Inspection Report Summary
The most recent inspection on April 10, 2025, identified deficiencies related to Life Safety Code requirements, including issues with commercial cooking equipment, portable space heater policies, and oxygen transfilling room signage. Earlier inspections showed a mixed pattern, with prior Life Safety Code surveys also citing fire safety and door closure issues, and annual surveys noting deficiencies in resident notification and oxygen administration. Main themes across deficiencies involved Life Safety Code compliance, medication administration, resident care documentation, and oxygen use. Several complaint investigations were conducted, most of which were unsubstantiated, though a substantiated complaint in early 2023 involved medication errors that led to hospital readmission and deficiencies in narcotic documentation and confidentiality. The facility’s inspection history shows ongoing challenges with regulatory compliance, particularly in safety and clinical care areas, with some improvement noted in complaint resolution but persistent Life Safety Code issues.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
13.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
229% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
81% occupied
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Life Safety
Census: 83
Capacity: 103
Deficiencies: 3
Date: Apr 10, 2025
Visit Reason
The survey was conducted as an Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey due to lack of a two-hour separation between assisted living and health care areas.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies included failure to ensure commercial cooking equipment met Life Safety Code standards, failure to enforce portable space heater policies, and failure to provide proper signage for oxygen transfilling rooms.
Deficiencies (3)
Failed to ensure 2 of 2 commercial cooking equipment open to the corridor met Life Safety Code requirements including suppression system inspection and manual release.
Failed to enforce portable space heater policy to ensure heaters are inspected and did not exceed 212 degrees for 1 of 1 portable space heaters used in staff areas.
Failed to ensure 2 of 2 liquid oxygen storage/transfer rooms were provided with signs indicating when oxygen transfilling is occurring.
Report Facts
Health care beds capacity: 70
Health care beds census: 56
Assisted living beds capacity: 33
Assisted living beds census: 27
Total census: 83
Deficiencies cited: 3
Residents potentially affected by cooking equipment deficiency: 60
Residents potentially affected by portable space heater deficiency: 50
Residents potentially affected by oxygen signage deficiency: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amorette Dunkle | Executive Director | Signed report and involved in exit conference |
| Maintenance Director | Interviewed regarding deficiencies related to cooking equipment, space heaters, and oxygen signage | |
| Direct Management Support (DMS) | Interviewed regarding deficiencies related to cooking equipment, space heaters, and oxygen signage |
Inspection Report
Life Safety
Deficiencies: 0
Date: Apr 10, 2025
Visit Reason
The visit was a Life Safety Code Recertification and State Licensure Survey conducted to assess compliance with fire safety and state licensure requirements.
Findings
Wellbrooke of Kokomo was found in compliance with Medicare/Medicaid participation requirements, the Life Safety Code from Fire, and the 2012 Edition of the NFPA 101 Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Annual Inspection
Census: 25
Capacity: 81
Deficiencies: 3
Date: Mar 18, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey and the Investigation of Complaint IN00449701.
Complaint Details
Complaint IN00449701 was investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies related to the complaint allegations were cited. Deficiencies were found related to failure to provide written notification to residents and representatives regarding transfer/discharge reasons and bed hold policies, and failure to administer oxygen at the correct physician ordered flow rate for two residents.
Deficiencies (3)
Facility failed to ensure residents and representatives were given written notification of the reason for transfer/discharge to the hospital for 5 residents.
Facility failed to ensure residents and representatives were given written notification of the facility's bed hold policy and charges at the time of transfer for 5 residents.
Facility failed to ensure oxygen was administered at the correct physician ordered flow rate for 2 residents.
Report Facts
Survey dates: 6
Census Bed Type - SNF/NF: 11
Census Bed Type - SNF: 45
Census Bed Type - Residential: 25
Total Capacity: 81
Census Payor Type - Medicare: 19
Census Payor Type - Medicaid: 9
Census Payor Type - Other: 28
Total Census: 56
Residents affected by transfer/discharge notification deficiency: 5
Residents affected by bed hold policy notification deficiency: 5
Residents affected by oxygen administration deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amorette Dunkle | Executive Director | Signed the report and mentioned in relation to lack of documentation for transfer/discharge and bed hold policy notifications. |
| Director of Nursing | Mentioned in interview regarding oxygen administration orders. | |
| Clinical Support Nurse | Interviewed regarding lack of documentation for transfer/discharge and bed hold policy notifications. | |
| LPN 1 | Interviewed regarding oxygen administration according to physician orders. |
Inspection Report
Renewal
Deficiencies: 0
Date: Mar 18, 2025
Visit Reason
The visit was a paper compliance review related to the Recertification and State Licensure survey completed on March 18, 2025.
