Inspection Reports for
Serenity Spring Senior Living at Northwood
2515 NEWTON ST, JASPER, IN, 47547
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
28.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
579% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
55% occupied
Based on a December 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Deficiencies: 6
Date: Jun 13, 2025
Visit Reason
Routine inspection to assess compliance with care plan participation, notification of changes, medication use, fall prevention, infection control, and other regulatory requirements.
Findings
The facility failed to ensure care plan conferences were held timely for several residents, failed to notify family/resident representatives of falls, failed to prevent unnecessary psychotropic medication use, failed to provide adequate supervision and fall prevention interventions, and failed to maintain proper infection control practices during incontinence care.
Deficiencies (6)
F 0553: Facility failed to ensure care plan conferences were held for 4 of 5 residents reviewed for unnecessary medications.
F 0580: Facility failed to notify family/resident representatives of falls for 4 of 5 residents reviewed.
F 0582: Facility failed to provide required notice to a resident discharged from Medicare services for 1 of 3 residents reviewed.
F 0605: Facility failed to prevent use of unnecessary psychotropic medications for 2 of 5 residents reviewed, including administration without physician order and lack of gradual dose reduction.
F 0689: Facility failed to ensure adequate supervision and assistive devices to prevent accidents for 4 of 5 residents reviewed for falls, with incomplete assessments and care plan updates.
F 0880: Facility failed to provide sanitary environment and proper hand hygiene during incontinence care for 3 residents observed, including inadequate handwashing and improper handling of incontinence pads.
Report Facts
Residents reviewed for unnecessary medications: 5
Residents reviewed for falls: 5
Residents reviewed for Medicare discharge notice: 3
Residents reviewed for psychotropic medication use: 5
Residents reviewed for fall prevention: 5
Residents observed for incontinence care: 3
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 0
Date: Dec 16, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00447709.
Complaint Details
Complaint IN00447709 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations are cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the complaint investigation.
Report Facts
Census Bed Type - SNF/NF: 72
Census Bed Type - Residential: 13
Census Bed Type - Total: 85
Census Payor Type - Medicare: 11
Census Payor Type - Medicaid: 40
Census Payor Type - Other: 21
Census Payor Type - Total: 72
Inspection Report
Complaint Investigation
Census: 61
Capacity: 74
Deficiencies: 0
Date: Nov 6, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00445932.
Complaint Details
Complaint IN00445932 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type Total: 74
Census Payor Type Total: 61
SNF Beds: 7
NF Beds: 41
Residential Beds: 13
NCC Beds: 13
Medicare Residents: 7
Medicaid Residents: 46
Other Payor Residents: 8
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 5, 2024
Visit Reason
The document reports on the completion of paper compliance for Post Survey Revisits (PSR) related to Emergency Preparedness and Life Safety Code Recertification surveys that previously exited on 07/30/24 and 06/04/24 respectively.
Findings
Serenity Springs Senior Living at Northwood was found in compliance with Medicare/Medicaid Emergency Preparedness Requirements and Life Safety Code from Fire and the 2012 Edition of the NFPA 101, as well as state licensure requirements.
Inspection Report
Re-Inspection
Census: 60
Capacity: 60
Deficiencies: 0
Date: Aug 1, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 2024-05-22, conducted to verify compliance following the prior survey.
Findings
Serenity Spring Senior Living at Northwood was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 during the Post Survey Revisit.
Report Facts
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 39
Census Payor Type - Other: 25
Total Census: 72
Inspection Report
Re-Inspection
Census: 60
Capacity: 107
Deficiencies: 2
Date: Jul 30, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Emergency Preparedness Survey conducted on 06/04/2024 and a Life Safety Code survey was conducted by the Indiana Department of Health to verify correction of previous deficiencies.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code requirements, including failure to maintain emergency preparedness training documentation and failure to ensure proper mechanical ventilation in the oxygen transfilling room. Corrective actions were implemented but the facility requested a desk review for final determination.
Deficiencies (2)
Failed to ensure the emergency preparedness training and testing program includes a training program with documentation and staff knowledge verification.
Failed to ensure the oxygen storage room where oxygen transferring takes place was provided with properly working mechanical ventilation.
