Inspection Reports for Morning Breeze Retirement Community & Healthcare Center
950 N Lakeview Dr, Greensburg, IN 47240, United States, IN, 47240
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Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 22, 2024
Visit Reason
Investigation of Complaint IN00444788 was conducted to review compliance related to the complaint.
Findings
The facility 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 of the complaint investigation.
Complaint Details
Complaint IN00444788 was investigated and corrected as of October 18, 2024.
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 1
Oct 18, 2024
Visit Reason
This visit was conducted for the investigation of Complaints IN00444788 and IN00444256. Complaint IN00444788 resulted in a Federal/State deficiency citation, while Complaint IN00444256 had no deficiencies related to the allegations.
Findings
The facility failed to ensure accurate documentation of narcotic pain medication administration for one of three residents reviewed (Resident C). Specifically, the medication administration record lacked documentation for certain doses of Morphine Sulfate. The facility provided a plan of correction including staff education and implementation of a performance improvement tool to monitor compliance.
Complaint Details
Complaint IN00444788 was substantiated with a Federal/State deficiency cited at F842. Complaint IN00444256 was not substantiated with any deficiencies.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure a resident's medication administration record accurately reflected the administration of narcotic pain medication for 1 of 3 residents reviewed (Resident C). | SS=D |
Report Facts
Census: 61
SNF beds: 1
SNF/NF beds: 47
Residential beds: 13
Medicare residents: 5
Medicaid residents: 35
Private residents: 8
Other residents: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| April D Hughes | RN | Signed the report as Laboratory Director or Provider/Supplier Representative |
| RN 2 | Interviewed regarding medication administration and documentation practices |
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 30, 2024
Visit Reason
The inspection was a paper compliance review for the Annual Recertification and State Licensure survey conducted on August 19, 2024.
Findings
Morning Breeze Retirement Community 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
Plan of Correction
Deficiencies: 0
Sep 24, 2024
Visit Reason
The document is a Plan of Correction related to paper compliance for the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey conducted on 09/12/2024 and completed on 09/24/2024.
Findings
Morning Breeze Retirement Community and Healthcare was found in compliance with the Emergency Preparedness Requirements and Life Safety Code requirements for Medicare and Medicaid participating providers and suppliers.
Inspection Report
Life Safety
Census: 50
Capacity: 64
Deficiencies: 2
Sep 12, 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 on 09/12/2024 to assess compliance with emergency preparedness and life safety requirements.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code requirements, specifically failing to implement emergency power system inspection, testing, and maintenance requirements, including failure to document the load percentage during monthly generator load tests as required by NFPA 110 and NFPA 99.
Severity Breakdown
SS=F: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to implement emergency power system inspection, testing, and maintenance requirements per NFPA 110 and Life Safety Code. | SS=F |
| Failed to exercise the generator for 12 of 12 months and failed to document the load percentage during monthly load tests as required by NFPA 110 and NFPA 99. | SS=F |
Report Facts
Certified beds: 64
Census: 50
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Witkemper | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Maintenance Director | Interviewed regarding emergency power system deficiencies and acknowledged findings | |
| Executive Director | Present at exit conference acknowledging findings |
Inspection Report
Renewal
Census: 13
Capacity: 61
Deficiencies: 2
Aug 19, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted on August 13, 14, 15, 16, and 19, 2024.
Findings
The facility was found to have deficiencies related to improper storage of medications, specifically an expired TB serum vial in the medication room, and unsafe hot water temperatures in 5 of 9 resident rooms. Corrective actions were implemented including medication audits, education on medication disposal, water heater maintenance, and monitoring of water temperatures.
Severity Breakdown
SS=D: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to appropriately store medications related to an expired medication vial in the Long Hall medication room refrigerator. | SS=D |
| Failed to provide safe water temperatures for 5 of 9 resident rooms observed, with temperatures exceeding 120 degrees Fahrenheit. | SS=E |
Report Facts
Survey dates: 5
Census total: 13
Total licensed capacity: 61
Expired medication open date: Jun 3, 2024
Water temperatures measured: 121.5
Completion date for corrective actions: Sep 5, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Witkemper | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Director of Nursing | DON | Interviewed regarding expired TB serum storage and medication audit |
| Maintenance Director | Interviewed and involved in water temperature testing and corrective actions | |
| Administrator | Interviewed regarding water temperature policy and corrective actions | |
| Dietary Manager | Provided calibrated thermometer and interviewed about water temperature measurements |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 0
May 14, 2024
Visit Reason
This visit was conducted to investigate Complaints IN00433563 and IN00434397 at Morning Breeze Retirement Community and Healthcare.
