Core of Dale

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe storage and preparation of food to prevent the outbreak of foodborne illness during 2 of 2 observations of the kitchen. During the kitchen observations the eggs were noted to not be pasteurized and the two scoops lying on the flour and sugar bulk containers were not covered. (Kitchen)

Inspectors wroteBased on interview and record review, the facility failed to ensure notification to a provider as ordered. The physician was not notified of a resident's blood sugar outside of parameters for 1 of 2 closed records reviewed. (Resident N)

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were given as ordered for 1 of 2 closed records reviewed, 1 of 5 residents reviewed for unnecessary medications, and 1 random observation during a medication pass. Insulin was not held as indicated in the order, blood pressure medication was not held as indicated, and medications were found under a resident's bed. (Resident 16, Resident B, Resident N)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the past survey results were easily accessible to visitors, residents, family members, and legal representatives of residents for 5 of 5 days during the survey period. The survey binder was in a closed room behind the East Hall nurse's station.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure posted nurse staffing forms were posted daily with the total working hours of unlicensed staff (CNA/QMA) for 5 of 5 days reviewed during the survey period. The posted nurse staffing form lacked the facility name and the total working hours of unlicensed staff was not included on the form.

Inspectors wroteBased on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies to carry out the functions of food and nutrition services. The Dietary Manager lacked appropriate certification.

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately test the dishwasher to verify it was functioning correctly. Staff lacked knowledge of the test strips used to test the sanitation chemicals in 1 of 2 observations of dishwasher use.

Inspectors wroteBased on interview and record review, the facility failed to deliver mail to the residents on Saturdays. Ten of ten anonymous residents interviewed indicated they failed to get mail every Saturday.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate resident assessments for 10 of 13 resident records reviewed. Minimum Data Set (MDS) assessments did not reflect accurate resident information. (Resident 6, Resident B, Resident D, Resident 3, Resident 1, Resident 8, Resident 2, Resident 19, Resident 23, Resident C)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure specific, comprehensive care plans were revised for 4 of 4 reviewed for behaviors related to sexual offenders. Care plans were not revised to include specific behaviors, restrictions, and interventions. (Resident B, Resident C, Resident D, Resident F)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a homelike environment for 6 of 15 resident rooms reviewed for the environment. Rooms and a hall had a strong urine odor, peri-cleanser and cream (used for incontinence care) were found in a resident refrigerator, call light strings in the bathrooms were soiled, and grab bars and the toilet seat were loose. (East Hall, [NAME] Hall, Resident rooms and or shared bathrooms, Rooms 101, 102, 103/105, 108/110, 207/209, 204/206)

Inspectors wroteBased on interview and record review, the facility failed to ensure a notice of transfer or discharge notice and a bed hold policy was given to residents or resident representatives for 2 of 2 residents reviewed for hospitalizations. There was no documentation of a resident or representative receiving a notice of transfer or discharge and a bed hold at the time of hospitalization. (Resident 1, Resident 7)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided by the facility met professional standards for 1 of 2 residents reviewed for nutrition. A resident's weights were not transferred into the clinical record, the medical provider and family were not notified of weight loss, the dietitian's recommended orders were not put into place, and the resident continued to have weight loss. (Resident G)

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from misappropriation for 1 of 3 residents reviewed for misappropriation. A resident's debit card was taken without consent and used by staff to withdraw $305.00 from the resident's bank account. (Resident D)

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from abuse for 1 of 3 residents reviewed for abuse. A resident was allegedly threatened with physical abuse and then was smacked by a staff member in retaliation for the resident striking the staff member during care. (Resident L)

Inspectors wroteA 2. On 8/13/24 at 9:15 A.M., an Indiana Department of Health Incident Report, dated 8/4/24, indicated Resident C was found walking up the road by a staff member. Facility was investigating how she got out. It was reported that a nurse left for lunch and resident may have followed the nurse out the front entrance door. Resident C was immediately returned to facility and placed on 1:1 for 2 hours and 15 minute checks for 72 hours. Facility immediately notified maintenance to check the doors and called (Name of Door Repair Company #1) to come and inspect the doors. On 8/13/24 at 9:30 A.M., Resident C's medical records were reviewed. admission date was 2/8/24. Diagnosis included, but were not limited to rheumatoid arthritis, coronary artery disease, hypertension, non-Alzheimer's dementia, seizure disorder, anxiety disorder, asthma, and hallucinations. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a notice of transfer or discharge was given to residents or resident representatives for 5 of 5 residents reviewed for hospitalizations. There was no documentation of a resident or representative receiving a notice of transfer or discharge at the time of hospitalization. (Resident 12, Resident 33, Resident 6, Resident 18, Resident 7)

