Inspection Reports for Premier Healthcare of New Harmony
251 HIGHWAY 66, IN, 47631
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 3, 2025, found the facility in compliance following a paper review related to complaint investigations. Earlier inspections showed a pattern of deficiencies primarily involving medication management, emergency preparedness, life safety code compliance, food safety, and resident care issues such as behavioral health services and abuse prevention. Several complaint investigations were substantiated, including failures in medication administration, food storage, resident self-determination, and timely reporting of incidents, though enforcement actions such as fines or license suspensions were not listed in the available reports. The facility has addressed some prior deficiencies through corrective actions and follow-up visits, with recent inspections showing improvement in emergency preparedness and life safety compliance. Overall, the facility’s inspection history reflects ongoing challenges in clinical and environmental areas but also evidence of corrective efforts over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
19 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
352% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
49 residents
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 3, 2025
Visit Reason
Paper compliance review to the Investigation of Complaints IN00454583 and IN00454320 completed on March 4, 2025.
Findings
Premier Health Care of New Harmony 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 of the investigations.
Complaint Details
The visit was related to complaint investigations IN00454583 and IN00454320. The facility was found in compliance.
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 2
Mar 4, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00454483 and IN00454320 related to alleged deficiencies at the facility.
Findings
The facility was found deficient for failing to ensure a resident received only physician-ordered medications, specifically a resident self-administering an unlabeled antacid without a physician's order. Additionally, the facility failed to report a water utility interruption that caused closure of the main dining room for approximately 48 hours.
Complaint Details
The investigation was triggered by complaints IN00454483 and IN00454320. Complaint IN00454483 deficiencies are cited at F9999. Complaint IN00454320 deficiencies are cited at F9999 and F755. The citation related to complaint IN00454320 involved medication self-administration and labeling issues.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Resident self-administered an antacid medication without proper labeling or physician order. | SS=D |
| Failure to report to the state agency a water utility interruption causing closure of the main dining room for approximately 48 hours. | — |
Report Facts
Census: 49
Medicare residents: 6
Medicaid residents: 37
Other residents: 6
Utility interruption duration: 48
Monitoring frequency: 5
Monitoring duration: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Peggy Lowery | Assistant Director of Nursing (ADON) | Provided facility policy and interviewed regarding medication self-administration and reporting procedures |
| LPN 6 | Licensed Practical Nurse | Interviewed regarding resident medication orders and self-administration |
| Dietary Manager | Interviewed regarding water pipe break and kitchen water interruption |
Inspection Report
Life Safety
Deficiencies: 0
Dec 5, 2024
Visit Reason
The visit was a Life Safety Code (LSC) Post Survey Revisit (PSR) related to the LSC Recertification and State Licensure Survey.
Findings
Premier Healthcare of New Harmony 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: 44
Capacity: 96
Deficiencies: 1
Nov 21, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 09/23/2024.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements due to failure to provide documentation of smoke detector sensitivity testing within the past 24 months. The deficiency was cited previously and a systemic plan of correction had not been implemented until this follow-up.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure documentation was available to show that all smoke detectors were sensitivity tested within the past 24 months as required by NFPA 72, National Fire Alarm Code. | SS=F |
Report Facts
Certified beds: 96
Census: 44
Smoke detectors: 30
Deficiency cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stacy Blue | Administrator | Present during record review and exit conference |
Inspection Report
Re-Inspection
Census: 50
Capacity: 50
Deficiencies: 0
Oct 31, 2024
Visit Reason
This visit was for the Post Survey Revisit (PSR) to the Recertification and State Licensure survey and the PSR to the Investigation of Complaint IN00443107 completed on 9/16/24.
Findings
Premier Healthcare of New Harmony 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 and the PSR to the Investigation of Complaint IN00443107 survey.
Complaint Details
Complaint IN00443107-corrected
Report Facts
Census SNF/NF beds: 50
Census Medicare residents: 5
Census Medicaid residents: 41
Census Other residents: 4
Inspection Report
Routine
Census: 46
Capacity: 96
Deficiencies: 20
Sep 23, 2024
Visit Reason
Routine Emergency Preparedness and Life Safety Code survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Emergency Preparedness requirements including failure to annually review and update the emergency preparedness plan, communication plan, and training/testing program. Deficiencies were also found in life safety code compliance including emergency lighting testing, smoke alarm maintenance, hazardous area door latching, kitchen fire suppression training, fire alarm system testing and maintenance, sprinkler system inspections, portable fire extinguisher inspections, GFCI protection in wet locations, fire drill documentation, generator testing and maintenance, and improper use of power strips.
