Inspection Reports for Ashton Creek Health and Rehabilitation Center
4111 PARK PLACE DRIVE, FORT WAYNE, IN, 46845
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 19, 2025, was a complaint investigation and found no deficiencies related to the allegations. Earlier inspections showed a pattern of deficiencies primarily involving resident care issues such as pain management, wound and ileostomy care, oral hygiene, and monitoring of meal intake, as well as some Life Safety Code concerns including enforcement of the non-smoking policy and maintenance of corridor doors. Complaint investigations were mostly unsubstantiated, with the exception of a few substantiated cases that resulted in citations for pain management, wound care, and oral hygiene. Enforcement actions such as fines or license suspensions were not listed in the available reports. The trend suggests some improvement over time, with the most recent inspections showing compliance and fewer cited deficiencies compared to earlier reports.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
13.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
221% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
111 residents
Based on a May 2025 inspection.
Census over time
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jul 2, 2025
Visit Reason
The inspection was conducted as an annual survey of Ashton Creek Health and Rehabilitation Center to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 0
Date: May 19, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00458054 at Ashton Creek Health and Rehabilitation Center.
Complaint Details
Investigation of Complaint IN00458054 found no deficiencies related to the allegations; the complaint was not substantiated.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable federal and state regulations.
Report Facts
Census: 111
Census Bed Type: 92
Census Bed Type: 19
Census Payor Type: 14
Census Payor Type: 60
Census Payor Type: 37
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 0
Date: Feb 21, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00453814.
Complaint Details
Complaint IN00453814 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 applicable regulations.
Report Facts
Census: 107
SNF/NF beds: 87
SNF beds: 20
Medicare residents: 13
Medicaid residents: 62
Other payor residents: 32
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 0
Date: Oct 28, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00445031.
Complaint Details
Complaint IN00445031 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00445031 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type - SNF/NF: 94
Census Bed Type - SNF: 21
Census Total: 115
Census Payor Type - Medicare: 18
Census Payor Type - Medicaid: 62
Census Payor Type - Other: 35
Census Payor Type - Total: 115
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 30, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00421612 and IN00421741.
Complaint Details
Investigation of Complaint IN00421612 and IN00421741; paper compliance review completed on September 11, 2024; facility found in compliance.
Findings
Ashton Creek Health and 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 Investigations.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 11, 2024
Visit Reason
The inspection was conducted due to a complaint (IN00442678) regarding inadequate pain management for a resident requiring such services.
Complaint Details
This citation relates to Complaint IN00442678.
Findings
The facility failed to provide effective pain management for Resident O, who had fractures and inflammatory arthritis causing severe pain. Despite physician orders for scheduled opioid medication, the resident did not consistently receive pain medication on schedule, resulting in inadequate pain relief and interference with rehabilitation.
Deficiencies (1)
Failed to provide safe, appropriate pain management for a resident requiring such services.
Report Facts
Residents reviewed for pain: 3
Pain rating: 8
Pain rating: 7
Pain medication frequency: 4
Scheduled medication times: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 5 (RN) | Interviewed regarding Resident O's missed 9:00 a.m. pain medication on 9/11/24. | |
| Director of Nursing | Interviewed regarding Resident O not receiving scheduled pain medication on 9/11/24 at 9:00 a.m. |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 107
Deficiencies: 1
Date: Sep 10, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00441977 and IN00442678. Complaint IN00442678 resulted in federal/state deficiencies related to pain management.
Complaint Details
Complaint IN00442678 was substantiated with federal/state deficiencies cited related to pain management. Complaint IN00441977 had no deficiencies related to the allegation.
Findings
The facility failed to provide effective pain management for 1 of 3 residents reviewed for pain. Resident O experienced severe pain that was not adequately managed, with pain medications not administered timely or routinely as prescribed.
Deficiencies (1)
Failure to provide effective pain management for Resident O, including not administering pain medication as scheduled and inadequate pain relief.
