Inspection Reports for The Waters of Hobart Skilled Nursing Facility
2901 W 37TH AVE, IN, 46342
Back to Facility ProfileInspection Report Summary
The most recent inspection on February 20, 2025, found no deficiencies related to the investigated complaints. Earlier inspections showed a pattern of deficiencies primarily involving resident care issues such as pressure ulcer treatment, medication administration, infection control, and communication with healthcare providers. Several complaint investigations substantiated deficiencies in these areas, including medication errors, infection control lapses, and incomplete documentation, but no fines, immediate jeopardy findings, or license actions were listed in the available reports. Most complaints were unsubstantiated or corrected upon re-inspection, and enforcement actions were not noted. The facility’s inspection history shows ongoing challenges in clinical care and infection control, with some improvement indicated by the absence of deficiencies in the most recent inspection.
Deficiencies (last 3 years)
Deficiencies (over 3 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
12
9
6
3
0
Census
Latest occupancy rate
100% occupied
Based on a February 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 58
Capacity: 58
Deficiencies: 0
Feb 20, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00447431 and IN00453551.
Findings
No deficiencies related to the allegations in complaints IN00447431 and IN00453551 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaints IN00447431 and IN00453551 found no deficiencies related to the allegations; both complaints were not substantiated.
Report Facts
Medicare census: 6
Medicaid census: 42
Other payor census: 10
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 2, 2024
Visit Reason
Paper compliance review to the Investigation of Complaints IN00440342 and IN00443034 completed on October 29, 2024.
Findings
The Waters of Hobart 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 to the complaint investigation.
Complaint Details
Investigation of Complaints IN00440342 and IN00443034; paper compliance review completed.
Inspection Report
Complaint Investigation
Census: 47
Capacity: 47
Deficiencies: 5
Oct 29, 2024
Visit Reason
This visit was for the investigation of complaints IN00440342 and IN00443034 regarding federal and state deficiencies related to pressure ulcer treatment, feeding tube management, dialysis communication, medical record documentation, and infection prevention.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate treatment for pressure ulcers, failure to follow physician orders for feeding tube care, lack of communication with dialysis center regarding resident location, incomplete and inaccurate medical record documentation, and failure to ensure proper use of personal protective equipment for residents on Enhanced Barrier Precautions.
Complaint Details
This visit was triggered by complaints IN00440342 and IN00443034. Deficiencies cited were related to allegations in these complaints, including pressure ulcer care, feeding tube management, dialysis communication, medical record documentation, and infection control.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure a resident with a pressure ulcer received necessary treatment and services to promote healing. | SS=D |
| Failed to ensure appropriate treatment and services were provided to residents with feeding tubes, related to physician's orders not followed when checking for proper placement of feeding tubes. | SS=D |
| Failed to have ongoing communication with a resident's dialysis center related to not checking on resident's location when they did not return from dialysis. | SS=D |
| Failed to ensure a resident's record had thorough and accurate documentation related to physician consult appointment, cardiac assessment, pressure ulcer assessment, and documentation of pressure ulcers. | SS=D |
| Failed to ensure correct Personal Protective Equipment (PPE) was used by staff when providing care to residents in Enhanced Barrier Precautions. | SS=D |
Report Facts
Census: 47
Total Capacity: 47
Residents with feeding tubes: 3
Residents reviewed for dialysis: 2
Residents reviewed for medical record documentation: 5
Residents reviewed for infection control: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mehay | Executive Director | Signed plan of correction and facility representative |
| LPN 1 | Nurse involved in pressure ulcer treatment observation | |
| CNA 1 | Staff involved in pressure ulcer care and infection control observation | |
| QMA 2 | Staff involved in pressure ulcer care and infection control observation | |
| Corporate Regional RN | Interviewed regarding wound care, dialysis communication, and documentation issues | |
| Assistant Director of Nursing | Interviewed regarding dialysis communication and infection control issues | |
| LPN 3 | Signed nurse progress note related to dialysis | |
| LPN 4 | Interviewed regarding dialysis discharge documentation | |
| Dialysis Staff 1 | Interviewed regarding resident discharge from dialysis | |
| RD 6 | Registered Dietitian | Informed about resident skin issues |
Inspection Report
Life Safety
Census: 44
Capacity: 110
Deficiencies: 0
Sep 23, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 08/05/24 by the Indiana Department of Health in accordance with 42 CFR Subpart 483.90(a).
