).
Report Facts
Residents reviewed for confidentiality: 45
Residents reviewed for medication orders: 15
Residents reviewed for nutrition and hydration: 5
Residents reviewed for pharmacy services: 5
Residents reviewed for laboratory services: 5
Residents reviewed for functioning call lights: 16
Weight loss percentage: 14.15
Weight loss percentage: 7.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Certified Nurse Aide | Mentioned in relation to confidentiality and feeding assistance deficiencies |
| RN 5 | Registered Nurse | Interviewed regarding medication administration and hold parameters |
| DON | Director of Nursing | Provided multiple policy documents and interviews related to deficiencies |
| RN 4 | Registered Nurse | Interviewed regarding fluid restriction monitoring |
| CNA 9 | Certified Nurse Aide | Observed and interviewed regarding food service and hygiene practices |
| DM | Dietary Manager | Interviewed regarding food preparation and serving practices |
| Maintenance Supervisor | Interviewed regarding call light system maintenance |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 53
Deficiencies: 0
Date: Nov 16, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00420160.
Complaint Details
Complaint IN00420160 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: 12
Medicaid census: 35
Other payor census: 6
Inspection Report
Complaint Investigation
Census: 47
Capacity: 47
Deficiencies: 0
Date: Sep 18, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00413498.
Complaint Details
Complaint IN00413498 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: 38
Other payor census: 5
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 28, 2023
Visit Reason
Annual inspection survey of Manderley Health Care Center to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 0
Date: May 18, 2023
Visit Reason
This visit was conducted for the investigation of three complaints: IN00407229, IN00405979, and IN00401642.
Complaint Details
Complaints IN00407229, IN00405979, and IN00401642 were investigated with no deficiencies found related to the allegations.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 43
Medicare residents: 3
Medicaid residents: 29
Other residents: 11
Inspection Report
Re-Inspection
Census: 46
Capacity: 71
Deficiencies: 0
Date: Apr 6, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 02/08/23 by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR survey, Manderley Health Care Center was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinklered with a fire alarm system and smoke detectors in all required areas.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 14, 2023
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Manderley Health Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 42
Capacity: 71
Deficiencies: 9
Date: Feb 8, 2023
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 02/08/2023 to assess compliance with Emergency Preparedness Requirements and Life Safety Code regulations.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies were identified related to smoke detector maintenance, sprinkler system spare parts, HVAC system use of egress corridors as return air plenums, fire drill timing, fire door inspection documentation, electrical receptacle grading, use of extension cords, and oxygen cylinder storage.
Deficiencies (9)
Failed to ensure documentation for preventative maintenance of smoke detectors in all resident rooms.
Failed to replace smoke alarms installed in 3 of 36 resident sleeping rooms that were more than 10 years old.
Failed to ensure the sprinkler system spare cabinet contained the minimum number of spare sprinklers for all types and temperature ratings.
Failed to ensure 4 of 4 egress corridors were not used as a portion of a return air system/plenum for HVAC ductwork.
Failed to conduct quarterly fire drills at unexpected times under varying conditions on the first and third shifts.
Failed to ensure annual inspection and testing of all fire door assemblies were completed with itemized location and all testing items per NFPA 80.
Failed to ensure nonhospital-grade electrical receptacles that failed annual testing in 7 of 36 resident sleeping rooms were replaced with hospital-grade receptacles.
Failed to ensure extension cords including power strips were not used as a substitute for fixed wiring; a power strip was used in a patient care vicinity for non-PCREE equipment.
Failed to ensure 2 of 2 cylinders of nonflammable gases such as oxygen were properly secured from falling.
Report Facts
Certified beds: 71
Census: 42
Resident sleeping rooms with smoke alarms older than 10 years: 3
Resident sleeping rooms with failed electrical receptacles replaced: 7
Fire drills not conducted at unexpected times: 3
Fire drills not conducted at unexpected times: 4
Spare sprinklers in cabinet: 6
Oxygen cylinders improperly stored: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tina Estes | HFA, RDO | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Maintenance Director | Interviewed regarding smoke detector maintenance, sprinkler system, fire drills, fire door inspections, electrical receptacles, extension cords, and oxygen cylinder storage | |
| Administrator | Interviewed and participated in exit conference regarding all findings |
Inspection Report
Annual Inspection
Census: 41
Capacity: 41
Deficiencies: 6
Date: Jan 27, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00398708 which was unsubstantiated due to lack of evidence.
