Below 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 Majestic Care Of Deming Park during CMS and state inspections, most recent first.
A cognitively impaired resident with dementia and a history of convulsions was found by a hospice CNA sitting on a male resident’s bed with her pants down and brief pulled aside, while the male resident, who had schizophrenia and a psychotic disorder with hallucinations, had his hands near her genital area. The encounter occurred behind a closed curtain in the male resident’s room. Prior to this, the female resident had been ambulating the halls as usual, and the facility had not yet identified or addressed her pattern of seeking out this male resident, whom she associated with her husband. Although both residents later denied that anything inappropriate occurred and staff had not previously observed sexual behaviors between them, surveyors determined that the facility failed to protect the cognitively impaired resident’s right to be free from sexual abuse, in violation of resident rights and abuse-prevention policies.
Staff did not report an allegation of resident-to-resident abuse to the state health department within the required timeframe after an incident involving two residents, despite facility policy mandating immediate notification. The delay occurred after the Social Services Director reported the event to the Administrator, who failed to ensure timely reporting.
A resident with severe cognitive impairment and a history of traumatic brain injury, identified as an elopement risk and wearing a WanderGuard, was able to leave the facility unsupervised after staff failed to visually check on her during their shift. The facility's alarm system did not alert staff to the exit, and the resident was later found outside with hypothermia and abnormal vital signs. Staff were not consistently aware of elopement risks, and required supervision protocols were not followed.
A resident with severe cognitive impairment and multiple comorbidities, identified as high risk for elopement, was able to leave the facility undetected overnight despite wearing a WanderGuard device. Staff failed to visually check on the resident during their shift, and the alarm system did not alert staff to the exit. The resident was found outside the facility with hypothermia and abnormal vital signs. Contributing factors included lack of staff awareness of elopement risk, inconsistent documentation and monitoring of safety devices, and a malfunctioning security system.
A resident with multiple sclerosis, moderate cognitive impairment, and dependence for ADLs was repeatedly observed with the call light out of reach, despite a care plan and facility policy requiring it to be accessible. The resident was unable to locate or use the call light on several occasions, and staff confirmed it should have been kept within reach.
Three residents did not receive showers and personal hygiene care according to their stated preferences and care plans. One resident received fewer showers than scheduled and was asked to sign off on care not provided, while another was observed with poor nail hygiene and had gaps in documentation for nail and hair care. A third resident's records showed conflicting information about bathing preferences and physician orders, resulting in missed showers. Staff interviews confirmed inconsistencies in documentation and a lack of clear policy for recording resident preferences.
A resident with multiple sclerosis and moderate cognitive impairment, dependent on staff for ADLs, was repeatedly observed with untrimmed fingernails and debris, indicating nail care was not consistently provided or documented as required by facility policy. An LPN confirmed nail care should have been done with each bath and as needed, but records showed missed or undocumented care.
A resident with a history of traumatic brain injury and multiple fractures was not safely transferred according to their care plan, which required two-person assistance and a Pivot Disk. Documentation showed inconsistent adherence to these requirements, and an incident occurred where the resident and a CNA fell during a transfer. Staff interviews revealed issues with bed locking mechanisms and non-use of the Pivot Disk, contributing to the unsafe conditions.
The facility failed to document and provide showers according to the personal preferences of three residents, leading to a deficiency in honoring resident choice and self-determination. One resident's wife reported he was not receiving the preferred two showers per week, often only receiving one. Another resident expressed not receiving showers as scheduled, with a significant gap in provision. A third resident reported receiving showers based on staff convenience rather than his preference. Resident Council meeting minutes highlighted ongoing concerns about shower provision.
A facility failed to conduct required respiratory assessments before nebulizer treatments, improperly stored respiratory equipment, and did not obtain a physician's order for oxygen supplementation for residents with COPD. Observations showed unbagged and undated nebulizer equipment, and interviews confirmed the lack of adherence to facility policies.
