Inspection Report
Re-Inspection
Census: 32
Capacity: 37
Deficiencies: 0
Dec 17, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Post Survey Revisit from 11/21/24 related to the Life Safety Code Recertification and State Licensure Survey conducted on 10/22/24.
Findings
At this PSR Life Safety Code survey, McGivney Health Care Center was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered except for a detached storage building, and the basement included apartment residences occupied by the public.
Report Facts
Facility capacity: 37
Census: 32
Inspection Report
Complaint Investigation
Census: 34
Capacity: 34
Deficiencies: 0
Dec 16, 2024
Visit Reason
This visit was conducted for the investigation of complaint IN00448510.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00448510 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 34
Total Capacity: 34
Medicare Residents: 1
Medicaid Residents: 32
Other Payor Residents: 1
Inspection Report
Re-Inspection
Census: 32
Capacity: 37
Deficiencies: 1
Nov 21, 2024
Visit Reason
A Post Survey Revisit was conducted to review Emergency Preparedness and Life Safety Code compliance following a previous survey on 10/22/24.
Findings
The facility was found in compliance with Emergency Preparedness requirements but was not in compliance with Life Safety Code due to one corridor door failing to close and latch properly, which could affect 5 staff and 23 residents. The facility had not implemented a systemic plan of correction from the prior citation.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility failed to ensure 1 of over 30 corridor doors had no impediment to closing and latching into the door frame and would resist the passage of smoke. | SS=E |
Report Facts
Certified beds: 37
Census: 32
Corridor doors inspected: 30
Staff potentially affected: 5
Residents potentially affected: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Randall Shera | Executive Director | Signed the report |
| Director of Operations | Interviewed regarding the deficient corridor door | |
| Maintenance Director | Provided information about the door closing mechanism |
Inspection Report
Life Safety
Census: 33
Capacity: 37
Deficiencies: 7
Oct 22, 2024
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with emergency preparedness, fire safety, and life safety code requirements.
Findings
The facility was found in substantial compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies included failure to maintain emergency power system inspection and testing, missing sprinkler escutcheon plate, unsecured portable fire extinguishers, corridor doors not closing properly, unprotected smoke barriers, failure to conduct fire drills on unexpected days, and failure to exercise the emergency generator monthly with proper load documentation.
Severity Breakdown
SS=C: 2
SS=E: 4
SS=F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to implement emergency power system inspection, testing, and maintenance requirements per NFPA 110 and Life Safety Code. | SS=C |
| Failed to maintain ceiling construction around sprinkler head; missing escutcheon plate. | SS=E |
| Failed to ensure 4 of 4 portable fire extinguishers in Maintenance Room were properly installed per NFPA 10. | SS=E |
| Failed to ensure 1 of over 30 corridor doors closed and latched properly to resist smoke passage. | SS=E |
| Failed to ensure all smoke barrier walls were protected to maintain smoke resistance. | SS=E |
| Failed to conduct quarterly fire drills on unexpected days and times under varying conditions. | SS=F |
| Failed to exercise the emergency generator for 12 of 12 months with required load documentation. | SS=C |
Report Facts
Certified beds: 37
Census: 33
Fire drills conducted: 10
Fire drills expected: 12
Generator exercise months missed: 12
Portable fire extinguishers unsecured: 4
Corridor doors with closure issues: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Randall Shera | Executive Director | Signed report as provider/supplier representative |
| Maintenance Director | Interviewed regarding emergency power system testing and fire drills; acknowledged findings | |
| Director of Operations | Interviewed regarding sprinkler escutcheon, fire extinguishers, corridor doors, and smoke barriers | |
| Assistant Director of Operations | Interviewed regarding sprinkler escutcheon, fire extinguishers, corridor doors, and smoke barriers; acknowledged findings |
Inspection Report
Renewal
Census: 33
Capacity: 33
Deficiencies: 5
Oct 2, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted over multiple days from September 25 to October 2, 2024.