Findings
Wellbrooke of Kokomo 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: 26
Deficiencies: 0
Date: Dec 19, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00448430 and IN00449465.
Complaint Details
Investigation of Complaints IN00448430 and IN00449465 found no deficiencies related to the allegations; facility was compliant.
Findings
No deficiencies related to the allegations in complaints IN00448430 and IN00449465 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Report Facts
Residential Census: 26
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 0
Date: Nov 21, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00441956 and IN00446583 at Wellbrooke of Kokomo.
Complaint Details
Investigation of Complaints IN00441956 and IN00446583 found no deficiencies related to the allegations; both complaints were not substantiated.
Findings
No deficiencies related to the allegations in complaints IN00441956 and IN00446583 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Resident census: 24
Inspection Report
Complaint Investigation
Census: 61
Capacity: 91
Deficiencies: 0
Date: May 2, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00433344.
Complaint Details
Complaint IN00433344 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00433344 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type - SNF/NF: 51
Census Bed Type - SNF: 10
Census Bed Type - Residential: 30
Census Payor Type - Medicare: 29
Census Payor Type - Medicaid: 9
Census Payor Type - Other: 23
Inspection Report
Re-Inspection
Census: 83
Deficiencies: 0
Date: Apr 15, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on February 14, 2024, conducted in conjunction with the Investigation of Complaint IN00432214.
Complaint Details
Complaint IN00432214 was investigated and no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey.
Report Facts
Census Bed Type: 83
Census Payor Type: 55
SNF/NF beds: 11
SNF beds: 44
Residential beds: 28
Medicare residents: 26
Medicaid residents: 11
Other payor residents: 18
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 0
Date: Apr 15, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00432214 and was conducted in conjunction with a Post Survey Revisit to the Recertification and State Licensure Survey completed on February 14, 2024.
Complaint Details
Complaint IN00432214 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00432214 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Report Facts
Census Bed Type: 83
Census Payor Type: 55
SNF/NF Beds: 11
SNF Beds: 44
Residential Beds: 28
Medicare Residents: 26
Medicaid Residents: 11
Other Payor Residents: 18
Inspection Report
Re-Inspection
Census: 54
Capacity: 70
Deficiencies: 0
Date: Mar 26, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted to verify compliance following a previous survey.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire regulations, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered with appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 70
Census: 54
Inspection Report
Life Safety
Census: 54
Capacity: 70
Deficiencies: 3
Date: Mar 4, 2024
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 03/04/2024.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies included a locked service hall exit door without posted code, obstruction preventing a kitchen storage room door from closing and latching, and storage obstructing sprinkler spray patterns in the Clean Utility Closet.
Deficiencies (3)
The exit door from the service hallway was magnetically locked and could be opened by entering a four-digit code, but the code was not posted at the exit.
The spray pattern for sprinkler heads was obstructed in the Clean Utility Closet due to storage stacked within 18 inches of the ceiling.
One corridor door (kitchen storage room door) was held open with a sack and pan, preventing it from self-closing and latching, which could allow passage of smoke.
Report Facts
Facility capacity: 70
Census: 54
Number of corridor doors inspected: 50
Number of staff potentially affected by sprinkler obstruction: 4
Number of staff potentially affected by corridor door deficiency: 6
Number of people potentially affected by locked exit door: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amorette Dunkle | Executive Director | Signed the report and present at exit conference |
| Director of Plant Operations | Interviewed regarding door locking and sprinkler deficiencies | |
| Facilities Management Support | Interviewed regarding door locking and sprinkler deficiencies |
Inspection Report
Renewal
Census: 29
Capacity: 85
Deficiencies: 9
Date: Feb 14, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey including a Residential Licensure Survey conducted from February 8 to 14, 2024.
Findings
The facility was found to have multiple deficiencies including failure to ensure proper medication self-administration assessments, inadequate evaluation of fall prevention interventions, failure to provide adequate ADL care such as facial hair removal and denture care, failure to identify and intervene on significant weight changes, failure to follow physician orders for oxygen use, failure to limit PRN psychotropic medication orders to 14 days, inaccurate advanced directive documentation, failure to re-evaluate oxygen orders, and improper medication cart cleanliness.
