Inspection Report Summary
The most recent inspection on July 2, 2025, found the facility in compliance with no deficiencies cited during complaint investigations and a post-survey revisit. Earlier inspections showed a pattern of deficiencies primarily related to resident care, including failure to follow hospital transfer recommendations leading to a fall injury, and issues with supervision and documentation of care plans, medication administration, and fall notifications. Complaint investigations were mostly unsubstantiated, though one substantiated complaint involved delayed notification and improper handling of a resident’s fall resulting in injury. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility appears to be addressing prior issues through corrective actions and education, with recent inspections showing improvement and compliance.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
11.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
181% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
230% occupied
Based on a July 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 0
Jul 2, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00461739 and was conducted in conjunction with a Post Survey Revisit to the Investigation of Complaint IN00459646 completed on June 10, 2025.
Findings
No deficiencies related to the allegations of Complaint IN00461739 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding this complaint.
Complaint Details
Complaint IN00461739 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Residential Census: 70
Inspection Report
Re-Inspection
Census: 54
Capacity: 54
Deficiencies: 0
Jul 2, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00459646 completed on June 10, 2025, and was conducted in conjunction with the Investigation of Complaint IN00461739.
Findings
Marquette 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 unrelated deficiencies cited during the Investigation of Complaint IN00459646.
Complaint Details
The visit was related to the investigation of complaints IN00459646 and IN00461739. The PSR addressed unrelated deficiencies cited during the investigation of complaint IN00459646.
Report Facts
Census SNF beds: 54
Census total residents: 54
Census Medicare residents: 16
Census other payor residents: 38
Inspection Report
Complaint Investigation
Census: 52
Capacity: 52
Deficiencies: 1
Jun 10, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00459646. The complaint investigation found no deficiencies related to the allegation, but unrelated deficiencies were cited.
Findings
The facility failed to ensure hospital recommendations related to transfers were followed for Resident B, resulting in an acute distal tibia fracture after a fall. The investigation revealed that Resident B was assisted by only one staff member during transfers despite hospital recommendations for two staff assist, and the resident fell while ambulating with a walker without a gait belt. The facility has implemented corrective actions including audits, staff education, and policy reviews to prevent future incidents.
Complaint Details
Complaint IN00459646 was investigated and no deficiencies related to the allegation were cited.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure hospital recommendations related to transfers were followed to prevent accidents for Resident B, resulting in an acute distal tibia fracture. | SS=G |
Report Facts
Census Bed Type: 52
Total Census: 52
Medicare Census: 12
Other Payor Census: 40
Audit Frequency: 5
Audit Frequency: 3
Audit Duration Weeks: 8
Audit Duration Months: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Cox | Administrator/ED | Signed the report |
| CNA 2 | Provided statements regarding Resident B's fall and assistance | |
| LPN 2 | Interviewed about Resident B's condition and assistance after fall | |
| Therapy Manager | Interviewed about Resident B's therapy evaluation and transfer status | |
| Director of Nursing | Director of Nursing | Provided interviews and facility policies related to safe lifting and abuse prevention |
Inspection Report
Re-Inspection
Census: 54
Capacity: 57
Deficiencies: 0
May 1, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted to verify compliance with previous deficiencies.
Findings
The facility was found in compliance with Requirements for Participation in Medicare, 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. The building was fully sprinklered with appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 57
Census: 54
Inspection Report
Life Safety
Census: 54
Capacity: 57
Deficiencies: 4
Feb 25, 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 not in compliance with Life Safety Code requirements. Deficiencies were identified related to hazardous area door self-closing devices, kitchen hood extinguishing system appliance positioning, sprinkler system escutcheon maintenance, and incomplete quarterly fire drills.