Findings
The facility was found deficient in developing comprehensive care plans addressing specific resident conditions, monitoring laboratory results for medications, documenting behaviors related to antipsychotic use, ensuring proper food storage in the kitchen refrigerator, and providing adequate living space per resident in one room. Plans of correction were provided for each deficiency.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to develop comprehensive care plans addressing constipation, insomnia, hyperlipidemia, and pain for 2 of 2 residents reviewed. | SS=D |
| Failed to obtain laboratory results for monitoring effectiveness of cholesterol medication for 1 of 5 residents reviewed for unnecessary medications. | SS=D |
| Failed to monitor and document a resident's delusions related to the use of an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications. | SS=D |
| Failed to ensure food was properly stored in a kitchen refrigerator for 1 of 1 kitchen reviewed for food service safety. | SS=D |
| Failed to provide at least 80 square feet per resident in 1 of 18 rooms reviewed for living space (Room 1). | SS=D |
Report Facts
Census: 33
Total Capacity: 33
Deficiencies cited: 5
Medication dosage: 145
Medication dosage: 17
Medication dosage: 10
Medication dosage: 6
Medication dosage: 100
Laboratory result: 188
Medication dosage: 7.5
Room size: 153.83
Living space per resident: 76.9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Randall Shera | Executive Director | Signed report and provided facility policies |
| Nurse Practitioner 2 | Indicated cholesterol labs should be checked at least annually | |
| Licensed Practical Nurse 3 | LPN | Provided information on resident behavior documentation |
| Director of Nursing | DON | Provided information on resident delusions and care plan requirements |
| Minimum Data Set Nurse | Provided information on care plan and laboratory monitoring policies | |
| Minimum Data Set Coordinator | Indicated lack of documentation of resident delusions | |
| Kitchen Manager | Indicated proper food storage requirements in kitchen refrigerator | |
| Maintenance Staff 4 | Assisted with room size observation |
Inspection Report
Renewal
Deficiencies: 0
Oct 2, 2024
Visit Reason
Paper compliance review for the Recertification and State Licensure survey.
Findings
McGivney 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
Complaint Investigation
Census: 33
Capacity: 33
Deficiencies: 0
Aug 15, 2024
Visit Reason
This visit was conducted for the investigation of complaint IN00439165.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00439165 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 33
Census Medicaid residents: 32
Census other residents: 1
Inspection Report
Complaint Investigation
Census: 32
Capacity: 32
Deficiencies: 0
Jun 3, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00430556, IN00434494, and IN00434495.
Findings
No deficiencies related to the allegations in complaints IN00430556, IN00434494, and IN00434495 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaints IN00430556, IN00434494, and IN00434495 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 32
Total census: 32
Census payor type Medicare: 1
Census payor type Medicaid: 30
Census payor type Other: 1
Inspection Report
Follow-Up
Census: 33
Capacity: 33
Deficiencies: 0
Dec 8, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on September 22, 2023, conducted in conjunction with the Investigation of Complaint IN00419292.
Findings
McGivney Health 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 and the complaint investigation. No deficiencies related to the complaint allegations were cited.
Complaint Details
Complaint IN00419292 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 33
Total Capacity: 33
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 31
Census Payor Type - Other: 1
Inspection Report
Complaint Investigation
Census: 33
Capacity: 33
Deficiencies: 0
Dec 8, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00419212 and was conducted in conjunction with a Post Survey Revisit to the Recertification and State Licensure Survey completed on September 22, 2023.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable federal and state regulations regarding the complaint investigation and the post survey revisit.
Complaint Details
Complaint IN00419212 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 33
Total Capacity: 33
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 31
Census Payor Type - Other: 1
Inspection Report
Re-Inspection
Census: 33
Capacity: 37
Deficiencies: 0
Dec 7, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 10/26/23 was performed to verify compliance with fire safety and licensure requirements.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire regulations, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered except for a detached storage building which was not sprinklered.
Report Facts
Facility capacity: 37
Census: 33
Inspection Report
Life Safety
Census: 33
Capacity: 37
Deficiencies: 6
Oct 26, 2023
Visit Reason
The Indiana Department of Health conducted a Life Safety Code Recertification and State Licensure Survey on 10/26/2023 to assess compliance with Medicare/Medicaid participation requirements and the 2012 NFPA 101 Life Safety Code.