Findings
The Waters of Hobart Skilled Nursing Facility was found in compliance with Requirements for Participation in Medicare, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Report Facts
Facility capacity: 110
Census: 44
Inspection Report
Life Safety
Census: 49
Capacity: 110
Deficiencies: 7
Aug 5, 2024
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101, Life Safety Code.
Findings
The facility was found not in compliance with Life Safety Code requirements due to deficiencies including missing ceiling tiles in the maintenance storage room, annular space around sprinkler heads in a resident bathroom, smoke passage issues with medicine room doors, exposed electrical wiring and unsecured electrical panels. Corrective actions were taken promptly and plans for ongoing monitoring were established.
Severity Breakdown
SS=E: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to maintain ceiling construction in maintenance storage room; missing ceiling tile could delay sprinkler activation. | SS=E |
| Failed to maintain ceiling construction in bathroom of resident rooms 151/153; annular space around sprinkler head. | SS=E |
| Medicine room door to corridor had a penetration (hole) allowing passage of smoke. | SS=E |
| Medicine room corridor door had impediment to closing and latching due to tape on crash plate. | SS=E |
| Electrical junction box in resident room 136 had exposed wiring. | SS=E |
| Electrical outlet in Environmental Director's office missing cover plate. | SS=E |
| Electrical panels in East Wing shower room and central nurse's station were unsecured. | SS=E |
Report Facts
Certified beds: 110
Census: 49
Residents affected: 20
Staff affected: 3
Staff affected: 5
Staff affected: 2
Residents and staff affected: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristina Herrera | Executive Director | Named during exit conference and report signature |
| Environmental Director | Interviewed regarding sprinkler and electrical deficiencies | |
| Maintenance Supervisor | Performed corrective actions on ceiling tiles, doors, electrical boxes, and panels | |
| Administrator | Verified corrective actions and provided staff in-service |
Inspection Report
Annual Inspection
Census: 50
Capacity: 50
Deficiencies: 11
Jul 11, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from July 8 to July 11, 2024.
Findings
The facility was found deficient in multiple areas including medication self-administration orders, transfer and discharge notices, ADL care, quality of care related to bruising and medication administration, foot care, range of motion management, bowel/bladder catheter care, tube feeding management, respiratory care, nurse staffing posting, and environmental conditions.
Severity Breakdown
SS=D: 9
SS=A: 1
SS=C: 1
SS=E: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to ensure residents had physician's orders and assessments for self-administration of medications for 2 residents. | SS=D |
| Failed to notify resident's responsible party in writing related to hospital transfer for 1 resident. | SS=A |
| Failed to provide ADL assistance related to nail care and facial hair removal for 2 residents. | SS=D |
| Failed to ensure areas of bruising were assessed and monitored, failed to administer medications according to orders, and failed to assess edema for residents. | SS=D |
| Failed to ensure Podiatrist's recommendations were followed related to toenail care for 1 resident. | SS=D |
| Failed to ensure splint was ordered and in place as recommended by therapy for 1 resident. | SS=D |
| Failed to ensure suprapubic catheter bag and tubing were kept off the floor for 1 resident. | SS=D |
| Failed to ensure enteral tube feedings were infusing at the correct time and flow rate for 2 residents. | SS=D |
| Failed to ensure oxygen was set at the correct flow rate and ordered by the physician for 3 residents. | SS=D |
| Failed to post daily nurse staffing sheet timely, affecting visibility of staffing and census information. | SS=C |
| Failed to ensure residents' environment was clean and in good repair, including personal items storage, floor tile condition, caulking, leaking toilets, tube feeding pole cleanliness, and odors in 1 unit. | SS=E |
Report Facts
Census: 50
Total Capacity: 50
Deficiencies cited: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristina Herrera | Executive Director | Signed the report and involved in notification and corrective action |
Inspection Report
Renewal
Deficiencies: 0
Jul 11, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure survey.
Findings
The Waters of Hobart 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 to the Recertification and State Licensure Survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 1, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00428486 plus unrelated deficiency.
Findings
The Waters of Hobart 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 to the complaint investigation.
Complaint Details
Investigation of Complaint IN00428486; paper compliance review found in compliance.
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 2
Mar 4, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00428486 regarding federal/state deficiencies related to the allegations.
