St Augustine Home For The Aged

Based on interview and record review, the facility failed to ensure a new Preadmission Screening and Resident Review (PASARR) was completed after an increase of an antipsychotic medication secondary to continued and increased behaviors for 1 of 1 resident reviewed for PASARR. (Resident 2) Findings include: The clinical record for Resident 2 was reviewed on 6/27/25 at 1:32 p.m. The diagnoses included, but were not limited to, anxiety disorder, major depressive disorder, and dementia with moderate psychotic disturbances. A Level I PASARR, dated 4/28/25, indicated Resident 2 did not currently have a known or suspected developmental condition or diagnosis that affects intellectual and/or adaptive functioning. The document also indicated if a status change occurred, symptoms increased, or other information suggested a potential serious mental illness, then the nursing facility must submit an updated screen to reevaluate the need for a PASARR Level II behavioral health evaluation. A physician's order, dated 4/22/25, indicated to administer Risperdal (an antipsychotic) 0.5 milligram (mg),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure a medication was held according to the physician's order for 1 of 1 resident reviewed for quality of care. (Resident 8) Findings include: The clinical record for Resident 8 was reviewed on 6/27/25 at 10:48 a.m. The diagnoses included, but were not limited to, congestive heart failure, atrial fibrillation, and type 2 diabetes. A physician's order, dated 12/20/23, indicated to give metoprolol (a medication to reduce blood pressure) 12.5 milligrams (mg) by mouth 2 times per day with instruction to hold the medication for a systolic blood pressure less than 110 or a heart rate less than 55. A review of the Medication Administration Record (MAR) indicated metoprolol 12.5 mg was administered against the physician's hold orders on the following dates: a. On 3/3/25, the medication was administered in the evening with a systolic blood pressure of 109. b. On 3/12/25, the medication was administered in the evening with a systolic blood pressure of 109. c. On 4/3/25, the medication was administered in the morning with a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure medications were dated after the medication was opened, expired blood glucose control solution was disposed of, and chemicals were properly stored for 1 of 1 medication cart and 1 of 1 medication storage room reviewed for medication storage. Findings include: 1. The medication cart was reviewed, on 6/27/25 at 9:00 a.m., and the following were observed: a. In the large top drawer of the medication cart, brimonidine tartrate ophthalmic solution (eye drops) had been opened and the bottle did not include an open date. Dorzolamide/Timolol ophthalmic solution (eye drops) had been opened, and the bottle did not include an open date. b. In the small top drawer of the medication cart, blood glucose control solution (solution used to ensure the blood glucose monitor was working correctly) had been opened on 5/11/25 after the expiration date of 3/1/25. 2. The medication storage room contained Clorox chemicals and a bottle of aerosol Raid (bug killer) stored under the sink. During an interview, on 6/27/25 at 9:21…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a CNA for 1 of 2 residents reviewed for abuse. (Resident B) The deficient practice was corrected on 9/25/24, prior to the start of the survey, and was therefore past noncompliance. Finding includes: A document, titled Indiana State Department of Health Survey Report System, indicated on 9/17/24 at approximately 7:45 a.m., the Executive Director (ED) was notified Resident B alleged CNA 1 knocked me out. The resident's description of the aide involved was consistent with the description of CNA 1. Later in the day on 9/17/24, a discoloration and raised area presented on Resident B's forehead. Staff interviews confirmed the raised area on Resident B's forehead was not present on the previous shift. The evidence pointed toward the resident's description of the incident to be accurate. CNA 1 was terminated. A handwritten facility statement dated 9/17/24 at 7:30 p.m. and signed by RN 2 indicated Resident B's left eye was slightly swollen. When asked if it…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's code status was obtained and accurately documented in the clinical record for 1 of 1 resident reviewed for advanced directives. (Resident 171) Finding includes: The clinical record for Resident 171 was reviewed on [DATE] at 2:58 p.m. The diagnoses included, but were not limited to, hypertension, severe protein-calorie malnutrition, hemorrhage from respiratory passages, and anemia. Resident 171 was admitted to the facility on [DATE]. A document, titled Long-Term Care Patient Summary, with post-acute care discharge instructions, dated [DATE], indicated Resident 171 did not have advanced directives. A document, titled Indiana Physician Orders for Scope of Treatment (POST), was prepared on [DATE]. The designation of the resident's preferences related to, attempt resuscitation/CPR, or do not attempt resuscitation/DNR was left blank. A code status was not documented on the face sheet. There was no order addressing code status found in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

