Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Premier Healthcare Of New Harmony during CMS and state inspections, most recent first.
The facility failed to ensure the Dietary Manager met the required qualifications for the role. The Dietary Manager stated she did not have a CDM certification and had not completed the test despite having the course books for two years. The ADON stated the certification test was required within six months to a year of hire, and the job description listed a CDM credential as a required qualification.
Infection Preventionist Role Not Dedicated Part Time Hours: The DON also served as the IP and stated she spent about two hours each work day on infection control tasks. The DON had been serving in both roles since September 2025, while the IP job description identified the position as full time and responsible for developing, implementing, and monitoring the facility's infection prevention and control program.
PRN lorazepam orders for several hospice residents lacked a specific duration of use after exceeding the 14-day limit. Residents with diagnoses including Alzheimer’s disease, dementia with behavioral disturbance, COPD, chronic respiratory failure, and senile degeneration of the brain had PRN anxiolytic orders for anxiety, restlessness, SOB, and pain with no stop dates or documented prescriber re-evaluation. A pharmacy review requested evaluation of continued PRN lorazepam use, but the physician signed without response, and the ADON stated she was unaware hospice residents were not exempt from the rule.
Inadequate Supervision on Dementia Unit: During meal service and activities in the Cardinal Hall dementia unit, the activities staff left the unit and no staff were observed on the unit or at the nurses' station when two residents appeared to have a verbal altercation. The unit's staffing form called for one full-time nurse and two full-time CNAs on day shift, and the facility policy required sufficient dementia-trained staff and continuous supervision.
Infection prevention measures were not consistently implemented for two residents with urinary catheters and during a dining observation. Two catheter drainage bags were observed resting on the floor while residents were in bed, and during lunch service on the Cardinal Unit, residents were not offered hand hygiene or clothing protectors before eating. The DON stated staff should offer hand hygiene and clothing protectors as needed, and the facility policy required residents to be offered, cued, or assisted with hand hygiene before meals.
A resident with Alzheimer's disease and severe cognitive impairment did not have quarterly care plan conferences completed as required. The resident was dependent on staff for transfers, toileting, and bathing, and the record showed the last care conference was held with the family present months earlier. The ADON confirmed no conference had been completed since July, despite the facility policy calling for quarterly care conferences every 90 days.
The facility failed to revise fall care plans with new interventions after falls for two residents. One resident with severe cognitive impairment and a history of multiple falls had a witnessed fall while sitting on the side of the bed, but the record did not show a new care plan intervention. Another resident with COPD and chronic respiratory failure had unwitnessed falls, yet the fall risk care plan lacked documentation of new interventions after those events.
Lack of Documentation Supporting Psychiatric Diagnoses: The facility failed to document the basis for schizoaffective disorder diagnoses for two residents receiving antipsychotic medications. One resident had severe cognitive impairment and was ordered risperidone, while another resident with Alzheimer's disease and limited communication was ordered Seroquel. In both cases, the record lacked physician documentation showing when or how the diagnoses were determined, and the ADON could not provide supporting records.
A QMA administered PRN tramadol and sumatriptan to a resident with dementia, pain, and migraine headaches without prior authorization from an LPN/RN, despite the resident’s orders requiring nurse approval before PRN administration. The eMAR showed multiple PRN doses given by the QMA without documented nurse contact or permission, even though the facility’s QMA scope required authorization and documentation before giving PRN meds.
Incomplete fall documentation was found for two residents. One resident with vascular dementia had a fall while out of the facility, with a note about knee swelling, pain, and an x-ray request, but the record lacked the fall documentation and related notifications. Another resident with Alzheimer's disease had a fall noted as known to the family and physician, but the chart lacked documentation of the event in progress notes, forms, documents, or assessments; the facility policy required falls to be evaluated and documented, including when and where they occurred and whether they were witnessed or unwitnessed.
Two residents with severe cognitive impairment and histories of wandering were not adequately supervised or monitored, leading to one resident entering another's room and causing a physical altercation that resulted in a bite wound and skin tear. Staff did not consistently document behaviors or update care plans, and there was no policy in place for behavior and wandering prevention.
A resident with no cognitive impairment was found self-administering an unlabeled antacid medication (Tums) from a plastic cup in her room, without a physician's order for the medication. Nursing staff confirmed there was no order for the antacid, and facility policy requiring reporting and removal of unauthorized bedside medications was not followed.
The facility failed to revise care plans quarterly for multiple residents, including those with UTIs and siderails, as required. Care conferences were often not conducted or documented, and catheter care was not consistently implemented. The DON acknowledged the lack of documentation for MDS meetings, contributing to the deficiency.
The facility failed to properly store and label medications, with loose pills found in medication carts and incomplete temperature logs in the medication storage room. Items in the treatment cart were not labeled or stored correctly, and a bottle of Tylenol lacked a resident label. The facility's policies on medication storage and labeling were not followed, resulting in these deficiencies.
The facility failed to properly store, label, and date food items, and did not adequately monitor chemical sanitization during kitchen observations. Items in storage were found unlabeled or past their use-by dates, and the kitchen staff did not maintain a log of sanitization test results, violating food safety standards.
The facility failed to ensure accurate documentation and management of falls for several residents, including those with cognitive impairments. Clinical records lacked neuro checks, IDT discussions, and care plan updates following falls, highlighting systemic issues in maintaining accurate medical records and resident safety.
The facility failed to implement Enhanced Barrier Precautions for a resident with a catheter and did not ensure proper hand hygiene during care activities. Staff were observed not sanitizing hands before and after glove use, and equipment was not cleaned between resident uses. These actions indicate non-compliance with infection control protocols.