Report Facts
Certified beds: 107
Census: 60
Oxygen cylinders: 21
Oxygen containers: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Greg Matheis | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Maintenance Director | Named in relation to training on emergency preparedness and oxygen room ventilation corrective actions |
Inspection Report
Routine
Census: 57
Capacity: 107
Deficiencies: 16
Date: Jun 4, 2024
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with federal and state regulations including emergency preparedness, fire safety, and facility operations.
Findings
The facility was found not in compliance with Emergency Preparedness requirements, including failure to maintain an updated emergency preparedness plan addressing patient population and services, lack of emergency preparedness training documentation, and incomplete after action reports for emergency exercises. Life Safety Code deficiencies included issues with delayed egress door accessibility and signage, lack of self-closing devices on hazardous area doors, fire alarm panel security and date/time accuracy, sprinkler obstructions and corrosion, fire pump testing, fire door inspection documentation, smoke barrier penetrations, oxygen storage safety, and mechanical ventilation in the oxygen transfilling room.
Deficiencies (16)
Emergency preparedness plan did not address special needs of client population or continuity of operations.
Emergency preparedness training and testing program incomplete; training documentation unavailable.
After action reports for annual emergency preparedness exercises were not completed.
Means of egress door in Garden Ridge dining room was unable to be unlocked with keypad or delayed egress process.
Delayed egress exit doors lacked proper signage and codes.
Central supply room door lacked a self-closing device.
Fire alarm panel was not locked and was in a trouble state with incorrect date/time displayed.
Fire alarm system date and time were inaccurate due to lightning strike damage.
Sprinkler heads obstructed by ceiling fan and storage shelves, and some sprinkler heads corroded.
Fire pump testing documentation incomplete; monthly testing not performed.
Dutch door did not have separate latching devices on upper and lower leaves and lacked astragal, rabbet, or bevel.
Penetrations in smoke barrier walls were not sealed to maintain smoke resistance.
Annual inspection and testing of fire door assemblies were not itemized.
Combustible materials stored within 5 feet of oxygen storage equipment.
Oxygen transfilling room lacked properly working mechanical ventilation.
Ceiling penetrations and sprinkler escutcheon issues noted in multiple rooms affecting sprinkler coverage.
Report Facts
Certified beds: 107
Census: 57
Oxygen cylinders: 21
Oxygen containers: 7
Sprinkler heads corroded: 2
Fire pump tests documented: 2
Fire door penetrations: 8
Fire door sprinkler escutcheon issues: 2
Smoke barrier penetrations: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Assistant | Interviewed and involved in multiple findings including emergency preparedness plan, training, door accessibility, fire alarm panel, sprinkler obstructions, and oxygen storage | |
| Maintenance Director | Responsible for auditing doors, sprinkler heads, fire panels, and emergency preparedness documentation |
Inspection Report
Routine
Deficiencies: 21
Date: May 22, 2024
Visit Reason
Routine inspection of Serenity Spring Senior Living at Northwood to assess compliance with healthcare regulations including resident care, medication management, safety, and infection control.
Findings
The facility had multiple deficiencies including failure to ensure residents were treated with dignity, inadequate response to abuse allegations, incomplete care plans, inaccurate assessments, inadequate fall prevention measures, improper medication management, infection control lapses, and environmental safety issues.
Deficiencies (21)
F 0550: Facility failed to ensure residents were treated with respect and dignity during feeding and care activities.
F 0558: Facility failed to provide services based on resident preferences, including failure to provide ice water when requested.
F 0578: Facility failed to clarify a resident's code status; physician orders conflicted with advance directive documentation.
F 0604: Facility failed to ensure resident's right to be free from physical restraints; bed rails were used without proper orders or consent.
F 0609: Facility failed to timely report an allegation of abuse involving a Certified Nurse Aide physically removing a resident's fingers from a lift.
F 0610: Facility failed to properly investigate an allegation of abuse involving a Certified Nurse Aide physically removing a resident's fingers from a lift.
F 0623: Facility failed to provide timely notification of transfer or discharge to residents or representatives for 5 residents.
F 0625: Facility failed to notify residents or representatives in writing about bed hold policies during hospitalizations for 5 residents.
F 0641: Facility failed to ensure accuracy of assessments for 14 residents; MDS assessments did not accurately reflect resident status including medication orders and restraint use.
