Inspection Reports for
Premier Healthcare of New Harmony

The facility was found deficient in multiple areas including failure to conduct quarterly care plan conferences, improper use and documentation of psychotropic medications, incomplete care plan revisions after falls, inadequate diagnostic documentation, medication administration by unqualified staff, insufficient supervision on the dementia unit, unqualified dietary manager, incomplete fall documentation, infection prevention lapses, and insufficient infection preventionist staffing.

This citation relates to Intake 2642554. The complaint involved inadequate supervision and failure to prevent a resident-to-resident altercation resulting in injury. The complaint was substantiated with findings of minimal harm.

The facility failed to ensure adequate supervision, behavior monitoring, and updating of care plans for residents with dementia, resulting in a resident-to-resident altercation causing injury. Documentation of behavioral monitoring was incomplete and the facility lacked a policy on resident behavior and wandering prevention.

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.

This citation relates to complaint IN00454320.

The facility failed to ensure a resident received only physician-ordered medications and that medications were properly labeled. A resident was found self-administering an antacid medication without a physician's order or proper labeling.

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.

This citation related to complaint IN00443107. The complaint involved failure to administer ordered IV antibiotics to Resident R, resulting in re-hospitalization. The complaint was substantiated based on findings.

The facility failed to ensure an intravenous antibiotic was administered according to physician orders for one resident, resulting in re-hospitalization. Documentation and communication deficiencies related to IV therapy orders, medication delivery, and monitoring were identified.

The facility had multiple deficiencies including failure to ensure proper medication self-administration orders and care plans, inadequate notification of resident representatives during changes in condition, incomplete clinical documentation during hospital transfers, inaccurate Minimum Data Set (MDS) assessments, incomplete care plans and care plan conferences, failure to meet professional standards in psychiatric diagnosis and medication monitoring, inadequate pressure ulcer care documentation, insufficient fall prevention and post-fall assessments, improper respiratory care and dialysis monitoring, unsafe medication storage and labeling, poor infection control practices including hand hygiene and enhanced barrier precautions, and unsanitary facility environment with urine odors and lack of emergency call system in visitor restroom.

This citation is related to Complaint IN00427118.

The facility failed to ensure food was stored and labeled appropriately, and the kitchen areas were not free of food debris. Multiple food items in the refrigerator, freezer, dry storage, and spice rack were found unlabeled or improperly stored, and grease buildup was noted under the kitchen hood.

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.

This Federal tag relates to complaints IN00418103 and IN00418102. The complaint was substantiated as the facility admitted to rescheduling the resident's appointment without proper notification due to transportation issues.

The facility failed to ensure that Resident B was notified or included in changes to her scheduled cardiologist appointments. The facility rescheduled appointments without the resident's involvement or permission due to transportation conflicts.

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 IN00412692 involved allegations of resident to resident abuse, failure to timely report incidents, and inadequate behavioral health care and care planning.

The facility failed to protect residents from abuse, did not timely report a resident to resident physical altercation to the state agency, and failed to provide necessary behavioral health care and update care plans following multiple behavioral incidents involving residents.

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.

The facility had multiple deficiencies including failure to ensure proper medication administration and assessments, inadequate notification to family regarding medication changes, inconsistent fall prevention interventions, improper catheter care leading to recurrent UTIs, inadequate pain management, improper storage and labeling of medications, failure to provide diets as ordered, unsanitary food preparation practices, and unsafe and unsanitary environmental conditions in resident areas.

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.