The facility did not provide an emergency call system in a public restroom used by residents, as observed during a survey. The restroom, located in the main hallway across from the beauty shop, lacked this essential safety feature. The Director of Nursing confirmed that residents used this restroom, and the facility's policy did not address the need for call lights, leading to the deficiency.
The facility was found to have persistent urine odors in the entrance hallway, conference room, and [NAME] Unit hallways over six days. Despite attempts to mask the smell with air freshener, the odors remained. The Administrator acknowledged the issue, and the facility's policy on maintaining a clean environment was provided.
The facility failed to ensure proper self-administration of medications for two residents. One resident had eye relief drops and pain relief medication at the bedside without a physician order, assessment, or care plan, despite being cognitively intact. Another resident with COPD also lacked the necessary documentation for self-medication. The DON confirmed that medications should not be left at the bedside without proper authorization and assessment.
A facility failed to notify a resident's representative of significant changes in the resident's condition and medication regimen. The resident, with severe cognitive impairment and multiple diagnoses, experienced medication adjustments and a hospital visit for a nasal fracture without the POA being informed, contrary to facility policy.
A resident with Alzheimer's and mobility issues was transferred to the hospital without proper clinical documentation. The facility's policy required that transfer forms and Advanced Directives accompany the resident, but this was not done. The ADON confirmed the paperwork was incomplete and missing.
A resident with Alzheimer's and mobility issues was transferred to the emergency department without receiving a notice of transfer. The facility's policy requires such notices to be provided, but the necessary paperwork was not completed, as confirmed by the ADON.
A resident with Alzheimer's Disease was transferred to the hospital without receiving a bed hold notice, as required by the facility's policy. The ADON confirmed that the necessary paperwork was not completed, resulting in a deficiency.
The facility failed to accurately complete MDS assessments for several residents, leading to discrepancies in documentation of restraints, medications, and falls. A resident's MDS inaccurately indicated bed rails as a restraint, while another's assessment incorrectly documented medication use, including anticoagulants and opioids. Additionally, a resident's fall was not recorded, and opioid use was omitted. The DON acknowledged errors in coding and misclassification of medications, despite the facility's adherence to the RAI Manual.
The facility failed to develop care plans for two residents with new diagnoses and medication orders, including a UTI and multiple medications. Additionally, care plan interventions were not followed for another resident, with missing documentation for monitoring side effects and behaviors. These deficiencies were acknowledged by the DON and highlighted by the facility's Comprehensive Care Plans policy.
A facility failed to document the rationale for a schizophrenia diagnosis for a resident with Alzheimer's, anxiety, and major depressive disorder. The resident's record lacked any assessment or explanation for the new diagnosis, despite receiving multiple medications. The ADON confirmed the absence of documentation, and the facility could not provide a relevant policy, leading to a deficiency finding.
The facility failed to monitor and document pressure ulcers for two residents, leading to deficiencies in wound care. One resident with multiple sclerosis and peripheral vascular disease had incomplete skin assessments, despite physician orders for daily care. Another resident with hemiplegia lacked wound assessments and rationale for treatments. The ADON confirmed missing documentation, contrary to the facility's policy for complete and accurate records.
A resident with Alzheimer's experienced multiple unwitnessed falls resulting in injuries due to inadequate supervision and failure to update care plans. The facility did not conduct thorough post-fall assessments or implement new interventions. Another resident exhibited unsafe wandering behaviors without appropriate care plans in place, highlighting deficiencies in managing exit-seeking behaviors.
The facility failed to provide proper respiratory care for two residents, with issues in oxygen equipment labeling and adherence to care plans. One resident received oxygen without proper labeling, and the facility lacked a system to document equipment changes. Another resident's care plan for pulse oximetry was not consistently implemented, with no physician order in place.
A facility failed to complete required Pre and Post Dialysis Assessments and Dialysis Communication Records for a resident with end-stage renal disease. Despite being marked as done in the MAR, multiple instances of missing documentation were found. The ADON confirmed that staff were supposed to complete these forms, highlighting a lapse in adherence to the facility's Hemodialysis policy, which requires coordination and communication with the dialysis facility.
A facility failed to monitor medication side effects and consider pharmacy recommendations for a resident with Alzheimer's, anxiety, and depression. Despite warnings of drug interactions and adverse symptoms like hallucinations and lethargy, the facility increased medication dosages without proper documentation or monitoring. Interviews revealed a lack of psychiatric services and inconsistent documentation of pharmacy recommendations.
A resident with bacteremia was re-hospitalized after a facility failed to administer an IV antibiotic as ordered. The resident returned from the hospital without antibiotic orders, and subsequent blood culture results were not communicated to the physician. An antibiotic order was delayed, and there was no documentation of IV care or communication with the pharmacy about the missing medication. The resident was sent back to the hospital for treatment after the resident's son intervened.
The facility failed to ensure food was stored and labeled appropriately, and the kitchen areas were free of food and debris. Observations included undated containers of various food items and food debris on the floors. Interviews with staff confirmed the need for proper dating and storage of food items.
Dietary Manager Lacked Required Certification
Penalty
Summary
The facility failed to ensure the kitchen manager met the required qualifications for the dietary manager position. During an interview on 12/1/25, the Dietary Manager stated she did not have a Certified Dietary Manager certification and said she had had the course books for two years but had not had time to complete the certification. During an interview on 12/3/25, the ADON stated the Dietary Manager was required to take the certification test within six months to a year of being hired. Review of employee files showed the Dietary Manager was hired on 3/5/24. On 12/4/25, the Administrator provided a current undated Director of Dietary Services job description that listed Certified Dietary Manager credential as a required education and experience qualification.
