Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Kingston Health Center Of Fort Wayne during CMS and state inspections, most recent first.
Kitchen sanitation was not maintained when live gnats were observed in the dining room area and multiple food carts were found covered in dried residue or holding leftover breakfast food. The DM and Administrator acknowledged the carts were not cleaned nightly as required, and the pest control log documented fruit flies, drain flies, food over the dishwasher area, and a need for improved sanitation. There was no documentation of regular cleaning for the area or carts, despite policy requiring routine cleaning and sanitizing of food carts after each use and meal.
Pest Control and Sanitation Lapses in Kitchen and Dining Areas: Live gnats were observed in the dining room near the dishwasher, along with carts covered in dried residue and carts holding leftover breakfast food awaiting washing. The DM and Administrator stated the carts were not cleaned nightly as required, and the pest control log documented fruit flies, drain flies, food around the dishwasher area, and a need for improved sanitation, with no documentation of additional treatment for the gnats.
A resident with epilepsy, hemiplegia, and diffuse TBI missed ordered doses of lacosamide after readmission because the medication was not available when due. The MAR showed two missed doses, and the resident later had a seizure. The family said they were not notified of the missed medication or its unavailability.
A QMA worked with an expired license and administered medications to ten residents on two occasions. The Administrator and DON confirmed the lapse and were unable to provide a policy on license verification during the survey.
Surveyors observed that the facility did not consistently maintain required sanitization levels for cleaning solutions in the kitchen, as dipstick tests repeatedly failed to show the minimum 150ppm concentration when using chemical release towels. Only after using a wall-mounted sanitizer dispenser did the solution meet standards. No policies were provided for the use of towels as a substitute for the dispenser, and most residents consumed food prepared in the affected kitchen.
A resident with dementia and a history of wandering exited the facility through a service hall door that was not properly secured or alarmed, despite care plan interventions and physician orders for a wanderguard. Staff were unaware of a delay in the door's rearming mechanism, and the incident was not immediately documented or assessed. Not all staff had received in-service training on elopement policies or the secured door system.
The facility did not provide or document required bed hold policy notifications prior to the discharge or transfer of three residents with complex medical needs. Discharge packets were incomplete or missing, and there was no evidence in the records or progress notes that the bed hold policy was explained or given to residents or their representatives, contrary to facility policy.
A resident with dementia and hemiplegia, requiring substantial ADL assistance, was repeatedly observed with long facial hair and dark debris under her fingernails during meals. Staff confirmed that nail and facial hair care should have been provided and that the resident had not refused such care. Review of records and care plans showed no documentation of care refusal, and facility policies requiring regular grooming and documentation were not followed.
A resident with multiple diagnoses did not receive oxygen therapy as ordered by the physician, with observations showing the oxygen concentrator was either off or set above the prescribed rate. Staff interviews confirmed the discrepancy, and the DON acknowledged that changes to oxygen administration require a new physician order.
The facility did not maintain adequate communication and documentation with the dialysis center for two residents with end stage renal disease, resulting in missing vital information such as vital signs, weights, dialysis run times, post-dialysis assessments, and medication details. There was no evidence that the facility attempted to obtain the missing information, despite policy requirements and the importance of this information for resident care.
A resident with right-sided paralysis and expressive aphasia reported being rushed and handled roughly by a CNA during personal care. Despite the resident's daughter raising concerns to staff, there was no follow-up documentation or evidence of a thorough investigation, and grievance forms were not readily available as required by facility policy.
A resident with a history of dementia and a recent hip surgery was not properly assessed or monitored for a surgical wound upon readmission to the facility. The facility's records lacked documentation of wound care or monitoring for infection, despite the presence of a surgical wound. Interviews with staff indicated that the wound should have been assessed and documented, but the facility did not have a specific policy for surgical wound care.
A facility failed to maintain accurate medical records for a resident with bipolar disorder, leading to discrepancies in medication management and dietary needs. The resident's elevated lithium levels were not properly documented or communicated, resulting in inconsistent medication adjustments. Additionally, the resident's edentulous status was not recorded, affecting his diet. Interviews revealed a lack of documentation policy, contributing to the deficiency.
