Inspection Report Summary
The most recent inspection on May 7, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a pattern of deficiencies primarily involving medication administration, documentation, resident care planning, and Life Safety Code compliance, including issues with door signage and door latching. Complaint investigations substantiated some concerns such as misappropriation of resident property, staff qualifications, and a resident choking incident that resulted in death, but enforcement actions like fines or license suspensions were not listed in the available reports. Several substantiated complaints were corrected promptly, and staff terminations occurred in cases of verbal abuse and theft. The facility’s recent inspections indicate improvement, with the latest surveys showing compliance and no new deficiencies cited.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
12 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
186% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
67% occupied
Based on a May 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 55
Capacity: 82
Deficiencies: 0
Date: May 7, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00458115.
Complaint Details
Complaint IN00458115 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: 82
Census payor type total: 55
SNF beds: 36
SNF/NF beds: 19
Residential beds: 27
Medicare residents: 19
Medicaid residents: 19
Other payor residents: 17
Inspection Report
Life Safety
Census: 53
Capacity: 74
Deficiencies: 0
Date: Mar 7, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this Life Safety Code survey, Wellbrooke of Carmel was found in compliance with Requirements for Participation Medicare/Medicaid and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinklered with appropriate fire barriers and smoke detection systems.
Inspection Report
Complaint Investigation
Census: 58
Capacity: 89
Deficiencies: 0
Date: Feb 25, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00452644.
Complaint Details
Complaint IN00452644 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 - SNF: 38
Census bed type - SNF/NF: 20
Census bed type - Residential: 31
Total licensed capacity: 89
Census payor type - Medicare: 25
Census payor type - Medicaid: 20
Census payor type - Other: 13
Total census: 58
Inspection Report
Life Safety
Census: 61
Capacity: 74
Deficiencies: 2
Date: Jan 28, 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 on January 28, 2025.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies included missing 'NO EXIT' signage on a door to an open space, and a resident room door that failed to latch properly.
Deficiencies (2)
Failed to ensure 1 of 1 door to the 'open space' outside the facility was not mistaken as a facility exit due to missing 'NO EXIT' signage.
Failed to ensure 1 of over 35 sets of resident room doors to the corridor would close completely and latch into the door frame.
Report Facts
Certified beds: 74
Census: 61
Residents affected: 12
Staff affected: 6
Visitors affected: 2
Residents affected: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kylie Carmack | Executive Director | Named in relation to exit conference and plan of correction |
| Director of Plant Operations | Named in relation to deficiencies regarding exit signage and door latching | |
| Assistant Director of Plant Operations | Participated in observations and discussions of deficiencies | |
| Facilities Maintenance Support Manager | Participated in observations and discussions of deficiencies |
Inspection Report
Annual Inspection
Census: 32
Capacity: 87
Deficiencies: 6
Date: Jan 17, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted from January 13 to 17, 2025.
Findings
The facility was found to have multiple deficiencies including failure to update a resident's code status according to advanced directives, failure to hold quarterly care plan meetings for residents, medication administration errors related to hold parameters and call notifications, inaccurate urinary catheter output documentation, and incomplete medication administration records. Additionally, the facility failed to complete a proper two-step tuberculosis screening for one resident.
Deficiencies (6)
Failed to ensure a resident's code status was changed when an out of hospital do not resuscitate declaration and order was received.
Failed to ensure a care plan meeting was offered or held for 3 residents on a quarterly basis.
Failed to ensure blood pressure medication was held according to physician's ordered hold parameters and physician was notified for elevated blood sugar levels for 3 residents.
Failed to ensure suprapubic catheter urine output was accurately recorded for 2 residents.
Failed to ensure medication administration or reason for non-administration was documented in the Medication Administration Record for 1 resident.
Failed to ensure a two-step Mantoux tuberculosis screening test was completed for 1 resident upon admission.