The facility failed to maintain accurate temperature logs and manage food expiration dates, as observed during kitchen inspections. Missing temperature entries for freezers and expired food items were found, with the Dietary Manager admitting to guessing temperatures and instructing staff to fill in logs inaccurately.
The facility failed to maintain proper catheter care for two residents, leading to potential infection risks. One resident's catheter bag and tubing were repeatedly observed in contact with the floor, and documentation of catheter care was inconsistent for both residents. Staff interviews confirmed an increase in UTIs, and the facility's policy on catheter care was not followed.
A resident requiring dialysis care did not receive meal trays for missed lunches while at dialysis, as the dietary staff was not informed of the resident's return. Additionally, the facility failed to consistently document the assessment of the resident's AV dialysis fistula, with missing entries in the Treatment Administration Records over several months.
The facility failed to properly administer inhaled medications, resulting in an 11.54% medication error rate. A nurse did not instruct two residents with COPD to rinse and spit after using corticosteroid inhalers and did not wait between administering different inhaled medications. This was against the facility's policy, as confirmed by LPNs.
The facility failed to properly label and dispose of medications in two storage rooms. An undated Aplisol vial was found, with staff unaware of its viability period, and an expired COVID vaccine was not disposed of as required. Facility policies on medication handling were not followed, resulting in these deficiencies.
A facility failed to assess and treat a resident's urinary catheter and follow up on continued hematuria, resulting in immediate jeopardy. The resident experienced a distended abdomen, low urine output, and bloody urine, but the physician was not notified, and no assessment or vital signs were obtained. The resident's condition worsened, leading to septic shock and respiratory failure, and the resident later expired.
A resident was left unattended in a mechanical lift pad by a CNA, contrary to the facility's policy requiring two-person assistance for transfers. The resident's records lacked documentation for the use of a mechanical lift and an appropriate care plan. Staff interviews confirmed the policy was not followed, leading to the deficiency.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to be free from sexual abuse. A hospice CNA entered a male resident’s room and found a female resident sitting on his bed with her pants down to her knees and her brief pulled to the side, while the male resident’s hands were near her vaginal area. The two residents were in the male resident’s room behind a pulled curtain when discovered. This incident was reported to the Indiana Department of Health as a reportable incident. The female resident, identified as having dementia, muscle weakness, and a history of convulsions, had a quarterly MDS indicating cognitive impairment. Her care plan later documented behavioral symptoms of seeking companionship with other residents. The DON indicated that the facility initially did not think there was a concern between this resident and other residents, and that it was later determined she was seeking the male resident because he resembled her husband. Prior to that determination, the resident had been observed walking around the hallways as usual, and there were no indications in the record that she had been restricted or more closely supervised to prevent such interactions. The male resident had diagnoses including schizophrenia, psychotic disorder with hallucinations, and adult failure to thrive, and his admission MDS indicated he was cognitively intact and receiving antipsychotic medication. His care plan, developed after the incident, noted a history of schizophrenia and psychotic disorder with hallucinations and that he could exhibit behaviors including inappropriate sexual interactions with others. Written statements from hospice CNAs described the scene in his room, with the female resident partially undressed and the male resident fully dressed with his hands near her genital area. Subsequent interviews and notes documented that both residents denied that anything inappropriate had occurred, and other staff present on the unit did not report observing inappropriate behaviors between the two residents prior to the incident. Nonetheless, the observed situation in the male resident’s room constituted a failure to protect the cognitively impaired female resident from sexual abuse. Facility policies provided by the DON indicated that when a resident is accused or suspected of abuse, the facility will ensure other residents are protected, which may include increased supervision, room changes, or transfer or discharge, and that residents have the right to a safe environment. In this case, the incident occurred despite these policies, and the surveyors determined that the facility failed to ensure the female resident’s right to be free from sexual abuse was protected.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to the Indiana Department of Health within the required timeframe for two residents. On the morning of the incident, one resident was observed yelling at another in a hallway, with staff intervening to separate them. The Social Services Director (SSD) witnessed the aftermath, spoke with those involved, and reported the incident to the former Administrator. The Administrator instructed the SSD to wait before documenting the event, indicating she wanted to consult someone first, but then left the facility without providing further direction. The SSD later entered progress notes about the incident, believing it had been reported to the state, as one resident had threatened another. However, the required notification to the Department of Health was not made within the mandated two-hour window after the allegation was made. Facility policy clearly required immediate reporting of any alleged abuse, but this protocol was not followed in this instance.