The facility failed to provide a dignified dining experience as some residents were not served meals simultaneously, leading to delays and dissatisfaction. A resident, without training or supervision, disrupted others by clearing tables during the meal. The facility's policy did not specify serving meals table by table, contributing to the issue.
The facility failed to prepare pureed food according to guidelines for five residents with specific dietary needs. A dietary staff member used unmeasured gravy and breaded pork tenderloin patties instead of following a recipe, resulting in inconsistent puree consistency. The residents had various medical conditions, including dysphagia, and required specific dietary textures. The facility's policy required the use of recipes, but this was not adhered to, leading to the deficiency.
The facility failed to ensure a sanitary environment in the dining room, where a resident was observed bussing tables without gloves or hand hygiene, spreading food residue. Other residents confirmed this was common due to short staffing, with no training provided. The DON acknowledged the lack of education on hand hygiene for the resident involved, despite the facility's infection control policy emphasizing a safe and sanitary environment.
A facility failed to ensure the timely formulation of an advanced directive for a cognitively intact resident after hospital readmission. The resident's DNR order was discontinued and not reinstated for several days, despite the care plan indicating a DNR status. Interviews revealed a lapse in updating the resident's code status, leading to an assumption of full code status until corrected.
The facility failed to complete all MDS sections for two residents, resulting in a deficiency. One resident's quarterly MDS lacked a BIMS score, with the therapy department responsible for section C completion. The MDS Coordinator was aware of the issue, which persisted for months. Another resident's admission MDS also missed a BIMS score, despite the resident's ability to converse and recall information. Meetings to address assessment timing were held, but no specific interventions were listed. The facility's policy lacked guidelines for MDS section completion.
A facility failed to provide trauma-informed care for a resident with PTSD, as the Trauma Screening Questionnaire was not completed upon admission, and no care plan was in place to address PTSD-related triggers. The resident's insomnia was not linked to PTSD, and there was no evidence of family collaboration or counseling attempts. The MDS was incomplete, and staff interviews revealed a lack of understanding and communication regarding the resident's PTSD triggers.
A resident experienced unrelieved pain due to delayed administration of pain medications and prolonged periods of sitting. The facility failed to develop and implement a comprehensive pain management plan, leading to the resident's early discharge due to ineffective pain control.
Kitchen sanitation and food cart cleaning not maintained
Penalty
Summary
The facility failed to follow sanitation methods to maintain a clean environment in the kitchen area. During observation, more than 22 live gnats were seen in the dining room corner opposite the dishwasher. Three carts were covered in dried yellow and white liquid, and three carts containing leftover breakfast food were waiting to be washed. The Dietary Manager stated pest control had treated the gnats and that cleaning had been increased, but also acknowledged there was no documentation showing the carts were cleaned nightly and that the carts observed had not been cleaned nightly based on their appearance. The Maintenance Director stated the pest control company had treated the area for gnats the prior week. The pest control log showed fruit flies in the kitchen area on 10/31/25, and on 11/13/25 drain flies were found in the kitchen sinks, food was present over the dishwasher area, and the kitchen/dining room area needed improved sanitation. The Administrator stated the carts were not cleaned nightly as required and that the area should have been cleaned to maintain sanitation and prevent pests. The facility had no documentation of regular cleaning for the area or carts, despite policies stating surfaces and floors are to be cleaned on a regular basis and food carts are to be cleaned and sanitized after each use and meal.
