Inspection Reports for
Premier Healthcare of New Harmony

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.

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.

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.

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.

Complaint IN00443107 - Federal/state deficiencies related to the allegations are cited at F-760.

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 IN00427118 was substantiated with federal/state deficiencies cited at F812 related to food safety requirements.

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 IN00412856 and IN00413640 had no deficiencies cited. Complaints IN00418102 and IN00418103 had federal/state deficiencies cited at F561 related to resident self-determination rights.

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 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.

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.

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.

This visit included the Investigation of Complaints IN00409452, IN00401469, IN00402291, and IN00407950. No deficiencies related to the allegations were cited for all complaints.

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 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.

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 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.

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 IN00391358 and IN00389439 were substantiated with related federal/state deficiencies cited at F842. Complaint IN00388604 was unsubstantiated due to lack of evidence.

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 IN00385198 was substantiated with federal/state deficiencies cited at F585. Complaints IN00384282 and IN00381838 were unsubstantiated due to lack of evidence.

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.