Findings
No deficiencies related to the allegations in either complaint 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 complaints.
Complaint Details
Complaint IN00433563 and Complaint IN00434397 were investigated; no deficiencies related to the allegations were cited for either complaint.
Report Facts
Census Bed Type Total: 58
Census Payor Type Total: 47
SNF Beds: 4
SNF/NF Beds: 43
Residential Beds: 11
Medicare Residents: 8
Medicaid Residents: 31
Other Residents: 8
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 0
Nov 1, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00419805, IN00419858, and IN00420398 at Morning Breeze Retirement Community and Healthcare.
Findings
No deficiencies related to the allegations in complaints IN00419805, IN00419858, and IN00420398 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Investigation of Complaints IN00419805, IN00419858, and IN00420398 found no deficiencies related to the allegations.
Report Facts
Census Bed Type: 63
Census Payor Type: 51
SNF/NF beds: 46
SNF beds: 5
Residential beds: 12
Medicare residents: 8
Medicaid residents: 35
Other payor residents: 8
Inspection Report
Life Safety
Census: 55
Capacity: 64
Deficiencies: 0
Aug 30, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 07/17/23 was performed by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR Life Safety Code survey, Morning Breeze Retirement Community and Healthcare 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 detection in required areas.
Report Facts
Facility capacity: 64
Census: 55
Inspection Report
Complaint Investigation
Census: 48
Capacity: 62
Deficiencies: 0
Aug 16, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00412653.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00412653; no deficiencies related to the allegations were cited.
Report Facts
Census Bed Type - SNF/NF: 41
Census Bed Type - SNF: 7
Census Bed Type - Residential: 14
Total Capacity: 62
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 38
Census Payor Type - Other: 4
Current Census: 48
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 15, 2023
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey was completed.
Findings
Morning Breeze Retirement Community 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
Annual Inspection
Census: 52
Capacity: 64
Deficiencies: 7
Jul 17, 2023
Visit Reason
An annual Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health to assess compliance with Medicare/Medicaid participation requirements and state regulations.
Findings
The facility was found not in compliance with several Life Safety Code requirements including means of egress obstructions, uneven exit discharge surfaces, improper installation of alcohol-based hand rub dispensers, unsecured fire alarm control panel, inadequate sprinkler system maintenance, incomplete fire drill scheduling, and improper use of power strips and extension cords.
Severity Breakdown
SS=F: 2
SS=E: 3
SS=C: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Corridor means of egress were obstructed by Personal Protective Equipment carts without wheels, reducing clear corridor width. | SS=F |
| One exit discharge had an uneven walking surface with a 2 to 3 inch grade difference between sidewalk and blacktop. | SS=E |
| An alcohol-based hand sanitizer dispenser was installed above an electrical outlet within 1 inch, violating installation requirements. | SS=E |
| Fire alarm control panel door was not locked and lacked a lock tumbler, risking unauthorized use. | SS=F |
| Sprinkler system spare sprinklers were not properly stored; six sprinklers were loose and not in protected slots. | SS=C |
| Fire drills were not conducted at unexpected times and days; 8 of 12 drills occurred near month-end, limiting unpredictability. | SS=C |
| Power strips were used improperly to power high current equipment such as dorm style refrigerators, and extension cords were used as substitutes for fixed wiring. | SS=E |
Report Facts
Certified beds: 64
Census: 52
Residents potentially affected: 25
Quarterly fire drills reviewed: 12
Fire drills conducted near month-end: 8
Power strips observed: 2
Extension cords observed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Witkemper | Maintenance Director | Acknowledged all findings and corrective actions during observations and exit conference |
Inspection Report
Annual Inspection
Census: 55
Capacity: 68
Deficiencies: 3
Jul 3, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted from June 26 to July 3, 2023.
Findings
The facility was found to have deficiencies related to failure to notify physicians of medication changes for 2 residents, inadequate wound treatment and documentation for 1 resident, and failure to follow fluid restriction orders for 1 resident. Corrective actions and education plans were implemented for these issues.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to notify residents' physician for medications not administered for 2 of 15 residents reviewed for notification of change. | SS=D |
| Failed to ensure wound treatments were administered appropriately and accurately assessed for 1 of 2 residents reviewed for pressure ulcers. | SS=D |
| Failed to follow a physician's order related to fluid restriction for 1 of 1 resident reviewed for dialysis. | SS=D |
Report Facts
Census Bed Type Total: 68
Census Payor Type Total: 55
Medication not administered dates for Resident 23: 18
Medication not administered dates for Resident 32: 16
Wound measurements: 4
Wound measurements: 4.3
Wound measurements: 4.8
Wound measurements: 0.4
Fluid restriction: 1200
Fluid restriction per meal: 240
Fluid restriction per medication pass: 160
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Witkemper | HFA | Facility representative who signed the plan of correction |
| LPN 3 | Licensed Practical Nurse | Interviewed regarding medication hold and notification procedures |
| LPN 4 | Licensed Practical Nurse | Interviewed regarding fluid restriction monitoring |
| FWN | Facility Wound Nurse | Interviewed regarding wound care and documentation |
| DON | Director of Nursing | Interviewed regarding medication notification and wound care policies |
| Nurse Practitioner | Interviewed regarding insulin medication administration | |
| CNA 5 | Certified Nurse Aide | Interviewed regarding fluid restriction awareness and enforcement |
Inspection Report
Follow-Up
Census: 59
Capacity: 64
Deficiencies: 0
Nov 21, 2022
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 09/26/22.