Pest Control and Sanitation Lapses in Kitchen and Dining Areas
Penalty
Summary
The facility failed to follow sanitation methods to prevent pests in the dining room and kitchen areas. During observation, 22 plus live gnats were seen in the dining room corner on the wall opposite the dishwasher. Three carts covered in dried yellow and white liquid were also observed, along with three carts of leftover breakfast food waiting to be washed. The Dietary Manager stated pest control had treated the gnats and that the issue had resolved, but also stated there was no documentation showing the carts were cleaned nightly and acknowledged the carts observed had not been cleaned nightly based on their appearance. The Maintenance Director stated the pest control company had treated the area for gnats the prior week. The pest control log showed fruit flies in the kitchen area and drain flies in the kitchen sinks, along with food all over the dishwasher area and a need for improved sanitation in the kitchen/dining room area. The log did not document that the area had been treated again for the gnats. The Administrator stated the carts were not cleaned nightly as required and that the area should have been cleaned to maintain sanitation and prevent pests. Facility policies stated surfaces and floors were to be cleaned on a regular basis and when visibly soiled, and food carts were to be cleaned and sanitized after each use and meal.
Missed antiseizure medication doses led to seizure
Penalty
Summary
The facility failed to follow physician orders for a resident with epilepsy, hemiplegia, and diffuse traumatic brain injury. The resident was readmitted from the hospital on an evening admission, and the active order dated 10/20/25 directed lacosamide oral solution 10 mg/mL, 20 mL by mouth every 12 hours for seizure prevention. The hospital MAR showed the resident had been receiving lacosamide 200 mg every 12 hours, with the next dose due at 9 PM on 10/19/25 after the last documented hospital dose at 9:46 AM that day. The MAR for 11/2025 showed the resident did not receive the antiseizure medication at 8 PM on 11/19/25 or at 8 AM on 11/20/25. The resident's family stated they were told the resident had a seizure on 11/20/25 at 6 PM and reported they were not notified of the missed doses or that the medication was unavailable. Facility documentation showed the unit manager called the pharmacy for a STAT order after learning the medication had not arrived, and a nursing note documented a seizure with family notification. The provider later reviewed the medication issue and noted the resident had missed two doses of the antiseizure medication, one on the evening of 10/19/25 and one on the morning of 10/20/25.
Unlicensed QMA Administered Medications
Penalty
Summary
The facility failed to ensure that a Qualified Medical Assistant (QMA) maintained a current license, as required for licensed staff. Record review showed that the QMA's license had expired, and interviews with the Administrator and Director of Nursing (DON) confirmed that the QMA worked on at least two occasions while her license was expired, administering medications to ten residents. The Administrator was initially unaware if the QMA had worked during the lapse, and the DON later provided timesheets confirming the QMA's work during the period of expired licensure. No policy regarding license verification was provided by the time of the survey exit.
Failure to Maintain Safe Sanitization Parameters for Kitchen Cleaning Solutions
Penalty
Summary
The facility failed to ensure that sanitization parameters for cleaning solutions used in the kitchen met professional standards. During multiple observations, the Dietary Manager (DM) tested the sanitization solution in the main kitchen using dipsticks, but the test strips did not change color, indicating the solution did not meet the minimum required concentration of 150ppm. The DM explained that chemical release towels were used to introduce the sanitizing chemical into the water, but even after changing the water and towels, the solution still did not reach the required strength during subsequent testing. Only after repeated attempts did the solution in the main kitchen reach the minimum standard, while the secondary kitchen's sanitization bucket continued to fail the test until it was refilled from a wall-mounted dispenser, at which point it tested at 300ppm. The report notes that 106 of 109 residents consume food prepared in the facility kitchen, but there were no policies provided regarding the use of towels as a replacement for the wall-mounted sanitization units. The observations and interviews confirm that the facility did not consistently maintain safe sanitization parameters for cleaning solutions in areas where food is prepared and served.