Report Facts
Survey dates: 5
Census: 32
Total capacity: 87
Residents affected: 1
Residents affected: 3
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandie Briggs | RN, Clinical Support | Named as Laboratory Director's or Provider/Supplier Representative who signed the report |
| Clinical Support Nurse 3 | Provided facility policies and interviews related to advanced directives, care plan meetings, medication administration, and infection control | |
| Director of Nursing | DON | Interviewed regarding code status update and tuberculosis testing |
| LPN 2 | Licensed Practical Nurse | Interviewed regarding emergency procedures and medication administration |
| LPN 5 | Licensed Practical Nurse | Interviewed regarding medication administration and urinary output documentation |
| CNA 4 | Certified Nursing Assistant | Interviewed regarding urinary catheter output measurement |
| CNA 6 | Certified Nursing Assistant | Interviewed regarding urinary catheter output documentation |
| CNA 7 | Certified Nursing Assistant | Interviewed regarding proper documentation of catheter outputs |
| Corporate Support Nurse 3 | Interviewed regarding medication administration documentation |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 17, 2025
Visit Reason
Paper compliance review for the Recertification and State Licensure survey completed on January 17, 2025.
Findings
Wellbrooke of Carmel 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: 58
Capacity: 90
Deficiencies: 0
Date: Oct 17, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00444938.
Complaint Details
Investigation of Complaint IN00444938 found 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: 90
Census payor type total: 58
Inspection Report
Complaint Investigation
Census: 51
Capacity: 83
Deficiencies: 1
Date: Aug 1, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00438719 regarding allegations of misappropriation of resident property.
Complaint Details
Complaint IN00438719 was substantiated with a federal/state deficiency cited at F602 related to misappropriation of property. The investigation included police involvement, staff termination, and resident interviews.
Findings
The facility failed to ensure a resident's credit card was kept safe and secure during her admission, resulting in unauthorized charges. A staff member was terminated for stealing the resident's credit card. The deficient practice was corrected prior to the survey date.
Deficiencies (1)
Failed to ensure a resident's credit card was kept safe and secure during admission, leading to misappropriation of property.
Report Facts
Census total: 51
Total capacity: 83
Unauthorized charge amount: 10.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper 1 | Housekeeper | Terminated staff member involved in theft of resident's credit card |
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 1
Date: May 30, 2024
Visit Reason
The visit was conducted to investigate complaints IN00430886, IN00434435, IN00434464, and IN00435005 regarding staff qualifications and licensure concerns at Wellbrooke of Carmel.
Complaint Details
The investigation was triggered by complaints IN00430886, IN00434435, IN00434464, and IN00435005. Complaints IN00430886, IN00434435, and IN00434464 had no deficiencies related to the allegations. Complaint IN00435005 was substantiated with a federal/state deficiency cited at F839 related to staff qualifications and licensure concerns.
Findings
The facility was found to have a deficiency related to staff qualifications where an employee worked as a Certified Nursing Assistant (CNA) and Qualified Medication Aide (QMA) without appropriate qualifications and certification for 34 days. The employee also worked under another person's name and lacked a completed job-specific orientation checklist. The deficiency was corrected prior to the survey.
Deficiencies (1)
Facility failed to ensure a staff member had appropriate qualifications and current certification to perform CNA and QMA duties and failed to ensure job-specific orientation checklist was completed and signed prior to working alone.
Report Facts
Census bed type - SNF/NF: 50
Census bed type - Residential: 33
Total census: 83
Census payor type - Medicare: 23
Census payor type - Medicaid: 16
Census payor type - Other: 11
Employee employment duration: 34
Employee shifts worked: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee 1 | Certified Nursing Assistant (CNA) and Qualified Medication Aide (QMA) | Worked without appropriate qualifications and certification, used another person's name, and lacked completed orientation checklist |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 72
Deficiencies: 2
Date: Feb 23, 2024
Visit Reason
This visit was for the Investigation of Nursing Home Complaint IN00428611, which resulted in a Partially Extended Survey - Immediate Jeopardy related to allegations of misappropriation of property and other deficiencies.
Complaint Details
Complaint IN00428611 was substantiated with federal/state deficiencies cited related to misappropriation of property and dietary care resulting in resident harm and death.
Findings
The facility failed to protect a resident from misappropriation of medications and failed to ensure staff followed the physician's order for a mechanical soft diet, resulting in a resident choking and death. The misappropriation issue was corrected prior to the survey. The dietary deficiency involved providing the wrong diet texture and inadequate meal assistance, leading to choking and death, which was also corrected prior to the survey.