Findings
At this PSR survey, Morning Breeze Retirement Community and Healthcare was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility was fully sprinklered in resident areas and had a fire alarm system with smoke detection in corridors and resident rooms.
Report Facts
Certified beds: 64
Census: 59
Inspection Report
Life Safety
Census: 60
Capacity: 64
Deficiencies: 6
Sep 26, 2022
Visit Reason
The survey was conducted as an Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with applicable federal regulations.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code requirements including failure to maintain an updated emergency preparedness plan addressing emerging infectious diseases, improper locking mechanisms on egress doors, incomplete fire alarm system out-of-service policy, lack of current inspection certificates for water heaters, and unsecured gas cylinders in storage areas.
Severity Breakdown
SS=F: 4
SS=E: 2
Deficiencies (6)
| 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 means of egress doors were readily accessible without requiring a tool or key from the egress side for residents without clinical security needs. | SS=E |
| Failed to provide a complete written policy for fire alarm system out-of-service procedures including notification and fire watch requirements. | SS=F |
| Failed to ensure 2 fuel fired water heaters had current inspection certificates to ensure safe operation. | SS=F |
| Failed to ensure 3 of 4 oxygen cylinders were properly secured from falling in the oxygen storage area. | SS=E |
| Failed to ensure 1 carbon dioxide cylinder was properly secured from falling in the kitchen. | SS=E |
Report Facts
Certified beds: 64
Census: 60
Deficiencies cited: 6
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 20, 2022
Visit Reason
The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Morning Breeze Retirement 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
Renewal
Census: 12
Capacity: 63
Deficiencies: 8
Aug 12, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure survey conducted August 8-12, 2022.
Findings
The facility was found to have multiple deficiencies including failure to follow insulin pen usage guidelines, failure to notify physicians of resident refusals for treatment, unsafe medication storage, failure to monitor medication parameters, lack of dementia care plans, improper catheter care, and incomplete resident discharge documentation.
Severity Breakdown
SS=D: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to follow manufacturer's guidelines related to insulin pen usage for 1 of 6 residents observed for medication administration. | SS=D |
| Failed to follow physician's orders related to interventions for a resident with congestive heart failure for 1 of 2 residents reviewed for edema. | SS=D |
| Failed to ensure residents' safety related to unauthorized medications at bedside for 2 of 24 residents observed and failed to implement appropriate interventions for a resident with altered mental status prior to a fall. | SS=D |
| Failed to follow appropriate infection control guidelines to prevent UTIs for residents with indwelling urinary catheters for 1 of 1 resident reviewed. | SS=D |
| Failed to develop a resident-centered care plan related to dementia for 1 of 2 residents reviewed for dementia care. | SS=D |
| Failed to monitor residents' blood pressure and heart rate before administering medications for 2 of 5 residents reviewed for unnecessary medications. | SS=D |
| Failed to store medication appropriately related to unlabeled insulin pens for 1 of 3 medication carts observed. | SS=D |
| Failed to document resident information related to discharge for 1 of 15 residents reviewed for identifiable information. | SS=D |
Report Facts
Survey dates: 5
Census: 12
Total licensed capacity: 63
Medication doses administered outside parameters: 22
Medication doses administered without BP check: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Witkemper | Provider contact for plan of correction and audit tools | |
| LPN 2 | Licensed Practical Nurse | Observed medication administration and insulin pen usage deficiencies |
| DON | Director of Nursing | Provided policies, medication records, and interviews related to deficiencies |
| LPN 8 | Licensed Practical Nurse | Interviewed regarding medication administration and resident care |
| QMA 5 | Qualified Medication Aide | Interviewed regarding medication cart and insulin pen labeling |
| ADON | Assistant Director of Nursing | Provided policies and interviews related to care plans and medication administration |
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