Infection Preventionist Role Not Dedicated Part Time Hours
Penalty
Summary
The facility failed to ensure the Infection Preventionist (IP) dedicated part-time hours to the IP role for 1 of 1 staff members reviewed for infection prevention. The full-time DON also served as the facility's IP and stated during interview that she dedicated around two hours each work day to infection control tasks. The DON reported she had been serving as both DON and IP since September 2025. The Administrator provided an IP job description stating the IP is responsible for developing, implementing, and monitoring the facility's Infection Prevention and Control program and that the position type and hours are full time. The Administrator also provided a DON job description stating the DON is responsible for the planning, development, and overall operation of the DON role to ensure guests receive quality care 24 hours a day.
PRN Lorazepam Orders Lacked Required Duration
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic medications, specifically lorazepam, included a specific duration of use when the orders extended beyond 14 days for residents receiving hospice services. Record review showed that four residents had PRN lorazepam orders for anxiety, restlessness, shortness of breath, and/or pain, and the orders did not contain stop dates or documentation showing that the prescriber re-evaluated the orders to support continued use beyond the 14-day limit. Resident 35 had Alzheimer’s disease, was dependent on staff for showering, toileting, and transfers, and had a PRN lorazepam intensol order started on 10/9/25 with no stop date. Resident 4 had dementia with behavioral disturbance and COPD, was severely cognitively impaired, was on hospice services, and had a PRN lorazepam order started on 10/18/24 with no end date. Resident 1 had chronic respiratory failure and COPD, was cognitively intact, was on hospice services, and had a PRN lorazepam order for terminal restlessness, anxiety, shortness of breath, and pain with no end date. Resident 40 had senile degeneration of the brain, was on hospice services, was not assessed for cognitive impairment because she was rarely or never understood, and had a PRN lorazepam order dated 5/6/25 with no stop date. A pharmacy review for Resident 40 requested evaluation of the continued need for PRN lorazepam and suggested discontinuation or adding a stop date for short-term use, but the physician signed the review without indicating a response. The clinical record lacked documentation showing a stop date or re-evaluation for the PRN antianxiety medication, and the ADON stated that PRN antianxiety medications required a 14-day stop date but was unaware that the regulation did not make an exception for hospice residents.
Inadequate Supervision on Dementia Unit
Penalty
Summary
The facility failed to ensure residents were provided adequate supervision on the dementia unit during a random observation in Cardinal Hall dining room. During meal service and activities, residents were seated in the dining room, and the activities staff left the unit at 11:59 A.M. At 12:29 P.M., two residents seated across the table from each other appeared to have a verbal altercation about one resident knocking on the table, and no staff members were observed on the dementia unit or at the nurses' station. At 12:33 P.M., the dining cart was delivered near the nurses' station by dietary, and an LPN was observed exiting a resident's room on the East hall adjacent to the dementia unit. Seven residents were residing in Cardinal Hall at the time of meal service. Review of the Alzheimer's/Dementia Special Care Unit form showed the unit should be staffed with one full-time nurse and two full-time CNAs during the day shift, and the facility's Dementia Care Unit Staffing Policy and Procedure stated the unit must be staffed with sufficient, qualified, and dementia trained personnel at all times and that staff must maintain continuous supervision.
Infection Prevention Measures Not Implemented for Catheter Care and Dining Hygiene
Penalty
Summary
The facility failed to implement infection prevention measures for residents with urinary catheters when catheter drainage bags were observed resting on the floor. Resident 3, who had diagnoses including multiple sclerosis, disorganized schizophrenia, and neuromuscular dysfunction of the bladder, was moderately cognitively impaired, dependent on staff for transferring, hygiene, and dressing, and had a suprapubic catheter with physician orders for routine catheter and urinary bag changes. On 12/1/25, Resident 3’s catheter bag was observed laying on the floor while the resident was lying in bed. Resident 39, who had diagnoses including neuromuscular dysfunction of the bladder and chronic kidney disease, was moderately cognitively impaired, dependent on staff for toileting, and had an indwelling catheter with orders for catheter and urinary bag changes every 14 days. The resident’s catheter bag was observed resting on the floor on two separate occasions while the resident was in bed. During a random dining observation on the Cardinal Unit, residents were seated in the dining room and lunch trays were served, but hand hygiene and clothing protectors were not offered to residents before eating. The DON stated staff serving in the dining room should offer hand hygiene and clothing protectors to residents who may need them, and the facility policy indicated residents are to be offered, cued, or assisted with hand hygiene before meals, snacks, and drinks.
Missed Quarterly Care Plan Conference
Penalty
Summary
The facility failed to ensure care plan conferences were completed quarterly for one resident with Alzheimer's Disease who had severe cognitive impairment and was dependent on staff for transfers, toileting, and bathing. The resident was admitted to the facility, and the most recent Quarterly MDS assessment dated 9/12/25 documented the resident's condition. A family member stated during interview that no care plan conferences had been held since the resident was admitted. Record review showed the most recent care plan conference occurred on 7/9/25 with the family member present, and the clinical record lacked documentation of any conference after that date. The ADON confirmed during interview that no care plan conference had been completed since July and stated that care plan conferences were to be completed quarterly. The facility also provided a policy stating quarterly care conferences are held every 90 days.