Report Facts
Census: 107
Total Capacity: 107
Pain medication doses scheduled: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Slate | Director of Clinical Services | Signed the report |
| Registered Nurse 5 | RN | Interviewed regarding Resident O's pain medication administration |
| Director of Nursing Services | Interviewed and responsible for reassessment and monitoring of pain management |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 27, 2024
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey, which also included a paper review of the Investigation of Complaint IN00438109 completed on July 22, 2024.
Complaint Details
Complaint IN00438109 was investigated and found to be corrected.
Findings
Ashton Creek Health and 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 review of the Recertification and State Licensure survey and the Investigation of Complaint IN00438109.
Inspection Report
Life Safety
Census: 111
Capacity: 139
Deficiencies: 0
Date: Aug 6, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a), respectively.
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 in Medicare/Medicaid and Life Safety from Fire and the 2012 edition of the NFPA 101 Life Safety Code.
Report Facts
Facility capacity: 139
Census: 111
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 22, 2024
Visit Reason
The inspection was conducted in response to a complaint (IN00438109) regarding concerns about inadequate monitoring of meal intakes and weights for residents, specifically Resident B and Resident 305.
Complaint Details
This citation is related to complaint IN00438109.
Findings
The facility failed to ensure proper monitoring of meal intakes and weights for two residents, resulting in significant unaddressed weight loss. Documentation of meal intake was incomplete, and supplements were not consistently offered or ordered as indicated in care plans. Staff inconsistencies in weight monitoring and failure to follow Nutrition at Risk (NAR) policy were noted.
Deficiencies (1)
Failure to ensure meal intakes and weights were monitored for Resident B and Resident 305.
Report Facts
Weight loss percentage: 6.73
Weight loss percentage: 20.32
Weight measurements: 148.6
Weight measurements: 138.6
Weight measurements: 134.6
Weight measurements: 186
Weight measurements: 148.2
Weight measurements: 146
Weight measurements: 148.6
Weight measurements: 141.2
Weight measurements: 200
Weight measurements: 200.2
Inspection Report
Annual Inspection
Census: 110
Capacity: 110
Deficiencies: 3
Date: Jul 22, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00438109, IN00437388, and IN00435894.
Complaint Details
Complaint IN00438109 resulted in federal/state deficiencies cited. Complaints IN00437388 and IN00435894 had no deficiencies related to the allegations.
Findings
The facility was found deficient in multiple areas including failure to provide adequate assistance with denture care and grooming for one resident, failure to monitor meal intakes and weights for two residents, and failure to ensure proper hand hygiene during meal preparation and service affecting all residents.
Deficiencies (3)
Failure to ensure assistance was provided with managing denture care and grooming of facial hair for 1 of 6 residents reviewed (Resident 40).
Failure to ensure meal intakes and weights were monitored for 2 of 3 residents reviewed (Resident B and Resident 305).
Failure to ensure hand hygiene was performed when necessary in the meal preparation and service process affecting all 110 residents.
Report Facts
Census: 110
Total Capacity: 110
Weight loss percentage: 6.73
Weight loss percentage: 20.32
Residents affected: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Derek Gibson | Laboratory Director's or Provider/Supplier Representative | Signed the report |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jul 22, 2024
Visit Reason
The inspection was conducted based on complaints regarding failure to provide assistance with denture care and grooming, failure to ensure meal intakes and weights were monitored, and failure to ensure proper hand hygiene during meal preparation and service.
Complaint Details
This citation is related to complaint IN00438109.
Findings
The facility failed to provide adequate assistance with denture care and facial hair grooming for Resident 40, failed to monitor meal intakes and weights for Residents B and 305, and failed to ensure hand hygiene was performed by dietary staff during meal preparation and service.
Deficiencies (3)
Failure to provide care and assistance with managing denture care and grooming of facial hair for Resident 40.
Failure to ensure meal intakes and weights were monitored for Residents B and 305.
Failure to ensure hand hygiene was performed when necessary in the meal preparation and service process.
