Inspection Reports for
Addison Pointe Health & Rehabilitation Center
780 DICKINSON ROAD, CHESTERTON, IN, 46304
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
17 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
305% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
88% occupied
Based on a May 2025 inspection.
Occupancy rate over time
Inspection Report
Re-Inspection
Census: 88
Capacity: 100
Deficiencies: 0
Date: May 27, 2025
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey that exited on 04/28/2025.
Findings
At the Emergency Preparedness survey, the facility was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. At the Life Safety Code survey, the facility was found in compliance with Requirements for Participation, including fire safety and sprinkler systems.
Report Facts
Certified beds: 100
Census: 88
Inspection Report
Life Safety
Census: 97
Capacity: 100
Deficiencies: 4
Date: Apr 28, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 04/28/2025 to assess compliance with Emergency Preparedness Requirements and Life Safety Code regulations.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements due to failure to maintain written records of monthly maintenance of lead-acid batteries. Life Safety Code deficiencies included failure to provide an approved method for returning kitchen appliances to their approved location, failure to maintain written records of lead-acid battery maintenance, failure to provide GFCI protection for an electrical receptacle near a sink, and use of a power strip as a substitute for fixed wiring for high current equipment.
Deficiencies (4)
Failed to maintain a written record of monthly testing of electrolyte specific gravity or battery conductance testing for lead-acid batteries of the emergency generator.
Failed to provide an approved method for returning cooking appliances to their approved design location under the kitchen hood extinguishing system.
Failed to provide GFCI protection for 1 electrical receptacle located within 6 feet of a sink in the 200 hall medication room.
Failed to ensure power strips were not used as a substitute for fixed wiring to provide power to equipment with a high current draw (refrigerator in resident room 414).
Report Facts
Certified beds: 100
Census: 97
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carol Whitehead | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Director of Plant Operations | Interviewed regarding deficiencies related to battery maintenance, kitchen appliance placement, electrical receptacle, and power strip usage |
Inspection Report
Annual Inspection
Census: 90
Capacity: 90
Deficiencies: 7
Date: Mar 21, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00455358.
Complaint Details
Complaint IN00455358 was investigated and no deficiencies related to the allegations were cited.
Findings
The facility was found deficient in multiple areas including failure to implement care plans for residents, incomplete ADL care, inadequate skin assessments, improper use of pressure reduction devices, failure to follow mechanical lift safety protocols, respiratory care deficiencies, and unsanitary kitchen conditions with lack of proper food labeling and temperature monitoring.
Deficiencies (7)
Failed to implement a resident's care plan related to positioning for 1 of 3 residents reviewed for limited range of motion.
Failed to ensure activities of daily living (ADLs) were completed for dependent residents, related to turning and repositioning for 1 of 2 residents reviewed for ADLs.
Failed to ensure areas of discoloration were assessed and monitored for 2 of 2 residents reviewed for non-pressure skin conditions.
Failed to ensure pressure reduction devices were in use for a resident with a pressure ulcer for 1 of 2 residents reviewed for pressure ulcers.
Failed to ensure a resident had adequate assistance and supervision during mechanical lift transfers, resulting in a fall and fracture.
Failed to ensure each resident requiring respiratory care received necessary services related to changing oxygen tubing for 1 of 4 residents reviewed for respiratory services.
Failed to maintain the kitchen in a sanitary manner and in good repair related to lack of monitoring of freezer, refrigerator, and dishwasher temperatures and food not labeled and dated.
Report Facts
Census: 90
Total Capacity: 90
Survey Dates: 5
Residents with Medicare: 13
Residents with Medicaid: 63
Residents with Other Payor: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carol Whitehead | HFA | Laboratory Director or Provider/Supplier Representative signature on report |
Inspection Report
Renewal
Deficiencies: 0
Date: Mar 21, 2025
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on March 21, 2025.
Findings
Addison Pointe Health & Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Recertification and State Licensure Survey.