Failure to Secure Exit Door Results in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease, cognitive impairment, and a history of wandering exited the facility through a side service hall exit door that was not properly secured. The resident was independently ambulatory, had demonstrated exit-seeking behaviors, and was assessed as being at significant risk for elopement. The care plan included the use of a wanderguard and regular checks of its function, and physician orders specified placement of the wanderguard and monitoring each shift. Despite these interventions, the resident was able to leave the building undetected and was only noticed by a dietary employee outside, after which the resident was promptly escorted back inside. Investigation revealed that the service hall exit door was not armed with wanderguard locking devices but was equipped with an alarm system that should have sounded when the door was opened. However, staff did not hear the alarm at the time of the incident. Subsequent testing by facility staff showed that the alarm did not sound when the door was opened, and it was unclear why the alarm had been disarmed. There was also confusion among staff regarding the door's locking mechanism, specifically about a delay in the door rearming after being closed, which was not widely understood by staff members. Documentation and interviews indicated that the event was not immediately or thoroughly documented in the resident's progress notes, with no immediate intervention or physical assessment recorded following the elopement. Staff in-service records showed that not all employees had received training on the elopement policy or the secured door system at the time of the incident. Manufacturer guidelines for the door's alarm system were reviewed, highlighting the potential for a rearm delay, but staff were generally unaware of this feature. The facility's policy required immediate assistance and documentation when a resident elopes, which was not fully followed in this case.
Failure to Provide Bed Hold Policy Documentation Prior to Resident Discharge
Penalty
Summary
The facility failed to provide required bed hold policy documentation and notification prior to the discharge or transfer of three residents. For each resident reviewed, there was no evidence in the medical record or discharge packet that the bed hold policy was explained or provided to the resident or their representative before transfer to the hospital. Specifically, discharge packets were either missing, incomplete, or left unsigned and undated, and progress notes did not mention any discussion or provision of the bed hold policy. In one case, the facility was unable to provide any documentation for a discharge event, and in another, the administrator confirmed that no bed hold policy was available for the date in question. The residents involved had significant medical conditions, including stroke, heart failure, seizures, diabetes, respiratory disease, and dementia. Despite the facility's policy stating that the bed hold notice and policy should be issued at the time of transfer or within 24 hours, there was no documentation to show that this requirement was met for any of the three residents. Interviews with the administrator revealed a lack of awareness regarding the need for documented proof of bed hold policy notification prior to discharge.
Failure to Provide Adequate Nail and Facial Hair Care for Dependent Resident
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for a resident who was unable to perform these tasks independently. Observations revealed that the resident had long, white facial hair on her chin and upper lip, as well as dark brown debris under several fingernails on both hands during multiple meal times. The debris under the nails did not match any food items served, and the resident's facial hair was noticeably long. Staff interviews confirmed that the resident's hands and nails should have been cleaned prior to meals and that facial hair should have been groomed, especially since the resident had not refused such care in the past. Record review indicated the resident had diagnoses of dementia with cognitive impairment and hemiplegia following a stroke, requiring substantial assistance with personal hygiene. The care plan specified the need for ADL assistance, including dressing and grooming, and required documentation of care provided. There was no documentation of care refusal in the progress notes. Facility policies required regular nail cleaning and facial shaving, with documentation of any refusals, but these were not followed for this resident.
Failure to Follow Physician's Orders for Oxygen Administration
Penalty
Summary
The facility failed to follow physician's orders for oxygen administration for a resident with diagnoses including Parkinson's disease, restlessness and agitation, and squamous cell carcinoma. Multiple observations over several days showed that the resident's oxygen concentrator was turned off and the nasal cannula was not in use, despite a physician's order to titrate oxygen via nasal cannula between room air and 2LPM to maintain oxygen saturation at or above 90% every shift. On subsequent days, the resident was observed receiving oxygen at 5LPM, which exceeded the physician's order. Staff interviews confirmed that the oxygen was set at 5LPM and that the resident's oxygen saturation was 95%. Upon realizing the discrepancy, staff adjusted the oxygen flow to 2LPM as per the order. The Director of Nursing confirmed that any change in oxygen administration outside of the physician's order would require a new order. Review of facility policy indicated that physician orders and progress notes should be maintained according to regulations, but the policy did not specifically state that physician orders must be followed. The deficiency was identified due to the failure to administer oxygen as prescribed and to ensure staff adhered to the physician's orders for respiratory care.