Severity Breakdown
SS=E: 3
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure the corridor door to 1 of 6 hazardous areas had a self-closing device causing the door to automatically close and latch. | SS=E |
| Failed to provide an approved method for returning cooking appliances to their approved design location under the kitchen hood extinguishing system. | SS=E |
| Failed to maintain the ceiling construction around a sprinkler head with a properly fitted escutcheon, leaving an annular space. | SS=E |
| Failed to conduct quarterly fire drills for 1 of 4 quarters, specifically missing a third shift fire drill in the second quarter of 2024. | SS=F |
Report Facts
Certified beds: 57
Census: 54
Residents potentially affected by hazardous door deficiency: 14
Staff potentially affected by hazardous door deficiency: 4
Visitors potentially affected by hazardous door deficiency: 2
Residents potentially affected by kitchen appliance positioning deficiency: 22
Staff potentially affected by kitchen appliance positioning deficiency: 6
Visitors potentially affected by kitchen appliance positioning deficiency: 2
Residents potentially affected by sprinkler escutcheon deficiency: 1
Staff potentially affected by sprinkler escutcheon deficiency: 2
Visitors potentially affected by sprinkler escutcheon deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Cox | Administrator | Named as Health Care Administrator involved in interviews and exit conference |
Inspection Report
Annual Inspection
Census: 122
Deficiencies: 10
Feb 5, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey including a State Residential Licensure Survey conducted on January 30, 31 and February 3, 4 and 5, 2025.
Findings
The facility was found deficient in multiple areas including failure to provide timely Medicare Non-Coverage Notices, failure to ensure privacy during medication administration, failure to schedule care plan meetings with residents or representatives, failure to notify physicians of out-of-range blood sugars, failure to obtain and document weekly weights, unclear physician oxygen orders, lack of two-handle cups for a resident, incomplete and inaccurate documentation, missing annual health statements, and incomplete tuberculosis screening.
Severity Breakdown
SS=D: 8
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to provide Notice of Medicare Non-Coverage and Skilled Nursing Facility Advance Beneficiary Notice timely for 1 of 3 residents reviewed. | SS=D |
| Failed to ensure privacy during medication administration for 1 of 1 resident reviewed. | SS=D |
| Failed to schedule care plan meetings with resident and/or representative for 2 of 8 residents reviewed. | SS=D |
| Failed to notify physician of blood sugars outside ordered parameters for 1 of 1 resident reviewed. | SS=D |
| Failed to obtain and document weekly weights according to physician order for 1 of 3 residents reviewed. | SS=D |
| Physician oxygen order unclear with two different oxygen flow rates for 1 of 2 residents reviewed. | SS=D |
| Failed to provide two-handle insulated cup for coffee for 1 of 1 resident reviewed for adaptive equipment. | SS=D |
| Failed to ensure documentation was complete and accurate for 2 of 2 residents reviewed. | SS=D |
| Failed to ensure residents had annual health statements documented for 7 of 7 residents reviewed. | — |
| Failed to ensure residents received 2-step tuberculosis screening test upon admission for 2 of 7 residents reviewed. | — |
Report Facts
Census SNF beds: 52
Census Residential beds: 70
Total Census: 122
Medicare Census: 8
Other Payor Census: 44
Deficiencies cited: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Cox | Administrator | Signed the report and referenced in plan of correction |
Inspection Report
Renewal
Deficiencies: 0
Feb 5, 2025
Visit Reason
Paper compliance review for the Recertification and State Licensure survey.
Findings
Marquette 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
Complaint Investigation
Census: 124
Deficiencies: 0
Sep 12, 2024
Visit Reason
This visit was conducted for the Investigation of Complaint IN00441629 and included a Residential COVID-19 Quality Assurance Walk Through.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation and the COVID-19 Quality Assurance Walk Through.
Complaint Details
Complaint IN00441629 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Residential Census: 124
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 0
Apr 23, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00432038.
Findings
No deficiencies related to the allegations are cited. Marquette was found to be in compliance with 410 IAC 16.2-5 in regard to the Investigation of Complaint IN00432038.
Complaint Details
Complaint IN00432038 - No deficiencies related to the allegations are cited.
Report Facts
Residential Census: 70
Inspection Report
Re-Inspection
Census: 53
Capacity: 53
Deficiencies: 0
Mar 19, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey and the Investigation of Residential Complaint IN00416352 completed on January 18, 2024.
Findings
Marquette was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey, the PSR to the Residential State Licensure Survey, and the PSR to the Investigation of Residential Complaint IN00416352.
Complaint Details
Complaint IN00416352 was corrected.