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Mar 21, 2025
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with healthcare regulations and standards at Addison Pointe Health & Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to implement care plans for residents, inadequate assistance with activities of daily living, insufficient assessment and monitoring of skin conditions, improper use of pressure ulcer prevention devices, inadequate supervision during mechanical lifts resulting in a resident fall with injury, failure to maintain respiratory care standards, and poor kitchen sanitation practices.
Deficiencies (7)
F 0656: The facility failed to implement a resident's care plan related to positioning for 1 of 3 residents reviewed for limited range of motion.
F 0677: The facility failed to ensure activities of daily living were completed for dependent residents related to turning and repositioning for 1 of 2 residents reviewed.
F 0684: The facility failed to assess and monitor areas of discoloration for 2 of 2 residents reviewed for non-pressure skin conditions.
F 0686: The facility failed to ensure pressure reduction devices were in use for a resident with a pressure ulcer for 1 of 2 residents reviewed.
F 0689: The facility failed to ensure adequate assistance and supervision during mechanical lift transfers, resulting in a resident fall and fracture.
F 0695: The facility failed to ensure respiratory care services included changing oxygen tubing as required for 1 of 4 residents reviewed.
F 0812: The facility failed to maintain the kitchen in a sanitary manner related to lack of monitoring of freezer, refrigerator, and dishwasher temperatures and food not labeled and dated.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 4
Residents affected: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 5 | Responded to Resident 21's fall and indicated staff re-training on Hoyer lift | |
| CNA 7 | Assisted with transfer resulting in Resident 21's fall | |
| CNA 25 | Provided written statement regarding Hoyer lift incident causing Resident 21's fall |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 0
Date: Nov 15, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00446032.
Complaint Details
Complaint IN00446032 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00446032 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 91
Census Bed Type: 81
Census Bed Type: 10
Census Payor Type: 14
Census Payor Type: 64
Census Payor Type: 13
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 0
Date: Sep 11, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00441909 at Addison Pointe Health & Rehabilitation Center.
Complaint Details
Complaint IN00441909 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census Bed Type - SNF/NF: 82
Census Bed Type - SNF: 9
Total Census: 91
Census Payor Type - Medicare: 9
Census Payor Type - Medicaid: 65
Census Payor Type - Other: 17
Total Census Payor: 91
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 26, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00435593 completed on July 31, 2024.
Complaint Details
Investigation of Complaint IN00435593 completed on July 31, 2024; facility found in compliance.
Findings
Addison Pointe Health & Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 2
Date: Jul 31, 2024
Visit Reason
This visit was for the investigation of multiple complaints (IN00434921, IN00434981, IN00435593, IN00435714, IN00435742, IN00436950, and IN00439525) at Addison Pointe Health & Rehabilitation Center.
Complaint Details
Complaint IN00435593 was substantiated with federal/state deficiencies cited at F880 related to infection prevention and control. Other complaints were not substantiated with deficiencies.
Findings
The investigation found no deficiencies related to most complaints except for Complaint IN00435593, which resulted in federal/state deficiencies cited at F880 related to infection prevention and control. Additionally, a grievance was not properly filed or resolved for a missing wheelchair for one resident, and staff failed to use proper PPE when providing care to a resident under Enhanced Barrier Precautions.
Deficiencies (2)
Failed to file and resolve a resident grievance for a missing wheelchair.
Failed to ensure correct Personal Protective Equipment (PPE) was used by staff when providing care to a resident in Enhanced Barrier Precautions.
Report Facts
Census: 96
Medicare Census: 17
Medicaid Census: 67
Other Payor Census: 12
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 31, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to grievances and infection control practices at the facility.
Complaint Details
This citation relates to Complaint IN00435593. The complaint involved failure to file and resolve a grievance about a missing wheelchair and failure to use proper PPE for infection control.
Findings
The facility failed to file and resolve a resident grievance regarding a missing wheelchair and failed to ensure correct Personal Protective Equipment (PPE) was used by staff when providing care to a resident under Enhanced Barrier Precautions.
Deficiencies (2)
F 0585: The facility failed to file and resolve a resident grievance for a missing wheelchair for 1 of 1 resident reviewed for grievances.
F 0880: The facility failed to ensure correct PPE was used by staff when providing care to a resident in Enhanced Barrier Precautions for 1 of 3 residents reviewed for infection control isolation practices.
