Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 St Elizabeth Healthcare Center during CMS and state inspections, most recent first.
A facility failed to ensure alternative menu choices were offered to residents who chose to eat in their rooms. Residents reported they could not receive alternate meal selections unless they went to the dining room to pick up the food themselves, and one resident said this was a recent change from prior practice. The DON said a corporate All Day Dining policy was being used to deny alternate choices to room-bound residents, while the Administrator and Corporate Support Nurse stated there was no facility policy supporting that process.
A resident with diagnoses including PTSD, bipolar disorder, borderline personality disorder, anxiety disorder, and cognitive communication deficit had a PASARR Level II that did not show PTSD as a documented diagnosis, despite the DON stating the resident had PTSD. The SSD stated that a new PASARR Level I was needed when a new mental health diagnosis or mental health medication was added, but it was not completed for this resident, and the facility did not provide a PASARR policy prior to exit.
A resident with PTSD, bipolar disorder, cognitive communication deficit, borderline personality disorder, and anxiety disorder did not have a care plan for PTSD in the electronic record. The PTSD diagnosis was added to the chart, and both the DON and SSD confirmed the diagnosis and that a PTSD care plan was missing.
The facility failed to ensure a resident received scheduled isosorbide dinitrate on time, with multiple MAR entries showing doses given outside the ordered times, and the resident reported having to wait after calling for her pills. The facility also failed to maintain a current MD order for a resident’s right temple skin impairment after the prior wound order ended, even though the dressing remained in place and the resident later preferred a Band-Aid over the island dressing.
A resident with a right femur fracture, prior lower-extremity fractures, difficulty walking, and dependence on staff for mobility and transfers was observed being moved from a wheelchair to bed with a gait belt and slide board. Therapy had recommended slide board transfers with two people and placement toward the resident's good leg, but the EMR had no physician order or comprehensive person-centered care plan for slide board use, and the DON confirmed none was in place.
Oxygen Therapy Order Not Implemented: A resident with COPD, Alzheimer’s disease, major depressive disorder, and HTN was observed receiving oxygen at 2 L and with the concentrator set at 3 L, while the record showed a physician’s order for 2 L continuous oxygen with titration parameters. The DON stated the resident had been on oxygen since admission without an order, and the facility policy required verification of a physician’s order before administering oxygen.
A resident with PTSD, panic disorder, major depressive disorder, bipolar disorder, borderline personality disorder, and anxiety disorder did not have a care plan documenting the PTSD root cause, triggers, or interventions. The resident’s profile listed trauma triggers and cultural preferences without specifics, and multiple behavior care plans addressed issues such as refusal of care, sexually inappropriate comments, false accusations, and hallucinations without linking them to PTSD. A trauma screening was delayed for months after the diagnosis was added, and when completed, it identified a potential traumatic experience but no triggers or cultural trauma.
The facility did not provide required written discharge notices and bed hold policy information, including cost details, to residents and their representatives during hospital transfers. Documentation and staff interviews confirmed that, despite facility policy, there was no evidence that this information was given to multiple residents with complex medical conditions at the time of their transfer.
Staff administered and read Mantoux TB skin tests without documented training and failed to record required times for test administration and reading, resulting in tests being read too early or without proper documentation. Residents with complex medical conditions were affected, and facility policy requiring trained staff and complete documentation was not followed.
Staff did not obtain a follow-up weight or document refusals for a resident who experienced significant weight loss and gain, and failed to notify the physician, dietitian, or family representative as required by facility policy. Interviews indicated inconsistent practices and lack of documentation regarding weight refusals and follow-up.
The facility did not resolve ongoing grievances from residents about delayed call light response times, as documented in multiple resident council meetings and confirmed by resident interviews. Despite repeated complaints and facility policies requiring follow-up, there was no evidence that specific concerns were addressed or resolved, and documentation of actions taken was lacking.