Failure to Prevent Elopement and Ensure Resident Supervision
Penalty
Summary
A resident with a history of traumatic brain injury, severe cognitive impairment, and identified as an elopement risk was able to leave the facility unsupervised during the night. The resident was wearing a WanderGuard bracelet, a device intended to prevent unsupervised exits, but the facility's alarm system failed to alert staff when the resident exited. Multiple staff members, including nurses and CNAs assigned to the resident's care, did not visually check on the resident during their shift, despite facility expectations and policies requiring residents to be checked at least every two hours. The last known observation of the resident was at approximately 9:40 p.m., after which no staff reported seeing or checking on her until the following morning. The resident was discovered missing during the day shift when a nurse went to check her blood sugar and found her room empty. A search was initiated, and the resident was found approximately 0.6 miles away from the facility, exhibiting signs of hypothermia and abnormal vital signs. Upon return, the resident was confused, had a low body temperature, and complained of pain. The WanderGuard device was found to be intact and functional when tested after the incident, but facility investigation revealed issues with the door's latch and mag-lock, which may have prevented the alarm from activating as intended. Staff interviews indicated a lack of awareness regarding which residents were at risk for elopement, and elopement risk was not included on assignment sheets. Documentation and staff statements confirmed that the resident had a care plan identifying her as an elopement risk, with interventions such as regular checks and use of the WanderGuard. However, these interventions were not consistently implemented, and staff did not follow the facility's policy for supervision and monitoring. The failure to provide adequate supervision and to ensure the effectiveness of the WanderGuard system resulted in the resident's unsupervised exit and exposure to harm.
Failure to Prevent Elopement and Provide Adequate Supervision
Penalty
Summary
A facility failed to provide adequate supervision and prevent an accident hazard when a resident with severe cognitive impairment, traumatic brain injury, Parkinson's disease, and type 2 diabetes eloped from the facility during the night. The resident, who was identified as being at high risk for elopement and falls, wore a WanderGuard bracelet intended to prevent unsupervised exits. Despite this, the resident was able to leave the facility undetected sometime after being last seen at 9:40 p.m. and was not discovered missing until the following morning at 7:11 a.m. when staff could not locate her. The resident was found approximately 0.6 miles away from the facility, exhibiting hypothermia and abnormal vital signs, and was returned to the facility for assessment and care. The investigation revealed that neither the night shift nurse nor the CNA assigned to the resident's hall visualized the resident during their entire 8-hour shift. Staff interviews indicated a lack of clarity regarding which residents were at risk for elopement, as this information was not included on CNA assignment sheets or point of care tasks. Additionally, staff were inconsistent in their understanding and documentation of required checks for the WanderGuard device, and some were unsure of their responsibilities regarding its function. The facility's alarm system failed to alert staff when the resident exited, and subsequent testing showed that the alarm was not audible in all areas of the building. There was also uncertainty about whether a vendor had access to the door alarm bypass code, which may have contributed to the resident's ability to exit undetected. Further contributing factors included a malfunctioning security camera system due to a power outage, which prevented review of surveillance footage, and a possible issue with the front door's magnetic lock, which may not have latched completely. The facility's policies required regular assessment and communication of elopement risk, as well as monitoring and documentation of interventions, but these were not consistently implemented. The lack of direct resident checks, insufficient staff awareness of elopement risk, and failure of the alarm system collectively led to the resident's unsupervised exit and subsequent exposure to harm.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was consistently kept within reach, as required by the resident's care plan and facility policy. On multiple occasions, the resident was observed lying in bed with the call light hanging off the side of the bed, nearly touching or halfway to the floor, making it inaccessible. During these times, the resident expressed uncertainty about the location of the call light and was unable to find it when attempting to do so. On one occasion, the call light was within reach and the resident was able to use it, but this was not consistently maintained. The resident involved had a diagnosis of multiple sclerosis, moderate cognitive impairment, and was dependent on staff for activities of daily living. The care plan identified the resident as being at risk for falls and specifically included an intervention to keep the call light within reach. Staff interviews confirmed that the call light should have been accessible to the resident at all times. Facility policy also required staff to ensure call lights were within reach and secured as needed.
