Inspection Reports for The Waters of Fort Wayne Skilled Nursing Facility
5544 E STATE BLVD, IN, 46815
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Moderate
Low
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 0
Apr 16, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00456786 at the Waters of Fort Wayne Skilled Nursing Facility.
Findings
No deficiencies related to the allegations in Complaint IN00456786 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00456786 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 37
Census Bed Type - SNF: 1
Census Bed Type - SNF/NF: 36
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 19
Census Payor Type - Other: 13
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 0
Jan 8, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00448115 at the Waters of Fort Wayne Skilled Nursing Facility.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable federal and state regulations.
Complaint Details
Investigation of Complaint IN00448115 found no deficiencies related to the allegations.
Report Facts
Census: 44
Census Bed Type - SNF/NF: 41
Census Bed Type - SNF: 3
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 22
Census Payor Type - Other: 14
Inspection Report
Re-Inspection
Census: 45
Capacity: 77
Deficiencies: 1
Nov 12, 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 09/19/2024.
Findings
The facility was found in compliance with Emergency Preparedness Requirements and in substantial compliance with Life Safety Code requirements. One deficiency was cited related to failure to maintain the automatic sprinkler system antifreeze concentration according to NFPA standards, which was corrected with a plan of correction.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to maintain automatic sprinkler system antifreeze concentration to meet NFPA 25 standards. | SS=C |
Report Facts
Facility capacity: 77
Census: 45
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cindy S. Lawson | Administrator | Named in exit conference and plan of correction verification |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 42
Deficiencies: 0
Nov 4, 2024
Visit Reason
This visit was conducted for the investigation of complaints identified as IN00444699.
Findings
No deficiencies related to the allegations in complaint IN00444699 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00444699 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 42
Total Capacity: 42
Medicare Census: 8
Medicaid Census: 30
Other Payor Census: 4
Inspection Report
Annual Inspection
Deficiencies: 0
Oct 1, 2024
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
The Waters of Fort Wayne Skilled Nursing Facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 41
Capacity: 77
Deficiencies: 15
Sep 19, 2024
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health to assess compliance with emergency preparedness and life safety requirements.
Findings
The facility was found not in compliance with emergency preparedness requirements including failure to conduct required emergency plan exercises and failure to maintain emergency power system testing. Life safety deficiencies included dead-end corridors exceeding 30 feet, missing exit signage, fire suppression system issues, interior wall finish flame spread documentation missing, sprinkler system antifreeze testing below required levels, unsecured portable fire extinguishers, resident room doors not fully smoke resistant or latching, penetrations in smoke barriers not properly sealed, missing electrical outlet cover plates and lack of GFCI protection, incomplete fire door inspections, incomplete electrical receptacle testing documentation, failure to exercise diesel generator annually, and improper use of power strips and extension cords.
Severity Breakdown
SS=F: 5
SS=C: 4
SS=E: 6
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to conduct exercises to test the emergency plan at least twice per year including unannounced staff drills. | SS=F |
| Failed to implement emergency power system requirements including missing documentation of monthly load bank testing. | SS=C |
| Dead-end corridor exceeded 30 feet without proper exit signage. | SS=E |
| Service hall lacked exit and directional signs with continuous illumination. | SS=E |
| Fire suppression system lacked automatic fuel shut off and staff were not instructed in use of UL 300 hood system. | SS=E |
| Interior wall finish in Social Services office did not have flame spread rating documentation. | SS=E |
| Failed to maintain automatic sprinkler system antifreeze concentration at required minimum temperature. | SS=F |
| Spare portable fire extinguishers in maintenance shop were unsecured. | SS=E |
| Resident room doors failed to resist passage of smoke and did not latch properly. | SS=E |
| Smoke barrier walls had penetrations sealed with unapproved materials and an unsealed hole. | SS=F |
| Electrical outlets in main lobby missing cover plates and lacked GFCI protection in wet location. | SS=E |
| Power strips and extension cords used as substitute for fixed wiring for high current equipment. | SS=E |
| Failed to complete annual inspection and testing of fire door assemblies with required documentation. | SS=C |
| Failed to ensure testing form for hospital grade electrical receptacles in resident rooms showed each receptacle tested. | SS=C |
| Failed to exercise diesel powered generator annually with required load bank testing. | SS=F |
Report Facts
Facility capacity: 77
Census: 41
Deficiencies cited: 15
Fire door assemblies inspected: 4
Resident room doors inspected: 12
Electrical receptacles tested: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cindy S. Lawson | Administrator | Named in exit conference and plan of correction verification |
Inspection Report
Annual Inspection
Census: 43
Capacity: 43
Deficiencies: 2
Sep 4, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaints IN00440344 and IN00440916.