Severity Breakdown
SS=F: 14
SS=E: 3
SS=C: 2
Deficiencies (20)
| Description | Severity |
|---|---|
| Failed to develop and maintain an emergency preparedness plan reviewed and updated at least annually. | SS=F |
| Failed to develop and maintain an emergency preparedness communication plan reviewed and updated at least annually. | SS=F |
| Failed to develop and maintain an emergency preparedness training and testing program reviewed and updated at least annually. | SS=F |
| Failed to conduct exercises to test the emergency plan at least twice per year including unannounced staff drills. | SS=F |
| Failed to maintain complete written record of monthly generator load testing and weekly generator inspections. | SS=F |
| Failed to ensure documentation for monthly 30 second testing of battery powered emergency lights for 4 of 4 lights. | SS=C |
| Failed to maintain 25 of 50 resident room battery operated smoke alarms replaced after 10 years and monthly testing documentation. | SS=F |
| Failed to ensure 1 of over 10 hazardous area doors closed completely and latched automatically. | SS=E |
| Failed to instruct staff in proper use of UL 300 hood fire suppression system in kitchen. | SS=F |
| Failed to ensure annual testing of all devices connected to fire alarm system was performed and documented. | SS=F |
| Failed to maintain semi-annual visual inspection documentation for fire alarm system. | SS=F |
| Failed to ensure smoke detector sensitivity testing within past 24 months. | SS=F |
| Failed to provide written documentation of sprinkler system inspections for 2 of 4 quarters and 5-year piping inspection. | SS=F |
| Failed to document monthly sprinkler system control valve inspections for 12 of 12 months. | SS=F |
| Failed to inspect all portable fire extinguishers monthly for 1 of 12 months. | SS=C |
| Failed to provide GFCI protection for 2 of over 10 wet location receptacles. | SS=E |
| Failed to provide quarterly fire drill documentation for 3 shifts during 4 quarters. | SS=F |
| Failed to maintain complete written record of monthly generator load testing for 1 of 1 generator during 1 of past 12 months. | SS=F |
| Failed to maintain written record of weekly generator inspections for 24 of 52 weeks. | SS=F |
| Used power strips and multi plugged adapters as substitute for fixed wiring in 1 of 50 resident rooms and 2 staff/resident areas. | SS=E |
Report Facts
Certified beds: 96
Census: 46
Fire drill reports missing: 18
Monthly generator inspections missing: 11
Sprinkler system inspection reports missing: 2
Sprinkler control valve inspections missing: 12
Battery powered smoke alarms older than 10 years: 25
Inspection Report
Annual Inspection
Census: 47
Capacity: 47
Deficiencies: 18
Sep 16, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00443107.
Findings
The facility was found deficient in multiple areas including medication self-administration, notification of changes in condition, transfer and discharge procedures, accuracy and revision of assessments and care plans, medication management, infection control, fall prevention and documentation, food safety, respiratory care, dialysis management, psychotropic medication monitoring, and environmental sanitation.
Complaint Details
Complaint IN00443107 - Federal/state deficiencies related to the allegations are cited at F-760.