Failure to Provide Showers and Personal Hygiene Care According to Resident Preferences
Penalty
Summary
The facility failed to ensure that showers and personal hygiene care were provided to residents according to their stated preferences and care plans. For one resident with hemiplegia and hemiparesis, documentation showed that he was scheduled for multiple showers but only received a portion of them, with some marked as refused or not applicable without proper justification. The resident reported not receiving the expected number of showers and being asked to sign off on shower sheets even when showers were not provided. The care plan and resident preference documents indicated a clear expectation for shower frequency and choice, but the facility's records and staff interviews revealed inconsistencies in both the provision and documentation of care. Another resident with paroxysmal atrial fibrillation and congestive heart failure was observed with poor personal hygiene, specifically debris under her fingernails, despite care plans indicating a need for assistance with ADLs, including bathing and nail care. Documentation showed gaps in the provision of nail care and hair washing, and there was a lack of refusal documentation for missed care. Staff interviews confirmed that shower sheets and point-of-care (POC) documentation should match, but discrepancies were found between the two, and some care activities were not consistently recorded. A third resident with multiple sclerosis and a recent patella fracture had conflicting documentation regarding bathing preferences and physician orders. While the care plan and task section of the electronic medical record indicated a preference for showers, a physician's order for bed baths only remained in the chart, and the resident did not receive showers as scheduled. Staff interviews revealed confusion about the resident's current preferences and orders, and the facility lacked a specific policy for documenting resident preferences, leading to inconsistencies in care delivery and record-keeping.
Failure to Provide and Document Required Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who required assistance with activities of daily living (ADLs) did not receive adequate nail care. Multiple observations over several days showed the resident lying in bed with untrimmed fingernails and dark debris underneath them. The resident reported that staff did not clean her nails very often. Review of the resident's care plan indicated a need for assistance with ADLs, including nail care on bath days and as necessary. The resident's diagnoses included multiple sclerosis, and the Minimum Data Set (MDS) assessment documented moderate cognitive impairment and dependence for ADLs. Documentation review revealed inconsistencies in recording nail care, with some shower sheets lacking evidence that nail care was provided or refused, and no progress notes indicating refusal. Facility policy required daily cleaning and regular trimming of nails, with documentation of care provided. An LPN confirmed that nail care should have been performed with each bath and as needed, but this was not consistently done or documented for the resident.
Failure to Ensure Safe Transfer Procedures
Penalty
Summary
The facility failed to ensure a safe transfer for a resident, identified as Resident C, who required extensive assistance due to a history of traumatic brain injury and multiple fractures from a motor vehicle accident. The resident's care plan specified the need for two-person assistance and the use of a Pivot Disk for transfers. However, documentation revealed that out of 69 transfer attempts, only 41 were conducted with two-person assistance, while three were done with only one person, and 25 transfers did not occur. Additionally, the Pivot Disk was not used during the transfer that resulted in an accident. An incident occurred when a CNA attempted to transfer Resident C from bed to wheelchair, during which the resident became unsteady, and both the CNA and the resident fell. The fall resulted in a skin tear for the resident. Interviews with staff revealed issues with bed locking mechanisms, which were not consistently reported or repaired, contributing to the unsafe transfer conditions. The CNAs admitted to not using the Pivot Disk, and the resident confirmed that the device was not used during her transfers. The Director of Nursing and the Administrator were unaware of the bed locking issues and the deviation from the prescribed transfer procedures. The facility's policy required adherence to individual transfer plans, but this was not followed, leading to the incident. The Certified Occupational Therapy Assistant noted that the resident only allowed therapy staff to use the Pivot Disk, indicating a lack of consistent practice among the nursing staff.