Complaint Details
Complaint IN00398708 was investigated and found unsubstantiated due to lack of evidence.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of medication refusals, improper insulin pen usage, failure to prevent pressure ulcers, inadequate dialysis site monitoring, medication availability issues, and unsanitary food storage and kitchen environment.
Deficiencies (6)
Failed to notify the physician of a resident's refusal of medications for 1 of 14 residents reviewed.
Failed to follow manufacturer's guidelines related to insulin pen usage for 1 of 14 residents reviewed.
Failed to prevent the development and worsening of a pressure ulcer for 1 of 5 residents reviewed for pressure ulcers.
Failed to adequately monitor dialysis access sites and fluid intake amounts for 3 of 3 residents reviewed for dialysis.
Failed to ensure a resident's medications were available related to their diagnoses for 1 of 7 residents reviewed for medications.
Failed to store food and provide a clean kitchen environment for 2 kitchen observations, potentially affecting all residents receiving food from the kitchen.
Report Facts
Census: 41
Total Capacity: 41
Medication refusal dates: 30
Pressure ulcer wound size: 3.6
Pressure ulcer wound size: 2.5
Medication administration missed dates: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Molly Negangard | Health Facility Administrator | Signed the report |
| RN 2 | Interviewed regarding medication refusals and insulin pen usage | |
| LPN 3 | Interviewed regarding dialysis site monitoring and fluid restriction | |
| LPN 4 | Interviewed regarding medication availability and Emergency Drug Kit usage | |
| Dietary Manager | Interviewed regarding kitchen sanitation and food storage | |
| Director of Nursing | DON | Provided policies and interviewed regarding multiple deficiencies |
| Assistant Director of Nursing | ADON | Provided documentation and interviewed regarding multiple deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Jan 27, 2023
Visit Reason
The inspection was conducted to investigate complaints related to medication administration, pressure ulcer care, dialysis care, pharmaceutical services, and kitchen sanitation at the nursing facility.
Complaint Details
The investigation was complaint-driven, focusing on medication administration errors, pressure ulcer care, dialysis monitoring, pharmaceutical service deficiencies, and kitchen sanitation issues. The complaints were substantiated with findings of minimal harm.
Findings
The facility failed to notify physicians of medication refusals, improperly administered insulin pens, did not prevent pressure ulcer development, inadequately monitored dialysis access and fluid intake, failed to ensure medication availability, and maintained unsanitary kitchen conditions.
Deficiencies (6)
F 0580: The facility failed to notify the physician of a resident's refusal of medications for 1 of 14 residents reviewed. Documentation of physician notification was lacking until 01/19/23 despite multiple refusals.
F 0684: The facility failed to follow manufacturer's guidelines for insulin pen usage for 1 of 14 residents. The nurse did not clean the insulin pen before applying the needle.
F 0686: The facility failed to prevent the development and worsening of a pressure ulcer for 1 of 5 residents at risk. Preventative measures were not documented prior to ulcer development on 12/01/22.
F 0698: The facility failed to adequately monitor dialysis access sites and fluid intake for 3 residents. Assessments were not documented on non-dialysis days and fluid intake was not recorded despite physician orders.
F 0755: The facility failed to ensure a resident's medications were available for hyperlipidemia and benign prostatic hyperplasia. Medications were missing for multiple days without documented physician notification.
F 0812: The facility failed to store food properly and maintain a clean kitchen environment. Observations included expired food, black substance on walls, dust-covered vents, and personal items stored near food containers.
Report Facts
Residents reviewed for medication refusal: 14
Residents reviewed for pressure ulcers: 5
Residents reviewed for dialysis care: 3
Residents reviewed for medication availability: 7
Residents affected by kitchen sanitation issues: 41
Inspection Report
Complaint Investigation
Census: 37
Capacity: 37
Deficiencies: 0
Date: Dec 7, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00390567 and IN00395609.
Complaint Details
Complaint IN00390567 - Substantiated with no deficiencies cited. Complaint IN00395609 - Unsubstantiated due to lack of evidence.
Findings
Complaint IN00390567 was substantiated but no deficiencies related to the allegations were cited. Complaint IN00395609 was unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 37
Total Capacity: 37
Medicare Census: 6
Medicaid Census: 23
Other Payor Census: 8
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