Report Facts
Census SNF beds: 53
Census total residents: 53
Census Medicare residents: 8
Census other payor residents: 45
Inspection Report
Life Safety
Census: 55
Capacity: 96
Deficiencies: 1
Jan 29, 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 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements. Specifically, the facility failed to document sprinkler system inspections in accordance with NFPA 25 standards, including missing weekly or monthly sprinkler gauge inspections and monthly control valve inspection documentation.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to document sprinkler system inspections in accordance with NFPA 25, including missing weekly or monthly sprinkler gauge inspections and monthly control valve inspection documentation. | SS=F |
Report Facts
Certified beds: 96
Census: 55
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Cox | Administrator | Signed the report |
| Maintenance Technician | Acknowledged lack of documentation for sprinkler system inspections | |
| Director of Operations | Acknowledged lack of documentation for sprinkler system inspections and participated in exit conference |
Inspection Report
Life Safety
Deficiencies: 0
Jan 29, 2024
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
Marquette was found in compliance with Medicare/Medicaid participation requirements, the Life Safety Code 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
Recertification
Census: 67
Deficiencies: 9
Jan 18, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey. This visit also included the Investigation of Nursing Home Complaint IN00416352 and Residential Complaint IN00423410.
Findings
The facility was cited for multiple deficiencies including failure to provide bed hold policy upon hospital transfer, inadequate supervision and care related to falls and use of assistive devices, failure to notify physicians of significant weight changes, failure to date oxygen tubing and obtain physician orders for oxygen, failure to protect cognitively impaired residents from sexual abuse, failure to conduct fire drills with local fire department participation, failure to assess residents for medication self-administration, and failure to document medication administration properly.
Complaint Details
Complaint IN00416352 - Federal/State deficiencies related to the allegations are cited at F684 and F689. Complaint IN00423410 - No deficiencies related to the allegations are cited.
Severity Breakdown
SS=D: 3
SS=G: 1
SS=E: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure bed hold policy was provided to resident or responsible party at hospital transfer. | SS=D |
| Failed to ensure resident with compression gloves had physician's order, care plan, and staff education. | SS=D |
| Failed to ensure adequate supervision and assistance to prevent falls and proper use of mechanical lifts for residents. | SS=G |
| Failed to notify physician of significant weight loss or gain per orders. | SS=D |
| Failed to ensure oxygen tubing was dated and physician orders for oxygen were obtained. | SS=E |
| Failed to protect cognitively impaired residents from sexual abuse related to sexual behaviors of a male resident. | — |
| Failed to ensure documentation of attempts to hold fire and disaster drills with local fire department at least every six months. | — |
| Failed to identify and assess resident for self-administration of medication. | — |
| Failed to document medication administration in the Medication Administration Record. | — |
Report Facts
Survey dates: 5
Census: 67
Weight loss percentage: 12.84
Weight gain pounds: 5
Medication doses missed: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 4 | Certified Nursing Assistant | Named in findings related to fall incident and sexual behavior incidents |
| LPN 5 | Licensed Practical Nurse | Named in findings related to fall incident and assessments |
| ADON | Assistant Director of Nursing | Interviewed regarding bed hold policy, weight notifications, and fall incidents |
| DON | Director of Nursing | Interviewed regarding fall incidents, sexual behavior incidents, and oxygen orders |
| QMA 28 | Qualified Medication Aide | Observed sexual behaviors of Resident 300 |
| LPN 2 | Licensed Practical Nurse | Interviewed regarding oxygen use and tubing dating |
| CNA 6 | Certified Nursing Assistant | Named in mechanical lift use without assistance |
| Executive Director | Interviewed regarding sexual behavior incidents | |
| Assisted Living Director | Interviewed regarding sexual behavior incidents and medication self-administration |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 50
Deficiencies: 0
Apr 19, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00403142 and IN00405924.
Findings
No deficiencies related to the allegations in complaints IN00403142 and IN00405924 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaints IN00403142 and IN00405924 found no deficiencies related to the allegations.
Report Facts
Census SNF beds: 50
Total Census: 50
Medicare Census: 15
Other Payor Census: 35
Inspection Report
Complaint Investigation
Census: 125
Deficiencies: 0
Feb 22, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00397915 and IN00401629.
Findings
Both complaints IN00397915 and IN00401629 were found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00397915 - Unsubstantiated due to lack of evidence. Complaint IN00401629 - Unsubstantiated due to lack of evidence.