F 0656: Facility failed to develop comprehensive person-centered care plans for 4 residents including lack of care plans for hospice, medications, and dining preferences.
F 0657: Facility failed to complete care plan conferences timely and revise care plans after changes for 4 residents.
F 0689: Facility failed to ensure adequate supervision and fall prevention interventions for 2 residents with multiple falls; neuro checks were incomplete and care plans not updated.
F 0690: Facility failed to provide appropriate care to prevent and treat urinary tract infections for 1 resident; infection control practices during incontinence care were inadequate.
F 0695: Facility failed to provide respiratory care consistent with orders for 3 residents; oxygen concentrators were dusty and orders for equipment maintenance were not followed.
F 0732: Facility failed to post nurse staffing information daily for 2 of 9 days during the survey.
F 0758: Facility failed to ensure residents were free from unnecessary psychotropic medications; PRN anti-anxiety medication was ordered beyond 14 days and antipsychotic was prescribed with unacceptable diagnosis.
F 0761: Facility failed to maintain safe and secure medication storage; loose pills were found in medication carts and refrigerator temperature logs were incomplete.
F 0812: Facility failed to ensure food service safety; staff handled food and utensils with bare hands during meal service.
F 0880: Facility failed to implement infection prevention and control practices; gloves were not changed between dirty and clean tasks during incontinence care and glucometer cleaning was inadequate.
F 0883: Facility failed to properly document influenza and pneumococcal vaccine consent/refusal and education for 3 residents.
F 0921: Facility failed to ensure a safe, functional, sanitary, and comfortable environment; multiple rooms had dust, damaged doors, loose grab bars, uncovered personal items, missing call lights, and exposed wiring.
Report Facts
Falls: 5
Falls: 3
Medication doses: 2
Medication doses: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 14 | Licensed Practical Nurse | Observed walking away from resident with urine under chair and feeding resident while standing |
| LPN 16 | Licensed Practical Nurse | Interviewed about resident code status and abuse allegation |
| LPN 18 | Licensed Practical Nurse | Interviewed about bed rails, restraints, and medication cart cleaning |
| LPN 19 | Licensed Practical Nurse | Interviewed about ice water provision and medication cart cleaning |
| LPN 37 | Licensed Practical Nurse | Weekend nurse interviewed about medication cart cleaning |
| LPN 61 | Licensed Practical Nurse | Interviewed about glucometer cleaning |
| CNA 53 | Certified Nurse Aide | Named in abuse allegation and criminal background check |
| CNA 5 | Certified Nurse Aide | Observed assisting resident with toileting and infection control lapses |
| CNA 7 | Certified Nurse Aide | Observed assisting resident with toileting and infection control lapses |
| CNA 10 | Certified Nurse Aide | Observed assisting resident with toileting and infection control lapses |
| CNA 12 | Certified Nurse Aide | Observed assisting resident with toileting and infection control lapses |
| QMA 59 | Qualified Medication Aide | Observed obtaining blood glucose and cleaning glucometer |
| QMA 3 | Qualified Medication Aide | Observed handling food with bare hands |
| DON | Director of Nursing | Interviewed about multiple findings including abuse, care plans, fall prevention, respiratory care, and medication management |
| Administrator | Administrator | Interviewed about abuse reporting, transfer notices, and vaccine policies |
| IP | Infection Preventionist | Interviewed about infection control practices and vaccine documentation |
| Kitchen Manager | Kitchen Manager | Interviewed about food handling practices |
| MDS Coordinator | MDS Coordinator | Interviewed about assessments, care plans, and fall risk |
| Dementia Care Coordinator | Dementia Care Coordinator | Provided policies and interviewed about care plans |
| Maintenance Director | Maintenance Director | Interviewed about environmental repairs |
Inspection Report
Recertification
Census: 24
Deficiencies: 23
Date: May 22, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey including a State Residential Licensure Survey.
Findings
The facility was found deficient in multiple areas including resident rights, care planning, infection control, medication management, environmental safety, staffing, and training. Specific issues included failure to treat residents with dignity, inadequate care plans, improper medication storage, incomplete staff training, and unsafe environmental conditions.
Deficiencies (23)
Failure to treat residents with respect and dignity during feeding and care.
Failure to provide services based on resident preferences, such as providing ice water upon request.