Findings
The facility was found deficient in following physician orders regarding weight monitoring for 2 of 16 residents reviewed and failed to monitor side effects of antipsychotic medication for 1 of 5 residents reviewed. No deficiencies were cited related to the complaints investigated.
Complaint Details
Complaint IN00440344 and Complaint IN00440916 were investigated with no deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to follow physician orders regarding weight monitoring for 2 of 16 residents reviewed (Resident 10 and Resident 6). | SS=D |
| Failed to monitor side effects of antipsychotic medication for 1 of 5 residents reviewed (Resident 20). | SS=D |
Report Facts
Census: 43
Total Capacity: 43
Medicare Census: 8
Medicaid Census: 27
Other Payor Census: 8
Weights not documented: 7
Weight gain: 7.3
Weight gain: 6
Weight gain: 12
Weight gain: 7.5
Weekly weights missing: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cindy Lawson | Administrator | Signed the report |
| Nurse Practitioner 9 | Nurse Practitioner | Named in findings related to failure to address weight gain and monitoring |
| Director of Nursing | Director of Nursing | Interviewed regarding weight monitoring and antipsychotic medication monitoring; involved in corrective actions |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 0
Jul 17, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00438808.
Findings
No deficiencies were cited related to the allegations in Complaint IN00438808. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00438808 found no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 32
Census Bed Type - NCC: 9
Total Census: 41
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 30
Census Payor Type - Other: 9
Total Census Payor: 41
Inspection Report
Complaint Investigation
Census: 40
Capacity: 40
Deficiencies: 0
May 28, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00434640.
Findings
No deficiencies related to the allegations in Complaint IN00434640 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00434640 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 26
Census Payor Type - Other: 12
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 19, 2024
Visit Reason
The document is a paper compliance review related to the investigation of complaints IN00431619 and IN00432369 completed on April 19, 2024.
Findings
The Waters of Fort Wayne Skilled Nursing Facility 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
This visit was related to complaint investigations IN00431619 and IN00432369. The facility was found to be in compliance.
Inspection Report
Complaint Investigation
Census: 47
Capacity: 47
Deficiencies: 2
Apr 18, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00431619, IN00432307, and IN00432367. Complaints IN00431619 and IN00432307 resulted in federal/state deficiencies, while complaint IN00432367 had no deficiencies cited.
Findings
The facility failed to ensure proper identification, assessment, and follow-up for acute changes in condition following two falls for one resident (Resident B). Additionally, the facility failed to provide trauma-informed care by identifying triggers and initiating resident-specific approaches for another resident (Resident C).
Complaint Details
This investigation was triggered by complaints IN00431619, IN00432307, and IN00432367. Deficiencies related to complaints IN00431619 and IN00432307 were substantiated with citations at F689 and F699 respectively. Complaint IN00432367 was not substantiated with deficiencies.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure identification, assessment, and follow-up for acute changes in resident's condition following two falls for Resident B. | SS=D |
| Failed to ensure triggers were identified and resident specific approaches initiated in providing trauma informed care for Resident C. | SS=D |
Report Facts
Census: 47
Total Capacity: 47
Medicare Census: 3
Medicaid Census: 34
Other Payor Census: 10
Falls documented: 2
Edema severity: 2
Oxygen saturation: 71
Heart rate: 134
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding Resident B's falls and care plan | |
| Rehabilitation Director | Interviewed regarding Resident B's therapy and condition post-falls | |
| Registered Nurse 5 | Interviewed about fall assessment and documentation procedures | |
| Social Service Director | Conducted psycho-social follow-up for Resident C and in-serviced staff on PTSD | |
| Administrator | Interviewed regarding trauma-informed care and facility policies | |
| Regional Nurse Consultant | Interviewed regarding trauma-informed care and Resident C's care plan | |
| CNA 3 | Interviewed about care provided to Resident C and issues with respecting modesty |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 0
Feb 28, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00427899.