Deficiencies (2)
Failed to protect a resident from misappropriation of medications, specifically 12 missing oxycodone tablets.
Failed to ensure staff followed the physician's order for a mechanical soft diet and failed to provide assistance with meals, resulting in a resident choking and death.
Report Facts
Missing oxycodone tablets: 12
Census: 43
Total capacity: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| QMA 5 | Named in medication misappropriation finding; counted narcotics and signed out medication. | |
| RN 11 | Named in medication misappropriation finding; took over medication carts but did not count narcotics at shift change. | |
| LPN 6 | Observed and attempted Heimlich Maneuver on Resident B during choking incident. | |
| LPN 8 | Performed Heimlich Maneuver on Resident B during choking incident. | |
| CNA 3 | Assisted Resident B during choking incident by clearing food from mouth. | |
| Cook 7 | Prepared and served Resident B's meal; called 911 during choking incident. | |
| CNA 6 | Attempted to clear food from Resident B's mouth during choking incident. | |
| CNA 9 | Observed choking incident and food being cleared from Resident B's mouth. | |
| Director of Nursing | Interviewed regarding narcotics misappropriation and dietary deficiencies. | |
| Corporate Support Nurse | Interviewed regarding narcotics misappropriation and dietary deficiencies. | |
| Speech and Language Pathologist | Provided expert input on Resident B's swallowing and diet needs. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 31, 2024
Visit Reason
Paper compliance review related to an unrelated deficiency cited during a complaint investigation completed on January 2, 2024.
Findings
Wellbrooke of Carmel 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 unrelated deficiency cited during the complaint investigation.
Inspection Report
Re-Inspection
Census: 48
Capacity: 74
Deficiencies: 0
Date: Jan 18, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 12/12/23 was performed to verify compliance with fire safety and licensure requirements.
Findings
At this PSR Life Safety Code survey, Wellbrooke of Carmel was found in compliance with Medicare/Medicaid participation requirements, the 2012 Edition of the NFPA 101 Life Safety Code, and state regulations. The facility was fully sprinklered with appropriate fire barriers and smoke detection systems.
Inspection Report
Complaint Investigation
Census: 42
Capacity: 42
Deficiencies: 2
Date: Jan 2, 2024
Visit Reason
This visit was for the investigation of Complaint IN00423497. The complaint allegations were not substantiated, but unrelated deficiencies were cited.
Complaint Details
Complaint IN00423497 was investigated with no deficiencies related to the allegations cited. The verbal abuse incident involved CNA 2 verbally abusing Resident 2, which was substantiated and corrected prior to the survey. CNA 2 was terminated for verbal abuse and gross misconduct. The facility provided staff training and conducted assessments following the incident.
Findings
The facility was found to have failed to ensure a resident was free from verbal abuse by a staff member, which was corrected prior to the survey. Additionally, the facility failed to provide toileting assistance to a resident who requested it, instructing her to use her brief instead.
Deficiencies (2)
Facility failed to ensure a resident was free from verbal abuse when a staff member was heard speaking loudly and using profanity to a resident (Resident 2).
Facility failed to provide toileting assistance when a resident requested help to use the toilet (Resident 3).
Report Facts
Census: 42
Total Capacity: 42
Deficiencies cited: 2
BIMS score: 12
BIMS score: 15
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 2 | Certified Nursing Assistant | Named in verbal abuse finding and terminated for verbal abuse and gross misconduct |
| LPN 3 | Licensed Practical Nurse | Interviewed regarding abuse reporting and education |
| Dietary Aide 5 | Dietary Aide | Witnessed verbal abuse and reported incident |
| LPN 9 | Licensed Practical Nurse | Witnessed verbal abuse and intervened |
| LPN 10 | Licensed Practical Nurse | Witnessed verbal abuse and intervened |
| CNA 4 | Certified Nursing Assistant | Reported toileting assistance refusal incident |
| Director of Nursing | Notified of abuse and toileting incidents, involved in corrective actions |
Inspection Report
Life Safety
Census: 51
Capacity: 74
Deficiencies: 4
Date: Dec 12, 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 on December 12, 2023.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies were identified related to egress door signage, hazardous area door self-closing devices, corridor door closing mechanisms, and improper storage of gas cylinders.