Failure to Ensure Ongoing Communication and Documentation for Dialysis Care
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the dialysis center for two residents diagnosed with end stage renal disease, diabetes, and either hypertension or hypotension, who had physician orders for dialysis three times per week. For both residents, multiple entries in the dialysis communication book were missing critical information from the dialysis center, including vital signs, weights, run times, dry weights, post-dialysis assessments, information on complications, medications administered, and whether labs were drawn. In some instances, the forms referenced attachments for medication details, but no such attachments or dosage information were present. There was no documentation in either resident's medical record indicating that the facility made further attempts to obtain the missing information from the dialysis center. During an interview, the Assistant Director of Nursing acknowledged the importance of this communication for monitoring complications and ensuring proper follow-up care, and stated that the expectation was to call the dialysis center to obtain the necessary information and document it accordingly. The facility's policy required collaboration with the dialysis provider and monitoring of residents before, during, and after dialysis treatments, but this was not followed as evidenced by the missing documentation and lack of follow-up.
Failure to Investigate and Document Resident Grievance
Penalty
Summary
The facility failed to ensure that grievances were thoroughly investigated, properly documented, and that appropriate corrective actions were taken for a resident who reported being rushed and handled roughly during personal care by a CNA. The resident, who had hemiplegia and hemiparesis following a stroke, was alert, oriented, and able to communicate her needs, despite expressive aphasia. After the incident, the resident's daughter reported concerns to nursing staff, and although the nurse checked on the resident and found no visible injuries, there was no further follow-up documentation in the medical record from the time of the complaint through the resident's discharge. Interviews with facility staff revealed a lack of clarity and consistency in the grievance process. The Social Services Director was unaware of how grievances were being tracked or resolved and reported no grievances for the relevant months. The Administrator stated that grievance forms were available, but during the survey, no forms were found in common areas or at the Social Services Director's office. The DON acknowledged that there was no documentation to show that the grievance had been addressed or that actions were taken to prevent further violations. The facility's policy required grievances to be tracked, investigated, and followed up within a specified timeframe, but these procedures were not followed in this case.
Failure to Monitor Surgical Wound
Penalty
Summary
The facility failed to properly assess and monitor a surgical wound for Resident P, who had a history of dementia with behavioral disturbance and a fracture of the right femur. After a fall on 12/17/24, Resident P underwent a right hip cemented hemiarthroplasty on 12/19/25. Upon readmission to the facility on 12/23/24, the Admission Evaluation and Baseline Plan of Care did not document the presence of a surgical wound, its condition, or any signs of infection. This lack of documentation persisted despite the resident having a surgical wound as indicated in the admission Minimum Data Set assessment dated 12/28/24. The facility's records, including the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for December 2024, did not show any surgical wound care, assessment, or monitoring for signs of infection. A nurse note on 12/24/24 mentioned moderate bleeding from the surgical site, but there was no documentation of physician notification or further wound assessment. From 12/25/24 to 1/6/25, there was no documentation regarding the surgical wound's status, including the condition of the staples or any signs of infection. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, revealed that the surgical wound should have been assessed and documented upon admission and monitored every shift. However, the facility lacked a specific policy for surgical wound care, relying instead on a general Wound and Skin Management Protocol. This protocol required an admission assessment within 24 hours and a plan of care for skin integrity, which was not adequately followed for Resident P's surgical wound.
Deficiency in Medical Record Accuracy and Resident Care
Penalty
Summary
The facility failed to maintain complete and accurate medical records for Resident D, as evidenced by several discrepancies in medication management and documentation. Resident D, who had a history of bipolar disorder, was prescribed Lithium Carbonate 300 mg ER twice daily. Despite an elevated blood lithium level of 1.6 mmol/L, there was no documentation of a physician order for the lab test or notes indicating the abnormal results were communicated to the doctor or NP. The medical NP adjusted the lithium dosage due to increased tremors, but the resident's wife expressed concerns about the change, leading to a reversion to the original dosage. However, the psychiatric NP later decreased the dosage again without nursing documentation explaining the change. Additionally, the facility failed to document Resident D's edentulous status, which affected his dietary needs. The initial nursing admission form did not note any oral issues, and the resident was placed on a regular texture diet despite having no teeth. A speech therapy evaluation later identified the resident's difficulty with chewing and swallowing, recommending a swallow study. However, there were no physician orders for this evaluation or study, and the resident's care plans did not reflect his need for soft foods. Interviews with the DON revealed a lack of policy regarding documentation, and no policy was available for review at the time of the survey exit. This lack of documentation and communication regarding Resident D's medication and dietary needs contributed to the facility's failure to safeguard resident-identifiable information and maintain medical records in accordance with professional standards.