Failure to Update Fall Care Plans After Resident Falls
Penalty
Summary
The facility failed to revise residents’ care plans with new interventions after falls for 2 of 4 residents reviewed. One resident had diagnoses including alcohol dependence with alcohol-induced persistent dementia, severe cognitive impairment, total dependence for ADLs, and a documented history of multiple falls with and without injury. The resident’s fall risk assessment identified the resident as at risk for falls, and the care plan included interventions such as assistance with transfers, a clutter-free environment, daily ADL assistance, nonskid footwear, and therapy as ordered. The actual falls care plan documented multiple falls, including a witnessed fall while sitting on the side of the bed, but the record lacked documentation showing that a new intervention was added to the care plan after that fall. Another resident had diagnoses including chronic respiratory failure and COPD, was cognitively intact, required supervision for eating, hygiene, dressing, and transferring, and had a history of falls. Physician orders included nonskid strips in front of the recliner and a commode riser for toileting transfers. After an unwitnessed fall from sliding out of bed and another unwitnessed fall identified in a post-fall evaluation, the current fall risk care plan did not contain documentation of new interventions for those falls. The ADON stated there should be a new intervention after each fall, and the facility’s comprehensive care plan policy stated that care plans are revised as information about the resident and the resident’s condition change.
Lack of Documentation Supporting Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure practitioner diagnostic practices met professional standards of care for two residents reviewed for medication use. One resident had diagnoses including dementia with behavioral disturbance and schizoaffective disorder, and the current quarterly MDS showed severe cognitive impairment, dependence on staff for transferring, toileting, and hygiene, and antipsychotic use during the lookback period. Current physician orders included risperidone 0.5 mg twice daily related to schizoaffective disorder, bipolar type, but the clinical record lacked documentation showing that this diagnosis existed before admission or explaining when and how it was determined. The ADON was unable to provide documentation supporting the diagnosis when asked. A second resident had diagnoses including schizoaffective disorder, bipolar type and Alzheimer's disease, and the most recent significant change MDS showed cognition could not be assessed because the resident was rarely understood and was dependent on staff for showering, toileting, and transfers. Physician orders included Seroquel 12.5 mg daily related to schizoaffective disorder, bipolar type, and the record showed the diagnosis was added after admission. A pharmacy recommendation signed by the physician did not identify a new diagnosis, and the clinical record, including progress notes, documents, and assessments, lacked documentation showing where the diagnosis came from. The ADON stated she was unsure where the diagnosis came from and could not locate a physician assessment or documentation that the physician gave the diagnosis.
QMA Administered PRN Medications Without Nurse Authorization
Penalty
Summary
The facility failed to ensure Qualified Medication Aides (QMAs) provided services within their scope of practice for 1 of 5 residents reviewed for medication use. Resident 7 had diagnoses including dementia, pain, and migraine headaches, and the most current Quarterly MDS assessment indicated the resident was cognitively intact, independent in all ADLs, and had received an opioid medication during the 7-day lookback period. Physician orders included tramadol 50 mg every 8 hours as needed for pain and sumatriptan succinate 25 mg every 24 hours as needed for migraine headaches. Review of Resident 7’s eMAR from 10/1/25 to 12/2/25 showed multiple administrations of tramadol 50 mg PRN by QMA 12 without authorization from a licensed nurse, including on 10/5/25, 10/14/25, 10/17/25, 10/18/25, 10/21/25, and 10/28/25. The eMAR also showed sumatriptan 25 mg PRN was administered by QMA 12 without authorization from a licensed nurse on 11/4/25. During interview, QMA 15 stated that before a QMA gave a PRN medication, authorization from a nurse was acquired and documented in the medication administration notes. The Administrator provided the facility’s QMA Scope of Practice, which stated PRN medication may be administered only if authorization is obtained from the licensed nurse on duty or on call and documented in the resident record.
Incomplete fall documentation in resident records
Penalty
Summary
The facility failed to ensure complete and accurate documentation was available in the clinical record for two residents reviewed for falls. One resident with vascular dementia was severely cognitively impaired, dependent on staff for bathing, and independent for transfers, with multiple prior falls documented in the care plan. The record included a health status progress note describing swelling to the left knee, moderate pain, and a request for an x-ray after a fall while the resident was out of the facility at an appointment, but the clinical record lacked documentation of the fall itself, notification to family regarding the fall, or the x-ray order in progress notes, forms, documents, or assessments. The DON stated staff would be expected to document a fall that occurred outside the facility once the resident returned. A second resident with Alzheimer's disease was unable to be assessed for cognition because the resident was rarely understood and was dependent on staff for showering, toileting, and transfers, with two or more falls without injury since the prior MDS assessment. The care plan identified prior actual falls and included an intervention to place the resident in a wheelchair and keep the resident in line of sight when up out of bed. A nurse's note stated the resident's family and physician were aware of a fall, but the clinical record lacked documentation of the fall in clinical progress notes, forms, documents, or assessments. The facility policy stated staff would evaluate and document falls, including when and where they happened and whether they were witnessed or unwitnessed.
Failure to Supervise and Monitor Residents with Dementia Resulting in Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring of residents with dementia and wandering behaviors, resulting in a resident-to-resident altercation that caused injury. One resident with severe cognitive impairment and a history of wandering was not properly observed or redirected, despite physician orders to monitor and document behaviors every shift. The resident's care plan identified wandering and impaired safety awareness, but documentation of behavioral monitoring was incomplete, and there was no evidence that staff consistently followed the monitoring protocol. Progress notes indicated multiple incidents of the resident entering other residents' rooms, exhibiting agitation, and being difficult to redirect prior to the altercation. An incident occurred in which the resident with wandering behaviors entered another resident's room, leading to a physical altercation where the resident bit another resident's forearm, resulting in a skin tear and bruising. The injured resident, who also had severe cognitive impairment, required wound care and was assessed for further injury. Documentation showed that the injured resident complained of pain and received treatment as ordered by the physician. Observations confirmed the presence of a healing wound on the resident's forearm following the incident. Interviews with staff revealed that the facility did not have a policy regarding resident behavior and wandering prevention. Additionally, the care plan for the resident who was injured was not updated following the increase in wandering and agitation behaviors observed in the other resident. The lack of adequate supervision, incomplete documentation, and failure to update care plans contributed to the occurrence of the altercation and subsequent injury.