Inspection Report
Life Safety
Census: 95
Capacity: 100
Deficiencies: 0
Date: Apr 25, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 03/14/24 was conducted by the Indiana Department of Health in accordance with 42 CFR Subpart 483.90(a).
Findings
At this Life Safety Code PSR, Addison Pointe Health & Rehabilitation Center was found in compliance with Requirements for Participation Medicare/Medicaid, Life Safety From Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinklered with a fire alarm system and smoke detectors in all resident sleeping rooms.
Report Facts
Facility capacity: 100
Census: 95
Generator rating: 200
Inspection Report
Life Safety
Census: 99
Capacity: 100
Deficiencies: 6
Date: Mar 14, 2024
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 standards.
Findings
The facility was found not in compliance with Life Safety Code requirements, with deficiencies including incomplete documentation and outdated battery smoke alarms, corridor doors not fully resisting smoke passage, failed door locking mechanisms, inadequate combustion air intake for fuel-fired equipment, improper use of power strips, and improper segregation and labeling of oxygen cylinders.
Deficiencies (6)
Failed to ensure documentation for preventative maintenance of 1 of 1 battery operated smoke alarms was complete.
Battery operated smoke alarm installed was over ten years old, violating NFPA 72 requirements.
One of approximately 10 corridor doors on 300 Hall did not completely resist the passage of smoke due to penetrations above the door handle.
Failed to provide intake combustion air from outside for 1 of 1 laundry rooms containing fuel fired equipment, creating potential carbon monoxide risk.
Power strip was used as a substitute for fixed wiring to provide power to high current draw equipment in resident room 316.
Failed to ensure 5 of 5 oxygen cylinders were segregated from full and empty cylinders and marked to avoid confusion.
Report Facts
Certified beds: 100
Census: 99
Deficiencies cited: 6
Residents potentially affected: 15
Residents potentially affected: 18
Residents potentially affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carol Whitehead | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Director of Plant Operations | Interviewed and involved in findings related to smoke alarms, door penetrations, combustion air intake, power strip, and oxygen cylinder storage | |
| Regional Director for Property Management | Participated in exit conference and discussed findings | |
| Executive Director | Participated via phone in exit conference and discussed findings |
Inspection Report
Renewal
Census: 87
Capacity: 87
Deficiencies: 5
Date: Feb 23, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from February 19 to 23, 2024.
Findings
The facility was found deficient in multiple areas including failure to ensure residents had physician orders and assessments for self-administration of medications, inadequate assessment and monitoring of skin conditions, failure to ensure finger orthotics were worn as ordered, insufficient monitoring of dialysis access sites, and incomplete documentation of meal consumption.
Deficiencies (5)
Failed to ensure residents had Physician's Orders and self-administration medication assessments for self-administered medications.
Failed to assess and monitor areas of bruising and obtain timely treatment orders for residents with skin tears.
Failed to ensure finger orthotics were available and worn as ordered for a resident reviewed for range of motion.
Failed to provide necessary care and services related to monitoring dialysis access site for a resident receiving hemodialysis.
Failed to ensure clinical records were complete and accurately documented related to meal consumption for a resident reviewed for nutrition.
Report Facts
Census SNF/NF: 77
Census SNF: 10
Total Census: 87
Medicare Census: 11
Medicaid Census: 63
Other Payor Census: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carol Whitehead | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| LPN 1 | Interviewed regarding resident medication self-administration | |
| Director of Nursing | Director of Nursing | Interviewed regarding medication orders, skin condition assessments, and dialysis monitoring |
| Wound Nurse | Interviewed regarding skin tear dressing and treatment | |
| Administrator | Administrator | Interviewed regarding finger splint orders and resident preferences |
Inspection Report
Renewal
Deficiencies: 0
Date: Feb 23, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on February 23, 2024.
Findings
Addison Pointe Health & Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Recertification and State Licensure Survey.