Deficient Dining Experience and Resident Involvement in Bussing Tables
Penalty
Summary
The facility failed to ensure a dignified dining experience for several residents, as observed during a dining session. Residents were not served their meals simultaneously, leading to delays and dissatisfaction. Specifically, Resident 49, Resident 76, and Resident 82 were seated together, but only Resident 49 received her meal initially, causing her to wait until her tablemates were served, resulting in her food becoming cold. The serving staff, identified as [NAME] 8, prioritized serving other tables before taking orders from Residents 76 and 82, which contradicted the facility's policy as explained by the Director of Nursing, who stated that residents at a table should be served at the same time. Additionally, Resident 77, who was not trained or supervised, took it upon herself to clear tables, disrupting other residents' dining experiences. She moved around the dining room, collecting dishes and silverware, and even moved Resident 49's wheelchair without consent. This behavior was not addressed by staff, and it was noted that residents often helped with bussing tables due to short staffing. The facility's policy on meal service did not specify that meals should be served table by table, contributing to the disorganized dining experience.
Failure to Prepare Pureed Food According to Guidelines
Penalty
Summary
The facility failed to ensure that pureed food was prepared according to guideline specifications for five residents requiring pureed diets. During an observation, a dietary staff member identified a pan of meat with charred spots and sticking to wax paper as pork tenderloin. The staff member used a grinder to puree the meat, adding unmeasured amounts of gravy instead of following a specific recipe. The recipe book did not include a recipe for pork tenderloin puree, and the kitchen manager was unaware of this omission. The dietary staff member used breaded pork tenderloin patties, which were not similar in style to the pork tenderloin served to other residents, and did not use a thickener, resulting in an inconsistent puree consistency. The residents involved had various medical conditions, including respiratory disease, heart disease, dementia, dysphagia, stroke, diabetes, Alzheimer's, adult failure to thrive, and malnutrition. Each resident had specific dietary orders for pureed or blenderized textures with thin or nectar thick consistencies. The facility's policy, dated April 2014, required the use of recipes when preparing menu items, but this policy was not followed, leading to the deficiency in food preparation for these residents.
Inadequate Infection Control in Dining Room
Penalty
Summary
The facility failed to maintain a sanitary environment in the dining area, specifically in the crown dining room, where 20 out of 108 residents consumed meals. During an observation, a resident was seen collecting plates, glasses, and silverware without wearing gloves or practicing hand hygiene. This resident had remnants of mashed potatoes on her hands and was touching tables and another resident's wheelchair, indicating a lack of sanitation. Staff in the dining room acknowledged the resident's actions but were unable to prevent them due to being occupied with other duties and being the only staff member present. Interviews with other residents revealed that it was common for residents to assist with bussing tables, especially during times of short staffing, without receiving any training or oversight on hand hygiene. The Director of Nursing confirmed that there was no available education on hand hygiene or sanitation principles for the resident involved in bussing activities. The facility's infection control policy, dated August 2019, emphasized maintaining a safe and sanitary environment, but there was no evidence of training or review of the resident's appropriateness for such tasks.
Failure to Ensure Timely Formulation of Advanced Directive
Penalty
Summary
The facility failed to ensure the formulation of an advanced directive for a resident after their readmission from the hospital. The resident, who was cognitively intact with a BIMS score of 14, had a history of respiratory failure, Parkinson's disease, and type 2 diabetes with chronic kidney disease. Upon review, it was found that the resident's DNR order was discontinued on 8/14/24 and not reinstated until 8/21/24, despite the resident's care plan indicating a DNR status. The resident declined to decide on an advanced directive status upon readmission on 8/19/24. Interviews with the facility's Administrator and DON revealed that the resident's code status should be documented in the physician orders and care plan. However, there was a lapse in updating the resident's code status, leading to an assumption of full code status until the DNR was reinstated on 8/21/24. The facility's policy required determining whether a resident had executed advanced directives and if a DNR order was desired while in the facility, which was not adhered to in this case.