Deficiencies (4)
Failed to ensure the means of egress through 1 of over 8 delayed egress locks was readily accessible and lacked proper signage indicating the door can be opened in 15 seconds by pushing.
Failed to ensure 1 of over 10 hazardous area doors, such as storage rooms, were provided with properly working self-closing devices.
Failed to ensure all corridor doors were provided with a means suitable for keeping the door closed, had no impediment to closing, latching and would resist the passage of smoke. Therapy door was propped open with a weight preventing self-closing.
Failed to ensure 5 of 5 cylinders of nonflammable gases such as oxygen were properly secured from falling; cylinders were found loose and not properly chained or supported.
Report Facts
Certified beds: 74
Census: 51
Delayed egress locks affected: 1
Hazardous area doors affected: 1
Corridor doors affected: 1
Gas cylinders unsecured: 5
Residents potentially affected by delayed egress door deficiency: 15
Residents potentially affected by hazardous area door deficiency: 10
Residents potentially affected by corridor door deficiency: 5
Staff potentially affected by gas cylinder deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Plant Operations | Interviewed regarding deficiencies related to egress doors, hazardous area doors, corridor doors, and gas cylinder storage | |
| Corporate Facilities Support Representative | Present during observations and exit conference acknowledging findings | |
| Director of Dietary Services | Educated on proper gas cylinder storage and responsible for weekly inspections | |
| Executive Director | Responsible for presenting inspection results to QAPI committee |
Inspection Report
Annual Inspection
Census: 78
Deficiencies: 8
Date: Nov 20, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the investigation of two complaints (IN00402602 and IN00406672).
Complaint Details
Complaint IN00402602 and Complaint IN00406672 were investigated with no deficiencies related to the allegations cited.
Findings
The facility was found to have multiple deficiencies including inaccurate discharge assessments, failure to coordinate PASARR assessments, medication errors, delayed fall interventions, failure to obtain accurate admission weights, improper medication storage, and incomplete documentation for psychotropic medication gradual dose reductions.
Deficiencies (8)
Failed to ensure the discharge MDS assessment was coded correctly for 1 resident.
Failed to ensure PASARR Level I had accurate information and was completed when residents had added mental health diagnoses and psychotropic medications for 2 residents.
Failed to ensure a resident received the correct dosage of a narcotic medication.
Failed to implement timely interventions after a fall with a stand-up lift which resulted in another fall for 1 resident.
Failed to obtain an admission weight upon admission and to obtain a timely reweight after the weight was determined invalid for 1 resident.
Failed to dispose of loose pills and have opened dates on medications in medication carts and medication room.
Failed to ensure narcotic medication card was intact and refrigerator temperature logs were incomplete.
Failed to identify time frame for gradual dose reduction and resident specific reasons for declining gradual dose reductions for psychotropic medications for 3 residents.
Report Facts
Survey dates: 2023-11-13 to 2023-11-20
Census Bed Type: 78
Medication errors: 5
Missing temperature log days: 151
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kylie Carmack | Executive Director | Signed the report |
| Clinical Support Nurse | Interviewed regarding PASARR process, fall interventions, and psychotropic medication policies | |
| Director of Nursing | Interviewed regarding medication errors, fall interventions, and refrigerator temperature logs | |
| Social Services Director | SSD | Interviewed regarding PASARR process and psychotropic medication policies |
| Certified Resident Medication Assistant 11 | CRMA | Interviewed regarding medication cart observations |
| Licensed Practical Nurse 5 | LPN | Interviewed regarding medication storage and disposal |
| Licensed Practical Nurse 4 | LPN | Interviewed regarding medication storage and disposal |
| Physical Therapy Assistant 10 | PTA | Interviewed regarding delay in physical therapy services |
| Physical Therapy Department Director | Interviewed regarding payer verification for physical therapy |
Inspection Report
Renewal
Deficiencies: 0
Date: Nov 20, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure survey.
Findings
Wellbrooke of Carmel 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
Complaint Investigation
Census: 69
Capacity: 88
Deficiencies: 0
Date: Feb 6, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00400644 at Wellbrooke of Carmel.