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Feb 23, 2024
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with healthcare regulations and standards at Addison Pointe Health & Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to ensure residents had physician orders for self-administration of medications, inadequate assessment and monitoring of skin conditions, failure to ensure finger orthotics were worn as ordered, insufficient monitoring of dialysis catheter sites, and incomplete clinical documentation related to meal consumption.
Deficiencies (5)
F 0554: The facility failed to ensure residents had physician orders and assessments for self-administration of medications for 1 of 1 residents reviewed.
F 0684: The facility failed to assess and monitor areas of bruising and obtain timely treatment orders for 2 of 2 residents reviewed for skin conditions non-pressure related.
F 0688: The facility failed to ensure finger orthotics were available and worn as ordered for 1 of 1 residents reviewed for range of motion.
F 0698: The facility failed to provide necessary dialysis care by not monitoring the dialysis access site for 1 of 1 residents reviewed for dialysis.
F 0842: The facility failed to ensure clinical records were complete and accurately documented related to meal consumption for 1 of 3 residents reviewed for nutrition.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding medication self-administration, skin condition monitoring, dialysis catheter monitoring, and clinical documentation deficiencies | |
| LPN 1 | Licensed Practical Nurse | Interviewed regarding medication self-administration observation |
| Wound Nurse | Interviewed regarding skin tear dressing assessment and physician order | |
| Administrator | Interviewed regarding finger orthotics and therapy orders |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 10, 2023
Visit Reason
The document is a paper compliance review related to an unrelated citation during the Investigation of Complaint IN00417350 completed on September 18, 2023.
Complaint Details
The visit was related to a complaint investigation (IN00417350) completed on September 18, 2023, with paper compliance reviewed and found in compliance.
Findings
Addison Pointe Health & Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the complaint investigation.
Inspection Report
Deficiencies: 1
Date: Sep 18, 2023
Visit Reason
The inspection was conducted to assess compliance with care standards related to activities of daily living, specifically focusing on incontinence care for residents.
Findings
The facility failed to ensure a dependent resident received timely assistance with incontinence care, resulting in a strong bowel movement odor persisting in a common area and delayed response by staff.
Deficiencies (1)
F 0677: The facility failed to provide timely activities of daily living assistance related to incontinence care for one resident, resulting in observable soiling and odor in a common area.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Observed walking past the affected area and interviewed regarding the odor and care concerns. | |
| Nurse 1 | Observed at nurses' station and medication cart; identified resident and confirmed odor source. |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 94
Deficiencies: 1
Date: Sep 18, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00417350. The complaint allegations were found to have no related deficiencies, but an unrelated deficiency was cited.
Complaint Details
Complaint IN00417350 was investigated and no deficiencies related to the allegations were cited. The cited deficiency was unrelated to the complaint.
Findings
The facility failed to ensure a dependent resident received timely assistance with activities of daily living related to incontinence care for 1 of 1 observed cases. A resident was found with bowel movement odor and soiling, and staff failed to promptly address the issue despite multiple staff passing by the area. Immediate corrective action was taken and systemic changes were planned.
Deficiencies (1)
Failure to provide timely ADL assistance related to incontinence care for a dependent resident.
Report Facts
Census: 94
Total Capacity: 94
Residents audited: 10
Audit frequency: 1
Audit frequency: 3
Audit frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tamara Zimmerman | Director of Nursing | Named in relation to observation and interview regarding the deficiency and corrective action |
| Nurse 1 | Observed and interviewed regarding the failure to provide timely incontinence care |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 15, 2023
Visit Reason
Paper compliance review to the Investigation of Complaints IN00408741 and IN00408800 completed on August 29, 2023.
Complaint Details
Investigation of Complaints IN00408741 and IN00408800; paper compliance review completed.
Findings
Addison Pointe Health & Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 29, 2023
Visit Reason
The inspection was conducted in response to complaints IN00408741 and IN00408800 regarding the facility's failure to accommodate resident needs related to activities, outings, and dietary preferences.
Complaint Details
The inspection relates to complaints IN00408741 and IN00408800 concerning failure to accommodate resident needs in activities, outings, and dietary services.