3. The clinical record for Resident 11 was reviewed on 9/17/24 at 2:41 p.m. The diagnoses included, but were not limited to, unspecified dementia, hyperlipidemia, age related osteoporosis, and unspecified atherosclerosis of native arteries of bilateral legs. A physician's order, with a start date of 7/1/24, indicated if a gain or loss of 4 pounds since the last weight, then weigh 4 days consecutively and notify provider if the gain or loss was valid. A vitals log indicated the following weights: On 7/1/2024, the weight was 157.0 pounds. On 8/1/2024, the weight was 156.7 pounds. On 9/1/2024, the weight was 161.5 pounds. On 9/1/24, the resident gained 4.8 pounds compared to the last weight. There was no documentation in the record to indicate the resident had been weighed for 4 days after the weight gain or notification to the provider of the gain had occurred. During an interview, on 9/19/24 at 3:07 p.m., the Director of Nursing (DON) indicated she did not see documentation to indicate the resident was weighed for those 4 days per the order. During an interview, on 9/20/24 at 10:52…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure urinary output was monitored as ordered by the physician for 1 of 1 resident reviewed for catheter care. (Resident 18) Finding includes: The clinical record for Resident 18 was reviewed on 9/17/24 at 3:33 p.m. The diagnoses included, but were not limited to, cerebral ischemia (acute brain injury from impaired blood flow to the brain), heart failure, and chronic respiratory failure with hypoxia (a condition which occurs from lack of oxygen in the blood). A care plan, initiated on 4/27/23, indicated the resident had an indwelling catheter related to bladder obstruction and urinary retention. The interventions included, but were not limited to, monitor and document urinary output per the facility policy. A physician's order, initiated on 4/6/23, indicated to record urinary output every shift. The Medication and Treatment Record, for August 2024, was missing urinary output documentation on the night shift for August 1st, the evening shift on August 18th, the night shift on August 21st, and the day shift on August 27th.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure oxygen tubing was dated for the day it was changed for 3 of 3 residents reviewed for respiratory care. (Residents 18, 12 and 10) Findings include: 1. During an observation, on 9/17/24 at 9:35 a.m., Resident 18 was observed in a recliner in her room. She was found to be using supplemental oxygen at two (2) liters per minute through a nasal cannula. The oxygen line did not have a date to show when the oxygen tubing had been changed. The clinical record for Resident 18 was reviewed on 9/17/24 at 3:33 p.m. The diagnoses included, but were not limited to, cerebral ischemia (acute brain injury from impaired blood flow to the brain), heart failure, and chronic respiratory failure with hypoxia (a condition which occurs from lack of oxygen in the blood). A physician's order, initiated on 7/11/24, indicated to provide oxygen at two (2) liters per minute via nasal cannula for chronic respiratory failure with hypoxia. 2. During an observation, on 9/16/24 at 10:33 a.m., Resident 12 was up in sitting up in her room.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to monitor the use of antibiotics including the use of standardized tools for the appropriateness of antibiotics prescribed for 1 of 5 residents reviewed for unnecessary medications. (Resident 11) Finding includes: The clinical record for Resident 11 was reviewed on 9/17/24 at 2:41 p.m. The diagnoses included, but were not limited to vitamin D deficiency, hypertension, polyosteoarthritis, and age-related osteoporosis. A physician's order, with a start date of 7/23/24, indicated the resident took Keflex (an antibiotic) oral capsule 250 milligrams (mg). During an interview, on 9/20/24 at 3:27 p.m., the Director of Nursing (DON) indicated their physician did the tracking