Severity Breakdown
SS=D: 11
SS=E: 6
Deficiencies (18)
| Description | Severity |
|---|---|
| Failed to ensure residents had physician orders, assessments, and care plans for self-administration of medications. | SS=D |
| Failed to notify a resident's representative during change in condition for a resident with severely impaired cognition. | SS=D |
| Failed to ensure proper clinical documentation was sent with a resident during hospital transfer. | SS=D |
| Failed to ensure a notice of transfer was provided during hospital transfer. | SS=D |
| Failed to ensure a bed hold was provided upon transfer for a resident. | SS=D |
| Failed to ensure Minimum Data Set (MDS) assessments were completed accurately for residents reviewed for restraints, unnecessary medications, and falls. | SS=D |
| Failed to develop and revise care plans timely for residents with new diagnoses, medications, UTIs, and falls. | SS=E |
| Failed to ensure practitioner's diagnostic practices met professional standards for a schizophrenia diagnosis in a resident over 65 years of age. | SS=D |
| Failed to monitor progression of pressure ulcers and document assessments for residents reviewed for wound care. | SS=D |
| Failed to provide care, services, and supervision to prevent accidents, lacked thorough and complete assessments post fall, and failed to update interventions after falls. | SS=D |
| Failed to ensure oxygen equipment was properly labeled and respiratory services were provided according to the care plan. | SS=D |
| Failed to provide ongoing assessment and monitoring for complications of dialysis by completing required dialysis assessments and communication records. | SS=D |
| Failed to ensure medication side effects were properly monitored and pharmacy recommendations were considered for residents on psychotropic medications. | SS=D |
| Failed to ensure proper storage and labeling of medications and proper monitoring of medication refrigerator temperatures. | SS=E |
| Failed to ensure enhanced barrier precautions were implemented for residents with indwelling catheters and failed to ensure hand hygiene and cleaning of equipment between residents. | SS=E |
| Failed to ensure emergency call system was available in visitor restroom used by residents. | SS=E |
| Failed to provide a safe and sanitary environment; urine odors were present in multiple facility areas. | SS=E |
| Failed to ensure accurate and complete documentation of falls including neuro checks, post fall evaluations, and interdisciplinary team discussions. | SS=E |
Report Facts
Survey dates: 6
Census: 47
Medicare census: 8
Medicaid census: 36
Other census: 3
Deficiency counts: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Peggye Lowery | Assistant Director of Nursing | Named in relation to medication self-administration and other findings |
| RN 11 | Registered Nurse | Observed during hand hygiene and catheter care |
| RN 18 | Registered Nurse | Observed during hand hygiene and medication pass |
| RN 3 | Registered Nurse | Observed during wound care |
| RN 7 | Registered Nurse | Observed during medication administration |
| CNA 20 | Certified Nursing Assistant | Observed during incontinence care |
| ADON | Assistant Director of Nursing | Provided multiple interviews and policy information |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 56
Deficiencies: 0
Jun 27, 2024
Visit Reason
This visit was for the investigation of complaints IN00436960, IN00436580, and IN00432210.
Findings
No deficiencies were cited related to the allegations in any of the three complaints investigated. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaints IN00436960, IN00436580, and IN00432210 were investigated with no deficiencies cited related to the allegations.
Report Facts
Census SNF/NF: 56
Total Capacity: 56
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 46
Census Payor Type - Other: 4
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 15, 2024
Visit Reason
Paper compliance review to the Investigation of Complaints IN00427118 completed on February 7, 2024.
Findings
Premier Health Care of New Harmony 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 of the Investigation of Complaints IN00427188 Survey.
Complaint Details
Investigation of Complaints IN00427118 completed on February 7, 2024; paper compliance review found in compliance.
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 1
Feb 6, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00427118 regarding federal and state deficiencies related to food procurement, storage, preparation, and serving sanitary practices.
Findings
The facility failed to ensure food was stored and labeled appropriately, and the kitchen areas were not free of food debris and paper in multiple locations including the walk-in freezer, refrigerator, and dry storage. Several food items were found unlabeled or undated, and grease buildup was noted on the hood vent.
Complaint Details
Complaint IN00427118 was substantiated with federal/state deficiencies cited at F812 related to food safety requirements.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Food containers were found not labeled in the dry storage area, walk-in freezer, walk-in refrigerator, and shelving for spices in the food preparation area. Food debris and paper were located in the walk-in freezer, drink refrigerator, refrigerator, and dry storage. Grease buildup was present on the hood vent. | SS=D |
Report Facts
Census: 57
Medicare residents: 4
Medicaid residents: 42
Other residents: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janie Swedenburg | Administrator | Named as Administrator providing plan of correction and interview |
| Cook 10 | Interviewed regarding food dating practices | |
| Cook 7 | Interviewed regarding food storage and labeling |
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 14, 2023
Visit Reason
Paper compliance review to the Investigation of Complaints IN00418102 and IN00418103 completed on October 3, 2023.
Findings
Premier Health Care of New Harmony 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 of the complaint investigations.
Inspection Report
Complaint Investigation
Census: 62
Capacity: 62
Deficiencies: 1
Oct 2, 2023
Visit Reason
This visit was for the investigation of complaints IN00412856, IN00413640, IN00418102, and IN00418103. Complaints IN00418102 and IN00418103 resulted in federal/state deficiencies cited at F561.
