Ashford Place Health Campus

Inspectors wroteBased on interview and record review, the facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for alarm use for 2 of 2 residents reviewed for falls. (Resident 17 and Resident 25)

Inspectors wroteBased on interview and record review, the facility failed to timely refer a resident for a level II evaluation for 1 of 1 resident reviewed for Preadmission Screening and Resident Review (PASRR). (Resident 19)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an insulin flex pen was primed prior to dialing up the dosage to be given when administering insulin per the manufacture directions for 1 of 2 residents observed during insulin administration. (Resident 8)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a gait belt was used during the manual transfer of a resident and to ensure an evaluation was conducted timely for the usage of personal alarms for 2 of 2 residents reviewed for accidents. (Resident 17 and Resident 25)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control was maintained by not disinfecting a glucometer (a device used to obtain blood sugar readings) per the manufacturer's instructions for 1 of 2 residents observed during medication administrations of blood sugar readings. (Resident 43)

Inspectors wroteBased on interview and record review, the facility failed to provide bathing, as scheduled, to 1 of 3 residents reviewed for bathing. (Resident D)

Inspectors wroteBased on interview and record review, the facility failed to ensure interventions to prevent falls were effectively implemented when Resident C exhibited signs and symptoms of lethargy, drowsiness, and sedation and failed to ensure staff used a gait belt during the transfer of a Resident D who required more than limited assistance with transfers for 2 of 3 residents reviewed for falls. This deficient practice resulted in Resident C falling in the shower and sustaining fractures to the left shoulder blade, the left second rib, and the endplate of the third lumbar spinal disc. (Resident C and Resident D)

Inspectors wroteBased on interview and record review, the facility failed to timely address a grievance for 1 of 1 resident reviewed for dignity (Resident B).

Inspectors wroteBased on interview and record review, the facility failed to ensure the required medical and contact information was sent to the hospital for 1 of 1 resident reviewed for discharge. (Resident 54)

Inspectors wroteBased on observation, interview and record review, the facility failed to timely revise a resident's care plans for refusal of showers and depression with individualized interventions for 1 of 5 residents reviewed for unnecessary medications (Resident 20).

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer a resident's medication, as ordered, and to timely address an issue with a physician's order for a new eye medication for a resident whose insurance did not cover the costs of the medication for 2 of 3 residents reviewed for pharmacy services and medication administration. (Resident E and Resident 16)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: an ophthalmic (eye) medication was labeled with the date it was opened (Resident 24); the timely destruction of medications for an expired resident (Resident 272); and the controlled medication lock box was permanently affixed within the medication refrigerator (Facility) when reviewed for medication storage and labeling.

Inspectors wroteBased on interview and record review, the facility failed to timely obtain a urinalysis, as ordered by the physician, for 1 of 5 residents reviewed for unnecessary medications (Resident 23).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control policy by not performing hand hygiene prior to glove use and after dropping a pill onto a medication cart, picking up the pill with bare hands and administering it to the resident for 1 of 3 residents reviewed during the medication administration observation. (Residents 9 and 16)

Inspectors wroteBased on interview and record review, the facility failed to protect the residents' right to be free from sexual abuse by not appropriately determining their capacity to consent to sexual interactions and implementing an effective plan to address the sexual activity between 2 residents for 2 of 2 resident's reviewed for abuse. (Resident 14 and Resident 28). The Immediate Jeopardy started on 5/5/22 when two cognitively impaired residents engaged in a sexual activity. Resident 14 and 28 continued to have sexual encounters after the 5/5/22 incident; resulting in increased falls, initiation of a prophylactic antibiotic, increase in antidepressant medication, initiation of a medication used to suppress sexual desire and emotional distress. [...]

Inspectors wroteBased on interview and record review, the facility failed to have the interdisciplinary team (IDT) determine and document that self administration of medications and treatments were clinically appropriate for 1 of 5 residents observed during medication administration. (Resident 40)

Inspectors wroteBased on interview and record review, the facility failed to report to the Indiana Department of Health (IDOH) resident to resident sexual activity without the competency to consent for 2 of 2 residents reviewed for abuse. (Resident 14 and Resident 28)

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately complete an admission Minimum Data Set Assessment for 1 of 2 residents reviewed for dental services (Resident 21).

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise a resident's hearing loss care plan to include the use of an amplifier device for 1 of 16 residents whose care plans were reviewed. (Resident 16)

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary services to maintain good grooming and personal hygiene for a resident who was unable to carry out activities of daily living by not ensuring twice weekly showers/complete bed baths for 1 of 1 residents reviewed for activities of daily living (ADLs).

Inspectors wroteBased on interview and record review, the facility failed to inform the physician of blood sugar results below 150, as ordered by the physician, for 1 of 1 resident reviewed for insulin (Resident 21).

Inspectors wroteBased on observation, interview, and record review, the facility failed to timely address a dental referral for 1 of 2 residents reviewed for dental services (Resident 21).

Inspectors wroteBased on interview and record review, the facility failed to identify and implement an effective corrective plan of action to address two residents that were having sexual interactions. This affected 2 of 2 residents reviewed for abuse. (Resident 14 and Resident 28)

Inspectors wroteBased on interview and record review, the facility failed to maintain contact isolation precautions for 1 of 6 resident reviewed for infections (Resident 13).

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident had a true infection with the usage of an antibiotic prophylactically for the prevention of Urinary Tract infections (UTI) for 1 of 5 residents reviewed for unnecessary medications. (Resident 28)

Inspectors wroteBased on interview and record review, the facility failed to test a resident who had symptoms of Covid-19 for Covid-19 for 1 of 1 resident reviewed for respiratory care. (Resident 4)