Findings
No deficiencies were cited related to the allegations in Complaint IN00427899. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00427899 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 41
Census Bed Type - SNF: 3
Census Bed Type - SNF/NF: 38
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 26
Census Payor Type - Other: 13
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 21, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of complaints IN00425818 and IN00426133.
Findings
The Waters of Fort Wayne Skilled Nursing Facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
The visit was related to complaint investigations IN00425818 and IN00426133, and the facility was found to be in compliance.
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Feb 6, 2024
Visit Reason
This visit was conducted for the investigation of two complaints, IN00425818 and IN00426133, related to allegations of abuse at the facility.
Findings
The facility failed to ensure residents were free from abuse for 1 of 3 residents reviewed (Resident B). Investigations confirmed inappropriate verbal abuse by staff members, resulting in termination of involved employees and implementation of corrective actions including staff education and ongoing monitoring.
Complaint Details
The investigation was triggered by complaints IN00425818 and IN00426133. Both complaints were substantiated with federal/state deficiencies cited at F600 related to abuse allegations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure residents were free from verbal abuse, neglect, and exploitation as required by regulation. | SS=D |
Report Facts
Census: 40
Skilled Nursing Facility beds: 3
Nursing Facility beds: 37
Medicare residents: 3
Medicaid residents: 34
Other payor residents: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 2 | Certified Nursing Assistant | Terminated following investigation for verbally abusing Resident B |
| CNA 4 | Certified Nursing Assistant | Terminated following investigation for verbally abusing Resident B |
| Cindy S. Lawson | Administrator | Provided interview and signed report |
Inspection Report
Re-Inspection
Census: 45
Capacity: 45
Deficiencies: 0
Nov 9, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00417508 completed on September 27, 2023, conducted in conjunction with the Recertification and State Licensure Survey completed on August 16, 2023.
Findings
The Waters of Fort Wayne Skilled Nursing Facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the Investigation of Complaint IN00417508, indicating the complaint was corrected.
Complaint Details
Investigation of Complaint IN00417508 was completed and found corrected as of the survey date November 9, 2023.
Report Facts
Census Bed Type: 45
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 30
Census Payor Type - Other: 7
Inspection Report
Re-Inspection
Census: 45
Capacity: 45
Deficiencies: 0
Nov 9, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on August 16, 2023, conducted in conjunction with a PSR to Complaint IN00417508.
Findings
The Waters of Fort Wayne Skilled Nursing 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 Recertification and State Licensure Survey.
Complaint Details
This visit was in conjunction with a PSR to Complaint IN00417508.
Report Facts
Census SNF beds: 45
Census total residents: 45
Census Medicare residents: 8
Census Medicaid residents: 30
Census other payor residents: 7
Inspection Report
Complaint Investigation
Census: 39
Capacity: 39
Deficiencies: 1
Sep 26, 2023
Visit Reason
This visit was for the investigation of Complaint IN00417508 related to federal and state deficiencies concerning dementia care and resident safety.
Findings
The facility failed to develop and implement individualized interventions for dementia care to support psychosocial well-being and address aggressive behaviors for two residents. Observations, interviews, and record reviews revealed inadequate activity programming, insufficient non-pharmacological interventions, multiple incidents of resident-to-resident altercations, and extensive bruising without proper documentation or care plan updates.