Findings
The facility was found not in compliance with Life Safety Code requirements, including issues with means of egress door locking codes, emergency lighting maintenance, hazardous area door self-closing, sprinkler head obstructions, annual fire door inspections, and improper use of flexible cords. Corrective actions were taken or planned for each deficiency.
Severity Breakdown
SS=F: 3
SS=E: 3
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure means of egress doors had complete and correct locking codes posted, affecting accessibility for residents without specialized security needs. | SS=F |
| Failed to maintain 1 of 1 battery powered emergency light in the transfer room in accordance with LSC 7.9. | SS=F |
| Failed to ensure corridor doors to 1 of over 5 hazardous rooms had self-closing devices that caused doors to automatically close and latch. | SS=E |
| Failed to ensure spray pattern for sprinkler heads were not obstructed in the Linen Closet. | SS=E |
| Failed to ensure annual inspection and testing of all fire door assemblies were completed as required. | SS=F |
| Failed to ensure 1 of 1 flexible cords were not used as a substitute for fixed wiring; power strip daisy chaining observed. | SS=E |
Report Facts
Certified beds: 37
Census: 33
Deficiencies cited: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Randall Shera | Executive Director | Signed report and present at exit conference |
| Admissions Director | Interviewed during survey and acknowledged findings | |
| Maintenance Director | Interviewed during survey and acknowledged findings; involved in corrective actions | |
| Administrator | Present at exit conference and acknowledged findings |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 34
Deficiencies: 0
Oct 11, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00418848.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Complaint IN00418848 - No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type: 34
Census Payor Type - Medicaid: 33
Census Payor Type - Other: 1
Inspection Report
Annual Inspection
Census: 35
Capacity: 35
Deficiencies: 21
Sep 22, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from September 17 to 22, 2023.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of significant changes, failure to report medication errors, incomplete assessments, inadequate care planning, insufficient staffing, medication administration errors, infection control deficiencies, environmental issues, and failure to provide timely snacks. Several policies and procedures were missing or not followed, and staff training and documentation were inadequate.
Severity Breakdown
SS=D: 18
SS=E: 4
SS=G: 1
Deficiencies (21)
| Description | Severity |
|---|---|
| Failed to notify physician of significant weight gain and blood sugar outside call parameters for 2 residents. | SS=D |
| Failed to report a significant medication error resulting in a 5-day ICU hospital stay. | SS=D |
| Failed to include new diagnosis of systolic heart failure in MDS assessment for 1 resident. | SS=D |
| Failed to complete another PASARR level I when resident was prescribed antipsychotic medication. | SS=D |
| Failed to develop a care plan for a resident with new seizure diagnosis. | SS=D |
| Failed to document and investigate a fall with major injury for 1 resident. | SS=D |
| Failed to provide timely incontinent care, failed to obtain culture and sensitivity after urinalysis, and failed to prevent recurrent UTI for 2 residents. | SS=D |
| Failed to ensure 24-hour CNA coverage during day and evening shifts and incomplete medication administration documentation. | SS=D |
| Failed to ensure RN coverage for 8 hours each day for 27 days in the third quarter. | SS=D |
| Failed to complete nurse aide performance reviews at least every 12 months for 5 CNAs. | SS=D |
| Failed to post nurse staffing information in a clearly visible area for residents and visitors. | SS=D |
| Failed to ensure resident received correct medication after significant medication error. | SS=G |
| Failed to ensure medication administration records were completely documented for 2 residents. | SS=D |
| Failed to maintain effective QAPI program with documentation of meetings, problem identification, staff feedback, and performance improvement. | SS=D |
| Failed to document annual review of infection control policies, ensure clean glucometers, and prevent soiled clothing on floor for 1 resident. | SS=E |
| Failed to establish antibiotic stewardship program and monitor antibiotic use including standardized criteria for appropriateness for 2 residents. | SS=E |
| Infection Preventionist was not knowledgeable, lacked documentation of infection surveillance and antibiotic stewardship, and was also acting as DON. | SS=E |
| Failed to ensure resident received influenza vaccination after consenting for 1 of 5 residents. | SS=D |
| Failed to ensure employee had documentation of Covid-19 vaccination or exemption for 1 of 3 employees. | SS=D |
| Failed to provide at least 80 square feet per resident in a double occupancy room (Room 1). | SS=D |
| Failed to ensure resident rooms and dining room were clean, painted, and free of debris and dirt. | SS=D |
Report Facts
Deficiencies cited: 23