Failure to clarify and document resident's code status accurately.
Use of physical restraints (bed rails) without proper orders, consent, or evaluation.
Failure to report and investigate an allegation of abuse involving a Certified Nurse Aide physically removing a resident's fingers from a lift.
Failure to provide proper notice of transfer or discharge to residents or representatives for hospitalizations.
Failure to provide bed hold policy and form to residents or representatives during hospitalizations.
Failure to ensure accuracy of Minimum Data Set (MDS) assessments reflecting resident status.
Failure to develop and implement comprehensive person-centered care plans addressing resident specific needs including hospice, medications, and dining preferences.
Failure to conduct timely care plan conferences and revise care plans after changes in resident status or medications.
Failure to ensure adequate supervision and interventions to prevent accidents and falls, including failure to complete neurological checks after falls.
Failure to provide services and assistance to prevent and treat urinary tract infections, and failure to follow infection control practices during incontinence care and blood glucose testing.
Failure to provide respiratory care consistent with resident orders and care plans; oxygen concentrators were dusty and orders not followed.
Failure to post nurse staffing sheets daily for all days during the survey period.
Failure to ensure psychotropic medications were used appropriately, including PRN orders exceeding 14 days and unacceptable diagnoses for antipsychotics.
Failure to maintain safe and secure storage of medications; loose pills found in medication carts and incomplete refrigerator temperature logs.
Failure to ensure food service safety; staff handled food and utensils with bare hands, and dishwasher chemical levels were not tested.
Failure to maintain infection control practices including hand hygiene and cleaning of glucometers between residents.
Failure to properly document influenza and pneumococcal vaccine education, consent, or refusal for residents.
Failure to maintain a safe, functional, sanitary, and comfortable environment; issues included dust on vents, damaged doors, loose grab bars, uncovered personal items, and damaged furniture.
Failure to provide dementia-specific training for staff and dementia care director as required by state regulations.
Failure to ensure food service department was directed by a competent supervisor with current training and experience.
Failure to ensure dining assistants completed required training program approved by the department.
Report Facts
Resident census: 24
Falls: 5
Dementia training hours: 6
Dishwasher chemical test ppm: 150
Oxygen flow rate: 3
Medication administration record review: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah McKenzie | HFA | Laboratory Director or Provider/Supplier Representative signature |
| LPN 14 | Licensed Practical Nurse | Mentioned in dignity and care findings |
| LPN 16 | Licensed Practical Nurse | Interviewed about resident code status |
| LPN 18 | Licensed Practical Nurse | Interviewed about bed rails and oxygen concentrator maintenance |
| LPN 19 | Licensed Practical Nurse | Interviewed about ice water and oxygen use |
| LPN 59 | Licensed Practical Nurse | Mentioned in dementia training records |
| CNA 53 | Certified Nurse Aide | Involved in abuse allegation |
| CNA 10 | Certified Nurse Aide | Observed in restraint and incontinence care |
| CNA 12 | Certified Nurse Aide | Observed in incontinence care |
| CNA 38 | Certified Nurse Aide | Mentioned in dementia training records |
| CNA 91 | Certified Nurse Aide | Mentioned in dementia training records |
| QMA 3 | Qualified Medication Aide | Observed handling food with bare hands |
| QMA 59 | Qualified Medication Aide | Observed glucometer cleaning |
| DON | Director of Nursing | Multiple interviews and policy discussions |
| Administrator | Facility Administrator | Multiple interviews and policy discussions |
| Kitchen Manager | Kitchen Manager | Interviewed about food safety and dishwasher |
| Assisted Living Manager | Assisted Living Manager | Interviewed about kitchen supervision and dining assistant training |
| Dietician | Dietician | Mentioned in food service supervision and training |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 18, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00422846 ending on December 12, 2023.
Complaint Details
Investigation of Complaint IN00422846 was reviewed and found to be in compliance.
Findings
Good Samaritan Society Northwood Residential Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 12, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to timely report an abuse allegation involving a resident.
Complaint Details
This citation relates to complaint IN00422846.