Findings
The facility failed to reasonably accommodate a resident's needs related to transportation for outings, did not provide scheduled activities and outings as planned, and failed to complete an annual activity assessment for one resident. Additionally, the facility did not provide dietary meals according to a resident's fluid restriction and diet dessert preferences.
Deficiencies (3)
F 0558: The facility failed to reasonably accommodate the needs and preferences of a resident by not transporting her to outings due to footrests on her wheelchair.
F 0679: The facility failed to provide scheduled activities and routine outings, and did not complete an annual activity assessment for one resident.
F 0806: The facility failed to provide a diet as requested per resident preference related to fluid restriction and diet desserts for one resident.
Report Facts
Residents reviewed for activities: 3
Fluid restriction: 1500
Beverage serving size: 8
Beverage serving size: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activity Director | Interviewed regarding activity scheduling, outings, and resident accommodations | |
| Administrator | Interviewed regarding transportation and bus usage prioritization | |
| Director of Nursing (DON) | Interviewed regarding activity locations and resident notifications | |
| Dietary Manager | Interviewed regarding dietary preferences and meal preparation | |
| Employee 1 | Observed providing brief exercise and playing guitar during activity time |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 3
Date: Aug 29, 2023
Visit Reason
The visit was conducted for the investigation of complaints IN00408741 and IN00408800 regarding federal and state deficiencies related to resident accommodations, activities, and dietary services.
Complaint Details
The investigation was triggered by complaints IN00408741 and IN00408800. Both complaints resulted in citations at F558, F679, and F806 related to resident accommodations, activities, and dietary services.
Findings
The facility failed to provide reasonable accommodations for resident needs related to transportation for outings, failed to ensure activities were provided as scheduled and failed to complete an annual activity assessment for one resident, and failed to provide dietary services according to resident preferences related to fluid restrictions and diet desserts.
Deficiencies (3)
Failed to provide reasonable accommodation of needs related to not transporting a resident to outings due to footrests on her wheelchair.
Failed to ensure activities were provided as scheduled and failed to provide routine outings as scheduled, and failed to ensure an annual activity assessment was completed for one resident.
Failed to provide a diet as requested per resident preference related to fluid restriction and diet desserts.
Report Facts
Census: 91
SNF beds: 10
SNF/NF beds: 81
Medicare residents: 10
Medicaid residents: 69
Other payor residents: 12
Inspection Report
Life Safety
Census: 92
Capacity: 100
Deficiencies: 4
Date: Jan 30, 2023
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) to assess compliance with fire safety and life safety code requirements.
Findings
The facility was found not in compliance with several Life Safety Code requirements including failure to test battery backup emergency lights monthly, incorrect date on the fire alarm control panel, blocked access to an electrical panel in the therapy storage room, and improper use of power strips for high power draw equipment in the admissions office.
Deficiencies (4)
Failed to ensure 2 of 2 battery backup emergency lights were tested monthly as required.
Failed to maintain the fire alarm system with accurate time and date information; fire alarm control panel displayed incorrect date (01/30/2003).
Failed to maintain access and working space around 1 electrical panel in the therapy storage room; storage was within 3 feet of the panel.
Failed to ensure power strips were not used as a substitute for fixed wiring to power equipment with high current draw in the admissions office.
Report Facts
Facility capacity: 100
Census: 92
Deficiencies cited: 4
Audit duration: 6
Audit frequency: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carol Whitehead | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Director of Plant Operations | Interviewed and involved in findings related to emergency lighting, fire alarm system, electrical panel access, and power strip use | |
| Administrator | Participated in exit conference and review of findings |
Inspection Report
Life Safety
Deficiencies: 0
Date: Jan 30, 2023
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey conducted on 01/30/23.
Findings
Addison Pointe Health & Rehabilitation Center was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Renewal
Deficiencies: 0
Date: Jan 13, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on January 13, 2023.
Findings
Addison Pointe Health & Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Recertification and State Licensure Survey.
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Jan 13, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with healthcare regulations and standards at Addison Pointe Health & Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including medication self-administration orders, assistance with activities of daily living, monitoring of anticoagulant side effects, pressure ulcer care, range of motion device use, urinary catheter care, dialysis assessments, medication administration timing and monitoring, and infection control practices.