Report Facts
BIMS score: 12
BIMS score: 3
BIMS score: 4
Weight loss percentage: 6.73
Weight loss percentage: 20.32
Meal intake records missing: 26
Residents affected: 1
Residents affected: 2
Residents affected: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide 20 | Certified Nurse Aide | Interviewed regarding Resident 40's denture care and refusal to wear denture. |
| Certified Nurse Aide 21 | Certified Nurse Aide | Interviewed regarding Resident 40's denture care and refusal to wear denture. |
| Director of Nursing | Director of Nursing | Interviewed regarding Resident 40's denture care and care plan, and weight monitoring. |
| Regional Nurse Consultant | Regional Nurse Consultant | Interviewed regarding Resident 40's care plan and denture refusal. |
| Administrator | Administrator | Interviewed regarding Resident 40's denture care documentation. |
| Dietary Manager | Dietary Manager | Observed and interviewed regarding hand hygiene practices in meal preparation. |
| Assistant Dietary Manager | Assistant Dietary Manager | Interviewed regarding hand hygiene expectations during meal service. |
| Regional Dietician | Regional Dietician | Interviewed regarding weight monitoring and care plans for Residents B and 305. |
| Employee 22 | Interviewed regarding Resident 305's admission condition and weight. |
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 0
Date: Apr 19, 2024
Visit Reason
This visit was for the investigation of Complaint IN00431852.
Complaint Details
Complaint IN00431852 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00431852 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type - SNF: 27
Census Bed Type - SNF/NF: 81
Census Total: 108
Census Payor Type - Medicare: 12
Census Payor Type - Medicaid: 66
Census Payor Type - Other: 30
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 0
Date: Apr 3, 2024
Visit Reason
This visit was for the investigation of Complaints IN00430893 and IN00431727.
Complaint Details
Complaint IN00430893 - No deficiencies related to the allegations are cited. Complaint IN00431727 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations in Complaints IN00430893 and IN00431727 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 112
Census SNF beds: 31
Census SNF/NF beds: 81
Census Medicare residents: 14
Census Medicaid residents: 67
Census Other payor residents: 31
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 3, 2024
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Ashton Creek Health and Rehabilitation Center.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 0
Date: Mar 15, 2024
Visit Reason
This visit was conducted for the investigation of Complaints IN00429197 and IN00429936.
Complaint Details
Complaint IN00429197 and Complaint IN00429936 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations in Complaints IN00429197 and IN00429936 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type - SNF: 30
Census Bed Type - SNF/NF: 83
Total Census: 113
Census Payor Type - Medicare: 38
Census Payor Type - Medicaid: 65
Census Payor Type - Other: 10
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 17, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to timely report a suspicious injury of unknown source for one resident and failure to assess and follow physician orders for treatment of a pressure ulcer for another resident.
Complaint Details
This citation relates to Complaint IN00421741 for the failure to timely report suspicious injury and Complaint IN00421612 for failure to assess and treat pressure ulcers as ordered.
Findings
The facility failed to timely report suspected abuse related to suspicious injuries on Resident N and failed to assess timely and follow physician orders for treatment of a pressure ulcer for Resident O. Both deficiencies were found to have minimal harm or potential for actual harm and affected a few residents.
Deficiencies (2)
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities for Resident N.
Failed to assess timely and follow physician orders for treatment of a pressure ulcer for Resident O.
Report Facts
Bruise measurements: 3
Bruise measurements: 4
Bruise measurements: 8
Bruise measurements: 6
Deficiencies cited: 2
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 2
Date: Nov 16, 2023
Visit Reason
This visit was conducted for the investigation of three complaints (IN00421612, IN00421620, and IN00421741) concerning alleged violations at Ashton Creek Health and Rehabilitation Center.
Complaint Details
Complaint IN00421612 had federal/state deficiencies cited related to pressure ulcer care. Complaint IN00421620 had no deficiencies cited. Complaint IN00421741 had federal/state deficiencies cited related to reporting alleged violations.