Findings
The facility failed to ensure timely reporting of an abuse allegation to facility administration and the state agency for one of two abuse allegations reviewed. Staff filed the abuse allegation as a grievance rather than immediately notifying the Director of Nursing or facility administrator, and the allegation was not reported to the state agency within the required two-hour time frame.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and failed to report the results of the investigation to proper authorities as required. Staff delayed reporting an abuse allegation by filing a grievance instead of immediate notification, and the state agency was notified the following day.
Inspection Report
Complaint Investigation
Census: 54
Capacity: 70
Deficiencies: 1
Date: Dec 12, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00422846 regarding allegations of abuse at the facility.
Complaint Details
Complaint IN00422846 was substantiated with federal/state deficiencies cited related to the allegations. The abuse allegation involved Resident D, who reported mistreatment by a staff member (CNA 12). The allegation was initially reported as a grievance rather than immediately to administration, delaying notification to the state agency until the following day.
Findings
The facility failed to ensure timely reporting of an abuse allegation to facility administration and the state agency for 1 of 2 abuse allegations reviewed. Staff filed the abuse allegation as a grievance rather than immediately notifying the Director of Nursing or facility administrator, resulting in delayed reporting beyond the required 2-hour timeframe.
Deficiencies (1)
Failure to ensure timely reporting of an abuse allegation to facility administration and to the state agency within the required 2-hour timeframe.
Report Facts
Census SNF/NF beds: 54
Census Residential beds: 16
Total licensed capacity: 70
Medicare census: 4
Medicaid census: 24
Other payor census: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Doane | Director of Nursing | Named in relation to the delayed reporting of abuse allegation and oversight of corrective actions |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 76
Deficiencies: 0
Date: Oct 23, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00418295.
Complaint Details
Investigation of Complaint IN00418295 found no deficiencies related to the allegations.
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 in regard to the complaint investigation.
Report Facts
Census SNF/NF beds: 59
Census Residential beds: 17
Total Capacity: 76
Census Medicare residents: 3
Census Medicaid residents: 33
Census Other payor residents: 23
Total Census residents: 59
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 18, 2023
Visit Reason
Paper compliance review to the Post Survey Revisit (PSR) to the PSR to the Recertification and State Licensure survey ending March 24, 2023.
Findings
Good Samaritan Society Northwood Residential Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Post Survey Revisit (PSR) to the PSR to the Recertification and State Licensure survey.
Inspection Report
Re-Inspection
Census: 51
Capacity: 107
Deficiencies: 0
Date: Mar 31, 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 following the initial survey on 02/20/23.
Findings
At this PSR, Good Samaritan Society Northwood Retirement Community was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility was fully sprinklered except for a detached garage used for storage and had a fire alarm system with hard wired smoke detectors in required areas.
Report Facts
Certified beds: 107
Census: 51
Inspection Report
Re-Inspection
Census: 72
Deficiencies: 0
Date: Mar 24, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00401247 completed on 2/9/23, conducted in conjunction with a PSR to the Recertification and State Licensure Survey including a State Residential Licensure Survey.
Complaint Details
Complaint IN00401247 was investigated and found to be corrected.
Findings
Good Samaritan Society Retirement Community 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 IN00401247. The complaint was corrected.
Report Facts
Census Bed Type - SNF/NF: 53
Census Bed Type - Residential: 19
Census Total: 72
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 26
Census Payor Type - Other: 19
Census Payor Type - Total: 53
Inspection Report
Follow-Up
Census: 72
Capacity: 72
Deficiencies: 4
Date: Mar 22, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 2/9/23, including a PSR to a State Residential Licensure Survey and a PSR to the Investigation of Complaint IN00401247 completed 2/9/23.
Complaint Details
Complaint IN00401247 was investigated and corrected as part of this revisit.
Findings
The facility had deficiencies related to care planning for residents with late-onset schizophrenia diagnoses, respiratory care including oxygen administration, and food storage and diet order management. The facility had not fully implemented systemic plans of correction from prior citations.
Deficiencies (4)
Failed to ensure acceptable standards of care for 4 of 7 residents with late-onset schizophrenia diagnoses; care plans and behavior monitoring were incomplete or not updated.
Failed to ensure residents received necessary respiratory care consistent with physician orders; oxygen use and care plans were not properly followed for 2 of 3 residents reviewed.
Food containers in kitchen and storage areas were not properly labeled with complete dates; expired and unlabeled foods were found.