Residents present: 35
Total licensed capacity: 35
Weight gain: 7
Blood glucose levels: 495
Blood glucose levels: 433
Medication error hospital stay: 5
Room size: 153.83
Room size per resident: 76.9
RN coverage days missed: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse 18 | Nurse | Named in medication error finding and terminated. |
| Director of Nursing | Director of Nursing | Named in multiple findings including failure to notify, infection control, staffing, and medication administration. |
| Executive Director | Executive Director | Named in multiple interviews related to findings and facility policies. |
| Qualified Medical Assistant 11 | Qualified Medical Assistant | Named in incontinent care and medication administration observations. |
| Certified Nursing Assistant 12 | Certified Nursing Assistant | Named in incontinent care observation. |
| Certified Nursing Assistant 13 | Certified Nursing Assistant | Named in incontinent care observation. |
| Director of Nursing (DON) | Director of Nursing | Named as Infection Preventionist and in multiple interviews. |
| Activity Director | Activity Director | Named in Covid-19 vaccination finding. |
| Dietary Staff 19 | Dietary Staff | Named in food safety and sanitation observations. |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 34
Deficiencies: 0
Feb 27, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00398991, IN00399098, and IN00402115.
Findings
Complaint IN00398991 and IN00402115 were unsubstantiated due to lack of evidence. Complaint IN00399098 was substantiated but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00398991 - Unsubstantiated due to lack of evidence. Complaint IN00399098 - Substantiated with no deficiencies cited. Complaint IN00402115 - Unsubstantiated due to lack of evidence.
Report Facts
Census SNF/NF beds: 34
Total census: 34
Medicaid census: 33
Other payor census: 1
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 30, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00393951 completed on November 14, 2022.
Findings
McGivney Health 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.
Complaint Details
Investigation of Complaint IN00393951; paper compliance review completed.
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 8, 2022
Visit Reason
The document reports on the completion of paper compliance for Life Safety Code Post Survey Revisits related to Life Safety Code Recertification and State Licensure Survey.
Findings
McGivney Health Care Center was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 Edition of the NFPA 101 Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Follow-Up
Census: 33
Capacity: 37
Deficiencies: 1
Nov 28, 2022
Visit Reason
This was a Post Survey Revisit (PSR) to a previous Life Safety Code Recertification and State Licensure Survey conducted on 08/15/22, to verify correction of prior deficiencies related to life safety and fire code compliance.
Findings
The facility was found not in compliance with life safety code requirements, specifically failing to ensure that all seven exit doors were readily accessible for residents without a clinical diagnosis requiring specialized security measures. The exit doors were magnetically locked and required a code not posted at the exits, which could affect all residents and visitors.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility failed to ensure the means of egress through 7 of 7 exits were readily accessible for residents without a clinical diagnosis requiring specialized security measures. | SS=F |
Report Facts
Facility capacity: 37
Census: 33
Number of deficient exits: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Randall Shera | Executive Director | Signed the report |
| Maintenance Director | Interviewed during survey regarding exit door locking deficiencies |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 1
Nov 14, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00393951, which was substantiated with federal/state deficiencies cited.
Findings
The facility failed to ensure that Medication and Treatment Administration Records (MAR/TAR) were documented after administration of medications and/or treatments for 3 of 3 residents reviewed (Residents B, C, and D). Missing documentation was found on multiple dates across various medications and treatments.
Complaint Details
Complaint IN00393951 was substantiated with federal/state deficiencies cited at F842 related to failure in documentation of medication and treatment administration.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure Medication and Treatment Administration Records were documented after administration of medications and/or treatments for 3 of 3 residents reviewed. | SS=D |
Report Facts
Census: 32
Residents reviewed: 3
Missing documentation instances: 100
Plan of Correction Completion Date: Nov 30, 2022
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 4, 2022
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on July 26, 2022.
Findings
McGivney Health 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
Plan of Correction
Deficiencies: 0
Nov 4, 2022
Visit Reason
Paper compliance review to the Investigation of Complaints IN00390886 and IN00388916 completed on September 27, 2022.