Resident Self-Administered Unordered and Unlabeled Medication
Penalty
Summary
A resident was observed self-administering an antacid medication (Tums, calcium carbonate) from an unlabeled plastic cup in her room. The cup contained multi-colored tablets with no identifying information, and the resident indicated she was using the medication for stomach discomfort. Review of the resident's medical record showed no physician order for calcium carbonate or any antacid medication, although there was an order allowing the resident to self-administer insulin and keep insulin and accu-check supplies at bedside. The resident's most recent assessment indicated no cognitive impairment, and a prior self-administration assessment confirmed capability to self-administer medications. During interviews, nursing staff confirmed that the resident did not have a physician's order to self-administer any medication other than insulin, and it was suggested that the antacid medication was likely brought in by the resident's family without notifying staff. Facility policy requires that any unauthorized medication found at the bedside be reported to the charge nurse and returned to the family or responsible party. This policy was not followed in this instance, resulting in the resident having access to and self-administering a medication that was not ordered or properly labeled.
Deficiency in Care Plan Revisions and Documentation
Penalty
Summary
The facility failed to ensure that care plans were revised quarterly for 12 out of 13 residents reviewed for care planning and conferences, as well as for residents with urinary tract infection catheters and siderails. This deficiency was identified through interviews and record reviews, revealing that care plans were not updated as required, and care conferences were either not conducted or not documented. For instance, Resident 7's clinical record lacked documentation of care plan conferences prior to February 2024, despite multiple offers being declined by the Power of Attorney. Resident 11's care plan was not implemented for catheter care on numerous dates across July, August, and September 2024, and the Director of Nursing acknowledged that catheter care should be done every shift with output documented. Additionally, the care plan for Resident 11's restraint use was not adequately updated, and care conferences were not conducted before February 2024. Similarly, Resident 17's care plan was not revised to reflect the current needs, and care conferences were not held as required. The report also highlights that several residents, including Residents 18, 23, and R, lacked documentation of care plan conferences over the past year. The facility's policy mandates that comprehensive care plans be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, but this was not adhered to. The Director of Nursing admitted that MDS meetings were held weekly but were not documented, contributing to the deficiency in care planning and conference documentation.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications across multiple areas, including three medication carts, one treatment cart, and a medication storage room. Observations revealed loose pills in the drawers of the medication carts on the 200-M, 300, and 400 Halls, with some pills lacking proper labeling. Additionally, the 200-M Hall treatment cart contained opened items such as Triple Antibiotic Ointment and Therahoney Gel that were not labeled or stored in individual resident bags. A bottle of Tylenol was found in the 300 Hall medication cart without a resident name or label, which was acknowledged by an LPN who indicated a label would be printed. The medication storage room also exhibited deficiencies, as the refrigerator temperature logs were incomplete for several days in September 2024. The Assistant Director of Nursing indicated that either nurses or Qualified Medication Aides were responsible for cleaning out the medication carts. The facility's policies on medication storage and labeling, provided by the Regional Consultant, emphasize the importance of proper labeling and temperature monitoring, yet these were not adhered to, leading to the observed deficiencies.
Improper Food Storage and Sanitization Monitoring
Penalty
Summary
The facility failed to ensure proper storage, labeling, and dating of food items in accordance with professional standards during two kitchen observations. During the initial tour of the kitchen, several items in the dry storage area, walk-in freezer, and walk-in fridge were found to be improperly labeled or undated. These included a bottle of apple cider vinegar, bags of Spanish rice, coffee cake, jalapenos, tomatoes, raw meat, pizza sauce, biscuits, pitchers of various liquids, and condiments such as ketchup and mustard. Many of these items were either past their use-by dates or lacked any labeling to indicate their freshness, which is a violation of food safety standards. Additionally, the facility did not adequately monitor the chemical sanitization process. The kitchen manager indicated that while a high-temperature dishwasher was used for most items, some were handwashed in a three-compartment sink. However, the kitchen staff did not maintain a log of the sanitization test results, which is necessary to ensure the effectiveness of the sanitization process. The regional consultant provided documentation outlining the requirements for date marking and manual warewashing, which the facility failed to adhere to, further contributing to the deficiency.
Deficiencies in Fall Documentation and Management
Penalty
Summary
The facility failed to ensure accurate and complete documentation of falls for several residents, leading to deficiencies in their care. Resident 9, diagnosed with Alzheimer's disease, experienced multiple falls, some of which were unwitnessed. The clinical records for these incidents lacked documentation of neuro checks and discussions by the Interdisciplinary Team (IDT). Additionally, the care plan was not consistently updated with new interventions following each fall, indicating a lapse in the facility's protocol for managing fall risks. Resident 12, with severe cognitive impairment, also experienced multiple unwitnessed falls. The clinical records for these incidents were incomplete, missing neuro checks and documentation of IDT discussions. In one instance, the facility failed to document the fall entirely, including the notification of the physician and the resident's representative. This lack of documentation and follow-up highlights a significant gap in the facility's fall prevention and management practices. Other residents, including Residents 19, 7, and 11, also experienced falls with similar documentation deficiencies. These included missing post-fall evaluations, neuro checks, and updates to care plans. The facility's failure to adhere to its fall prevention protocol and ensure comprehensive documentation for each fall incident reflects a systemic issue in maintaining accurate medical records and safeguarding resident safety.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling catheter. Over several days, surveyors observed that there was no EBP sign on the resident's door, despite the resident's medical conditions, including chronic kidney disease and benign prostatic hyperplasia, which necessitated the use of a catheter. The resident was dependent on staff for various activities, and the lack of EBP signage indicated a failure to adhere to infection prevention protocols. Additionally, the facility did not ensure proper hand hygiene practices during incontinence care and medication administration. On multiple occasions, staff members were observed not sanitizing their hands before and after glove use, and after performing tasks such as incontinence care and medication administration. This included instances where staff touched items in the resident's room with contaminated gloves and failed to perform hand hygiene before entering and after leaving residents' rooms. The facility also failed to clean equipment between resident uses. Observations included a blood pressure cuff and glucometer not being cleaned after use on residents. During wound care, a nurse was seen applying medication directly to a wound bed without using sterile applicators and not performing adequate hand hygiene during glove changes. These actions demonstrate a lack of adherence to the facility's policies on hand hygiene and equipment cleaning, contributing to the risk of infection transmission.