Incomplete MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the completion of all Minimum Data Set (MDS) sections for two residents, leading to a deficiency. Resident 76's quarterly MDS assessment did not include a completed Basic Interview for Mental Status (BIMS) score, as each question was marked as not assessed. The Director of Therapy acknowledged that the therapy department was responsible for completing MDS section C and identified a problem with completion, which had been an issue for several months. The MDS Coordinator confirmed awareness of the incomplete or untimely completion of section C, indicating that the MDS department should receive completed sections by the end of the business day on the Assessment Reference Date. Resident 66's admission MDS also lacked a BIMS score assessment. During an interview, Resident 66 demonstrated the ability to converse, recall information, and use reasoning skills. Despite meetings held by the facility to address comprehensive assessment and timing, the Performance Improvement Plan (PIP) did not list any specific interventions. The facility's current policy did not provide guidelines for the completion of each MDS section, and an undated document indicated that the therapy department was responsible for BIMS scoring. The policy from April 2014 stated that MDS Nurses should complete every MDS within seven days of the assessment date.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with heart disease, depression, and PTSD. Upon review, it was found that the resident's Trauma Screening Questionnaire was not completed upon admission, and there was no care plan in place to address or mitigate PTSD-related triggers. The resident's insomnia was not identified as a symptom of PTSD, and there were no progress notes indicating family collaboration to identify PTSD triggers. Additionally, there was no evidence of counseling or talk therapy being attempted for the resident. The resident's admission Minimum Data Set (MDS) was incomplete, with sections for mental status and mood not fully assessed. Interviews with staff revealed a lack of understanding and communication regarding the resident's PTSD triggers. The Social Services Director admitted to not completing the mood section and expressed concern about upsetting the resident by discussing PTSD further. The Director of Nursing acknowledged that the resident should have been care planned for PTSD and monitored for triggers, but was unsure if the family had been contacted for additional information. The facility's policy on trauma-informed care was not followed, as the necessary screenings and interventions were not implemented.
Failure to Ensure Appropriate Pain Management
Penalty
Summary
The facility failed to ensure appropriate pain management for Resident Q, who was admitted for rehabilitation services following a pelvic fracture. Despite being prescribed Hydrocodone-Acetaminophen for pain, the resident reported experiencing unrelieved pain due to delayed administration of pain medications and prolonged periods of sitting in a chair and on the toilet. The resident's pain was not adequately assessed or managed, leading to her early discharge from the facility due to ineffective pain control. The resident's medical record indicated that pain medications were not administered timely, and non-pharmacological interventions were not consistently offered. The Medication Administration Record (MAR) showed significant gaps in the administration of pain medication, with the resident often waiting several hours between doses. Additionally, there was no documentation of non-pharmacological interventions being provided, despite the resident's complaints of severe pain. The facility's Director of Nursing confirmed that a comprehensive pain management plan, including non-pharmacological interventions, should have been developed and implemented for residents experiencing pain. However, the facility did not use a comprehensive pain assessment form, and there were no changes made to the resident's plan of care to address her pain management needs. The facility's policy on pain assessment and management was not followed, resulting in inadequate pain control for the resident.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
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Nursing homes near Fort Wayne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| University Park Rehabilitation And Healthcare | 1.6 mi | ★★★★★ | 4 | 0 |
| Glenbrook Rehabilitation & Skilled Nursing Center | 2 mi | ★★★★★ | 10 | 0 |
| Towne House Retirement Community | 2.1 mi | ★★★★★ | 1 | 0 |
| Summit City Nursing And Rehabilitation | 2.2 mi | ★★★★★ | 9 | 0 |
| Canterbury Nursing And Rehabilitation Center | 2.5 mi | ★★★★★ | 7 | 0 |
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