The facility failed to document the progress of a non-pressure skin wound, monitor and document edema for a resident with a splint, and notify physicians of elevated blood sugar readings. Additionally, the facility did not follow physician's orders for medications for multiple residents, as confirmed through observations, record reviews, and staff interviews.
The facility failed to ensure proper respiratory care for three residents, leading to deficiencies in oxygen administration. Observations revealed inconsistencies in oxygen flow rates and undated oxygen tubing, contrary to physician's orders. Interviews with staff indicated a lack of adherence to prescribed oxygen levels.
The facility failed to ensure staff followed infection control standards, including handwashing during food service, using enhanced barrier precautions during wound care, and proper handling of soiled linens. Staff members acknowledged these lapses during interviews.
The facility failed to address and document resident council concerns about call light response times over several months. Residents reported long wait times for call light responses, sometimes up to an hour, and had to provide their own care due to staff inaction. The facility's policies on grievance resolution were not followed, leading to unresolved and undocumented concerns.
The facility failed to provide the required 48-hour Notice of Medicare Non-Coverage (NOMNC) for two residents, giving only a 24-hour notice instead. The Executive Director could not explain the reason for the insufficient notice period, as the responsible staff member was on leave. The facility's policy mandates a 2-day notice prior to Medicare discharge.
The facility failed to complete a revised PASARR level I for a resident after prescribing duloxetine for depression. The oversight was confirmed by the Executive Director and Clinical Support Nurse, who noted the facility did not have a specific PASARR policy.
The facility failed to remove expired medications and ensure proper labeling in the 500 back hall medication cart. Expired bottles of Robitussin DM and Geri tussin Liquid were found, along with unlabeled Tums, Diclofenac gel, and Children's Tylenol. A QMA was unaware of which residents were receiving the unlabeled medications and acknowledged the expired medications should have been removed.
The facility failed to maintain resident rooms and hallways in good repair and free of odors. Observations showed missing carpet and loud, old beds. Several rooms had strong urine odors, and staff were unaware of actions being taken to address the issue. The facility did not provide an environmental policy at the time of the exit conference.
Alternative Meal Choices Not Offered to Residents Eating in Rooms
Penalty
Summary
The facility failed to ensure alternative food choices were offered to residents who chose to receive meals in their rooms. During interviews, Resident 4 stated that the alternative food choices listed on the menu were not available to residents who ate in their rooms. Resident 40 stated she chose to eat in her room and had to go to the dining room to pick up her meal and bring it back herself in order to receive food from the alternative menu, and said this was a recent change from prior practice. Resident 41 stated a new policy had recently been put in place and he could not receive food choices from the alternative menu unless he went to the dining room to eat for meals. The DON stated the facility had a corporate policy titled All Day Dining and that residents who chose to eat in their rooms could not have the option for alternative menu choices. The DON said the corporate policy had been in place for about a year and was activated at this facility in January. The Administrator stated residents who ate in their rooms could not receive an alternative meal unless they physically went to the dining room to pick it up, or someone else had to take them or their family obtain it for them, and stated there was no facility policy indicating this process. The Corporate Support Nurse stated there was no dining policy in place related to residents who chose to eat in their rooms not receiving alternative menu options, and that the process should not have been in place.
Failure to Complete PASARR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure a PASARR was completed when a resident had a new mental health diagnosis added. Resident 24’s clinical record showed diagnoses including PTSD, bipolar disorder, cognitive communication deficit, borderline personality disorder, and anxiety disorder. A PASARR Level II dated 6/19/22 had PTSD handwritten on the document, but during interview the DON stated the resident had a PTSD diagnosis, and the PASARR help desk later indicated there were no records showing PTSD on that Level II document. During interview, the SSD stated that when a resident had a new mental health diagnosis or mental health medication added, a new PASARR Level I needed to be completed. The record review and interviews showed that this was not done for Resident 24 after the PTSD diagnosis was added. The facility also did not provide a PASARR policy prior to exit.