for antibiotics. She was not aware of anybody who did surveillance using the McGeer criteria (surveillance definitions used to identify infections) in the facility. The nurses would report the signs and symptoms to the physician but did not use a specific protocol. There was no documentation of a surveillance tool used for the resident. A current policy, titled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to thoroughly investigate an allegation and immediately take action to prevent further abuse or mistreatment from occurring while the investigation was in progress for 1 of 1 resident reviewed regarding abuse or mistreatment. (Resident 10) Finding includes: The record for Resident 10 was reviewed on 07/07/2023 at 2:21 p.m. Diagnoses included, but were not limited to, dementia with mood disturbance, anxiety disorder, major depressive disorder, total retinal detachment affecting the right eye, general muscle weakness, unsteadiness on feet, and repeated falls. A current MDS (Minimum Data Set) assessment, dated 05/30/2023, indicated the resident had a BIMs (Brief Interview for Mental Status) score of 9, indicating the resident demonstrated a cognitive impairment. A progress note, dated 02/19/2023 at 7:00 p.m., indicated Late Entry .Writer spoke to Resident in regard to her complaint of left wrist pain. There was noticeable redness on her left small finger and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure a significant change Minimum Data Set (MDS) assessment was completed for a resident with a fall resulting in injury, left sided weakness, and increased behavioral issues for 1 of 3 residents reviewed for MDS assessments. (Resident 7) Finding includes: The record for Resident 7 was reviewed on 07/07/23 at 10:26 a.m. Diagnoses included, but were not limited to, cerebral infarction (stroke), dementia, and repeated falls. A nursing progress note, dated 5/16/22 at 1:22 a.m., indicated the resident fell resulting in an injury on the back and a raised area on the back of the head. The initial neurological checks were within normal limits. A physician's progress note, dated 5/16/23 at 10:15 a.m., indicated the spouse noticed differences in the resident's neurological status and was concerned. The facility called 911 for further evaluation. A progress note, dated 5/23/23 at 5:10 p.m., indicated the resident was re-admitted into the facility and the MD (Medical Doctor) was notified of the return. A progress note, dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure a Registered Nurse was in the facility for 8 hours during a 24-hour period for 9 days of the first quarter of 2023 reviewed for sufficient staffing. (2/4, 2/5, 2/18, 2/19, 2/25, 2/26 and 3/5, 3/11, 3/19) Finding includes: A Payroll-Based Journal (PBJ) Staffing report, for the first quarter of 2023, indicated the facility failed to have Registered Nurse coverage for 02/4, 2/5, 2/18, 2/19, 2/25, 2/26, 3/5, 3/11, and 3/19. During a record review, on 07/11/2023 at 10:19 a.m., the actual worked staffing schedules indicated there was no RN coverage for 02/4, 2/5, 2/18, 2/19, 2/25,2/26, 3/5, 3/11, and 3/19. During an interview, on 07/07/23 at 11:56 a.m., the Facility Scheduler indicated the PBJ staffing showed there was no RN staffing coverage for 6 days in February and 3 days in March. She would have to get with the Human Resources Director to verify if the information on the PBJ was correct. During an interview, on 07/07/2023 at 3:41 p.m., the Human Resources Director indicated they did not have RN coverage on the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure medications were disposed of according to regulations and standards of practice for 1 of 5 residents reviewed for medication observation. (Resident 21) Findings include: During a medication observation, on 07/07/23 at 9:48 a.m., LPN 10 prepared the following medications for Resident 21: furosemide (a medication used to decrease fluid in the body) 20 mg (milligrams), acetaminophen (a mild pain medication) 500 mg, prednisone (a steroid) 5 mg, apixaban (a blood thinner) 2 mg, amiodarone HCL (used for an irregular heartbeat) 200 mg and mixed with pudding. The resident refused the medications due to nausea. The nurse took the medication into the soiled utility room and flushed them down the hopper (a flushing rim sink used for disposal of blood or body fluids) (e.g., bedpan washing). During an interview, on 07/07/23 at 10:00 a.m., LPN 10 indicated she had disposed of them in the hopper before. During an interview, on 07/10/23 at 11:30 a.m., LPN 4 indicated she disposed of refused medications in the biohazard…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.