Report Facts
Census Bed Type - SNF/NF: 54
Census Bed Type - Residential: 71
Census Bed Type - Total: 125
Census Payor Type - Medicare: 22
Census Payor Type - Other: 32
Census Payor Type - Total: 54
Inspection Report
Re-Inspection
Census: 55
Capacity: 96
Deficiencies: 0
Feb 2, 2023
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 12/06/22 and 12/07/22.
Findings
At this PSR survey, Marquette was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, as well as with Requirements for Participation in Medicare, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Report Facts
Certified beds: 96
Census: 55
Inspection Report
Re-Inspection
Census: 122
Deficiencies: 0
Jan 18, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on November 3, 2022, including a PSR to the State Residential Licensure Survey and a PSR to the Investigation of Complaint IN00395442 completed on November 29, 2022.
Findings
Marquette was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey. Complaint IN00395442 was corrected.
Complaint Details
Complaint IN00395442 was investigated and found to be corrected.
Report Facts
Census SNF beds: 53
Census Residential beds: 69
Total census: 122
Census Medicare: 20
Census Other payor: 33
Total census payor: 53
Inspection Report
Follow-Up
Census: 122
Deficiencies: 0
Jan 17, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00395442 completed on November 29, 2022, conducted in conjunction with PSRs to the Recertification and State Licensure Surveys completed on November 3, 2022.
Findings
Marquette was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the PSR to the Investigation of Complaint IN00395442. The complaint was corrected.
Complaint Details
Complaint IN00395442 was investigated and found to be corrected.
Report Facts
Census SNF beds: 53
Census Residential beds: 69
Total Census: 122
Census Medicare: 20
Census Other payor: 33
Inspection Report
Life Safety
Census: 56
Capacity: 96
Deficiencies: 7
Dec 6, 2022
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal regulations.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code requirements including failure to maintain an all-hazards emergency preparedness plan, corridor doors that did not self-close and latch, improperly secured egress doors, therapy room doors propped open, unsealed smoke barrier penetrations, lack of recent fire damper inspections, and oxygen storage room door not self-closing.
Severity Breakdown
SS=F: 2
SS=E: 5
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to maintain an emergency preparedness plan based on a documented, facility-based and community-based risk assessment including emerging infectious diseases. | SS=F |
| Failed to ensure 1 of 1 corridor door sets to the second floor dining room would self close and latch into the door frame. | SS=E |
| Failed to ensure means of egress through 1 of 3 second floor exits were readily accessible; keypad code to exit door was not posted. | SS=E |
| Failed to ensure 1 of 1 therapy rooms was separated from the corridor by a partition capable of resisting the passage of smoke; doors propped open with wedges. | SS=E |
| Failed to ensure 3 of 4 smoke barrier walls on the second floor were protected to maintain the fire resistance of the smoke barrier; holes not firestopped. | SS=E |
| Failed to ensure all fire dampers were inspected and maintained within the most recent four year period in accordance with NFPA 90A. | SS=F |
| Failed to ensure 1 of 2 indoor oxygen storage areas was in accordance with NFPA 99; oxygen storage room door was not self closing. | SS=E |
Report Facts
Certified beds: 96
Census: 56
Deficiencies cited: 7
Inspection Report
Complaint Investigation
Census: 56
Capacity: 56
Deficiencies: 2
Nov 28, 2022
Visit Reason
This visit was for the investigation of Complaint IN00395442, which was substantiated. The complaint involved failure to notify the physician and resident representative of an unwitnessed fall and failure to follow proper procedures related to the fall.
Findings
The facility failed to notify the physician and resident representative of an unwitnessed fall until six days after the event, failed to document assessments and neurological checks after the fall, and failed to use the correct transfer equipment for the resident. Resident C suffered a fractured clavicle as a result. The facility provided education and implemented audits to ensure compliance with fall prevention and notification policies.
Complaint Details
Complaint IN00395442 was substantiated. The complaint involved failure to notify the physician and resident representative of an unwitnessed fall until six days after the event, failure to document assessments and neurological checks, and improper transfer of the resident leading to injury.