Deficiencies (9)
F 0554: The facility failed to ensure residents had Physician's Orders and assessments for self-administration of medications for 1 of 1 residents reviewed.
F 0677: The facility failed to provide shaving assistance to a dependent resident related to activities of daily living for 1 of 4 residents reviewed.
F 0684: The facility failed to assess and monitor areas of bruising for 2 of 2 residents reviewed for anticoagulant medication side effects.
F 0686: The facility failed to implement Registered Dietitian's recommendations for a nutritional supplement for 1 of 2 residents with pressure ulcers.
F 0688: The facility failed to ensure a palm protector was in place as ordered for 1 of 1 residents reviewed for limited range of motion.
F 0690: The facility failed to ensure a resident's urinary catheter bag was not placed on the floor for 1 of 2 residents reviewed for urinary tract infections.
F 0698: The facility failed to complete pre and post dialysis assessments for 1 of 1 residents reviewed for dialysis.
F 0757: The facility failed to ensure heart rate was checked prior to cardiac medication, medications were given at correct times, and side effects monitored for 3 of 5 residents reviewed for unnecessary medications.
F 0880: The facility failed to ensure infection control guidelines were followed related to hand hygiene and proper disposal of lancets during medication pass for 1 of 8 residents observed.
Report Facts
Residents reviewed for ADL care: 4
Residents reviewed for anticoagulant side effects: 2
Residents reviewed for pressure ulcers: 2
Residents reviewed for limited range of motion: 1
Residents reviewed for urinary tract infections: 2
Residents reviewed for dialysis: 1
Residents reviewed for unnecessary medications: 5
Residents observed during medication pass: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding medication self-administration orders, bruising assessments, anticoagulant care, and medication monitoring. | |
| Director of Nursing | Interviewed regarding bruising assessments, catheter care, dialysis assessments, medication monitoring, and infection control practices. | |
| CNA 1 | Interviewed regarding resident refusal of shaving and palm protector use. | |
| LPN 1 | Interviewed regarding resident refusal of shaving and palm protector use. | |
| LPN 2 | Interviewed regarding dialysis assessment documentation. | |
| RN 2 | Observed and interviewed regarding hand hygiene and lancet disposal during medication pass. | |
| Wound Nurse | Interviewed regarding nutritional supplement order for pressure ulcer. |
Inspection Report
Annual Inspection
Census: 88
Capacity: 88
Deficiencies: 9
Date: Jan 9, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from January 9 to January 13, 2023.
Findings
The facility was found deficient in multiple areas including medication self-administration assessments, ADL care, monitoring of bruising related to anticoagulants, pressure ulcer treatment, range of motion management, catheter care, dialysis assessments, medication administration, and infection control practices.
Deficiencies (9)
Failed to ensure residents had Physician's Orders and assessments for self-administration of medications.
Failed to provide ADL assistance related to shaving for a dependent resident.
Failed to assess and monitor areas of bruising for residents on anticoagulants.
Failed to ensure a resident with pressure ulcers received necessary treatment and nutritional supplements.
Failed to ensure a palm protector was in place as ordered for a resident with limited range of motion.
Failed to ensure urinary catheter bag was not placed on the floor and was covered appropriately.
Failed to complete pre and post dialysis assessments for a resident receiving dialysis.
Failed to ensure medication administration included monitoring heart rate, correct timing, and side effect monitoring for certain medications.
Failed to ensure infection control guidelines were followed including hand hygiene before and after glove use and proper disposal of lancets.
Report Facts
Census: 88
Total Capacity: 88
Deficiencies cited: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carol Whitehead | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| RN 2 | Named in infection control deficiency for improper glove use and lancet disposal |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 88
Deficiencies: 0
Date: Aug 4, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00383382.
Complaint Details
Complaint IN00383382 was substantiated, but no deficiencies related to the allegations were cited.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type - SNF/NF: 80
Census Bed Type - SNF: 8
Total Census: 88
Census Payor Type - Medicare: 10
Census Payor Type - Medicaid: 64
Census Payor Type - Other: 14
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