Resident diet orders were not reviewed and revised by the physician as the resident's condition required for 5 of 5 residents reviewed; diet orders were missing from current physician orders.
Report Facts
Census Bed Type - SNF/NF: 53
Census Bed Type - Residential: 19
Total Census: 72
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 26
Census Payor Type - Other: 19
Deficiency counts: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Edwin Onwukegwu | Administrator | Signed the report and plan of correction |
| RN 5 | Interviewed regarding schizophrenia care plan updates and oxygen order compliance | |
| RN 9 | Interviewed regarding oxygen use for Resident 29 | |
| LPN 64 | Interviewed regarding oxygen use for Resident 29 | |
| LPN 7 | Interviewed regarding oxygen orders and hospice communication for Resident 16 | |
| Cook 37 | Interviewed regarding food storage and outdated food items | |
| Director of Nursing | DON | Interviewed regarding diet order reviews and resident assessments |
| Residential Manager | Interviewed regarding food storage observations |
Inspection Report
Routine
Census: 56
Capacity: 107
Deficiencies: 14
Date: Feb 20, 2023
Visit Reason
Routine Emergency Preparedness and Life Safety Code survey conducted by the Indiana Department of Health to assess compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance with Emergency Preparedness requirements including failure to annually review and update the emergency preparedness plan, maintain a complete all-hazard risk assessment, ensure cooperation with local emergency officials, develop and implement emergency policies and procedures, maintain a system to track staff and residents during emergencies, maintain medical documentation, develop arrangements with other facilities, maintain a communication plan, conduct training and testing programs, and ensure life safety code compliance including proper signage on delayed egress doors, cooking equipment safety, evacuation plans, and electrical equipment use.
Deficiencies (14)
Failed to develop and maintain an emergency preparedness plan reviewed and updated at least annually.
Failed to maintain a complete all-hazard risk assessment utilizing an all-hazards approach.
Failed to ensure emergency preparedness plan included cooperation and collaboration with local, tribal, regional, State, or Federal emergency preparedness officials.
Failed to develop and implement emergency preparedness policies and procedures reviewed and updated at least annually.
Failed to include a system to track the location of on-duty staff and sheltered residents during and after an emergency.
Failed to include a system of medical documentation that preserves resident information, protects confidentiality, and secures availability of records.
Failed to develop arrangements with other facilities to receive residents in the event of limitations or cessation of operations.
Failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State, and local laws.
Failed to develop and maintain an emergency preparedness training and testing program reviewed and updated at least annually.
Failed to conduct exercises to test the emergency plan at least twice per year including unannounced staff drills.
Failed to ensure means of egress doors with delayed egress locks were equipped with required signage and code posted near keypad.
Failed to ensure cook tops in two rooms were shut off at the switch when not in use.
Failed to provide a complete facility specific written fire safety plan addressing all required components including use of K-class fire extinguisher, removal of wheeled equipment, alarm transmission, and emergency phone call to fire department.
Used power strip as a substitute for fixed wiring in a dining room.
Report Facts
Facility capacity: 107
Facility census: 56
Number of delayed egress locks without signage: 13
Number of cook tops not shut off: 2
Number of power strips used improperly: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and acknowledged deficiencies related to emergency preparedness plan, fire safety plan, delayed egress door signage, cook top usage, and power strip use. | |
| Maintenance Assistant #1 | Present during observations and exit conference related to multiple deficiencies. |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Feb 9, 2023
Visit Reason
The inspection was conducted based on complaints and concerns regarding medication administration, fall prevention, infection control, hospice communication, respiratory care, staffing postings, and COVID-19 vaccination exemptions.
Complaint Details
The inspection was complaint-driven, focusing on medication administration errors, fall prevention failures, infection control breaches including COVID-19 precautions, hospice communication issues, respiratory care deficiencies, staffing posting noncompliance, and staff vaccination exemption concerns.
Findings
The facility failed to ensure proper medication administration standards, adequate fall prevention and supervision, appropriate infection control practices including COVID-19 precautions, effective communication with hospice providers, adherence to physician oxygen orders, and proper posting of nurse staffing information. Additionally, staff COVID-19 vaccination exemptions lacked clinically recognized contraindications.