Missing PTSD Care Plan
Penalty
Summary
A comprehensive person-centered care plan was not developed and implemented for Resident 24, who had diagnoses including PTSD, bipolar disorder, cognitive communication deficit, borderline personality disorder, and anxiety disorder. The clinical record showed PTSD was added to the resident’s diagnosis list on 5/5/24, and a PASARR level II dated 6/19/22 also handwrittenly identified PTSD. However, no care plan was located in the resident’s electronic record related to PTSD. During interviews, the DON confirmed the resident had a PTSD diagnosis, and the SSD stated Resident 24 did not have a care plan for PTSD and should have one.
Delayed medication administration and missing wound treatment order
Penalty
Summary
The facility failed to ensure Resident 24 received isosorbide dinitrate according to the scheduled administration time. Resident 24 had diagnoses including PTSD, osteoarthritis of the left shoulder, bipolar disorder, cognitive communication deficit, borderline personality disorder, and anxiety disorder, and her care plan identified a potential for cardiovascular distress with interventions to administer medications as ordered. The physician’s order directed one-half tablet of isosorbide dinitrate 30 mg twice daily, scheduled for 8:00 a.m. and 6:00 p.m., but the MAR showed multiple doses given later than scheduled, including doses administered at 9:52 a.m., 11:25 p.m., 8:23 p.m., 11:39 a.m., 7:12 p.m., 8:08 p.m., 7:28 p.m., 7:49 p.m., 9:10 p.m., and 9:02 p.m. Resident 24 stated she did not always receive her medication on time and had to wait after using her call light. The facility also failed to ensure Resident 56 had a current physician’s order for treatment of a non-pressure skin impairment on the right temple. Resident 56 had diagnoses including myocardial infarction, pulmonary disease, long-term use of anticoagulants, and adult failure to thrive, and her care plan identified her as at risk for skin breakdown with interventions for treatments when ordered. The record contained an order, initiated 2/21/26 and ending 3/2/26, to cleanse the temple wound, apply skin prep, and cover with a border dressing as needed if dislodged or soiled, but no current physician’s order was present after 3/2/26. Observations showed a white island dressing on the right temple on multiple dates, including one instance with old blood visible through the dressing, and later a Band-Aid was in place after the resident stated she preferred it over the island dressing.
Failure to Implement Slide Board Transfer Orders and Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive assessment, person-centered care plan, and physician's orders were implemented for the use of a slide board during transfers for Resident 44. Resident 44 had diagnoses including a displaced spiral fracture of the right femur, venous insufficiency, moderate protein-calorie malnutrition, history of falls, fracture of the left tibia and fibula, difficulty walking, osteoporosis, disorders of bone density and structure, and osteoarthritis. After returning from a hospital stay for the right femur fracture, therapy recommended on 12/12/25 that a slide board be placed in the room and used for transfers with two people, a gait belt, and placement toward the resident's good leg (left). Quarterly MDS assessments later indicated the resident used a wheelchair and was dependent on staff for mobility and transfers. During an observation, CNA 6 and QMA 7 transferred Resident 44 from a wheelchair to the bed using a gait belt and a slide board. The electronic medical record did not contain a physician's order or a comprehensive person-centered care plan for the use of a slide board for transfers. The DON confirmed during interview that there was no physician's order or care plan in place for slide board use with transfers. The facility policy on comprehensive care plans stated that comprehensive care plans will be developed and remain accurate and current.
Oxygen Therapy Order Not Implemented
Penalty
Summary
The facility failed to ensure a physician’s order for oxygen was implemented for one resident reviewed for respiratory care. Resident 62 had diagnoses including COPD, Alzheimer’s disease, major depressive disorder, and hypertension, and the care plan indicated the resident received oxygen therapy with interventions to monitor oxygen saturation, monitor for signs and symptoms of respiratory distress, and administer oxygen by nasal cannula as ordered. During observation, the resident was seen receiving oxygen at 2 L, and at another observation the oxygen concentrator was set at 3 L per minute. The clinical record showed a physician’s order dated 3/6/26 for 2 L of oxygen continuously, with staff allowed to titrate to keep oxygen saturations above 90% but not exceed 4 L without physician notification. The DON stated the facility had noticed the resident did not have an oxygen order and confirmed the liter flow that day, noting the resident had been on oxygen therapy since admission and did not have an order. The facility policy on Administration of Oxygen required verification of a physician’s order for the procedure.