Findings
The facility failed to ensure physician's orders for monitoring an external cardiac device were followed for 1 resident. Additionally, infection control guidelines were not properly implemented, including failure to wear required PPE and perform hand hygiene in isolation rooms.
Complaint Details
Complaint IN00428486 was substantiated with federal/state deficiencies cited at F684 related to the allegations.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure Physician's Orders for monitoring an external cardiac device were followed for 1 of 1 residents reviewed for specialty care. | SS=D |
| Failed to ensure infection control guidelines were in place and implemented, including PPE use and hand hygiene in COVID-19 positive and droplet/contact isolation rooms. | SS=D |
Report Facts
Census: 45
Medicare residents: 8
Medicaid residents: 29
Other residents: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristina Herrera | Executive Director | Signed report |
| Director of Nursing | Interviewed regarding monitoring of external cardiac device and infection control practices | |
| Hospice Aid 1 | Observed failing to wear PPE and perform hand hygiene in isolation room | |
| Hospice Nurse 1 | Observed not wearing required PPE in isolation room | |
| Laundry Aid 1 | Observed entering isolation room without PPE | |
| Speech Therapist 1 | Observed entering isolation room without eye protection | |
| Activity Aid 1 | Observed entering isolation room without PPE and unaware of isolation status |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 27, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00424611 and an unrelated deficiency.
Findings
The Waters of Hobart 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 investigation.
Complaint Details
Investigation of Complaint IN00424611; paper compliance review completed with findings of compliance.
Inspection Report
Complaint Investigation
Census: 46
Capacity: 46
Deficiencies: 3
Feb 6, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00424611, which involved federal and state deficiencies related to pharmacy services and medication administration.
Findings
The facility was found deficient in pharmacy services related to failure to provide scheduled pain medication for one resident, a medication error rate exceeding 5% for two residents during medication pass, and failure to implement proper infection control measures including hand hygiene during medication administration and wound care.
Complaint Details
Complaint IN00424611 was substantiated with federal and state deficiencies cited at tags F755 (pharmacy services) and F759 (medication errors).
Severity Breakdown
SS=D: 2
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure pharmacy services were provided for a resident related to scheduled pain medication not given as ordered. | SS=D |
| Medication error rate of 14.8% observed during medication administration for two residents. | SS=E |
| Failure to ensure infection control measures including hand hygiene during medication pass and wound care. | SS=D |
Report Facts
Census: 46
Total Capacity: 46
Medication error rate: 14.8
Medication errors observed: 4
Medication opportunities: 27
Medication not given: 22
Medication not given: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristina Herrera | Executive Director | Signed the report |
| RN 1 | Prepared medications during observed medication pass with errors; no longer employed by facility | |
| LPN 1 | Observed medication pass, interviewed regarding medication errors and infection control lapses | |
| QMA 1 | Observed medication pass, did not perform hand hygiene between residents, educated on medication administration and infection control | |
| Director of Nursing | DON | Interviewed regarding pharmacy ordering difficulties and corrective actions |
| Infection Control Nurse | Provided education on handwashing and infection control to staff |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 2, 2024
Visit Reason
Paper compliance review related to an unrelated deficiency cited during the Investigation of Complaint IN00421593 completed on November 29, 2023.
Findings
The Waters of Hobart 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 investigation.
Complaint Details
Investigation of Complaint IN00421593 completed on November 29, 2023; paper compliance review conducted.
Inspection Report
Complaint Investigation
Census: 38
Capacity: 38
Deficiencies: 1
Nov 29, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00421593. The complaint allegations were not substantiated, but an unrelated deficiency was cited.
Findings
The facility failed to ensure adequate pain management for one resident (Resident B), including lack of monitoring for signs of narcotic withdrawal, incomplete pain assessments, and lack of non-pharmacological interventions. The resident's opioid medication was discontinued without adequate follow-up on pain control or withdrawal symptoms.
Complaint Details
Complaint IN00421593 was investigated and no deficiencies related to the allegations were cited. An unrelated deficiency regarding pain management was cited.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure pain management including monitoring for narcotic withdrawal, medication effectiveness, and provision of non-pharmacological interventions for one resident. | SS=D |
Report Facts
Census: 38
Total Capacity: 38
Medicare Census: 5
Medicaid Census: 25
Other Payor Census: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Duhaime | Interim Administrator | Signed the report |
Inspection Report
Re-Inspection
Census: 41
Deficiencies: 0
Oct 12, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00409913, IN00411506, IN00412700, IN00413008, IN00413907, IN00415513, and IN00416438 completed on 2023-08-30.
