Inspection Reports for Waters of Chesterfield Skilled Nursing Facility
524 ANDERSON RD, IN, 46017
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 36
Capacity: 36
Deficiencies: 1
May 30, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00458362 concerning federal and state deficiencies related to the allegations.
Findings
The facility failed to make prompt efforts to resolve a grievance for a resident requesting a vegetarian diet. The resident's dietary preference was not properly documented or addressed until a care plan meeting was held, after which a plan was developed and implemented to meet the resident's needs.
Complaint Details
Complaint IN00458362 was substantiated with federal/state deficiencies cited at F585 related to grievances about the resident's vegetarian diet and the facility's failure to promptly resolve the grievance.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to make prompt efforts to resolve a grievance for a resident requesting a vegetarian diet. | SS=D |
Report Facts
Census: 36
Total Capacity: 36
Medicare Census: 1
Medicaid Census: 25
Other Payor Census: 10
Inspection Report
Re-Inspection
Census: 43
Capacity: 60
Deficiencies: 0
Mar 10, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 02/07/25 was performed by the Indiana Department of Health.
Findings
At this PSR survey, Waters of Chesterfield Skilled Nursing Facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Report Facts
Facility capacity: 60
Census: 43
Inspection Report
Re-Inspection
Census: 41
Capacity: 41
Deficiencies: 0
Feb 28, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on January 13, 2025.
Findings
The Waters of Chesterfield 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 Recertification and State Licensure Survey.
Report Facts
Census: 41
Total Capacity: 41
Medicare Census: 6
Medicaid Census: 25
Other Payor Census: 10
Inspection Report
Life Safety
Census: 43
Capacity: 60
Deficiencies: 3
Feb 7, 2025
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 but was found not in compliance with Life Safety Code requirements. Deficiencies included failure to protect a hazardous storage area with a self-closing door, inadequate smoking area containers, and insufficient space in the oxygen transfilling room.
Severity Breakdown
SS=E: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure a room greater than 50 square feet used for storage of large amounts of combustibles was protected as a hazardous area with a self-closing door. | SS=E |
| Failed to ensure smoking areas were provided with metal or noncombustible containers with self-closing covers to dispose of cigarette butts. | SS=E |
| Failed to ensure oxygen transfilling took place in a room separated from any portion of the facility with adequate space for transfilling with the door closed. | SS=E |
Report Facts
Deficiencies cited: 3
Census: 43
Total Capacity: 60
Combustible boxes: 30
Liquid oxygen tanks: 4
Potentially affected residents: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eileen R Thomas | Administrator | Named in relation to findings and exit conference. |
Inspection Report
Annual Inspection
Census: 39
Capacity: 39
Deficiencies: 6
Jan 13, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from January 7 to January 13, 2025.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate menus for pureed diets, failure to provide timely Medicare non-coverage notifications, failure to notify physicians of weight changes as ordered, improper insulin labeling and disposal, unsafe food handling practices, and incomplete annual dementia training for staff.
Severity Breakdown
SS=D: 4
SS=F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to develop and provide a menu to encourage intake and promote dignity for residents who received a pureed diet. | SS=D |
| Failed to provide the appropriate 48-hour notification of Medicare A Non-coverage for residents reviewed. | SS=D |
| Failed to notify the physician as ordered for changes in daily weights for a resident reviewed for weight loss/gain. | SS=D |
| Failed to ensure insulin vials were dated when opened and disposed of when expired for medication storage. | SS=D |
| Failed to ensure food was prepared and served under safe and sanitary conditions, including improper glove use and cross contamination risks during meal service. | SS=F |
| Failed to ensure required annual dementia education was completed for employees reviewed for required annual training. | — |
Report Facts
Survey dates: 5
Census: 39
Total Capacity: 39
Residents on Medicare: 5
Residents on Medicaid: 26
Residents on Other payor types: 8
Insulin expiration days: 28
Dementia training hours: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eileen Thomas | Administrator | Signed report and provided facility policies. |
| LPN 3 | Social Service Director | Interviewed regarding Medicare non-coverage notification process. |
| Speech Therapist 4 | Speech Therapist | Interviewed regarding therapy discharge forms and Medicare meetings. |
| LPN 5 | Licensed Practical Nurse | Interviewed regarding weight documentation and physician notifications. |
| RN 6 | Registered Nurse | Observed medication storage and insulin labeling. |
| Acting Dietary Manager | Observed during meal service and interviewed regarding food handling and glove use. | |
| Director of Contracted Dietary Food Services Company | Interviewed regarding proper food serving procedures. | |
| CNA 8 | Certified Nursing Assistant | Employee record reviewed for dementia training. |
| LPN 9 | Licensed Practical Nurse | Employee record reviewed for dementia training. |
| RN 11 | Registered Nurse | Employee record reviewed for dementia training. |
| Transportation Driver | Employee record reviewed for dementia training. |
Inspection Report
Follow-Up
Census: 44
Capacity: 60
Deficiencies: 0
Dec 16, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to investigate Complaint Number IN00445598 that exited on 10/30/24.