Deficiencies (9)
Failure to ensure a resident had a self medication administration assessment and order for self medication storage.
Failure to observe and evaluate for appropriate and safe use of fall prevention interventions for a resident.
Failure to ensure facial hair was shaved and denture care provided for residents reviewed for ADL care.
Failure to identify significant weight changes and implement timely interventions for residents reviewed for weight changes.
Failure to ensure physician's order for oxygen use was present and followed.
Failure to ensure PRN psychotropic medications were prescribed only for 14 days and reviewed for continued need.
Failure to ensure the Electronic Health Record contained accurate information about a resident's advanced directives.
Failure to re-evaluate a physician's order to wear oxygen continuously for a resident.
Failure to ensure medication storage cart was free from loose pills and debris.
Report Facts
Survey dates: 5
Census: 29
Total Capacity: 85
Loose pills: 28
Weight gain: 17
Weight loss: 18.1
Oxygen liters: 3
PRN lorazepam dose: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amorette Dunkle | Executive Director | Signed the report |
| Clinical Support Nurse | Provided multiple interviews and policy information related to deficiencies | |
| Director of Health Services | Named in corrective action plans and interviews related to medication and fall interventions | |
| Director of Nursing | Interviewed regarding PRN medication orders | |
| LPN 3 | Interviewed regarding resident oxygen use | |
| Certified Nursing Assistant 8 | Interviewed regarding denture care |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 8, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00421571 completed on December 1, 2023.
Complaint Details
Investigation of Complaint IN00421571; paper compliance review completed and found in compliance.
Findings
Wellbrooke of Kokomo 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.
Inspection Report
Complaint Investigation
Census: 51
Capacity: 80
Deficiencies: 2
Date: Dec 1, 2023
Visit Reason
This visit was conducted for the investigation of Nursing Home Complaint IN00421571 and Residential Complaints IN00418364 and IN00421240.
Complaint Details
Complaint IN00421571 had federal/state deficiencies cited at F0842 related to narcotic medication documentation. Complaint IN00418364 had state deficiencies cited at R0054 related to residents' rights and confidentiality. Complaint IN00421240 had no deficiencies cited.
Findings
The facility was found deficient in maintaining accurate documentation of narcotic pain medication administration for one resident and failed to ensure confidentiality of residents' medical information for three residents. No adverse effects were noted from these deficiencies.
Deficiencies (2)
Failed to ensure accurate documentation of narcotic pain medication being signed out for 1 of 3 residents reviewed.
Failed to ensure residents' medical information was kept confidential and private for 3 of 3 residents reviewed.
Report Facts
Census total: 51
Total licensed capacity: 80
Narcotic doses undocumented: 4
Residents affected by confidentiality breach: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Took unauthorized pictures of residents' medical information on personal cell phone |
| RN 4 | Registered Nurse | Interviewed regarding narcotic documentation and confidentiality breach |
| RN 5 | Registered Nurse | Interviewed regarding narcotic documentation |
| RN 6 | Registered Nurse | Present during interview about confidentiality breach |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 84
Deficiencies: 0
Date: Jul 28, 2023
Visit Reason
The visit was conducted to investigate complaints IN00410300, IN00410703, IN00413206, and IN00413734 at Wellbrooke of Kokomo.
Complaint Details
Complaints IN00410300, IN00410703, IN00413206, and IN00413734 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the complaints were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census SNF/NF beds: 54
Census Residential beds: 30
Total licensed capacity: 84
Census Medicare residents: 33
Census Medicaid residents: 5
Census Other payor residents: 16
Total census residents: 54
Inspection Report
Re-Inspection
Census: 47
Deficiencies: 0
Date: May 1, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00402582 completed on March 8, 2023.
Complaint Details
Complaint IN00402582 - Corrected.
Findings
Wellbrooke of Kokomo 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 IN00402582.
Report Facts
Census: 47
Census Bed Type - SNF/NF: 11
Census Bed Type - SNF: 36
Census Payor Type - Medicare: 26
Census Payor Type - Medicaid: 11
Census Payor Type - Other: 10
Inspection Report
Life Safety
Census: 78
Capacity: 108
Deficiencies: 0
Date: Mar 8, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 01/17/23 was conducted by the Indiana Department of Health in accordance with 42 CFR Subpart 483.90(a).
Findings
At this Life Safety Code Survey, Wellbrooke of Kokomo was found in compliance with the Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 483.90(a).
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 2
Date: Mar 7, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00402582 regarding federal and state deficiencies related to allegations of medication errors and reporting violations.