Findings
The Waters of Hobart 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 PSR to the Investigation of Complaints. All cited complaints were corrected.
Complaint Details
This re-inspection was related to multiple complaints (IN00409913, IN00411506, IN00412700, IN00413008, IN00413907, IN00415513, IN00416438) which were all found to be corrected.
Report Facts
Census SNF/NF: 41
Census Medicare: 8
Census Medicaid: 25
Census Other: 8
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 6
Aug 30, 2023
Visit Reason
This visit was for the investigation of multiple complaints related to the facility's compliance with federal and state regulations.
Findings
The facility was found deficient in multiple areas including honoring resident medication preferences, timely assistance with activities of daily living, quality of care related to falls, pressure ulcer care, intravenous fluid management, and pharmacy services including narcotic medication documentation.
Complaint Details
This visit was triggered by multiple complaints (IN00409913, IN00411506, IN00412700, IN00413008, IN00413907, IN00415513, IN00416438) alleging various deficiencies related to resident care, medication administration, fall management, pressure ulcer care, and pharmacy services.
Severity Breakdown
SS=D: 5
SS=G: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure a resident's preference to receive medications at a different time were honored to not interrupt sleep patterns. | SS=D |
| Failed to ensure a dependent resident received timely help with incontinence care. | SS=D |
| Failed to assess a resident and promptly notify the physician after a fall resulting in delayed treatment and hospitalization for a fracture, and failed to complete assessment including vital signs after a fall for another resident. | SS=G |
| Failed to ensure residents with pressure ulcers received necessary treatment and services to promote healing, including turning, repositioning, and treatment completion. | SS=D |
| Failed to ensure intravenous catheters were monitored, assessed, and bandages and tubing were changed as ordered. | SS=D |
| Failed to establish and maintain a system that accounted for, periodically reconciled, and ensured disposition of all controlled drugs, with incomplete and inaccurate narcotic medication documentation. | SS=D |
Report Facts
Census: 46
Medication administration times: 3
Pressure ulcer measurements: 5
Duration of antibiotic treatment: 38
Narcotic doses: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judith Hoese | Administrator | Signed the report |
Inspection Report
Re-Inspection
Census: 42
Capacity: 110
Deficiencies: 0
Jul 3, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted for the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey that exited on 05/25/23.
Findings
At this Emergency Preparedness PSR and Life Safety Code PSR, The Waters of Hobart was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements for Medicare and Medicaid Participating Providers and Suppliers.
Report Facts
Certified beds: 110
Census: 42
Emergency generator power: 230
Inspection Report
Routine
Census: 42
Capacity: 110
Deficiencies: 10
May 25, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health to assess compliance with Medicare and Medicaid participation requirements and life safety codes.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements, Life Safety Code requirements including means of egress obstructions, exit door impediments, hazardous area door self-closing devices, fire alarm and sprinkler system policies, ceiling penetrations affecting sprinkler operation, unsecured electrical panels, HVAC corridor return air issues, and improper use of power strips.
Severity Breakdown
SS=F: 4
SS=E: 4
SS=D: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to conduct exercises to test the emergency plan at least twice per year including unannounced staff drills. | SS=F |
| Means of egress corridors contained obstructions such as over 20 cardboard boxes in the South 100 Hall corridor. | SS=E |
| Exit discharge door in the main dining area required excessive force to open. | SS=E |
| Corridor door to linen storage room lacked a self-closing device that latches properly. | SS=E |
| Fire alarm system out-of-service policy lacked complete instructions for contacting Indiana Department of Health via specified gateway and email. | SS=F |
| Sprinkler system maintenance and testing: ceiling penetrations at nurses stations could delay sprinkler activation. | SS=E |
| Sprinkler system out-of-service policy lacked correct procedures for impairment notification and fire watch. | SS=F |
| Electrical panels in the kitchen were unsecured and unlocked. | SS=D |
| Egress corridors were used as return air plenums for HVAC ductwork serving adjoining areas. | SS=E |
| Power strips were used as a substitute for fixed wiring to provide power to high current draw equipment such as a microwave. | SS=D |
Report Facts
Certified beds: 110
Census: 42
Cardboard boxes: 20
Electrical panels: 2
Egress corridors: 2
Power strips: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jarrett Mitchell | Administrator | Named as facility administrator and involved in corrective action oversight |
| Maintenance Supervisor | Involved in findings related to emergency preparedness exercises, corridor obstructions, door repairs, fire watch policy, sprinkler system maintenance, electrical panel security, HVAC issues, and power strip use | |
| Maintenance Assistant #1 | Involved in observations and exit conference discussions related to multiple deficiencies |
Inspection Report
Plan of Correction
Deficiencies: 0
May 12, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure survey.