Failure to Document and Implement Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that care strategies were documented and implemented for a resident with a history of PTSD. Resident 24 had diagnoses that included PTSD, panic disorder, major depressive disorder, bipolar disorder, cognitive communication deficit, borderline personality disorder, and anxiety disorder. PTSD was added to the resident’s diagnosis list on 5/5/24, but the clinical record did not contain a care plan related to PTSD, the root cause, the triggers to watch for, or the interventions to implement in response to a trigger. Resident 24’s profile care guide listed cultural preferences and trauma triggers, but there was no documentation after that statement identifying what the preferences or triggers were. The guide also noted the resident was cared for in pairs and that male staff should remain out of the room if possible due to staffing. Multiple care plans addressed behaviors such as false accusations toward staff, sexually inappropriate comments, repetitive complaints, refusal of care, negative statements, refusal to allow some staff into the room, self-determination of care, non-compliance with diet and medications, refusal to be awakened at night, and visual hallucinations, but none of these care plans identified whether the behaviors were related to PTSD or its root cause. A trauma screening tool was not completed until at least 9 months after PTSD was added to the diagnosis list. When the screening was completed, it indicated the resident had experienced a potential traumatic experience of PTSD, but no triggers or cultural trauma were voiced or identified. During interviews, the Social Service Director stated the trauma screening was not completed when the diagnosis was first added, and the Clinical Support Nurse stated the facility was not trained on trauma-informed information until June 2024. The facility policy stated social services would complete the social history observation upon admission, annually, and with significant change, incorporating trauma, triggers, and cultural preferences, and would update the care plan and resident profile with any trauma and cultural needs.
Failure to Provide Written Discharge and Bed Hold Policy Information During Hospital Transfers
Penalty
Summary
The facility failed to provide required written documentation regarding the reason for discharge and the bed hold policy, including cost information, to residents and their representatives during hospital transfers. For four residents with complex medical histories, including conditions such as spina bifida, diabetes, congestive heart failure, dementia, and stroke, there was no evidence in the clinical records that written notices or bed hold policy details were given at the time of transfer. In several cases, nursing notes documented the transfer to the hospital but did not indicate that the residents or their representatives received the necessary information. One resident specifically reported not recalling receipt of discharge or bed hold policy documents. Interviews with facility staff, including the DON and Clinical Support Nurse, confirmed that while discharge paperwork was typically sent with the resident to the hospital, there was no documentation in the electronic health record to show that the required information was provided to the residents or their representatives. Facility policies required advance communication of bed hold options and charges, but the records reviewed did not demonstrate compliance with these requirements for the residents transferred to the hospital.
Failure to Document Training and Proper Administration of TB Skin Tests
Penalty
Summary
The facility failed to ensure that staff administering and reading Mantoux skin tests for tuberculosis (TB) had documented training, and did not consistently document all required elements of the TB testing procedure. Specifically, there was no documentation of the time the second step Mantoux test was administered or read for one employee, making it impossible to confirm the required 48-hour interval before reading the test. Additionally, for three residents, clinical records showed that TB skin tests were administered and read by nurses without documentation of required training, and in some cases, the tests were read before the 48-hour minimum had elapsed. The facility's own policies required that Mantoux tests be administered and read by staff with documented training and that the date and time of administration and reading be recorded. Residents involved had complex medical histories, including conditions such as spina bifida with hydrocephalus, type 2 diabetes mellitus, paraplegia, cerebral palsy, chronic respiratory failure, dementia, and other significant diagnoses. The records for these residents showed missing documentation of the time of TB test administration and reading, and in some cases, the tests were read too early. Interviews with the Infection Prevention Nurse and the Director of Nursing confirmed that the required training documentation was missing for several nurses, and that the facility could not verify training for some staff members.