Findings
The facility was found deficient in timely reporting of a suspicious injury of unknown source for one resident, and failed to timely assess and follow physician orders for treatment of a pressure ulcer for another resident. One complaint was substantiated with deficiencies cited, one complaint had no deficiencies, and another complaint had deficiencies related to reporting alleged violations and pressure ulcer care.
Deficiencies (2)
Failed to report timely a suspicious injury of unknown source for Resident N.
Failed to assess timely and follow physician orders for treatment of a pressure ulcer for Resident O.
Report Facts
Census: 109
SNF/NF beds: 84
SNF beds: 25
Medicare residents: 30
Medicaid residents: 58
Other payor residents: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Sevier | RN | Laboratory Director's or Provider/Supplier Representative's signature on report |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 11, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00421612 and IN00421741.
Complaint Details
Complaint investigations IN00421612 and IN00421741 were reviewed for paper compliance and found to be in compliance.
Findings
Ashton Creek Health and 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 Investigations.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Oct 14, 2023
Visit Reason
The inspection was conducted as a standard annual survey of Ashton Creek Health and Rehabilitation Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, indicating the facility met all required standards at the time of the survey.
Inspection Report
Complaint Investigation
Census: 110
Capacity: 110
Deficiencies: 0
Date: Oct 14, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00417566, IN00417614, IN00417759, and IN00418668, and included a COVID-19 Focused Infection Control Survey.
Complaint Details
Complaints IN00417566, IN00417614, IN00417759, and IN00418668 were investigated and no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations in any of the complaints were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaints and infection control survey.
Report Facts
Census Bed Type: 110
Census Payor Type - Medicare: 26
Census Payor Type - Medicaid: 62
Census Payor Type - Other: 22
Inspection Report
Re-Inspection
Census: 108
Capacity: 139
Deficiencies: 0
Date: Oct 3, 2023
Visit Reason
A 2nd Post Survey Revisit (PSR) to the 1st PSR that exited on 09/06/23 for the Life Safety Code Recertification and State Licensure Survey that exited on 07/19/23 was conducted by the Indiana Department of Health in accordance with 42 CFR Subpart 483.90(a).
Findings
At this PSR survey, Ashton Creek Health and 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. The facility was fully sprinklered with a fire alarm system and smoke detection throughout.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 18, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00415361 completed on August 23, 2023.
Complaint Details
Investigation of Complaint IN00415361 completed on August 23, 2023; facility found in compliance.
Findings
Ashton Creek Health and 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
Re-Inspection
Census: 108
Capacity: 139
Deficiencies: 1
Date: Sep 6, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 07/19/23.
Findings
At this PSR survey, the facility was found in compliance with Emergency Preparedness Requirements. However, the facility was found not in compliance with Life Safety Code requirements due to failure to enforce the non-smoking policy on campus, specifically staff smoking near the employee entrance. A plan of correction was implemented to address this deficiency.
Deficiencies (1)
Failure to enforce non-smoking policy on facility property, evidenced by staff smoking near the storage shed and cigarette butts found on the ground outside the service hall.
Report Facts
Facility capacity: 139
Census: 108
Audit frequency: 2
Audit frequency: 1
Audit frequency: 3
Audit frequency: 1
Plan of correction completion date: Sep 19, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Derek Gibson | Maintenance Director | Interviewed and confirmed smoking on property by staff; named in findings related to enforcement of non-smoking policy |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 23, 2023
Visit Reason
The inspection was conducted in response to a complaint (IN00415361) regarding failure to provide oral hygiene care to a dependent resident.
Complaint Details
This Federal citation is related to Complaint IN00415361. Resident D would refuse care at times but no refusal documentation was available. Resident D had severe cognitive impairment and required one-person assistance with personal hygiene. Personal hygiene, including oral care, was not completed on multiple dates between 7/24/23 and 8/22/23 as documented in the point of care history report.
Findings
The facility failed to ensure oral hygiene care was completed for 1 of 3 dependent residents (Resident D). Interviews and record reviews revealed Resident D did not receive assistance with oral hygiene on multiple occasions despite needing help and family requests for twice daily care.