Deficiencies (8)
F 0658: The facility failed to ensure acceptable standards of care for medication administration for residents diagnosed with schizophrenia/schizoaffective disorder without documentation to substantiate the diagnosis.
F 0689: The facility failed to provide adequate supervision and assistive devices to prevent accidents, resulting in multiple falls and fractures for Resident 44 and insufficient fall prevention interventions for Resident 28.
F 0690: The facility failed to provide appropriate care for an incontinent resident with a urinary tract infection, including improper hygiene and handwashing practices during incontinence care.
F 0695: The facility failed to provide safe and appropriate respiratory care by not following physician oxygen orders and lacking a care plan for oxygen use for two residents.
F 0732: The facility failed to post completed nurse staffing sheets daily with specific staff numbers and hours for 6 of 6 days during the survey.
F 0849: The facility failed to ensure a communication process with hospice personnel was developed and implemented, including documentation of communication between the facility and hospice for one resident.
F 0880: The facility failed to properly prevent and contain COVID-19 by inadequate hand hygiene, improper glove use, failure to sanitize hands before medication administration, and improper use of PPE including N95 masks.
F 0888: The facility failed to ensure staff COVID-19 vaccination medical exemptions specified clinically recognized contraindications for one staff member.
Report Facts
Falls: 9
Falls: 8
Staffing sheets missing details: 6
Oxygen flow rate: 3
Oxygen flow rate: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff 10 | Staff member with a COVID-19 vaccine medical exemption due to family history of Guillain Barre syndrome. | |
| LPN 37 | Licensed Practical Nurse | Indicated oxygen order for Resident 29 was 2 LPM but observed at 3 LPM with empty humidification bottle. |
| CNA 88 | Certified Nurse Aide | Observed providing incontinence care without changing gloves between tasks and improper hand hygiene. |
| QMA 65 | Qualified Medication Aide | Observed preparing medications without sanitizing hands before administration. |
| DON | Director of Nursing | Provided interviews regarding hospice communication, infection control, and medication administration policies. |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 77
Deficiencies: 1
Date: Feb 9, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00400564, IN00401247, and IN00398107, in conjunction with a recertification and state licensure survey including a State Residential Licensure Survey.
Complaint Details
Complaint IN00400564 was unsubstantiated due to lack of evidence. Complaint IN00401247 was substantiated with federal/state deficiencies cited at F880. Complaint IN00398107 was substantiated with no deficiencies related to the allegations cited.
Findings
The facility was found to have deficiencies related to infection prevention and control practices, including improper glove use, inadequate hand hygiene, improper PPE use, and medication administration errors. Complaint IN00401247 was substantiated with federal/state deficiencies cited at F880, while complaint IN00400564 was unsubstantiated and IN00398107 substantiated with no deficiencies cited.
Deficiencies (1)
Failure to properly prevent and control infections including improper glove use, inadequate hand hygiene, improper PPE use, and failure to sanitize hands prior to medication administration.
Report Facts
Census: 77
Licensed Capacity: 77
SNF/NF Beds: 55
Residential Beds: 22
Medicare Residents: 11
Medicaid Residents: 29
Other Payor Residents: 15
Hand hygiene audits: 5
Medication pass audits: 5
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 15
Date: Feb 9, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Complaints IN00398107, IN00401247, and IN00400564. The visit included a State Residential Licensure Survey.
Complaint Details
Complaint IN00398107 was substantiated with no deficiencies cited related to the allegations. Complaint IN00401247 was substantiated with federal/state deficiencies cited at F880. Complaint IN00400564 was unsubstantiated due to lack of evidence.
Findings
The facility was found to have multiple deficiencies including failure to ensure professional standards in medication administration and diagnosis documentation, inadequate supervision to prevent resident falls, improper incontinent care, failure to provide necessary respiratory care, incomplete nurse staffing postings, lack of communication with hospice providers, infection control lapses including improper PPE use and hand hygiene, incomplete staff COVID-19 vaccination documentation, missing tuberculosis screening and dementia training for staff, absence of a dementia unit director, and failure to maintain proper diet orders for residents.
Deficiencies (15)
Failed to ensure acceptable standards of care for residents related to medication administration and diagnosis documentation of schizophrenia/schizoaffective disorder.
Failed to ensure adequate supervision and assistive devices to prevent accidents resulting in multiple falls and fractures.