Failure to Re-Weigh and Notify on Significant Resident Weight Changes
Penalty
Summary
Staff failed to obtain a follow-up weight for a resident who experienced significant fluctuations in weight, including a 23.65% loss in one month followed by a 27.49% gain the next month. There was no documentation of any re-weighing to confirm these significant changes, nor was there evidence that the physician, dietitian, or family representative were notified of the weight variances. The facility's own policy required re-weighing for weights outside the normal range and notification of significant weight changes, but these steps were not documented as completed. Interviews with staff revealed inconsistent practices regarding resident refusals to be weighed, with some staff stating they would attempt multiple times and inform management if a resident refused. However, there was no documentation of refusals or follow-up attempts for this resident, and some staff indicated the resident did not typically refuse to be weighed. The facility lacked a clear documentation policy for these situations, despite having written guidelines for weight tracking and management.
Failure to Resolve Resident Council Grievances Regarding Call Light Response
Penalty
Summary
The facility failed to resolve ongoing resident council concerns and grievances related to call light response times for three of five residents reviewed. Resident council meeting minutes over several months documented repeated complaints about long call light wait times, with no evidence of resolution. Residents reported waiting from 30 minutes to over an hour for assistance, including instances where a resident remained in soiled conditions for extended periods. Interviews with residents confirmed that the issue persisted over time, and the facility's documentation did not show specific actions taken to address or resolve these concerns. Facility staff, including the Clinical Support Nurse and Activity Director, indicated that grievances were recorded and reviewed by management, but could not provide evidence of specific concerns or their resolution. The only available call light audits covered a limited period, and facility policies required that grievances and recommendations be brought to the attention of leadership and reported back to the resident council, which was not demonstrated in practice. The deficiency was identified through interviews, record reviews, and examination of facility policies and procedures.
Failure to Document Wound Care and Notify Physicians of Abnormal Conditions
Penalty
Summary
The facility failed to assess and document the progress of a non-pressure skin wound for Resident 23. Despite having a physician's order to clean and dress the wound every five days, there was no documentation in the electronic health record (EHR) after the initial measurement on 2/25/24. The Director of Nursing Services (DNS) confirmed that the wound should have been assessed and measured weekly but was not. This lapse in documentation and follow-up care was evident during observations and interviews conducted on 4/16/24 and 4/17/24. Resident 37 had a left hand/wrist splint device in place, and her left wrist, hand, and fingers were swollen. Despite a physician's order to monitor for blanching, color, and odor three times a day, there was no documentation of the edema in the EHR. The DNS confirmed that there was no care plan in place for the resident's fracture and that the swelling and open skin area should have been documented. This deficiency was observed and confirmed during interviews on 4/18/24 and 4/19/24. The facility also failed to notify physicians of elevated blood sugar readings and to follow physician's orders for medications for multiple residents. For example, Resident 31 had blood glucose levels significantly above the normal range, but there was no documentation of physician notification. Similarly, Resident 29 received insulin despite blood sugar levels being below the threshold specified in the physician's order. Resident 16 was given digoxin despite having a pulse rate below the threshold, and there was no documentation of physician notification. These deficiencies were confirmed through record reviews and interviews with staff on 4/18/24 and 4/19/24.