Severity Breakdown
SS=D: 1
SS=G: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to notify physician and resident representative of an unwitnessed fall until six days after the event. | SS=D |
| Failure to report a fall on the date of the fall, failure to document assessments and neurological checks after a fall, and failure to transfer a resident using the correct transfer equipment. | SS=G |
Report Facts
Census: 56
Total Capacity: 56
Fall notification delay: 6
Fall date: Oct 29, 2022
Notification date: Nov 3, 2022
Event report completion date: Nov 4, 2022
Audit duration: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Cox | Administrator | Signed report |
| LPN 2 | Nurse involved in delayed notification and documentation of fall | |
| LPN 1 | Nurse who assessed resident after bruising was noted | |
| Director of Nursing | Director of Nursing | Provided interviews, education, and corrective action plans |
| Nurse Practitioner 5 | Nurse Practitioner | Signed x-ray order and assessment |
Inspection Report
Annual Inspection
Census: 69
Deficiencies: 12
Nov 3, 2022
Visit Reason
This visit was for a State Residential Licensure Survey including a Recertification and State Licensure Survey conducted from October 27 to November 3, 2022.
Findings
The facility was found deficient in multiple areas including resident rights and dignity during meal assistance, timely completion and submission of Minimum Data Set (MDS) assessments, quality of care related to change of condition notifications, pressure ulcer care, fall prevention and root cause analysis, pain management, unnecessary medications, medication administration errors, food safety hand hygiene, and signed service plans for residents.
Severity Breakdown
SS=D: 8
SS=G: 1
SS=E: 2
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to ensure residents were assisted to eat with dignity when staff stood over them during meal service. | SS=D |
| Failed to complete and submit comprehensive and quarterly MDS assessments in accordance with required timeframes for multiple residents. | SS=D |
| Failed to complete, encode and transmit Discharge MDS assessments timely for multiple residents. | — |
| Failed to identify change of condition, ensure physician order was followed, and notify physician timely for Resident 28 with low blood pressure. | SS=D |
| Failed to ensure residents at risk for pressure ulcers received necessary care and treatment to prevent worsening and promote healing for Resident 73. | SS=G |
| Failed to ensure staff followed fall interventions and completed root cause analysis for residents with falls. | SS=E |
| Failed to ensure physician was notified when pain medication was not filled by pharmacy upon admission for Resident 193. | SS=D |
| Failed to monitor blood pressure as ordered when administering medication for Resident 87. | SS=D |
| Failed to ensure diagnoses were appropriate for use of psychotropic medications for Residents 69 and 75. | SS=D |
| Medication error rate exceeded 5% during medication administration observations including errors with levothyroxine timing, unavailable medication, and insulin pen priming. | SS=D |
| Failed to ensure proper hand hygiene was completed during food distribution and feeding assistance for two staff members. | SS=D |
| Failed to provide signed service plans for 5 of 7 residents reviewed. | — |
Report Facts
Survey dates: 6
Residents observed during meal service: 11
Residents reviewed for MDS assessments: 11
Residents with late MDS assessments: 26
Residents with missing discharge MDS: 10
Blood pressure readings for Resident 28: 8
Pressure ulcer size: 2
Pressure ulcer size: 1
Falls reported: 87
Medication error rate: 9.68
Residents reviewed for service plan signatures: 7
Residents lacking service plan signatures: 47
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 2 | Licensed Practical Nurse | Observed standing over resident during meal assistance and improper hand hygiene |
| LPN 3 | Licensed Practical Nurse | Observed medication administration with timing and availability errors |
| LPN 1 | Licensed Practical Nurse | Observed insulin pen administration without priming needle |
| Director of Nursing | Provided interviews regarding policies, expectations, and deficiencies | |
| Assistant Director of Nursing | Provided interviews regarding policies, expectations, and deficiencies | |
| Consulting Pharmacist | Provided interview regarding psychotropic medication use | |
| Nursing Assistant | Reported resident wheelchair incident | |
| Hospice Nurse Practitioner | Provided interview regarding resident medication and condition |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 1
Aug 29, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00374617, which was substantiated with state deficiencies cited related to the allegations.
Findings
The facility failed to document blood sugar results and insulin administration for 1 of 3 residents reviewed, specifically Resident C, on multiple dates in August 2022 as required by policy and physician orders.
Complaint Details
Complaint IN00374617 was substantiated with state deficiencies related to the allegations cited at R243.
Deficiencies (1)
| Description |
|---|
| Failed to document blood sugar results and insulin administration for Resident C on multiple dates in August 2022. |
Report Facts
Residential Census: 62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Assisted Living | Interviewed and indicated expectation that Medication/Treatment Administration Records be signed off after treatment or medication administration |
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