Findings
The facility failed to ensure a resident's right of self-determination was promoted for 1 of 3 residents reviewed. Specifically, a resident's scheduled appointment was rescheduled by the facility without notifying or including the resident in the change of plan. The facility took corrective actions including informing the resident, educating staff, and implementing a quality assurance plan to monitor compliance.
Complaint Details
Complaint IN00412856 and IN00413640 had no deficiencies cited. Complaints IN00418102 and IN00418103 had federal/state deficiencies cited at F561 related to resident self-determination rights.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure a resident's right of self-determination was promoted; a resident's scheduled appointment was rescheduled without notification or inclusion in the change of plan. | SS=D |
Report Facts
Census: 62
Total Capacity: 62
Medicare Census: 4
Medicaid Census: 48
Other Payor Census: 10
Appointments Monitored Weekly: 5
Quality Assurance Monitoring Duration: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janie Swedenburg | Administrator | Signed the report and involved in corrective action oversight |
Inspection Report
Follow-Up
Census: 59
Capacity: 96
Deficiencies: 0
Aug 30, 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 06/27/23.
Findings
At this PSR, Premier Healthcare of New Harmony was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Participation in Medicare/Medicaid. The facility was fully sprinklered except for detached maintenance and storage areas.
Inspection Report
Follow-Up
Census: 63
Capacity: 63
Deficiencies: 0
Aug 4, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00412692 completed on 2023-07-13, conducted in conjunction with the PSR to the Recertification and State Licensure Survey completed on 2023-06-09.
Findings
Premier Healthcare of New Harmony 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 IN00412692. The complaint was corrected.
Complaint Details
Complaint IN00412692 was investigated and found to be corrected.
Report Facts
Census SNF/NF: 63
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 42
Census Payor Type - Other: 9
Inspection Report
Re-Inspection
Census: 63
Capacity: 63
Deficiencies: 0
Aug 4, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 2023-06-09, conducted in conjunction with a PSR to the Investigation of Complaint IN00412692 completed on 2023-07-13.
Findings
Premier Healthcare of New Harmony 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 Details
This visit was in conjunction with a Post Survey Revisit to the Investigation of Complaint IN00412692 completed on 2023-07-13.
Report Facts
Census: 63
Total Capacity: 63
Medicare Census: 7
Medicaid Census: 47
Other Payor Census: 9
Inspection Report
Complaint Investigation
Census: 63
Capacity: 63
Deficiencies: 3
Jul 12, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00412806 and IN00412692. Complaint IN00412806 had no deficiencies cited, while complaint IN00412692 resulted in federal/state deficiencies related to abuse, neglect, and behavioral health care.
Findings
The facility failed to ensure residents were free from abuse, specifically resident-to-resident physical altercations involving Resident B, Resident C, and Resident D. The facility also failed to report an incident within the required timeframe and did not adequately update care plans or provide behavioral health services for residents with behavioral issues.
Complaint Details
Complaint IN00412806: No deficiencies cited. Complaint IN00412692: Deficiencies cited related to abuse, neglect, and behavioral health care. The facility failed to prevent resident-to-resident abuse, failed to report an incident timely, and failed to provide adequate behavioral health services and care plan updates.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure residents were free from abuse, neglect, and exploitation, including failure to update care plans and provide psych services following resident-to-resident altercations. | SS=D |
| Failure to report a resident-to-resident physical altercation to the state agency within the required timeframe. | SS=D |
| Failure to provide necessary behavioral health care and services, including failure to update care plans and implement continuing interventions following behavioral incidents. | SS=D |
Report Facts
Census: 63
Total Capacity: 63
Medicare Census: 4
Medicaid Census: 48
Other Payor Census: 11
Survey Dates: 2
Monitoring Period: 72
Audit Period: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janie Swedenburg | Administrator | Named in relation to findings and plan of correction |
Inspection Report
Life Safety
Census: 62
Capacity: 96
Deficiencies: 11
Jun 27, 2023
Visit Reason
An Emergency Preparedness Survey and 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).
Findings
The facility was found not in compliance with emergency power system inspection and testing, fire alarm system sensitivity testing, sprinkler system control valve inspections, corridor door smoke resistance, fuel-fired water heater inspections, fire drill documentation, oxygen room fire door assembly inspection, generator weekly inspection documentation, and improper use of power strips and multi-plug adapters. Oxygen cylinders were also found unsecured.