Lack of Emergency Call System in Resident-Used Restroom
Penalty
Summary
The facility failed to ensure the safety of residents by not providing an emergency call system in a public restroom used by residents. During a survey conducted from September 9 to September 16, 2024, it was observed that the visitor restroom located in the main hallway across from the beauty shop lacked an emergency call system. This restroom was used by residents visiting the beauty shop, as confirmed by the Director of Nursing during an interview on September 16, 2024. The facility's policy on Personal Property-Home Like Environment, provided by the Regional Clinical Support Nurse, did not include information regarding the requirement for call lights, contributing to the deficiency.
Persistent Urine Odors in Facility
Penalty
Summary
The facility failed to maintain a safe and sanitary environment, as evidenced by persistent urine odors observed over a period of six days in various areas, including the entrance hallway, conference room, and [NAME] Unit hallways. Specific observations included the presence of urine odors in the entrance hallway and conference room on multiple occasions, as well as in the [NAME] Hall Unit Nurses Station and the hallway outside the conference room. The strong smell of urine was noted despite attempts to mask it with air freshener. During an interview, the Administrator acknowledged that the facility should be free of smells and clean. The facility's policy on maintaining a home-like environment, which includes daily cleaning to eliminate odors, was provided by the Regional Clinical Support Nurse.
Failure to Ensure Proper Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents who had medications at their bedside had the necessary physician orders, self-administration assessments, and care plans in place. Resident 14 was observed on multiple occasions with eye relief drops and cooling pain relief medication on the bedside table. Despite being cognitively intact and requiring partial assistance with daily activities, Resident 14's clinical record lacked a physician order, self-administration assessment, and care plan for the self-administration of these medications. Similarly, Resident 36, who was diagnosed with COPD and was cognitively intact, was found to be independent with some activities but needed supervision with mobility and transfer. The clinical record for Resident 36 also lacked the necessary order and care plan for self-medication. The Director of Nursing confirmed that medications should not be left at the bedside without an order and self-medication administration assessment. The facility's policy requires an interdisciplinary team to determine the appropriateness of self-administration, considering factors such as cognitive status and comprehension of medication instructions.
Failure to Notify Resident's Representative of Condition Changes
Penalty
Summary
The facility failed to notify a resident's representative during a change in condition, specifically for a resident with severely impaired cognition who was reviewed for unnecessary medications. The resident, who was admitted with diagnoses including Alzheimer's Disease, anxiety, major depressive disorder, and visual/auditory hallucinations, was completely dependent on staff for daily activities and was receiving multiple psychotropic medications. Despite significant changes in medication dosages, such as increases in Olanzapine and Sertraline, and the initiation of Haloperidol, there was no documentation of notification to the resident's power of attorney (POA). Additionally, the resident was seen in a hospital office for a nasal bone fracture, and the physician noted that the POA was unaware of the visit and the discussion of treatment options. The facility's policy requires notifying the resident's representative of any new events, changes in condition, or order updates, which was not adhered to in this case. The assistant director of nursing confirmed that staff are expected to notify the resident's representative under such circumstances, highlighting a lapse in following the facility's notification policy.
Failure to Provide Documentation During Resident Transfer
Penalty
Summary
The facility failed to ensure proper clinical documentation was sent with a resident during a transfer to the hospital. Resident 37, who was admitted with diagnoses including Alzheimer's Disease and abnormalities of gait and mobility, was completely dependent on staff for daily activities and was on multiple medications. On a specific date, Resident 37 was transferred to the emergency department by ambulance, but the clinical record lacked documentation of the paperwork sent with the resident. The Assistant Director of Nursing confirmed that the necessary paperwork was not completed and did not exist. The facility's policy required that original copies of the transfer form and Advanced Directive accompany the resident, with copies retained for the medical record, but this was not adhered to in this instance.
Failure to Provide Transfer Notice to Resident
Penalty
Summary
The facility failed to provide a notice of transfer to a resident or their representative during a hospital transfer. This deficiency was identified for one of the four residents reviewed for hospital transfers. The resident in question, who was admitted with diagnoses including Alzheimer's Disease and mobility issues, was transferred to the emergency department by ambulance. The clinical record did not contain documentation of the notice of transfer being provided to the resident or their representative. During an interview, the Assistant Director of Nursing (ADON) confirmed that the necessary paperwork for the transfer was not completed and did not exist. The facility's policy requires that a notice of transfer and the facility's bed hold policy be provided to the resident and their representative, and that copies of notices for emergency transfers be sent to the Ombudsman. However, this procedure was not followed in the case of the resident transferred on the specified date.
Failure to Provide Bed Hold Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide a bed hold notice upon the transfer of a resident to the hospital. Resident 37, who was admitted with diagnoses including Alzheimer's Disease and abnormalities of gait and mobility, was transferred to the emergency department by ambulance. The resident's clinical record did not contain documentation of the bed hold notice being provided at the time of transfer. During an interview, the Assistant Director of Nursing (ADON) confirmed that the necessary paperwork for the transfer on the specified date was not completed and did not exist. The facility's policy on transfer and discharge requires that a notice of transfer and the facility's bed hold policy be provided to the resident and their representative, but this was not adhered to in the case of Resident 37.