Deficiencies (1)
Failure to provide oral hygiene care to Resident D who required assistance.
Report Facts
Dates/times personal hygiene not completed: 22
BIMS score: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide 2 | Certified Nurse Aide | Indicated residents received oral hygiene care daily but had not assisted Resident D on 8/23/23 |
| Qualified Medication Aide 3 | Qualified Medication Aide | Indicated oral hygiene care was performed during AM and PM care and was unsure if Resident D had received assistance on 8/23/23 |
| Certified Nurse Aide 4 | Certified Nurse Aide | Indicated oral care should be completed no later than 8 AM and Resident D had not received oral care on 8/23/23 |
| Assistant Director of Nursing | Assistant Director of Nursing | Indicated oral hygiene care was completed in AM and HS, Resident D required assistance with all ADLs, and no refusal documentation was available |
| Administrator | Administrator | Indicated Resident D would refuse care at times and no refusal documentation was available |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 107
Deficiencies: 1
Date: Aug 23, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00415361 regarding allegations related to oral hygiene care for dependent residents.
Complaint Details
Complaint IN00415361 was substantiated with federal/state deficiencies cited at F677 related to failure to provide oral hygiene care to Resident D.
Findings
The facility failed to ensure oral hygiene was completed for 1 of 3 dependent residents (Resident D). Interviews and record reviews confirmed Resident D did not receive assistance with oral hygiene on multiple occasions, including the day of the survey.
Deficiencies (1)
Failed to ensure oral hygiene was completed for 1 of 3 dependent residents (Resident D).
Report Facts
Census: 107
Total Capacity: 107
Medicare Census: 29
Medicaid Census: 61
Other Payor Census: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Derek Gibson | Laboratory Director or Provider/Supplier Representative | Signed the report |
| Certified Nurse Aide 2 | Interviewed regarding oral hygiene care for Resident D | |
| Qualified Medication Aide 3 | Interviewed regarding oral hygiene care for Resident D | |
| Certified Nurse Aide 4 | Interviewed regarding oral hygiene care for Resident D | |
| Assistant Director of Nursing (ADON) | Interviewed regarding oral hygiene care and policies | |
| Administrator | Interviewed regarding oral hygiene care and refusal documentation |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 14, 2023
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey completed on July 11, 2023.
Findings
Ashton Creek Health and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 0
Date: Aug 11, 2023
Visit Reason
This visit was conducted for the investigation of two complaints, IN00413055 and IN00413435.
Complaint Details
Investigation of Complaint IN00413055 and IN00413435 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in either complaint were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type Total: 108
Census Payor Type Medicare: 28
Census Payor Type Medicaid: 69
Census Payor Type Other: 11
Inspection Report
Routine
Census: 111
Capacity: 139
Deficiencies: 8
Date: Jul 19, 2023
Visit Reason
A routine Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal regulations.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements, including failure to review and update the Emergency Preparedness Plan, Policies and Procedures, Communication Plan, and Training and Testing program annually. Additionally, Life Safety Code deficiencies were identified including a laundry door propped open without a compliant release device, kitchen corridor doors blocked open, sprinkler heads loaded with dirt in the carport, and failure to enforce the non-smoking policy on campus.
Deficiencies (8)
Failed to review and update the Emergency Preparedness Plan at least annually.
Failed to review and update the Emergency Preparedness Policies and Procedures at least annually.
Failed to review and update the Emergency Preparedness Communication Plan at least annually.
Failed to review and update the Emergency Preparedness Training and Testing program at least annually.
Laundry room door to hazardous area was propped open with a device that did not release with the fire alarm.
Two kitchen corridor doors were blocked from closing due to carts, leaving cooking facilities open to the corridor.
Six sprinkler heads in the carport were loaded with dirt and foreign material.
Facility failed to enforce non-smoking policy; staff were observed smoking on campus.