Findings
At this PSR survey, Waters of Chesterfield Skilled Nursing Facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code.
Complaint Details
Complaint IN00445598 was corrected as of the survey date.
Report Facts
Facility capacity: 60
Census: 44
Inspection Report
Complaint Investigation
Census: 44
Capacity: 60
Deficiencies: 2
Oct 30, 2024
Visit Reason
An investigation of Complaint Number IN00445598 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a). The complaint was substantiated with federal and state deficiencies cited.
Findings
The facility failed to ensure staff were properly trained and followed the written emergency fire safety plan during a fire emergency involving an electrical fire in an oxygen concentrator. Additionally, the facility failed to conduct required maintenance and maintain complete documentation of inspections for Patient Care Related Electrical Equipment (PCREE).
Complaint Details
Complaint Number IN00445598 was substantiated with federal and state deficiencies related to fire safety and electrical equipment maintenance.
Severity Breakdown
SS=F: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure staff were properly trained and followed the written emergency fire safety plan during a fire emergency, including failure to activate fire alarms, notify fire department, evacuate affected smoke compartment, and properly extinguish fire. | SS=F |
| Failure to conduct required maintenance and maintain complete documentation of inspections for Patient Care Related Electrical Equipment (PCREE), including oxygen concentrators and other electrical medical equipment. | SS=F |
Report Facts
Facility capacity: 60
Census: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eileen Thomas | Administrator | Named in relation to findings and exit conference |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 0
Oct 7, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00443661.
Findings
No deficiencies related to the allegations in Complaint IN00443661 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00443661 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 44
Medicare residents: 4
Medicaid residents: 26
Other payor residents: 14
Inspection Report
Complaint Investigation
Census: 44
Capacity: 60
Deficiencies: 0
Sep 25, 2024
Visit Reason
An investigation of Complaint Number IN00443689 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
No deficiencies related to the complaint allegation were cited. The facility was found in compliance with Requirements for Participation in Medicare/Medicaid and Life Safety Code regulations.
Complaint Details
Complaint Number IN00443689 was investigated and found to have no deficiencies related to the allegation.
Report Facts
Facility capacity: 60
Census: 44
Inspection Report
Complaint Investigation
Census: 42
Capacity: 42
Deficiencies: 0
May 14, 2024
Visit Reason
This visit was conducted for the investigation of Complaints IN00430748 and IN00434505.
Findings
No deficiencies related to the allegations in Complaints IN00430748 and IN00434505 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00430748 and Complaint IN00434505 were investigated with no deficiencies cited related to the allegations.
Report Facts
Census: 42
Total Capacity: 42
Medicare Census: 2
Medicaid Census: 22
Other Payor Census: 18
Inspection Report
Follow-Up
Census: 50
Capacity: 60
Deficiencies: 0
Mar 14, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 02/06/24.
Findings
At this Post Survey Revisit, The Waters of Chesterfield Skilled Nursing Facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Inspection Report
Routine
Census: 44
Capacity: 60
Deficiencies: 5
Feb 6, 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, life safety from fire, and related safety codes.
Findings
The facility was found not in compliance with emergency preparedness requirements, life safety code requirements including corridor obstructions, sprinkler system maintenance, electrical wiring protection, and annual fire door inspections. Corrective actions and plans of correction were documented for each deficiency.