Complaint Details
Complaint IN00400644 was substantiated but no deficiencies related to the allegations were cited.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
SNF/NF census: 69
Residential census: 19
Total census: 88
Medicare census: 18
Medicaid census: 19
Other payor census: 32
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 0
Date: Jan 23, 2023
Visit Reason
This visit was conducted for the investigation of Complaints IN00399711 and IN00394468.
Complaint Details
Complaint IN00399711 - Substantiated with no deficiencies cited. Complaint IN00394468 - Unsubstantiated due to lack of evidence.
Findings
Complaint IN00399711 was substantiated but no deficiencies related to the allegations were cited. Complaint IN00394468 was unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 48
Census Payor Type: 48
Inspection Report
Re-Inspection
Census: 48
Capacity: 74
Deficiencies: 0
Date: Jan 6, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 11/22/22 was performed by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR Life Safety Code survey, Wellbrooke of Carmel was found in compliance with Requirements for Participation Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety From Fire and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. All areas where residents have customary access and all areas providing facility services were sprinklered.
Inspection Report
Re-Inspection
Census: 78
Capacity: 78
Deficiencies: 0
Date: Dec 29, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on October 25, 2022, including a PSR to the Investigation of Complaint IN00389872 completed on September 20, 2022.
Complaint Details
Complaint IN00389872 was investigated and found to be corrected.
Findings
Wellbrooke of Carmel 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. The complaint IN00389872 was corrected.
Report Facts
Census Bed Type - SNF/NF: 54
Census Bed Type - Residential: 24
Total Census: 78
Census Payor Type - Medicare: 21
Census Payor Type - Medicaid: 19
Census Payor Type - Other: 14
Total Census Payor Type: 54
Inspection Report
Re-Inspection
Census: 78
Deficiencies: 0
Date: Dec 29, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00389872 completed on September 20, 2022, conducted in conjunction with PSRs to the Recertification and State Licensure Surveys completed on October 25, 2022.
Complaint Details
Complaint IN00389872 was corrected.
Findings
Wellbrooke of Carmel 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 Complaint IN00389872.
Report Facts
Census Bed Type - SNF/NF: 54
Census Bed Type - Residential: 24
Census Bed Type - Total: 78
Census Payor Type - Medicare: 21
Census Payor Type - Medicaid: 19
Census Payor Type - Other: 14
Census Payor Type - Total: 54
Inspection Report
Life Safety
Census: 49
Capacity: 74
Deficiencies: 3
Date: Nov 22, 2022
Visit Reason
The survey was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 standards.
Findings
The facility was found not in compliance with Life Safety Code requirements due to deficiencies including a corridor door that failed to self-close and latch, an uncovered electrical junction box in the elevator mechanical room, and improper use of a flexible extension cord in the Bistro Area. Immediate interventions were taken to correct these issues.
Deficiencies (3)
Corridor door to kitchen supply closet failed to self-close and latch, not resisting passage of smoke.
Electrical junction box in elevator mechanical room was uncovered with exposed wiring.
Flexible extension cord used as a substitute for fixed wiring in the Bistro Area.
Report Facts
Certified beds: 74
Census: 49
Corridor doors inspected: 30
Staff potentially affected: 2
Staff potentially affected: 2
Residents and staff potentially affected: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Timothy Yale | Executive Director | Signed report and present at exit conference. |
| Director of Plant Operations | Acknowledged deficiencies and involved in corrective actions and education. | |
| Assistant Director of Plant Operations | Acknowledged deficiencies and present during observations and exit conference. | |
| Corporate Facilities Support Representative | Acknowledged deficiencies and present during observations and exit conference. |
Inspection Report
Renewal
Census: 50
Capacity: 74
Deficiencies: 17
Date: Oct 25, 2022
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 medication self-administration, advance directives, ADL care, bowel protocol implementation, hot water temperature safety, catheter care, PICC line care, bed rail use, RN staffing, psychotropic medication use, medication administration errors, food service sanitation, infection control, environmental safety, and personnel file compliance.
Deficiencies (17)
Failed to ensure interdisciplinary team determined which medications may be self-administered and failed to ensure a physician's order was obtained for self-administration for 1 resident.
Failed to ensure advance directives were reviewed, obtained or updated to reflect residents' current wishes for 6 residents.
Failed to provide assistance with activities of daily living related to shaving for 2 residents.
Failed to implement bowel protocol interventions after a resident did not have a bowel movement for 1 resident.