Report Facts
Facility capacity: 139
Census: 111
Deficiency completion date: 2023
Number of sprinkler heads loaded with dirt: 6
Number of kitchen corridor doors blocked: 2
Number of kitchen corridor doors total: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Molly Linder | Administrator | Named in relation to review and exit conference of findings |
| Maintenance Director | Interviewed and involved in observations and exit conference |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jul 11, 2023
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements related to resident care, medication management, privacy, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure resident privacy, inconsistent bathing care, inadequate care planning and staff education for a resident with a shunt, inconsistent management and documentation of tube feeding for a resident, and unsafe medication storage practices for some residents.
Deficiencies (5)
Failure to ensure privacy for 4 of 32 residents, with staff entering rooms without knocking.
Failure to ensure a resident received scheduled shower/bed baths consistently.
Failure to provide appropriate care and staff education for a resident with a shunt.
Failure to manage tube feeding consistently and document intake for a resident with a feeding tube.
Failure to ensure safe medication storage for 2 of 8 residents, including medications left at bedside without proper assessment or orders.
Report Facts
Residents reviewed for privacy: 32
Residents affected by privacy deficiency: 4
Residents reviewed for bathing care: 23
Residents affected by bathing deficiency: 1
Residents reviewed for shunt care: 1
Residents reviewed for tube feeding management: 4
Residents affected by tube feeding deficiency: 1
Residents reviewed for medication storage: 8
Residents affected by medication storage deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 4 | Licensed Practical Nurse | Named in interview regarding shunt care knowledge |
| LPN 5 | Licensed Practical Nurse | Named in interview regarding verbal report and care plan knowledge |
| CNA 6 | Certified Nursing Aid | Named in interview regarding resident care needs |
| Assistant Director of Nurses | ADON | Removed medication from bedside and identified it |
| Regional Nurse Consultant | RNC | Provided interview on privacy and medication storage policies |
| Director of Nursing | DON | Provided interviews and policies related to bathing, shunt care, tube feeding, and medication storage |
| Respiratory Therapist 25 | Respiratory Therapist | Conducted self-administration assessment for Resident 215 |
| Registered Nurse 20 | RN | Named in privacy deficiency for entering room without knocking |
| Case Manager 21 | Named in privacy deficiency for entering room without knocking | |
| Certified Nurse Aide 24 | CNA | Named in privacy deficiency for entering room without knocking |
| CNA 22 | Certified Nurse Aide | Named in privacy deficiency for entering room without knocking |
| CNA 23 | Certified Nurse Aide | Named in privacy deficiency for entering room without knocking |
| CNA 100 | Certified Nurse Aide | Named in bathing deficiency interview |
Inspection Report
Renewal
Census: 110
Capacity: 110
Deficiencies: 5
Date: Jul 11, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted on July 5, 6, 7, 10 and 11, 2023.
Findings
The facility was found deficient in multiple areas including failure to ensure resident privacy, inconsistent bathing care, inadequate care for a resident with a shunt, inconsistent tube feeding management, and unsafe medication storage practices.
Deficiencies (5)
Failed to ensure privacy for 4 of 32 residents when staff entered rooms without knocking.
Failed to ensure a resident received scheduled showers/bed baths consistently.
Failed to ensure care for a resident with a shunt including lack of care plan and staff education.
Failed to manage tube feeding consistently for a resident including documentation discrepancies.
Failed to ensure safe medication storage for 2 residents with medications found unsecured.