Severity Breakdown
SS=F: 3
SS=E: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills. | SS=F |
| Failed to ensure 2 of 4 corridor means of egresses were continuously maintained free of obstructions; PPE carts lacked wheels. | SS=E |
| Failed to maintain automatic sprinkler systems in accordance with NFPA 25; 5-year internal pipe inspection recommended flushing but documentation was unavailable. | SS=F |
| Failed to ensure electrical wiring was protected; exposed wiring found on outside electrical receptacle and broken light fixture; electrical panel in 100 hall was unsecured. | SS=E |
| Failed to ensure annual inspection and testing of fire door assemblies were completed and itemized as required by NFPA 80. | SS=F |
Report Facts
Facility capacity: 60
Census: 44
Deficiency count: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Locke | HFA | Signed the report |
| Maintenance Supervisor | Named in multiple findings related to emergency preparedness exercises, corridor obstructions, sprinkler system maintenance, electrical wiring, and fire door inspections | |
| Administrator | Named in corrective actions and monitoring of compliance | |
| Assistant Director of Nursing | Involved in exit conference and findings review |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 46
Deficiencies: 0
Jan 31, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00426899.
Findings
No deficiencies related to the allegations in Complaint IN00426899 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00426899 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 5
Medicaid census: 21
Other payor census: 20
Inspection Report
Annual Inspection
Census: 45
Capacity: 45
Deficiencies: 5
Jan 22, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted on January 16, 17, 18, 19, and 22, 2024.
Findings
The facility was found deficient in multiple areas including development and implementation of comprehensive care plans with measurable goals, timely review and revision of care plans, nutrition and hydration status maintenance, provision of medically related social services, and ensuring food is palatable and served at proper temperatures. Several residents' care plans lacked individualized, measurable goals and appropriate behavior management. Weight loss interventions and dietary documentation were inadequate. Social services for residents with major mental illness were insufficient. Residents reported dissatisfaction with food quality and temperature.
Severity Breakdown
SS=E: 3
SS=D: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure care plans had measurable goals and individualized approaches for 4 of 14 residents reviewed. | SS=E |
| Failed to review and revise care plans timely for 1 of 14 residents reviewed. | SS=E |
| Failed to assess and intervene for nutritional decline and weight loss for 1 of 3 residents reviewed for nutrition. | SS=D |
| Failed to provide medically related social services to residents with major mental illness related to behavior monitoring and management for 4 of 4 residents reviewed. | SS=E |
| Failed to ensure food was palatable, attractive, and served at safe and appetizing temperatures as reported by residents and observed by surveyors. | SS=D |
Report Facts
Survey dates: 5
Census: 45
Total capacity: 45
Weight loss: 15.1
Food temperature log missing entries: 28
Inspection Report
Annual Inspection
Deficiencies: 0
Jan 22, 2024
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Waters of Chesterfield 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
Complaint Investigation
Census: 45
Capacity: 45
Deficiencies: 0
Dec 21, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00422930, conducted in conjunction with a PSR to the Investigation of Complaint IN00419585 completed on November 21, 2023.
Findings
No deficiencies related to the allegations of Complaint IN00422930 were cited. Complaint IN00419585 was corrected. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaint IN00422930 found no deficiencies related to the allegations. Complaint IN00419585 was corrected.
Report Facts
Census SNF/NF beds: 45
Total census: 45
Medicare census: 1
Medicaid census: 23
Other payor census: 21
Inspection Report
Re-Inspection
Census: 45
Capacity: 45
Deficiencies: 0
Dec 21, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00419585 completed on November 21, 2023, conducted in conjunction with the Investigation of Complaint IN00422930.
Findings
Complaint IN00419585 was corrected. No deficiencies related to allegations were cited for Complaint IN00422930. The facility was found to be in compliance with relevant federal and state regulations.
Complaint Details
Investigation of Complaint IN00419585 was corrected; Complaint IN00422930 had no deficiencies related to allegations cited.
Report Facts
Census SNF/NF: 45
Total Capacity: 45
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 23
Census Payor Type - Other: 21
Inspection Report
Complaint Investigation
Census: 45
Capacity: 45
Deficiencies: 1
Nov 21, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00419585 regarding failure to obtain therapy services in a timely manner for a resident admitted following a stroke.