Complaint Details
Complaint IN00417508 was substantiated with federal and state deficiencies cited at F744 related to inadequate dementia care and failure to prevent resident-to-resident altercations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to develop and implement individualized interventions for dementia care to support psychosocial well-being and address aggressive behaviors. | SS=D |
Report Facts
Census: 39
Total Capacity: 39
Medicaid Census: 28
Other Payor Census: 11
Date Survey Completed: Sep 27, 2023
Date Survey Started: Sep 26, 2023
Safety Checks Frequency: 15
Audit Frequency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cindy S. Lawson | Administrator | Signed the report and involved in facility oversight |
| LPN 3 | Licensed Practical Nurse, MCU Director | Newly designated MCU Director responsible for activities on the memory care unit |
| LPN 9 | Licensed Practical Nurse | Interviewed regarding Resident B's behaviors and interventions |
| CNA 5 | Certified Nurse Aide | Observed assisting Resident B and interviewed about care and behaviors |
| CNA 8 | Certified Nurse Aide | Interviewed about Resident C's condition and behaviors |
| CNA 12 | Certified Nurse Aide | Interviewed about activity staff and Resident B's behaviors |
| RN 8 | Registered Nurse | Provided assessment information on Resident B |
Inspection Report
Life Safety
Census: 41
Capacity: 77
Deficiencies: 4
Aug 29, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with emergency preparedness requirements and life safety code regulations.
Findings
The facility was found not in compliance with emergency preparedness training requirements, battery backup emergency lighting testing, access to electrical power panels, and oxygen storage room signage. Deficiencies included failure to conduct annual emergency preparedness training, failure to test emergency lighting monthly and annually, blocked access to electrical panels, and missing caution signage on the oxygen storage room.
Severity Breakdown
SS=F: 1
SS=E: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to conduct annual training for the Emergency Preparedness Program (EPP) and demonstrate staff knowledge of emergency procedures. | SS=F |
| Failed to ensure 2 of 2 battery backup emergency lights were properly tested monthly and annually. | SS=E |
| Failed to ensure access and working space was maintained for 3 of 3 electrical power panels, with items stored blocking access. | SS=E |
| Failed to provide a precautionary sign readable from 5 feet on the oxygen storage room door indicating 'CAUTION: OXIDIZING GAS(ES) STORED'. | SS=E |
Report Facts
Facility capacity: 77
Census: 41
Battery backup emergency lights: 2
Electrical power panels: 3
Residents potentially affected by oxygen storage signage deficiency: 30
Inspection Report
Deficiencies: 0
Aug 29, 2023
Visit Reason
The inspection was conducted to assess compliance with Emergency Preparedness requirements and Life Safety Code Recertification and State Licensure Survey.
Findings
The Waters of Fort Wayne Skilled Nursing Facility was found in compliance with Medicare/Medicaid Emergency Preparedness requirements and Life Safety Code requirements, including fire safety standards.
Inspection Report
Annual Inspection
Census: 40
Capacity: 40
Deficiencies: 3
Aug 16, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted on August 10, 11, 14, 15 and 16, 2023.
Findings
The facility was found deficient in ensuring timely communication of residents' code status changes, maintaining kitchen sanitation and food safety standards, and implementing an effective Quality Assurance Performance Improvement (QAPI) program. Deficiencies were noted in code status documentation for one resident, unsanitary kitchen conditions affecting all residents, and failure to have a fully effective QAPI process for all residents.
Severity Breakdown
SS=D: 1
SS=E: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure communication of code status for 1 of 3 residents reviewed (Resident 37). | SS=D |
| Failed to ensure kitchen sanitation was maintained for 40 of 41 residents; multiple sanitation issues observed in kitchen equipment and environment. | SS=E |
| Failed to ensure a process was in place to identify and correct quality deficiencies for 41 of 41 residents currently residing in the facility. | SS=E |
Report Facts
Deficiencies cited: 3
Facility census: 40
Total licensed capacity: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natalie Smith | HFA/RDO | Signed as Laboratory Director's or Provider/Supplier Representative. |
| RN 6 | Interviewed regarding reliance on shift change report and medical records for resident care. | |
| Director of Nursing | DON | Interviewed regarding code status orders and care plan updates. |
| Administrator | Provided documentation and interviews regarding resident code status and care plans. | |
| Cook 2 | Interviewed and observed regarding kitchen sanitation and cleaning practices. | |
| Regional Operation Manager | Interviewed regarding kitchen cleaning schedules and policies. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 30, 2022
Visit Reason
Paper compliance review to the Investigation of Complaint IN00392499 completed on November 7, 2022.