Failure to Honor Resident Shower Preferences
Penalty
Summary
The facility failed to document and provide showers according to the personal preferences of three residents, leading to a deficiency in honoring resident choice and self-determination. Resident 57's wife reported that he was not receiving the preferred two showers per week, often only receiving one. His care plan specified showers on Monday and Friday evenings, but records from April and May 2024 showed only bed baths without hair washing on several dates, with no documentation of refusals. The issue was raised in Resident Council meetings, and the Unit Manager acknowledged a lack of proper documentation and staff education. Resident 14 expressed that she was not receiving showers as scheduled, with her last shower recorded on May 27, 2024, despite her preference for showers on Tuesday and Saturday evenings. Her care plan, dated November 28, 2023, indicated these preferences, but there was a significant gap in shower provision. The MDS assessment showed moderate cognitive impairment, but no behaviors for rejecting care were documented. Resident 11 reported receiving showers based on staff convenience rather than his preference for Monday and Thursday evenings. His care plan, dated August 17, 2023, reflected these preferences, but the electronic records lacked documentation for specific dates. The Assistant Director of Nursing noted that missing entries could be due to missed charting rather than missed showers. Resident Council meeting minutes from March to May 2024 highlighted ongoing concerns about shower provision, with responses from management indicating audits and grievance processes were in place.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to conduct a respiratory assessment on a resident before administering a nebulizer treatment. During a medication administration observation, a registered nurse administered an albuterol nebulization solution to a resident with chronic obstructive pulmonary disease (COPD) without completing a respiratory assessment. The resident's medical records indicated a physician's order to document vital signs and perform a respiratory assessment before and after nebulizer treatments, but the Medication Administration Record lacked documentation of these assessments for May and June 2024. Interviews with nursing staff and the resident confirmed that assessments were not conducted as required by the facility's policy. The facility also failed to ensure proper storage of respiratory equipment for multiple residents. Observations revealed that nebulizer mouthpieces and tubing were left unbagged and undated on residents' beds or tables. This was noted for three residents, including one who was unable to reach the equipment without assistance. The facility's policy required that nebulizer equipment be disassembled, rinsed, air-dried, and stored in a zip-lock bag with a date label, but these procedures were not followed. Interviews with staff confirmed the expectation for proper storage and dating of equipment, which was not adhered to. Additionally, the facility did not obtain a physician's order for oxygen supplementation for a resident who was receiving oxygen via nasal cannula. The resident's record lacked documentation of a physician's order for oxygen administration, despite the resident indicating that she had been receiving oxygen since a recent hospital visit. The facility's policy stated that oxygen should be administered under a physician's order, except in emergencies, and orders should be obtained as soon as practicable. Interviews with staff highlighted the expectation for obtaining timely orders, which was not met in this case.
Deficiency in Food Storage and Temperature Logging
Penalty
Summary
The facility failed to maintain proper documentation and management of food storage temperatures and expiration dates, as observed during two kitchen inspections. During an initial kitchen tour, it was noted that temperature logs for the potato freezer, vegetable and meat freezer, and ice cream freezer were missing entries for two consecutive days. Additionally, outdated food items, including an opened gallon of milk and hard-boiled eggs, were found in the reach-in refrigerator. The Dietary Manager acknowledged the expired items and subsequently closed the refrigerator, preventing further inspection. In a follow-up interview, the Dietary Manager admitted to instructing a staff member to fill in the missing temperature logs with another staff member's initials, based on an 'educated guess' rather than actual recorded data. The facility's policy requires temperatures to be logged twice daily and for refrigerated food to be labeled, dated, and monitored to ensure timely use or disposal. However, these procedures were not followed, as evidenced by the missing temperature logs and expired food items found during the inspections.