Failed to provide appropriate treatment and services for urinary and bowel incontinence, including proper cleaning and toileting assistance.
Failed to ensure residents received necessary respiratory care consistent with physician orders and care plans.
Failed to post completed nurse staffing sheets daily with required details for multiple days.
Failed to ensure communication process and documentation between hospice personnel and facility staff for hospice residents.
Failed to properly prevent and contain COVID-19 including improper glove use, hand hygiene, PPE use, and medication handling.
Failed to ensure staff COVID-19 vaccination medical exemptions met criteria for clinically recognized contraindications.
Failed to ensure tuberculin skin tests or risk assessments were completed for employees and residents as required.
Failed to ensure dementia-specific training was completed for staff with regular resident contact.
Failed to designate a dementia director/coordinator and complete a Dementia Disclosure Agreement for the dementia unit.
Failed to ensure a CPR and First Aid certified staff member was present on all shifts.
Failed to ensure inservice education and training on resident rights and dementia were completed for staff.
Failed to ensure food containers in kitchen were properly labeled with complete dates.
Failed to ensure diet orders were reviewed, revised by physician, and in place for residents as required.
Report Facts
Survey dates: January 30, February 1, 2, 3, 6, 7, 8, 9, 2023
Resident census: 77
Falls for Resident 44: 9
Staffing posting days missing details: 6
Residents reviewed for diet orders: 8
Employees missing TB testing or risk assessment: 6
Employees missing dementia training: 9
Staffing schedule missing CPR/FA certified staff: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Edwin Onwukegwu | Administrator | Signed report and provided interviews |
| Director of Nursing | DON | Interviewed regarding diagnosis documentation, fall prevention, hospice communication, infection control, and medication administration |
| CNA 73 | Interviewed about Resident 44 falls | |
| RN 5 | Registered Nurse | Observed and interviewed regarding Resident 28 and Resident B care |
| LPN 37 | Licensed Practical Nurse | Interviewed about oxygen therapy for Resident 29 |
| Infection Preventionist | IP | Interviewed about infection control practices and COVID-19 vaccination |
| Staff 10 | Staff member with COVID-19 vaccination medical exemption reviewed | |
| Facility Manager | Interviewed about food storage practices | |
| Senior Living Manager | Interviewed about diet orders | |
| Administrator | Multiple interviews regarding policies and deficiencies |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 2
Date: Aug 31, 2022
Visit Reason
This visit was for the investigation into complaints IN00387875, IN00385146, IN00388219, and IN00385792, all of which were substantiated with related federal/state deficiencies cited.
Complaint Details
Complaints IN00387875, IN00385146, IN00388219, and IN00385792 were all substantiated with federal/state deficiencies cited at F0656 and F0677.
Findings
The facility failed to ensure the plan of care was followed for nutrition and medication administration for multiple residents, including failure to weigh residents as ordered and late medication administration. Additionally, the facility failed to provide adequate assistance with bathing for residents requiring help, resulting in missed showers.
Deficiencies (2)
Failed to develop and implement a comprehensive person-centered care plan including measurable objectives and timeframes, specifically related to medication administration and weight monitoring.
Failed to provide assistance with activities of daily living, specifically bathing, for residents requiring help, resulting in missed showers.
Report Facts
Census SNF/NF beds: 62
Census Residential beds: 24
Total census: 86
Medicare census: 2
Medicaid census: 44
Other payor census: 16
Resident H weight decline: 16
Resident R weight decline: 11
Resident M missed medication date: 1
Resident V late medication administration: 1
Resident M showers documented: 4
Resident K showers documented: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 7 | Licensed Practical Nurse | Provided interview about medication administration timing and policy |
| Director of Nursing | Provided education to nursing staff on medication pass documentation and timely medication administration | |
| Facility Administrator | Provided interviews and facility policies related to care plans, medication administration, and activities of daily living |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 31, 2022
Visit Reason
Paper compliance review to the Investigation of Complaints IN00387875, IN00385146, IN00388219, and IN00385792 conducted on August 31, 2022.
Complaint Details
The visit was related to investigations of complaints IN00387875, IN00385146, IN00388219, and IN00385792; compliance was found.
Findings
Good Samaritan Society Northwood Retirement 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.
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