Failed to ensure hot water temperatures remained between 105 and 120 degrees Fahrenheit for 1 resident.
Failed to ensure resident received treatment and care in accordance with professional standards for catheter care for 1 resident.
Failed to assess and document PICC line care for 2 residents.
Failed to obtain physician's order, assessment, care plan, and consent for use of side rails for 1 resident.
Failed to serve food in accordance with professional standards for food service safety when kitchen staff failed to remove gloves and sanitize hands and failed to wear proper hair restraints for 2 staff.
Failed to follow CDC guidelines to prevent transmission of MRSA for 1 resident.
Failed to implement routine inspections of a resident's bed to ensure proper working order for 1 resident.
Failed to provide signed service plans for 5 residents.
Failed to ensure medications were administered as ordered during 2 medication administration observations.
Failed to provide a safe, clean, and comfortable interior environment for 1 resident receiving IV medications.
Failed to ensure new employees received required TB testing, physical exams, job descriptions, orientation, dementia, abuse, and resident rights training for multiple employees.
Failed to provide signed service plans for 5 residents.
Failed to administer admission 2-step and annual TB skin tests for 2 residents.
Report Facts
Census: 50
Total Capacity: 74
Medication error rate: 8
Medication administration observations: 25
Residents reviewed for service plans: 5
Residents reviewed for TB skin testing: 5
Residents reviewed for personnel files: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Timothy Yale | Executive Director | Signed report and plan of correction |
| Licensed Practical Nurse 3 | Interviewed about code status documentation | |
| Licensed Practical Nurse 6 | Interviewed about PICC line care and catheter care | |
| Qualified Medication Aide 2 | Observed medication administration errors | |
| Qualified Medication Aide 3 | Observed medication administration errors | |
| Director of Nursing | Interviewed about code status, PICC line care, and medication administration | |
| Corporate Support Nurse | Provided multiple interviews regarding policies, procedures, and findings | |
| Clinical Nurse Support | Interviewed about PICC line care and code status | |
| Assistant Director of Nursing | Interviewed about PICC line care and infection control | |
| Director of Plant Operations | Interviewed about hot water temperature and bed safety | |
| Nursing Assistant | Interviewed about code status and shaving assistance | |
| Nursing Assistant 9 | Personnel file reviewed | |
| Cook 4 | Observed food service sanitation violation | |
| Cook 5 | Observed food service sanitation violation |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 2
Date: Sep 20, 2022
Visit Reason
This visit was conducted for the investigation of two complaints, IN00389872 and IN00387577. Complaint IN00389872 was substantiated with related deficiencies cited, while complaint IN00387577 was substantiated with no related deficiencies cited.
Complaint Details
Complaint IN00389872 was substantiated with federal/state deficiencies cited at F760 and F842. Complaint IN00387577 was substantiated with no deficiencies cited.
Findings
The facility was found to have deficiencies related to medication administration errors involving narcotic orders and documentation, and failure to maintain proper resident records including signatures on Controlled Drug Use Records and accurate medication administration documentation. The facility implemented corrective actions including staff education and auditing procedures.
Deficiencies (2)
Failed to ensure a narcotic medication was transcribed correctly from the hospital discharge order to the Medication Administration Record for 1 of 3 residents reviewed for medication administration (Resident B).
Failed to provide a signature on a resident's Controlled Drug Use Record for 1 of 12 entries and failed to document a narcotic administration in the Medication Administration Record for 1 of 3 residents reviewed for documentation (Resident B).
Report Facts
Census: 61
Medicare census: 12
Medicaid census: 20
Other payor census: 29
Deficiency count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Entered medication order and involved in narcotic transcription error | |
| Director of Nursing | Director of Nursing | Entered medication order and commented on order accuracy checks |
| Corporate Support Nurse | Provided interviews and facility policies, discussed transcription error and documentation issues | |
| LPN 2 | Interviewed regarding contacting on-call physician about narcotic availability | |
| Director of Health Services | Director of Health Services | Responsible for ongoing audits and quality assurance monitoring |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 0
Date: Jul 28, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00386181.
Complaint Details
Complaint IN00386181 was substantiated but no deficiencies related to the allegations were cited.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with the relevant regulations.
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