Failure in Catheter Care Documentation and Maintenance
Penalty
Summary
The facility failed to ensure proper care and maintenance of indwelling urinary catheters for two residents, leading to potential risks of urinary tract infections. Resident 56 was observed multiple times with her catheter bag and tubing in contact with the floor, which is against the facility's policy for infection control. The resident had a history of obstructive and reflux uropathy and required extensive assistance with activities of daily living. Despite a care plan indicating the risk of infections related to the catheter, there were several instances where catheter care was not documented as completed. Resident 41, who had diagnoses including hemiplegia and neuromuscular dysfunction of the bladder, also had an indwelling urinary catheter. The care plan required catheter care every shift, but the Treatment Administration Record (TAR) showed missing documentation for several shifts in May 2024. This lack of documentation suggests that catheter care may not have been consistently performed, increasing the risk of infection for the resident. Interviews with staff, including the Infection Preventionist and Certified Nursing Assistants, revealed that there was an increase in UTIs in February and March 2024, but no specific root cause was identified. The staff acknowledged that catheter care should be documented in the medical record when completed. The facility's policy, revised in September 2014, emphasized keeping catheter tubing and drainage bags off the floor and documenting catheter care, which was not adhered to in these cases.
Failure to Provide Adequate Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide adequate dialysis care for a resident, identified as Resident 27, who required dialysis services. The resident did not receive meal trays for lunches missed while attending dialysis sessions. Despite having a care plan that emphasized the need for adequate nutrition due to dialysis, the dietary staff was not informed of the resident's return from dialysis, resulting in missed meals. The Dietary Manager confirmed that the resident was not receiving lunch meals upon returning from dialysis, as the staff was unaware of the resident's schedule. Additionally, the facility did not consistently document the assessment of the resident's arteriovenous (AV) dialysis fistula, as required by the physician's order. The Treatment Administration Records (TARs) for March, April, and May 2024 showed missing documentation for the assessment of the AV fistula on several shifts. The Director of Nursing Services acknowledged the documentation gaps and indicated that the issue was being investigated through the facility's Quality Assurance and Performance Improvement (QAPI) program.
Improper Administration of Inhaled Medications
Penalty
Summary
The facility failed to ensure proper administration of inhaled medications, resulting in a medication error rate of 11.54 percent. During a medication administration observation, a registered nurse administered a Symbicort inhaler to a resident with chronic obstructive pulmonary disease (COPD) without allowing the resident to rinse and spit with water afterward. Additionally, the nurse did not wait before administering a second inhaled medication, Incruse Ellipta, to the same resident. The resident's care plan indicated a need for proper medication administration to manage respiratory distress related to COPD. In another instance, the same registered nurse administered Trelegy Ellipta to a different resident with COPD, again failing to instruct the resident to rinse and spit with water after use. Interviews with licensed practical nurses confirmed that the facility's policy required residents to rinse and gargle with water after using corticosteroid inhalers and to wait several minutes between administering different inhaled medications. The facility's policy was not followed, contributing to the observed medication errors.
Medication Labeling and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and disposal of medications in two medication storage rooms. During an inspection, an undated and opened multi-use vial of Aplisol was found in the 200-hall medication storage room refrigerator. The label indicated it was for facility stock, but staff members, including an LPN, RN, and Unit Manager, were unaware of how long the Aplisol solution was viable once opened. It was later confirmed by the LPN that the Aplisol was good for 30 days once opened, as per facility policy, which was not adhered to in this instance. Additionally, in the 100-hall medication storage room refrigerator, a COVID vaccine labeled for a resident was found to be expired since March 27, 2024. The Unit Manager acknowledged the expiration and indicated that the Infection Preventionist nurse was responsible for handling vaccines and Aplisol solutions. The expired vaccine should have been disposed of according to the facility's policy, which mandates the removal and destruction of expired medications. The facility's policies on medication administration and Aplisol usage were not followed, leading to these deficiencies.