Findings
McGivney Health 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 Investigations.
Complaint Details
The visit was related to complaint investigations IN00390886 and IN00388916; compliance was confirmed.
Inspection Report
Complaint Investigation
Census: 32
Capacity: 32
Deficiencies: 0
Oct 24, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00392586.
Findings
The complaint IN00392586 was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00392586 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Census Bed Type: 32
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 31
Inspection Report
Re-Inspection
Census: 33
Capacity: 37
Deficiencies: 1
Oct 11, 2022
Visit Reason
This was a Post Survey Revisit (PSR) to the Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey conducted to verify compliance following a prior survey on 08/15/22.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Specifically, 7 of 7 exit doors were magnetically locked without posted codes, restricting egress for residents without clinical diagnoses requiring specialized security measures.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility failed to ensure the means of egress through 7 of 7 exits were readily accessible for residents without a clinical diagnosis requiring specialized security measures; exit doors were magnetically locked and codes were not posted. | SS=F |
Report Facts
Facility capacity: 37
Census: 33
Number of exits with locked doors: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Randall Shera | Executive Director | Named in relation to findings and exit conference |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 34
Deficiencies: 4
Sep 27, 2022
Visit Reason
This visit was conducted for the investigation of two substantiated complaints (IN00390886 and IN00388916) and included a COVID-19 Focused Infection Control Survey.
Findings
The facility was found deficient in multiple areas including failure to notify the responsible party of an unwitnessed fall, failure to complete neurological assessments after a fall, failure to have a registered nurse on site for 8 hours daily, and failure to implement proper infection control policies including mask usage.
Complaint Details
Complaint IN00390886 was substantiated with deficiencies cited at F580, F689, and F880. Complaint IN00388916 was substantiated with deficiency cited at F727.
Severity Breakdown
SS=D: 3
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to notify the responsible party of an unwitnessed fall for 1 of 3 residents reviewed. | SS=D |
| Failed to complete neurological assessments after an unwitnessed fall for 1 of 3 residents reviewed. | SS=D |
| Failed to ensure a Registered Nurse was on site for 8 hours a day for 60 of 63 days from July 27, 2022 to September 27, 2022. | SS=F |
| Failed to develop and implement written policies and procedures for infection control, including failure to ensure staff wore face masks appropriately. | SS=D |
Report Facts
Census: 34
Total Capacity: 34
Days without RN coverage for 8 hours: 60
Days in review period: 63
Residents affected: 34
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Randall Shera | Executive Director | Provided facility policies and interviews related to deficiencies |
| LPN 3 | Interviewed regarding notification of family after resident fall and documentation | |
| LPN 4 | Interviewed regarding neurological assessments and mask usage observations | |
| LPN 1 | Interviewed regarding absence of Director of Nursing and RN coverage | |
| CNA 2 | Observed not wearing mask and interviewed about mask policy | |
| QMA 3 | Observed wearing mask below chin and interviewed about mask policy | |
| Housekeeping Staff 5 | Observed wearing mask below nose and interviewed about mask policy |
Inspection Report
Annual Inspection
Census: 32
Capacity: 37
Deficiencies: 14
Aug 15, 2022
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with Medicare/Medicaid participation requirements and safety codes.
Findings
The facility was found substantially compliant with Emergency Preparedness Requirements but had multiple deficiencies related to emergency preparedness training, emergency power system testing, life safety code violations including corridor obstructions, exit signage, hazardous area door self-closing devices, kitchen fire suppression inspection, smoke barrier integrity, electrical safety, and use of portable space heaters.