Inaccurate MDS Assessments for Restraints, Medications, and Falls
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for several residents, leading to discrepancies in the documentation of restraints, medications, and falls. For Resident 11, the MDS assessment inaccurately indicated the use of bed rails as a restraint, despite physician orders for bilateral 1/2 siderails for assistance with positioning and turning. Similarly, Resident 19's MDS assessment incorrectly documented the use of anticoagulants and opioids, although the resident was not on anticoagulants and had a prescription for hydrocodone-acetaminophen for pain management. The assessment also inaccurately noted the use of bed rails as a restraint. Resident 37's MDS assessment failed to record a fall that occurred since the previous assessment and omitted the use of opioids, despite the resident receiving such medication. The Director of Nursing (DON) acknowledged errors in coding the MDS assessments, including misclassifying Plavix as an anticoagulant instead of an antiplatelet and incorrectly documenting the use of restraints. These inaccuracies highlight a lack of adherence to the Resident Assessment Instruction (RAI) Manual, which the facility claims to follow.
Deficiencies in Care Planning and Documentation
Penalty
Summary
The facility failed to develop care plans for residents with new diagnoses and medication orders, leading to deficiencies in care planning for two residents. Resident 12, who had a new diagnosis of a urinary tract infection (UTI) and was prescribed Ciprofloxacin, did not have a care plan addressing the UTI or antibiotic use. This oversight was acknowledged by the Director of Nursing (DON), who indicated that care plans should be developed for residents with new infections or antibiotic orders. Similarly, Resident 7, who was on multiple medications including antiplatelets and anticoagulants, lacked a care plan for these medications, which was also confirmed by the DON. Additionally, the facility failed to follow care plan interventions for Resident 17, who was on several medications including antipsychotics, antidepressants, and anticoagulants. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) for August and September 2024 showed multiple instances where documentation was lacking, and care plan interventions were not followed, such as monitoring for side effects and behaviors. The facility's Comprehensive Care Plans policy, provided by the Regional Consultant, emphasized the need for care plans to describe services necessary to maintain residents' well-being, highlighting the deficiencies in the facility's care planning and documentation practices.
Failure to Document Rationale for Schizophrenia Diagnosis
Penalty
Summary
The facility failed to ensure that a practitioner's diagnostic practices met professional standards of care for a resident diagnosed with schizophrenia. The resident, who was over a certain age and had been admitted with diagnoses including Alzheimer's Disease, anxiety, major depressive disorder, and visual/auditory hallucinations, received a new diagnosis of schizophrenia. However, the clinical record lacked documentation explaining the rationale for this diagnosis or any assessment that led to it. The resident's Minimum Data Set (MDS) assessment indicated severe cognitive impairment and complete dependence on staff for daily activities, and the resident was receiving multiple medications, including antipsychotics and antidepressants. During an interview, the Assistant Director of Nursing (ADON) confirmed that there was no documented rationale for the schizophrenia diagnosis. Additionally, the facility was unable to provide a policy related to ensuring services met professional standards. This lack of documentation and policy adherence contributed to the deficiency identified by the surveyors.
Deficiency in Pressure Ulcer Monitoring and Documentation
Penalty
Summary
The facility failed to adequately monitor and document the progression of pressure ulcers for two residents, leading to deficiencies in wound care management. Resident 23, who has multiple sclerosis and peripheral vascular disease, was found to have incomplete skin assessments for several weeks in August and September. Despite having physician orders for daily wound care and weekly skin assessments, the documentation was lacking. The Assistant Director of Nursing (ADON) confirmed that a contracted wound physician had been following the resident's wound progress, but staff were still required to document weekly assessments, which they failed to do. Similarly, Resident 18, diagnosed with hemiplegia and hemiparesis, also experienced a lack of proper wound documentation. The resident's clinical record did not include wound assessments or a rationale for the application of wound treatments to the lumbar and thoracic spine. Weekly skin assessments were also missing for several weeks in August and September. The ADON indicated that the dressings were applied for pressure prevention, but no documentation was completed. The facility's policy was to follow standard nursing practice and ensure complete and accurate documentation, which was not adhered to in these cases.
Inadequate Fall Prevention and Supervision in LTC Facility
Penalty
Summary
The facility failed to provide adequate care and supervision to prevent accidents for Resident 37, who experienced multiple unwitnessed falls resulting in injuries, including a nose fracture. The resident, diagnosed with Alzheimer's Disease and other conditions, was on multiple psychotropic medications, which were not adequately monitored for interactions and side effects. Despite the resident's high fall risk, the care plan was not updated after falls, and there was a lack of thorough post-fall assessments and interventions. Resident 37's clinical records showed a pattern of inadequate documentation and follow-up after falls. The care plan was not revised after the initial fall, and subsequent falls were not properly evaluated by the interdisciplinary team to determine their causes or to implement new interventions. The facility's failure to conduct complete neuro assessments and fall risk evaluations further contributed to the resident's repeated falls and injuries. Additionally, the facility failed to address unsafe wandering behaviors for Resident 201, who exhibited exit-seeking behaviors. Despite multiple documented instances of wandering and attempts to exit the facility, there were no care plans in place to manage these behaviors. The facility's policies on elopement and wandering were not effectively implemented, as evidenced by the resident's ability to open a door to a restricted area without staff intervention.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, leading to deficiencies in oxygen equipment labeling and adherence to care plans. Resident 15 was observed receiving oxygen via nasal cannula without proper labeling on the oxygen tubing or humidification bottle. The oxygen concentrator was left on while the resident was not in the room, and the tubing was improperly stored. The clinical record for Resident 15 lacked an order to change the oxygen tubing and humidification bottle, despite the resident's diagnoses of chronic respiratory failure and COPD. Resident 11's care plan included an intervention for pulse oximetry twice daily, but the facility failed to implement this consistently. The vital sign record showed infrequent pulse oximetry readings, and there was no physician order for pulse oximetry. Interviews with the DON and ADON revealed that the facility did not have a system to document or monitor the changing of oxygen equipment, and staff were expected to check dates on equipment without a formal process in place. The facility's policy on oxygen administration was not followed, contributing to the deficiencies observed.