Deficiencies in Respiratory Care
Penalty
Summary
The facility failed to ensure proper respiratory care for three residents, leading to deficiencies in oxygen administration. For Resident 23, observations revealed that the oxygen tubing was not dated, and the oxygen flow rate was inconsistently set at 1.5 liters, 2 liters, and 3 liters per minute, contrary to the physician's orders. The resident's care plan indicated a need for supplemental oxygen to manage chronic conditions such as congestive heart failure and chronic obstructive pulmonary disease, but the prescribed oxygen levels were not maintained consistently. Resident 31 was observed using an empty portable oxygen tank on multiple occasions, and the oxygen flow rate was set incorrectly at various times. The oxygen tubing was also not dated. Despite the physician's order for 2 liters of continuous oxygen, the flow rate was observed to be set at 2.5 liters and just under 3 liters. Interviews with staff indicated a lack of adherence to the prescribed oxygen flow rate, with only nurses authorized to adjust the flow rate. Resident 20's oxygen flow rate was observed to be set at 4 to 5 liters, contrary to the physician's order of 3 liters. The oxygen tubing was not dated, and the resident reported frequently asking staff to increase the oxygen flow when experiencing difficulty breathing. The resident's care plan and physician's orders were not followed, leading to inconsistent oxygen administration. Interviews with staff revealed a lack of awareness of the updated oxygen order, resulting in the incorrect flow rate being administered.
Infection Control Lapses
Penalty
Summary
The facility failed to ensure staff followed infection control standards in several instances. The Assistant Food Director was observed serving food to residents without washing his hands between serving plates on multiple occasions. Additionally, Guest Relations staff was seen touching her face and arm and then serving food without washing her hands. Both staff members acknowledged their lapses in hand hygiene during interviews. The Director of Health Services (DHS) and an RN did not follow enhanced barrier precautions while providing wound care and handling a urinary catheter for a resident with stage 3 and unstageable pressure ulcers, paraplegia, and osteomyelitis. Despite a physician's order requiring the use of gloves and gowns during high-contact care activities, both staff members only wore gloves. The DHS admitted they should have worn gowns during the procedure. Other infection control lapses included a Qualified Medication Aide (QMA) not changing gloves after performing incontinence care and then touching the resident's blankets and call light. A resident's catheter bag was found on the floor, and another resident had personal items and linens improperly stored on the floor and chair. Additionally, a soiled brief was left on a resident's bed, and a CNA was observed carrying soiled linens down the hall without placing them in a trash bag first. Staff members acknowledged these lapses during interviews, and the facility's policies on infection control were not followed in these instances.
Failure to Address and Document Resident Council Concerns
Penalty
Summary
The facility failed to ensure resident council concerns and grievances were addressed and documented in the meeting minutes for four of the twelve months reviewed. Specifically, concerns about call light response times were repeatedly raised by residents during council meetings in July 2023, January 2024, February 2024, and March 2024, but these concerns were not documented as reviewed or resolved in subsequent meeting minutes. Residents reported that call lights often went unanswered for extended periods, sometimes up to an hour or more, and in some cases, residents had to provide their own care due to the lack of timely response from staff. The Activity Director, who assisted residents in filling out grievances, was unaware of why the call light concerns had not been addressed, and the Director of Nursing Services confirmed that there was no documentation of call light audits being completed. The facility's policies on resident council meetings, resident rights, and the resident concern process were not followed. These policies require that grievances and recommendations be brought to the attention of the Executive Director, who should forward them to the appropriate department leader for attention and response. The resolutions should be documented and reported back to the Resident Council at the next meeting. However, this process was not adhered to, as evidenced by the lack of follow-up and resolution documentation in the meeting minutes. This failure to address and document resident concerns about call light response times indicates a significant lapse in the facility's grievance resolution process.
Failure to Provide 48-Hour Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to ensure the Notice of Medicare Non-Coverage (NOMNC) was given 48 hours prior to the end of Medicare benefits for two residents. For Resident 38, the NOMNC indicated that Medicare services would end on 3/13/24, but the resident signed the notice on 3/12/24, providing only a 24-hour notice. Similarly, for Resident 101, the NOMNC indicated that Medicare services would end on 3/5/24, but the resident signed the notice on 3/4/24, also providing only a 24-hour notice. During an interview, the Executive Director (ED) was unable to explain the reason for the insufficient notice period, as the staff responsible for completing the notices was on leave. The facility's current policy, last reviewed on 12/31/23, requires the NOMNC to be issued 2 calendar days prior to the actual discharge from Medicare.