Findings
The Waters of Fort Wayne 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 to the Complaint Investigation.
Complaint Details
Investigation of Complaint IN00392499 completed; facility found in compliance.
Inspection Report
Life Safety
Census: 46
Capacity: 77
Deficiencies: 0
Nov 15, 2022
Visit Reason
An Emergency Preparedness Survey and a 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), respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Participation in Medicare/Medicaid, including fire safety standards. The facility is fully sprinklered with a fire alarm system and partially protected by a diesel power generator.
Report Facts
Facility capacity: 77
Census: 46
Inspection Report
Complaint Investigation
Census: 49
Capacity: 49
Deficiencies: 1
Nov 7, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00392499, which was substantiated with federal and state deficiencies cited.
Findings
The facility failed to implement fall interventions and update care plans to prevent further falls for 2 of 3 residents reviewed (Resident U and Resident V). Multiple falls occurred without proper fall investigation, root cause analysis, or care plan updates. The facility policy requires fall investigations, root cause analysis, and care plan updates, but these were not consistently followed.
Complaint Details
Complaint IN00392499 was substantiated. The complaint involved failure to implement fall interventions and update care plans for residents at risk of falls.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to implement fall interventions and update care plans to prevent further falls for Resident U and Resident V. | SS=D |
Report Facts
Number of residents present: 49
Total licensed capacity: 49
Number of falls for Resident U: 8
Date of survey completion: Nov 7, 2022
Date of quality review: Nov 10, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Duggan | Administrator | Named in relation to the plan of correction and interview regarding fall alarm use |
Inspection Report
Annual Inspection
Deficiencies: 0
Oct 17, 2022
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey was completed.
Findings
Miller's Merry Manor was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review for the Recertification and State Licensure survey.
Inspection Report
Annual Inspection
Census: 52
Capacity: 52
Deficiencies: 4
Sep 29, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from September 23 to September 29, 2022.
Findings
The facility was found to have deficiencies related to failure to identify and maintain code status for residents, incomplete transfer and discharge documentation, failure to monitor side effects of psychotropic medications, and incomplete quality assurance efforts regarding advance directives.
Severity Breakdown
SS=D: 3
SS=E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to identify and maintain code status requirements for 3 of 13 residents. | SS=D |
| Failed to complete assessment for transfer documentation for 1 of 2 residents reviewed. | SS=D |
| Failed to ensure side effects of antidepressant and antipsychotic medications were monitored for 1 of 5 residents reviewed. | SS=D |
| Failed to ensure complete records of quality assurance efforts for 4 of 12 months regarding advance directives. | SS=E |
Report Facts
Census: 52
Total Capacity: 52
Residents with code status issues: 3
Residents reviewed for transfer documentation: 2
Residents reviewed for psychotropic medication monitoring: 5
Months with incomplete QAPI records: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Duggan | HFA | Signed Plan of Correction request |
| RN 4 | Interviewed regarding code status for residents 50, 7, and 27 | |
| Director of Nursing | DON | Provided policies, interviews, and information regarding transfer documentation and psychotropic medication monitoring |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 0
Aug 15, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00386805.
Findings
The complaint was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00386805 was substantiated; however, no deficiencies related to the allegations were cited.
Report Facts
Census: 53
Census Bed Type - SNF/NF: 47
Census Bed Type - SNF: 6
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 41
Census Payor Type - Other: 5
Loading inspection reports...