Findings
The facility failed to obtain timely specialized rehabilitative therapy services (physical, occupational, and speech therapy) for Resident B after admission following a stroke due to payer source denial and lack of timely communication with the corporate office. Therapy services were eventually authorized after multiple re-evaluations and requests.
Complaint Details
Complaint IN00419585 was substantiated with federal/state deficiency cited at F825 related to failure to provide/obtain specialized rehab services in a timely manner for Resident B.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to obtain specialized rehabilitative therapy services in a timely manner for a resident admitted following a stroke. | SS=D |
Report Facts
Census: 45
Total Capacity: 45
Medicare Residents: 4
Medicaid Residents: 25
Other Payor Residents: 16
Therapy Frequency Recommendation: 5
Therapy Frequency Recommendation: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Locke | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 44
Deficiencies: 0
Oct 5, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00416154 and IN00415194 at Waters of Chesterfield Skilled Nursing Facility.
Findings
No deficiencies related to the allegations in complaints IN00416154 and IN00415194 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 IN00416154 - No deficiencies related to the allegations are cited. Complaint IN00415194 - No deficiencies related to the allegations are cited.
Report Facts
Census: 44
Total Capacity: 44
Medicare Census: 4
Medicaid Census: 30
Other Payor Census: 10
Inspection Report
Complaint Investigation
Census: 38
Capacity: 38
Deficiencies: 0
Jul 13, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00410699 and IN00411992.
Findings
No deficiencies related to the allegations in complaints IN00410699 and IN00411992 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00410699 and IN00411992 found no deficiencies related to the allegations.
Report Facts
Census: 38
Total Capacity: 38
Payor Type Census: 1
Payor Type Census: 23
Payor Type Census: 14
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 0
Jun 9, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00408087.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00408087 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 33
Census Bed Type - SNF: 8
Census Total: 41
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 21
Census Payor Type - Other: 15
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 15, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00403926 and COVID-19 Focused Infection Control Survey.
Findings
Waters of Chesterfield 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 and COVID-19 Focused Infection Control Survey.
Complaint Details
Investigation of Complaint IN00403926 was conducted with paper compliance review.
Report Facts
Facility number: 524
Provider number: 155617
AIM number: 100267090
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
Mar 14, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00400630, IN00403559, and IN00403926, including a COVID-19 Focused Infection Control Survey.
Findings
The facility was found deficient for failing to properly prevent and contain COVID-19 by permitting an employee (Dietary Cook 9) to work while symptomatic during a COVID-19 outbreak. Complaints IN00400630 and IN00403559 had no deficiencies cited. The facility lacked a policy for monitoring staff symptoms but has since implemented corrective actions including staff education and daily symptom screening.
Complaint Details
Complaint IN00400630 and IN00403559 had no deficiencies related to the allegations. Complaint IN00403926 was substantiated with federal/state deficiencies cited at F880 related to infection prevention and control.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly prevent/contain COVID-19 by permitting an employee to work in the kitchen with symptoms of COVID-19 during a facility outbreak. | SS=D |
Report Facts
Census: 38
Medicare residents: 8
Medicaid residents: 17
Other residents: 13
Scheduled work hours: 8
Date of alleged compliance: Apr 3, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Cook 9 | Dietary Cook | Named in infection control deficiency for working while symptomatic with COVID-19 |
| Kimberly Locke | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
Inspection Report
Re-Inspection
Census: 40
Capacity: 60
Deficiencies: 0
Feb 23, 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 originally conducted on 01/24/23 by the Indiana Department of Health.
Findings
At this Post Survey Revisit, Waters of Chesterfield Skilled Nursing Facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Inspection Report
Annual Inspection
Deficiencies: 0
Feb 7, 2023
Visit Reason
The inspection was a paper compliance review related to the Annual Recertification and State Licensure Survey conducted on January 13, 2023.
Findings
Waters of Chesterfield 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.
Report Facts
Facility number: 524
Provider number: 155617
AIM number: 100267090
Inspection Report
Routine
Census: 40
Capacity: 60
Deficiencies: 11
Jan 24, 2023
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with Medicare and Medicaid requirements and fire safety codes.