Severity Breakdown
SS=F: 7
SS=E: 4
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to maintain written record of weekly emergency generator inspections for 29 of 52 weeks. | SS=F |
| Failed to provide complete documentation for four hour test of emergency power standby system within past 36 months. | SS=F |
| Failed to ensure documentation for sensitivity testing of 4 duct smoke detectors was performed. | SS=F |
| Failed to document monthly sprinkler system control valve inspections for past 12 months. | SS=F |
| Failed to ensure 1 corridor door resisted passage of smoke due to holes in door. | SS=E |
| Failed to ensure 4 fuel-fired water heaters had current inspection certificates. | SS=F |
| Failed to provide quarterly fire drill documentation for 2 of 3 shifts during 4 of 4 quarters and failed to document transmission of fire alarm signal to monitoring company. | SS=F |
| Failed to ensure annual inspection and testing of oxygen room fire door assembly was completed. | SS=E |
| Failed to ensure weekly written record of emergency generator inspections was maintained for 29 of 52 weeks. | SS=F |
| Failed to ensure power strip and multi-plug adapter were not used as substitute for fixed wiring in 2 staff areas. | SS=E |
| Failed to ensure cylinders of nonflammable gases such as oxygen were properly secured from falling. | SS=E |
Report Facts
Certified beds: 96
Census: 62
Weeks missing generator inspection documentation: 29
Fire drills performed: 13
Fuel-fired water heaters: 4
Fire drill shifts missing documentation: 2
Fire drill quarters missing documentation: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janie Swedenburg | Administrator | Named in relation to findings and exit conference |
| Maintenance Director | Named in relation to findings, interviews, and exit conference |
Inspection Report
Annual Inspection
Census: 64
Capacity: 64
Deficiencies: 13
Jun 9, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey including the Investigation of Complaints IN00409452, IN00401469, IN00402291, and IN00407950.
Findings
The facility had deficiencies related to medication administration, notification of changes, fall prevention, catheter care, pain management, medication labeling and storage, food safety, and environmental conditions. Several residents had issues with self-administration assessments, notification of medication administration to family, fall interventions, catheter care, and unnecessary medications. Environmental and food safety concerns were also noted.
Complaint Details
This visit included the Investigation of Complaints IN00409452, IN00401469, IN00402291, and IN00407950. No deficiencies related to the allegations were cited for all complaints.
Severity Breakdown
SS=D: 8
SS=G: 1
SS=C: 1
SS=E: 2
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 5 residents observed during medication pass had a self administration assessment and order (Resident 8). | SS=D |
| Failed to provide notification of change for 1 of 6 residents reviewed for unnecessary medications (Resident 48). | SS=D |
| Failed to ensure residents received supervision and consistent implementation of interventions to prevent falls for 2 of 5 residents reviewed for accidents (Resident 40, Resident 48). | SS=D |
| Failed to ensure appropriate treatment and services were provided to prevent urinary tract infections that resulted in hospitalizations for 1 of 2 residents reviewed for Urinary Catheter and UTI (Resident 21). | SS=G |
| Failed to ensure pain management was provided for 1 of 1 residents reviewed (Resident 28). | SS=D |
| Failed to post completed nurse staffing sheets daily for 5 of 5 days during the survey. | SS=C |
| Failed to provide medically-related social services to meet resident's needs for 1 of 4 residents reviewed for vision and dental services (Resident 48). | SS=D |
| Failed to ensure medications were administered appropriately for 1 of 6 residents reviewed for unnecessary medication use; PRN anti-anxiety medication and narcotic pain medication administered without rationale (Resident 48). | SS=D |
| Failed to ensure residents were free from unnecessary medications; PRN anti-anxiety medications ordered for greater than 14 days without rationale (Resident 21, Resident 48). | SS=D |
| Failed to ensure proper storage of medications; loose pills found in medication carts and improperly labeled bulk and over-the-counter medications in wound/treatment carts. | SS=D |
| Failed to ensure meals were prepared to meet resident's needs according to the plan of care; resident not provided diet as ordered (Resident 48). | SS=D |
| Failed to ensure food was stored and served in accordance with professional standards for food service safety; food open to air in freezer, holes in kitchen walls, expired label on flour, food touched with soiled gloves. | SS=E |
| Failed to ensure a safe, comfortable, and sanitary environment in 1 of 4 resident halls; cracks and missing tiles in floor, sticky floor, broken toilet paper holder, broken window blinds, torn privacy curtains, peeling paint and missing wall layers. | SS=E |