Findings
The Waters of Hobart 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 to the Recertification and State Licensure Survey.
Inspection Report
Annual Inspection
Census: 46
Capacity: 46
Deficiencies: 10
May 8, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from May 8 to May 12, 2023.
Findings
The facility was found deficient in multiple areas including medication self-administration, ADL care, activities programming, quality of care related to skin and respiratory treatments, pain management, unnecessary drug use, lab services notification, food safety, and infection control including COVID-19 protocols.
Severity Breakdown
SS=D: 8
SS=E: 1
SS=F: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to ensure residents had Physician's Orders and assessments for self-administration of medications for 2 residents. | SS=D |
| Failed to ensure dependent resident received necessary ADL services related to long and dirty fingernails. | SS=D |
| Failed to implement resident-centered activity program meeting preferences for 1 resident. | SS=D |
| Failed to monitor, assess, and obtain treatments for diabetic ulcers and bruises for 2 residents. | SS=D |
| Failed to ensure proper oxygen administration flow rate for 2 residents. | SS=D |
| Failed to ensure scheduled pain medication was administered for 1 resident. | SS=D |
| Failed to manage medications appropriately including monitoring blood glucose, blood pressure, and respiratory rates for 4 residents. | SS=E |
| Failed to promptly notify physician of abnormal lab results for 1 resident. | SS=D |
| Failed to maintain sanitary kitchen conditions including trash behind stove, grease on vent hood, and dried food spillage on steam table. | SS=F |
| Failed to ensure infection control guidelines including COVID-19 respiratory screening assessments were completed every shift for 2 residents. | SS=D |
Report Facts
Census: 46
Total Capacity: 46
Deficiencies cited: 10
Potassium level: 5.1
Blood Urea Nitrogen (BUN): 34
Creatinine: 1.7
Hemoglobin: 13.2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jarrett Mitchell | Administrator | Signed the report |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 10, 2023
Visit Reason
Paper compliance review to the investigation of Complaints IN00385701 and IN00396036 completed on March 1, 2023.
Findings
The Waters of Hobart 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 to the complaint investigation.
Complaint Details
The visit was related to complaint investigations IN00385701 and IN00396036, with paper compliance completed and found in compliance.
Inspection Report
Complaint Investigation
Census: 37
Capacity: 37
Deficiencies: 2
Mar 1, 2023
Visit Reason
This visit was for the Investigation of Complaints IN00385701 and IN00396036 conducted on February 28 and March 1, 2023.
Findings
The facility failed to ensure a medication self-administration assessment was completed before leaving medications at the bedside for one resident. Additionally, care plan interventions and treatment orders for pressure ulcers were not in place or updated for two residents at risk or with pressure ulcers.
Complaint Details
The investigation was triggered by Complaints IN00385701 and IN00396036. Complaint IN00385701 related to medication self-administration assessment failure. Complaint IN00396036 related to pressure ulcer care and treatment deficiencies.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure a medication self-administration assessment was completed prior to leaving medications at the bedside for 1 of 1 random observations of medications (Resident C). | SS=D |
| Failed to ensure care plan interventions were in place for residents at risk for pressure ulcers and new pressure ulcers were assessed and treatment orders obtained for 2 of 3 residents reviewed (Residents G and D). | SS=D |
Report Facts
Census: 37
Total Capacity: 37
Medicare Census: 5
Medicaid Census: 20
Other Payor Census: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jarrett Mitchell | Administrator | Signed the report and identified as facility administrator |
| Assistant Director of Nursing | Interviewed regarding medication self-administration assessment; no full name provided | |
| Director of Nursing | Interviewed regarding pressure ulcer care and wound nurse protocol; no full name provided |
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