Findings
The facility was found not in compliance with Emergency Preparedness training and testing requirements, Life Safety Code corridor obstructions, exit door locking mechanisms, self-closing doors, fire alarm system maintenance, sprinkler system gauge testing, smoke detection coverage, and oxygen storage/transfer procedures.
Severity Breakdown
SS=F: 3
SS=E: 3
SS=D: 4
SS=C: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to conduct annual Emergency Preparedness Program training and demonstrate staff knowledge. | SS=F |
| Failed to conduct one of the two required annual exercises to test the emergency plan including unannounced staff drills. | SS=F |
| Two corridor exit doors had privacy curtains that would obstruct egress when extended; a desk was stored in a corridor obstructing egress. | SS=E |
| Kitchen exit door had two latching devices, violating single latch requirement. | SS=D |
| Kitchen exit door to hazardous area had a kick down door stop holding door open, preventing self-closing. | SS=D |
| Laundry corridor door to hazardous area did not latch into the frame when self-closing. | SS=D |
| Fire alarm system annual inspection documentation was missing. | SS=F |
| Fire alarm system lacked smoke detector coverage in library area open to corridor. | SS=E |
| Sprinkler system pressure gauge was older than 5 years without evidence of recalibration or replacement. | SS=C |
| Fuel-fired boilers lacked current inspection certificates. | SS=D |
| Oxygen storage/transfer room used improperly with door held open during transfilling due to overcrowding. | SS=D |
Report Facts
Facility capacity: 60
Census: 40
Deficiency count: 11
Emergency Preparedness training missing months: 6
Sprinkler gauge age: 5
Inspection Report
Annual Inspection
Census: 36
Capacity: 36
Deficiencies: 6
Jan 9, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from January 9 to January 13, 2023.
Findings
The facility was found deficient in multiple areas including failure to complete Notice of Medicare Non-Coverage for one resident, failure to obtain daily weights and notify physician for weight gain for one resident, failure to implement and monitor weight loss interventions for one resident, failure to provide humidification on oxygen concentrators for three residents, failure to present pharmacist recommendations to physicians for two residents, and deficiencies in personnel records including incomplete dementia training, orientation, TB testing, job descriptions, and incomplete criminal background checks.
Severity Breakdown
SS=B: 1
SS=D: 4
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to complete a Notice of Medicare Non-Coverage (NOMNC) notification for 1 of 2 residents reviewed for beneficiary notifications (Resident 89). | SS=B |
| Failed to obtain daily weights per physician's order and failed to notify physician of weight gain for 1 of 1 resident reviewed for edema (Resident 35). | SS=D |
| Failed to ensure recommended weight loss interventions had been implemented and monitored for acceptance for 1 of 3 residents reviewed for nutrition (Resident 20). | SS=D |
| Failed to place humidification on oxygen concentrator machines for resident comfort for 3 of 4 residents reviewed for respiratory care (Residents 4, 8, and 33). | SS=D |
| Failed to ensure consultant pharmacist recommendations had been presented to the physician for review and consideration for order changes for 2 of 5 residents reviewed for unnecessary medications (Residents 3 and 18). | SS=D |
| Failed to ensure staff had completed personnel files including annual dementia training, job specific orientation, TB assessments, job descriptions, and complete criminal background checks for multiple employees. | — |
Report Facts
Census: 36
Total Capacity: 36
Weight gain: 4.6
Weight loss: 7.7
Weight loss: 2.8
Weight loss percentage: 9.2
Dementia training hours: 3
Dementia training hours completed: 1.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Locke | Administrator | Provided facility policies and interviews regarding deficiencies |
| Social Services Director | Confirmed resident received NOMNC but copy was shredded | |
| MDS Coordinator | Interviewed regarding NOMNC documentation | |
| Business Office Manager | Provided information on personnel files and background checks | |
| Administrator | Interviewed about weight monitoring, oxygen humidification, and pharmacy recommendations |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 35
Deficiencies: 0
Oct 27, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00389180.
Findings
The complaint IN00389180 was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00389180 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Medicare residents: 2
Medicaid residents: 25
Other residents: 8
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