Report Facts
Survey dates: June 5, 6, 7, 8, 9, 2023
Resident census: 64
Total capacity: 64
Falls: 28
Antibiotic courses: 11
Hospital admissions: 5
Antibiotic treatments: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 14 | Certified Nursing Aide | Named in catheter care finding |
| CNA 19 | Certified Nursing Aide | Named in catheter care finding |
| RN 21 | Registered Nurse | Named in fall prevention and medication storage findings |
| LPN 25 | Licensed Practical Nurse | Named in pain management and medication administration findings |
| CNA 3 | Certified Nursing Aide | Named in vision/dental care and pain management findings |
| CNA 7 | Certified Nursing Aide | Named in fall prevention and vision/dental care findings |
| CNA 9 | Certified Nursing Aide | Named in diet and meal observation |
| CNA 4 | Certified Nursing Aide | Named in catheter care interview |
| Kitchen Staff 5 | Kitchen Staff | Named in food safety and handling observation |
| DON | Director of Nursing | Named in multiple findings including medication administration, staffing, catheter care, and antibiotic stewardship |
| Administrator | Named in multiple findings including staffing, social services, and policies | |
| Social Services Director | Named in vision/dental care and behavior tracking findings | |
| IP Nurse | Infection Preventionist Nurse | Named in antibiotic stewardship and medication administration findings |
| RD | Registered Dietician | Named in diet and meal observation |
| Maintenance Supervisor | Named in environmental condition findings | |
| Clinical Consultant | Named in medication administration and behavior tracking findings |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 24, 2023
Visit Reason
Paper compliance review to the Investigation of Complaints IN00399979, IN00394992, and IN00394540 completed on January 26, 2023.
Findings
Premier Health Care of New Harmony 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 of the investigations.
Complaint Details
The visit was related to complaint investigations IN00399979, IN00394992, and IN00394540. The facility was found to be in compliance.
Inspection Report
Complaint Investigation
Census: 52
Capacity: 52
Deficiencies: 2
Jan 24, 2023
Visit Reason
This visit was for the investigation of multiple complaints (IN00399979, IN00399109, IN00398119, IN00394992, and IN00394540) regarding the facility's compliance with care and safety standards.
Findings
The facility was found to have deficiencies related to medication administration (failure to prime insulin pen), and food safety (unlabeled and undated food, food stored on the floor, and leaking water softener in the kitchen). Some complaints were substantiated with cited deficiencies, while others were unsubstantiated or had no deficiencies cited.
Complaint Details
Complaint IN00399979 - Substantiated with deficiencies cited at F812. Complaint IN00399109 - Unsubstantiated due to lack of evidence. Complaint IN00398119 - Substantiated with no deficiencies cited. Complaint IN00394992 - Substantiated with deficiencies cited at F658. Complaint IN00394540 - Substantiated with deficiencies cited at F658.
Severity Breakdown
SS=D: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure medications were administered according to manufacturer's guidance; insulin was administered from a NovoLog FlexPen without priming prior to administration. | SS=D |
| Failure to ensure food was stored in accordance with professional standards for food service safety; unlabeled and undated food in refrigerators and freezer, food stored on the floor, kitchen floor not cleaned routinely, and leaking water softener on kitchen floor. | SS=E |
Report Facts
Census: 52
Total Capacity: 52
Medicare Census: 3
Medicaid Census: 39
Other Payor Census: 10
Insulin dose: 16
Monitoring frequency: 3
Monitoring duration: 8
Monitoring duration: 8
Food storage monitoring frequency: 5
Food storage monitoring duration: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janie Swedenburg | Laboratory Director or Provider/Supplier Representative | Signed the report |
| QMA 1 | Qualified Medication Assistant | Named in medication administration deficiency for failing to prime insulin pen |
| RN 2 | Registered Nurse | Interviewed regarding insulin pen administration knowledge |
| Dietary Manager | Interviewed regarding kitchen conditions and food storage deficiencies | |
| Facility Administrator | Provided facility policies and conducted in-service trainings | |
| DON | Director of Nursing | Performed in-service training on insulin pen use and monitoring |
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 2, 2022
Visit Reason
Paper compliance review to the Investigation of Complaints IN00393317 and IN00393426 completed on November 2, 2022.
Findings
Premier Health Care of New Harmony 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 of the investigations.
Complaint Details
The visit was related to the investigation of complaints IN00393317 and IN00393426; compliance was found.