Failure to Complete Dialysis Assessments and Communication Records
Penalty
Summary
The facility failed to provide ongoing assessment and monitoring for a resident requiring dialysis, specifically by not completing Pre Dialysis Assessments, Post Dialysis Assessments, and Dialysis Communication Records as required. Resident 15, who was cognitively intact and required dialysis due to end-stage renal disease, attended dialysis sessions three times a week. However, the clinical record showed multiple instances where the required assessments and communication records were not completed, despite being marked as done in the Medication Administration Record (MAR). The Assistant Director of Nursing (ADON) confirmed that staff were supposed to complete these forms and that marking them as complete on the MAR without actual documentation was incorrect. The facility's Hemodialysis policy emphasized the importance of coordination and communication between the nursing home and the dialysis facility, including the completion of documentation to ensure treatments were provided as ordered. The lack of completed forms on several dates indicates a failure in adhering to these documentation and communication protocols.
Failure to Monitor Medication Side Effects and Consider Pharmacy Recommendations
Penalty
Summary
The facility failed to properly monitor medication side effects and consider pharmacy recommendations for a resident with multiple diagnoses, including Alzheimer's Disease, anxiety, major depressive disorder, and visual/auditory hallucinations. The resident was on a regimen of psychotropic medications, including antipsychotics, antidepressants, and opioids, without adequate monitoring for side effects or effectiveness. Despite pharmacy recommendations for a gradual dose reduction (GDR) and concerns about drug interactions, the facility did not implement these suggestions, and the resident continued to experience adverse symptoms such as lethargy, pacing, hallucinations, and tearfulness. The resident's medication regimen included Lorazepam, Morphine Sulfate, Olanzapine, Mirtazapine, Sertraline, and Haloperidol, with documented drug-to-drug interactions that could lead to severe conditions like serotonin syndrome and neuroleptic malignant syndrome. Despite these warnings, the facility increased dosages and added new medications without proper documentation of side effect monitoring. The resident exhibited symptoms such as drooling, hallucinations, and nonsensical speech, which were not adequately assessed or addressed in the clinical records. Interviews with facility staff revealed that pharmacy recommendations for GDR were not consistently documented or signed by the physician, and the resident had not received psychiatric services since admission, despite consent from the resident's POA. The facility's policy required monitoring for side effects and complications related to psychoactive medications, but this was not effectively implemented, leading to a deficiency in the care provided to the resident.
Failure to Administer IV Antibiotic Leads to Re-hospitalization
Penalty
Summary
The facility failed to administer an intravenous (IV) antibiotic to a resident in accordance with physician orders, resulting in the resident being re-hospitalized. The resident, who had diagnoses including congestive heart failure, diabetes mellitus, and bacteremia, was initially sent to the hospital for pneumonia evaluation and treatment. Upon returning to the facility, the resident had no antibiotic orders, and subsequent blood culture results indicating bacteremia were not communicated to the physician by the staff. A physician's order for the antibiotic ertapenem sodium was entered with a start date that was delayed, and there were no orders for IV placement, maintenance, flushing, or dressing change. The resident's midline IV was placed, but there was a lack of documentation regarding its assessment and monitoring for signs of bacteremia. The antibiotic was not delivered to the facility as expected, and there was no evidence that staff notified the physician or communicated with the pharmacy about the missing medication. The resident was eventually transported to the hospital for IV antibiotic treatment after the resident's son contacted the physician. The facility's Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the lack of documentation and communication regarding the antibiotic order and IV care. The facility's policies on IV catheter care, notification of changes, and pharmacy services were not adequately followed, contributing to the deficiency.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to ensure food was stored and labeled appropriately, and the kitchen areas were free of food and debris. During an initial tour of the kitchen, surveyors observed multiple instances of improperly labeled or unlabeled food items in the walk-in refrigerator, drink refrigerator, spice rack, and dry storage area. Specific observations included undated containers of orange juice, lemonade, milk, cucumbers, garlic, dressings, lemon juice, and various spices. Additionally, food debris and paper were found on the floors of the walk-in freezer, drink refrigerator, and dry storage area. The vent under the hood also had a grease buildup. Interviews with kitchen staff confirmed that food items should be dated when opened or prepared, and crumbs should be stored in closed bins with marked dates. The Administrator, who was temporarily supervising the dietary department, provided outdated policies from 2010 that indicated food should be stored in labeled and dated bins or containers. The deficiency was related to a complaint investigation and highlighted the facility's failure to adhere to proper food storage and labeling standards, as well as maintaining cleanliness in the kitchen areas.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 248 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near New Harmony
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Haven On The River | 9.8 mi | ★★★★★ | 13 | 1 |
| Mount Vernon Nursing And Rehabilitation | 13.8 mi | ★★★★★ | 3 | 0 |
| White County Rehab And Nursing | 14 mi | ★★★★★ | 2 | 0 |
| Wabash Senior Living & Rehab | 14.2 mi | ★★★★★ | 10 | 1 |
| Transcendent Healthcare Of Owensville | 15 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.