Report Facts
Survey dates: 5
Census SNF/NF beds: 99
Census SNF beds: 11
Total census: 110
Medicare census: 10
Medicaid census: 71
Other payor census: 29
Residents reviewed for privacy deficiency: 4
Residents reviewed for bathing deficiency: 23
Residents reviewed for shunt care deficiency: 1
Residents reviewed for tube feeding deficiency: 4
Residents reviewed for medication storage deficiency: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Steohanie Slate | Director of Nursing | Named in relation to staff re-inservicing and monitoring plans for multiple deficiencies |
| Nurse 20 | Registered Nurse | Named in privacy deficiency for entering resident room without knocking |
| Manager 21 | Named in privacy deficiency for entering resident room without knocking | |
| CNA 24 | Certified Nurse Aide | Named in privacy deficiency for entering resident room without knocking |
| CNA 22 | Certified Nurse Aide | Named in privacy deficiency for entering resident room without knocking |
| CNA 23 | Certified Nurse Aide | Named in privacy deficiency for entering resident room without knocking |
| CNA 100 | Certified Nurse Aide | Named in bathing deficiency for inconsistent bed bath provision |
| LPN 4 | Licensed Practical Nurse | Named in shunt care deficiency interview |
| LPN 5 | Licensed Practical Nurse | Named in shunt care deficiency interview |
| CNA 6 | Certified Nursing Aid | Named in shunt care deficiency interview |
| Respiratory Therapist 25 | Named in medication self-administration assessment | |
| Assistant Director of Nurses | ADON | Named in medication storage deficiency for removing unsecured medication |
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 0
Date: May 17, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00406900.
Complaint Details
Complaint IN00406900 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations of Complaint IN00406900 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type - SNF/NF: 87
Census Bed Type - SNF: 22
Census Total: 109
Census Payor Type - Medicare: 22
Census Payor Type - Medicaid: 72
Census Payor Type - Other: 15
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 3, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00404416 completed on April 12, 2023.
Complaint Details
Investigation of Complaint IN00404416 completed on April 12, 2023; facility found in compliance.
Findings
Ashton Creek Health and 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
Complaint Investigation
Deficiencies: 2
Date: Apr 12, 2023
Visit Reason
The inspection was conducted in response to a complaint (IN00404416) regarding the facility's failure to provide appropriate wound care and ileostomy management for Resident D.
Complaint Details
The complaint alleged that Resident D's ileostomy bag was leaking liquid stool into her abdominal surgical wound, causing continuous contamination, dermatitis, and recurrent cellulitis. The resident was reportedly left lying in stool-covered towels until staff could change the bag and felt neglected due to the time-consuming nature of her care.
Findings
The facility failed to follow physician orders for follow-up wound care and ileostomy management for Resident D, resulting in ongoing wound infection, leakage of the ileostomy bag, skin irritation, and inadequate referral to the wound clinic. The resident experienced continuous contamination of the abdominal wound due to a poorly sealed ostomy bag and was admitted to the hospital as a result.
Deficiencies (2)
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals related to wound care follow-up.
Failure to provide necessary care and services for management of an ileostomy, including preventing leakage and protecting the surgical wound.
Report Facts
Residents reviewed: 3
Residents affected: 1
Date of survey completion: Apr 12, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Wound Care Nurse | Interviewed on 4/11/23; indicated referral to wound clinic had not been completed as ordered | |
| Regional Nurse Consultant | Interviewed on 4/12/23; indicated staff should have obtained physician orders and documented care |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 108
Deficiencies: 2
Date: Apr 11, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00404416 and IN00404800. Complaint IN00404416 resulted in federal/state deficiencies cited, while Complaint IN00404800 had no deficiencies related to the allegation.
Complaint Details
Complaint IN00404416 was substantiated with federal/state deficiencies cited at F684 and F691 related to wound care and ileostomy management. Complaint IN00404800 had no deficiencies cited.
Findings
The facility failed to follow physician orders for follow-up wound care and failed to provide necessary care and services for management of an ileostomy for one resident (Resident D). The resident experienced ongoing issues with leaking ileostomy bags contaminating a surgical abdominal wound, causing pain, skin irritation, and infection risk. The facility did not complete ordered referrals to the wound clinic and lacked proper documentation and interventions to manage the ileostomy and wound care.
Deficiencies (2)
Failed to follow physician orders for follow-up wound care for Resident D.
Failed to provide necessary care and services for management of an ileostomy for Resident D.
Report Facts
Census: 108
Total Capacity: 108
Survey Dates: April 11 and 12, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Sevier | RN | Laboratory Director's or Provider/Supplier Representative's signature on report |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 108
Deficiencies: 1
Date: Jan 26, 2023
Visit Reason
This visit was conducted for the investigation of two complaints, IN00399776 and IN00400088. Complaint IN00399776 was substantiated with related federal/state deficiencies cited, while Complaint IN00400088 was substantiated with no deficiencies cited.