Complaint Details
Complaint IN00402582 was substantiated with federal and state deficiencies cited at F609 and F760 related to medication errors and failure to report. Resident B was affected by significant medication errors and failure to report these errors timely to the state.
Findings
The facility failed to ensure significant medication errors were reported to the Indiana Department of Health and failed to ensure a resident received medications according to hospital discharge instructions. Resident B experienced multiple medication administration errors, including incorrect dosing and missed doses of Eliquis, leading to hospital readmission for acute pulmonary embolism and bilateral DVTs. The facility identified transcription errors and pharmacy delivery issues as contributing factors.
Deficiencies (2)
Failed to report significant medication errors to the Indiana Department of Health as required.
Failed to ensure a resident received medications according to hospital discharge instructions, resulting in significant medication errors and hospital readmission.
Report Facts
Census: 73
Medication doses missed: 9
Survey dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amorette Dunkle | Executive Director | Named in relation to findings and plan of correction |
| Director of Nursing | DON | Interviewed regarding medication error and transcription issues |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 24, 2023
Visit Reason
Paper compliance review to the Post Survey Revisit (PSR) related to the Recertification and State Licensure Survey completed on February 2, 2023.
Findings
Wellbrooke of Kokomo 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 PSR to the Recertification and State Licensure Survey.
Inspection Report
Follow-Up
Census: 84
Deficiencies: 2
Date: Feb 1, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey and Investigation of Complaints completed on December 7, 2022, to verify correction of previous deficiencies.
Complaint Details
This visit included a PSR to the Investigation of Complaints IN00379823, IN00398008, IN00388766, IN00392390, IN00394256 and IN00394417 completed on December 7, 2022. All complaints were corrected.
Findings
The facility failed to ensure new PASARR screenings were completed when antipsychotic medications and new mental health diagnoses were added for 5 residents. Additionally, the facility failed to ensure appropriate diagnoses for psychotropic medication use, completion of Abnormal Involuntary Movement Scale (AIMS), and medication blood levels for 3 residents. The facility was found to be in compliance with the State Residential Licensure Survey requirements.
Deficiencies (2)
Failed to ensure a new PASARR was completed when antipsychotic medication and new mental health diagnosis was added for 5 residents.
Failed to ensure residents had appropriate diagnosis for psychotropic medications, completion of AIMS, and medication blood levels for 3 residents.
Report Facts
Census Bed Type Total: 84
Residential Census: 31
Residents affected by PASARR deficiency: 5
Residents affected by psychotropic medication deficiency: 3
Survey dates: 2023-02-01 to 2023-02-02
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amorette Dunkle | Executive Director | Signed the report |
| Social Services Director | Interviewed regarding PASARR deficiencies and facility efforts to correct | |
| Clinical Support Nurse | Provided policy information and interview regarding psychotropic medication deficiencies | |
| Director of Health Services | Re-in-serviced on psychotropic medication requirements and responsible for ongoing audits |
Inspection Report
Life Safety
Census: 53
Capacity: 70
Deficiencies: 9
Date: Jan 17, 2023
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 the 2012 edition of the NFPA 101 Life Safety Code.
Findings
The facility was found not in compliance with several Life Safety Code requirements including fire alarm system operation, sprinkler system maintenance, corridor door latching, smoke barrier door closure, fire drill scheduling, trash receptacle storage, power strip compliance, and gas cylinder storage and segregation.
Deficiencies (9)
Fire alarm control panel had incorrect time displayed, indicating system defect.
Sprinkler system lacked proper storage of spare sprinklers; one sprinkler not in protected slot.
One corridor door to resident room 222 did not latch properly due to hinge problem.
Smoke barrier doors near resident room 217 would not close fully due to carpeting obstruction.
Fire drills were not conducted at unexpected times on all shifts for 4 of 4 quarters.
Trash receptacles (plastic totes) in one corridor exceeded allowed capacity and were improperly stored.
Power strip in resident room 222 did not meet UL 1363 standards for non-PCREE equipment.
Empty oxygen cylinders were not segregated or marked to avoid confusion in storage rooms.
One 'E' type oxygen cylinder was not properly chained or supported in the oxygen storage room.