Inspection Report
Complaint Investigation
Census: 52
Capacity: 52
Deficiencies: 2
Nov 1, 2022
Visit Reason
This visit was for the investigation of two complaints, IN00393317 and IN00393426, both of which were substantiated with related federal/state deficiencies cited.
Findings
The facility failed to ensure residents received care by qualified staff for 3 of 4 resident record reviews, specifically regarding Qualified Medication Aides (QMAs) completing assessments they were not authorized to perform. Additionally, the facility failed to post accurate nurse staffing sheets daily for 2 of 2 days during the survey.
Complaint Details
Complaint IN00393317 was substantiated with deficiencies cited at F659 related to qualified persons providing care. Complaint IN00393426 was substantiated with deficiencies cited at F732 related to nurse staffing information posting.
Severity Breakdown
SS=D: 1
SS=C: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure residents received care by qualified staff; QMAs documented assessments they were not authorized to perform. | SS=D |
| Facility failed to post accurate nurse staffing sheets daily as required. | SS=C |
Report Facts
Resident census: 52
Total licensed capacity: 52
Medicare residents: 4
Medicaid residents: 43
Other payor residents: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janie Swedenburg | Administrator | Facility Administrator who provided policy and signed documents |
| RN 18 | Registered Nurse | Interviewed regarding follow-up assessments after PRN medications |
| QMA 9 | Qualified Medication Aide | Interviewed regarding scope of practice and PRN medication administration |
| ADON | Assistant Director of Nursing | Interviewed regarding QMA scope of practice and medication administration |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 59
Deficiencies: 1
Oct 11, 2022
Visit Reason
This visit was for the investigation of complaints IN00388604, IN00389439, and IN00391358.
Findings
The facility failed to maintain complete and accurate clinical records for residents receiving controlled substances, with multiple doses not recorded in the medical administration records and lack of pain assessments and follow-up documentation for three residents reviewed.
Complaint Details
Complaint IN00391358 and IN00389439 were substantiated with related federal/state deficiencies cited at F842. Complaint IN00388604 was unsubstantiated due to lack of evidence.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to maintain clinical records that were complete and accurate for residents receiving controlled substances (Residents G, H, and J). | SS=D |
Report Facts
Census: 59
Total Capacity: 59
Medicare Census: 10
Medicaid Census: 37
Other Payor Census: 12
Medication doses not recorded: 7
Medication doses not recorded: 16
Medication doses not recorded: 11
Medication doses not recorded: 5
Medication doses not recorded: 20
Medication doses not recorded: 22
Medication doses not recorded: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janie Swedenburg | Administrator | Signed the report and provided current medication administration policy |
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 11, 2022
Visit Reason
Paper compliance review to the Investigation of Complaints IN00391358 and IN00389439 completed on October 11, 2022.
Findings
Premier Health Care of New Harmony 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 of the complaint investigations.
Complaint Details
The visit was related to investigations of complaints IN00391358 and IN00389439; compliance was found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 27, 2022
Visit Reason
Paper compliance review to the Investigation of Complaint IN00385198 completed on July 28, 2022.
Findings
Premier Health Care of New Harmony 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 of the complaint investigation.
Complaint Details
Investigation of Complaint IN00385198 completed on July 28, 2022; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 63
Capacity: 63
Deficiencies: 1
Jul 26, 2022
Visit Reason
This visit was for the investigation of complaints IN00385198, IN00384282, and IN00381838. Complaint IN00385198 was substantiated, while the other two complaints were unsubstantiated due to lack of evidence.
Findings
The facility failed to promptly take steps to resolve grievances reported by residents and inform them of the findings or conclusions of their concerns. Resident Council meeting minutes from April to June 2022 showed unresolved issues such as delayed nursing responses, medication supply problems, and lack of follow-up on grievances. The facility has since implemented corrective actions including audits, in-services, and improved grievance follow-up procedures.
Complaint Details
Complaint IN00385198 was substantiated with federal/state deficiencies cited at F585. Complaints IN00384282 and IN00381838 were unsubstantiated due to lack of evidence.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to promptly resolve grievances and inform residents of findings or conclusions related to their concerns as evidenced by Resident Council meeting minutes and resident interviews. | SS=E |
Report Facts
Census: 63
Total Capacity: 63
Medicare Residents: 4
Medicaid Residents: 43
Other Payor Residents: 16
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