Severity Breakdown
SS=C: 4
SS=E: 7
SS=F: 1
SS=D: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to conduct annual training for the Emergency Preparedness Program (EPP) and demonstrate staff knowledge. | SS=C |
| Failed to conduct exercises to test the emergency plan at least twice per year including unannounced staff drills. | SS=C |
| Failed to implement emergency power system inspection, testing, and maintenance requirements including missing 3-year 4-hour load test and no documentation of load percentage during monthly tests. | SS=C |
| One corridor means of egress was obstructed by boxes of paper. | SS=E |
| One corridor did not meet clear width requirements due to fixed furniture not properly installed. | SS=E |
| Corridor doors to two hazardous rooms were not provided with self-closing devices. | SS=E |
| Kitchen fire suppression system was not inspected semiannually. | SS=E |
| Smoke barrier walls were not properly protected to maintain smoke resistance due to an opening in the ceiling. | SS=E |
| Smoke barrier doors did not restrict smoke movement due to incomplete closing, leaving a gap. | SS=F |
| Three fuel fired water heaters lacked current inspection certificates. | SS=C |
| Electrical junction box under stairs lacked a cover and had exposed wiring. | SS=E |
| Three wet location electrical outlets were not protected by ground fault circuit interrupters (GFCI). | SS=E |
| Portable space heater was used in the Charge Nurses office, which is prohibited. | SS=E |
| Flexible cords were used as a substitute for fixed wiring in the boiler room. | SS=D |
Report Facts
Certified beds: 37
Census: 32
Deficiencies cited: 15
Annual training date: Sep 6, 2022
Emergency power 4-hour load test date: Aug 29, 2022
Water heater inspection expiration: Jun 12, 2019
Scheduled water heater inspection: Sep 16, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding emergency preparedness training, emergency power system testing, life safety deficiencies, and corrective actions |
Inspection Report
Annual Inspection
Census: 31
Capacity: 31
Deficiencies: 12
Jul 26, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from July 19 to July 26, 2022.
Findings
The facility was found deficient in multiple areas including failure to maintain accurate documentation of code status, failure to notify physicians and guardians of significant changes, incomplete care plans, inadequate discharge summaries, insufficient fall prevention interventions, lack of proper side rail assessments and consents, failure to complete AIMS assessments for psychotropic medications, improper food handling practices, incomplete immunization documentation, and inadequate COVID-19 testing for exempt staff. Additionally, the facility had a room that did not meet the minimum square footage per resident but had a waiver in place.
Severity Breakdown
SS=D: 7
SS=E: 3
SS=F: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to maintain accurate documentation of a resident's code status when care plan was not in agreement with physician orders. | SS=D |
| Failed to notify physician of blood sugar outside call parameters and failed to notify guardian of hospital transfer. | SS=D |
| Failed to ensure timely notification of changes in Medicare Part A coverage to resident or guardian. | SS=D |
| Failed to develop and implement comprehensive care plans addressing diabetes, constipation, anticoagulant use, pain, pressure wound care, code status preferences, and discharge planning. | SS=E |
| Failed to ensure discharge summary was complete including recapitulation of stay and medication reconciliation. | SS=D |
| Failed to provide adequate supervision and fall interventions for a resident requiring physical assistance. | SS=D |
| Failed to obtain order, complete assessment, and obtain consent for use of bed rails. | SS=D |
| Failed to complete AIMS assessments for residents on psychotropic medications in a timely manner. | SS=E |
| Failed to ensure cook wore gloves while preparing pureed food. | SS=D |
| Failed to offer and document influenza and pneumococcal vaccinations for residents. | SS=E |
| Failed to test exempt employees for COVID-19 twice weekly during high community transmission. | SS=F |
| Failed to provide at least 80 square feet per resident in a multiple resident room (Room 1) but had a waiver in place. | SS=D |
Report Facts
Residents present: 31
Total licensed capacity: 31
Residents reviewed for advanced directives: 12
Residents reviewed for notification of change: 2
Residents reviewed for beneficiary notices: 3
Residents reviewed for care plans: 13
Residents reviewed for discharge planning: 1
Residents reviewed for accidents: 1
Residents reviewed for bed rails: 1
Residents reviewed for unnecessary medications: 5
Residents reviewed for immunizations: 5
Exempt employees not tested twice weekly: 10
Residents in Room 1: 2
Room 1 size: 153.83
Square feet per resident in Room 1: 76.9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager | Indicated physician notification and AIMS assessment responsibilities | |
| Social Services Director | Responsible for care planning and code status documentation | |
| Director of Nursing | Responsible for notification of changes and AIMS assessments | |
| Executive Director | Provided information on discharge summaries, COVID-19 testing, and room waiver | |
| Dietary Manager | Observed food preparation and glove use | |
| Cook 1 | Observed pureeing food without gloves |
Loading inspection reports...