Report Facts
Facility capacity: 70
Census: 53
Fire drills missing unexpected timing: 4
Trash receptacle capacity: 60
Trash receptacle allowed capacity: 32
Trash receptacle allowed area: 64
Oxygen cylinders improperly secured: 1
Oxygen cylinders improperly segregated: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amorette Dunkle | Executive Director | Signed report and provided education to Director of Plant Operations on various deficiencies |
| Director of Plant Operations | Named in multiple findings related to fire alarm, sprinkler system, door repairs, fire drills, trash receptacles, power strips, and oxygen cylinder storage | |
| Facilities Management Support | Participated in observations and interviews related to multiple deficiencies |
Inspection Report
Recertification
Census: 30
Deficiencies: 22
Date: Dec 7, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey, including investigation of multiple complaints.
Complaint Details
Complaints IN00379823, IN00389008, IN00388766, IN00392390, IN00394256, and IN00394417 were substantiated with related federal deficiencies cited.
Findings
The facility was found to have multiple deficiencies including failure to ensure resident dignity, failure to obtain physician orders for code status, failure to notify physicians of significant weight changes and low blood sugar readings, failure to notify residents of Medicare non-coverage options, failure to maintain resident privacy, failure to complete PASARR evaluations, incomplete care plans, failure to provide scheduled showers, quality of care issues related to wound care and falls, urinary catheter and UTI management issues, nutrition and hydration monitoring deficiencies, respiratory care issues, insufficient nursing staff, medication errors, medication storage issues, incomplete resident records, infection control deficiencies, and failure to ensure staff competency in medication administration.
Deficiencies (22)
Failure to ensure a resident was treated with dignity when staff failed to ensure her clothing covered exposed skin.
Failure to obtain a physician's order for a code status to reflect the do not resuscitate form.
Failure to notify physicians of significant weight changes, failure to administer long-acting insulin properly, and failure to notify physicians of low blood sugar readings.
Failure to document resident or family choice regarding end of therapy services on skilled nursing facility advance beneficiary notice of non-coverage forms.
Failure to ensure residents' confidential information was kept private and secure.
Failure to complete PASARR evaluations when residents had new mental health diagnoses and were prescribed antipsychotic medications.
Failure to implement comprehensive care plans for use of anticonvulsant medication and related diagnoses.
Failure to provide scheduled showers for a resident needing assistance with activities of daily living.
Failure to determine if a resident was cleared to have showers after a surgical procedure.
Failure to assess a resident's skin for new wounds and pre-medicate prior to dressing changes.
Failure to monitor a resident for concussion and hematoma after a fall.
Failure to obtain physician orders for urinary catheter use and to identify cause of worsening urinary symptoms.
Failure to ensure resident weights were monitored and interventions implemented for significant weight changes.
Failure to follow physician orders for oxygen usage, including lack of physician order and failure to date oxygen tubing.
Failure to ensure sufficient nursing staff to provide care, including failure to respond timely to call lights and address resident concerns.
Failure to ensure staff competency and licensure for medication aides administering medications.
Failure to ensure residents had appropriate diagnosis for psychotropic medications and to complete required assessments.
Failure to ensure residents were free of significant medication errors including pain medication, blood pressure medication, and insulin administration.
Failure to label and properly store medications and biologicals, including refrigerator temperature logs and resident self-administered medications.
Failure to maintain complete, accurate, and confidential resident records including documentation of food intake and service plans signed by residents or representatives.
Failure to ensure staff competency in insulin administration including priming insulin pens prior to administration.
Failure to maintain infection prevention and control program including failure to ensure doors remained closed during aerosol treatments and staff wore PPE.
Report Facts
Census: 30
Survey dates: 8
Weight loss: 5.05
Weight loss: 9.3
Weight gain: 7.56
Weight loss: 5.8
Weight gain: 7.04
Weight loss: 11.37
Weight loss: 6.96
Weight loss: 17.16
Weight loss: 15.35
Weight loss: 7.86
Weight loss: 11.98
Blood pressure readings: 29
Medication doses missed: 29
Days worked as QMA without certification: 123
Medication administration days reviewed: 226
Medication administration errors: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CRCA 19 | Certified Resident Care Aide | Worked as Certified Resident Medication Aide without proper certification for 123 days |
| RN 5 | Registered Nurse | Administered aerosol treatment without PPE and did not shut door during treatment |
| Clinical Support Nurse | Provided multiple interviews and policy clarifications | |
| Executive Director | Provided multiple interviews and plan of correction statements | |
| DHS | Director of Health Services | Provided multiple interviews and plan of correction statements |
| CNA 3 | Certified Nursing Assistant | Observed resident privacy issues and provided statements on shower scheduling |
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