Failure to Complete Revised PASARR Level I After Prescribing Psychotropic Medication
Penalty
Summary
The facility failed to ensure a revised Preadmission Screen and Resident Review (PASARR) level I was completed after psychotropic medications were prescribed for a resident. The clinical record for the resident indicated diagnoses including depression, anxiety disorder, dementia, congestive heart failure, and hypertension. A PASARR level I, dated earlier in the month, indicated the resident did not require a level II and was not taking any mental health medications. However, a physician's order later in the month prescribed duloxetine, an antidepressant, for the resident's depression. The care plan was updated to reflect the risk of adverse effects from the antidepressant medication, but a new PASARR level I was not completed within the required 14-day period after the medication was prescribed. The facility's Executive Director and Clinical Support Nurse confirmed the oversight during interviews, noting that the facility did not have a specific PASARR policy and relied on the Indiana PASARR Standard Operating Procedure Revenue & Collections.
Expired and Unlabeled Medications Found in Medication Cart
Penalty
Summary
The facility failed to ensure expired medications were removed from the medication cart and that medications were properly labeled. During an observation, a partial bottle of Robitussin DM with an expiration date of 2/22/24 and a partial bottle of Geri tussin Liquid 100/5 with an expiration date of 3/18/24 were found in the 500 back hall medication cart. Additionally, the bottom drawer contained a partial bottle of Tums and two tubes of Diclofenac sodium topical gel 1%, all of which were unlabeled. A partial bottle of Children's Tylenol was also found with a resident's name written in marker but not properly labeled. During an interview, a Qualified Medication Aide (QMA) indicated she did not know which resident(s) were receiving the Tums and Diclofenac gel and acknowledged that the expired medications should have been removed. She subsequently took the expired medications to the Director of Nursing Services for destruction. The facility's current policy on medication storage, received from the Clinical Support Nurse, indicated that outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or with insecure closures should be immediately removed from inventory and disposed of according to procedures for medication disposal. Another policy on medication administration guidelines emphasized the importance of checking the label, container, and contents for integrity and comparing them against the medication administration record before administering any medication. The facility's failure to adhere to these policies resulted in the presence of expired and unlabeled medications in the medication cart, posing a potential risk to resident safety.
Facility Fails to Maintain Clean and Odor-Free Environment
Penalty
Summary
The facility failed to ensure that resident rooms and hallways were in good repair and free of odors. Observations revealed that the doorway of one room was missing approximately 18 inches of carpet, and the hallway between two rooms had missing pieces of carpet around gold floor plates. Additionally, one room's bed was very loud when moving up and down due to dried grease on the bed frame, and the beds were old with the manufacturer no longer in business. The Maintenance Director confirmed that there were no purchase orders for the carpet or the beds. Several rooms had a strong urine odor that extended into the hallway. Interviews with staff indicated that the 500 hall always had a strong odor, and the Assistant Director of Nursing Services was unaware of any actions being taken to address the issue. The Maintenance Support mentioned that exhaust fans had been changed, but the odor persisted, possibly due to a resident spilling urine on the carpet. The facility did not provide an environmental policy at the time of the exit conference, although a policy on Resident Rights indicated that residents have the right to a safe, clean, comfortable, and homelike environment.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Delphi
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Milner Community Health Care | 12 mi | ★★★★★ | 6 | 0 |
| White Oak Health Campus | 12.8 mi | ★★★★★ | 12 | 0 |
| Indiana Veterans Home | 13.2 mi | ★★★★★ | 4 | 0 |
| Monticello Healthcare | 13.5 mi | ★★★★★ | 0 | 0 |
| Heritage Healthcare | 14.1 mi | ★★★★★ | 7 | 0 |
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