Failure to Assess and Treat Urinary Catheter Leading to Resident's Death
Penalty
Summary
The facility failed to assess and treat a resident's urinary catheter and follow up on continued hematuria, resulting in immediate jeopardy. Resident B, with a history of urinary catheter, severe sepsis with septic shock, and urinary tract infection (UTI), experienced a distended abdomen and low urine output. The catheter was changed, and bloody urine was returned, but the physician was not notified, and no assessment or vital signs were obtained. Several hours later, Resident B had black emesis, blood clots from the catheter, and bloody urine, leading to septic shock and respiratory failure. The resident was sent to the hospital and later expired. Resident B's medical record indicated multiple diagnoses, including chronic obstructive pulmonary disease (COPD), severe sepsis with septic shock, hematuria, and UTI. The resident had physician orders for various medications and catheter care, but the facility failed to notify the physician of abnormal findings and did not document communication with the urologist. The resident's condition worsened over several hours, with no follow-up assessments or vital signs recorded. The facility's documentation lacked evidence of timely communication with the physician or urologist regarding the resident's condition. Interviews with staff revealed that the nurse did not notify the physician because the issue was not considered a change in condition. The Director of Nursing Services (DNS) was not informed until the next morning, and the resident was sent to the hospital with significant delays. The facility's policies on change of condition and catheter care were not followed, leading to the resident's deteriorating condition and eventual death. The facility's failure to provide appropriate care and timely communication with medical professionals resulted in immediate jeopardy for Resident B.
Removal Plan
- The facility assessed all residents with urinary catheters for signs and symptoms of infection.
- Nursing staff were in-serviced on catheter care and urinary tract infections.
- Staff were educated on assessment and change of condition with urinary catheters.
Failure to Follow Mechanical Lift Transfer Policy
Penalty
Summary
The facility failed to follow its policy and procedure for safe mechanical lift transfers for Resident K. On the day of the incident, Resident K, who was alert and oriented, was placed in a lift pad by a CNA who then left the room without completing the transfer. The resident remained unattended in the lift pad, attached to the mechanical lift, until an occupational therapist and an LPN arrived to complete the transfer. The resident reported minor leg pain but no injuries were documented. The facility's policy requires two staff members to assist with mechanical lift transfers, which was not adhered to in this case. Resident K's clinical records revealed a lack of documentation for a physician's order to use a mechanical lift for transfers and an absence of a care plan addressing the use of the mechanical lift. The resident's quarterly MDS indicated she was cognitively intact, had an indwelling Foley catheter, and was dependent on staff for transfers. Interviews with various staff members, including the Director of Nursing Services, confirmed that the facility's policy mandates two persons to assist with mechanical lift transfers, and that the resident should not have been left unattended. The facility's policies on mechanical lift use and comprehensive care plans were reviewed and found to be consistent with the requirement for two-person assistance during transfers. However, the incident involving Resident K demonstrated a failure to adhere to these policies, resulting in the resident being left in a potentially hazardous situation. The deficiency was identified through observation, interviews, and record reviews, highlighting a lapse in following established safety protocols for resident transfers.
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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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Nursing homes near Terre Haute
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Signature Healthcare Of Terre Haute | 2 mi | ★★★★★ | 19 | 0 |
| Southwood Healthcare Center | 2.2 mi | ★★★★★ | 24 | 2 |
| Harrison's Crossing Health Campus | 2.7 mi | ★★★★★ | 2 | 0 |
| Westminster Village Health & Rehab | 3 mi | ★★★★★ | 1 | 0 |
| Westridge Health Care Center | 3.3 mi | ★★★★★ | 10 | 0 |
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