Inspectors wroteBased on interview and record review, the facility failed to ensure a bed hold policy was given to residents or resident representatives for 5 of 5 residents reviewed for hospitalizations. There was no documentation of a resident or representative receiving a bed hold policy at the time of hospitalization. (Resident 12, Resident 33, Resident 6, Resident 18, Resident 7)

Inspectors wroteBased on observation and interview, the facility failed to ensure infection control practices were in place for 4 of 4 residents during incontinence care and 1 of 1 resident during wound care. Staff failed to sanitize hands and change gloves between dirty to clean tasks. Staff failed to lather for at least 20 seconds when washing hands. (Resident 2, Resident 12, Resident 15, Resident 31, Resident 35)

Inspectors wroteBased on observation, interview, and record review, the facility failed to clarify a Resident's code status for 1 of 2 residents reviewed for advanced directives. A Resident's current Physician Orders did not match the signed DNR (Do Not Resuscitate) form. (Resident 41)

Inspectors wroteBased on interview and record review, the facility failed to ensure accuracy of MDS (Minimum Data Set) Assessments for 3 of 17 resident assessments reviewed. A resident's traumatic brain injury, a resident's history of CVA (Cerebrovascular Accident), and a resident's antiplatelet use were not marked on the MDS Assessments. (Resident 5, Resident 14, Resident B)

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a care plan for 3 of 5 residents reviewed for Unnecessary Medications. Three residents did not have a care plan for antiplatelets while receiving an antiplatelet. (Resident C, Resident 3, Resident 10)

Inspectors wroteBased on interview and record review, the facility failed to revise care plans and physician orders to reflect the current status of residents for 2 of 17 resident care plans reviewed. A resident's physician order for a pre-op diet was not removed after the procedure, a care plan for respiratory illness was not removed when the resident recovered from the illness, and a resident with current antianxiety and anticoagulant care plans was not receiving either medication. (Resident 14, Resident 10)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's safety by sufficiently tracking behaviors and assessing residents that were at risk for behaviors according to their plan of care for 2 of 2 residents reviewed for behavior monitoring. The behavior tracking system used by the facility staff was inconsistent and ineffective for monitoring behaviors to keep residents safe for 2 of 2 residents. (Resident B, Resident 4)

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate documentation for 2 of 7 residents reviewed for accidents. A resident's fall risk assessments, MD notes, and evaluations did not accurately reflect the resident's current status, and a resident's clinical record reflected him as present in the facility while hospitalized . (Resident 4, Resident 5)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary treatment and services for 2 of 3 residents diagnosed with dementia with behavioral disturbances. Residents' plan of care were not updated following persistent behaviors, recommended treatments and orders were not followed, outside services were not updated on continuing behaviors, and residents were left unsupervised. (Resident B, Resident C, Resident D, Resident F)

Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation for 1 of 2 allegations of resident abuse reviewed. Following an allegation of verbal abuse, all potential witnesses were not interviewed, and multiple resident interviews were not conducted on the unit where the alleged abuse occurred. (Resident B)

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from verbal abuse for 2 of 4 allegations of abuse. A staff member threatened to hit a resident while providing care, and a staff member was overheard talking down to a resident while administering medication, and then referred to the resident as lazy. (Resident C, Resident D)

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from abuse for 2 of 3 residents reviewed for allegations of abuse. A resident reported feeling fearful after verbally abusive behavior from nursing staff and a resident was told to shut up and stop acting like a baby. (Resident D, Resident F)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with activities of daily living (ADLs) for 3 of 4 residents reviewed for bathing. Residents requiring assistance with bathing were not offered bathing regarding their preferences or regarding their plan of care. (Resident B, Resident D, Resident F)