Complaint Details
Complaint IN00399776 was substantiated with federal/state deficiencies cited at F623 related to failure to provide proper notice before transfer/discharge. Complaint IN00400088 was substantiated with no deficiencies cited.
Findings
The facility failed to ensure that residents were properly notified of discharge for 1 of 8 residents reviewed (Resident B). Specifically, Resident B was discharged without proper notice and documentation, including failure to provide a timely Notice of Medicare Non-Coverage (NOMNC) and transfer/discharge forms signed by the resident or representative.
Deficiencies (1)
Failure to ensure residents were notified of discharge for 1 of 8 residents reviewed (Resident B).
Report Facts
Census: 108
Total Capacity: 108
Deficiencies cited: 1
Audit frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Molly Linder | Administrator | Signed the report and involved in oversight of corrective actions |
| Director of Nursing | Responsible for audits and corrective actions related to discharge notification deficiencies | |
| Licensed Practical Nurse 6 | LPN | Interviewed regarding notice requirements prior to discharge |
| Social Services 3 | Interviewed regarding notification of planned discharge and NOMNC process | |
| Case Manager 2 | Interviewed regarding NOMNC issuance and discharge notification | |
| Director of Rehab | DOR | Interviewed regarding discharge notification process and care team communication |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 26, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00399776.
Complaint Details
Investigation of Complaint IN00399776 completed on January 26, 2023; facility found in compliance.
Findings
Ashton Creek Health and 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
Life Safety
Census: 102
Capacity: 139
Deficiencies: 0
Date: Jan 17, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code PSR Survey conducted on 12/12/22 for the Life Safety Code Annual Recertification survey that exited on 10/20/22 was conducted by the Indiana Department of Health in accordance with 42 CFR Subpart 483.90(a).
Findings
At this PSR survey, Ashton Creek Health and 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. The facility was fully sprinklered with a fire alarm system and smoke detection throughout.
Inspection Report
Re-Inspection
Census: 102
Capacity: 139
Deficiencies: 2
Date: Dec 12, 2022
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 10/20/22 was performed to verify compliance with previous deficiencies.
Findings
The facility was found not in compliance with Life Safety Code requirements, including obstructions in a corridor exit path affecting 30 residents and a kitchen corridor door blocked from closing affecting 50 residents. The facility failed to implement systemic plans to prevent recurrence of these deficiencies.
Deficiencies (2)
Failed to ensure 1 of 10 corridor means of egresses were continuously maintained free of obstructions; 20 boxes and totes obstructed the exit hall from the dining room to the rear exit.
Failed to maintain 1 of 4 kitchen corridor doors to ensure cooking facilities serving 30 or more residents were not open to the corridor; a kitchen door was blocked from closing by a cart.
Report Facts
Residents affected: 30
Residents affected: 50
Boxes and totes obstructing corridor: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Molly Linder | Administrator | Signed report and mentioned in exit conference |
| Maintenance Director | Interviewed regarding corridor obstruction and kitchen door blockage |
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 0
Date: Nov 21, 2022
Visit Reason
This visit was for the investigation of complaints IN00394528.
Complaint Details
Complaint IN00394528 was investigated and found unsubstantiated due to lack of evidence.
Findings
The complaint IN00394528 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations regarding the complaint.
Report Facts
Census: 113
SNF/NF beds: 73
SNF beds: 40
Medicare residents: 14
Medicaid residents: 58
Other residents: 41
Inspection Report
Life Safety
Census: 102
Capacity: 139
Deficiencies: 6
Date: Oct 20, 2022
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal regulations.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements, with multiple deficiencies related to means of egress, cooking facilities, sprinkler system installation, smoking regulations, electrical systems maintenance, and use of power cords.
Deficiencies (6)
Laundry storeroom door was locked with a padlock from the outside and could not be opened from the inside if locked, potentially trapping staff inside.
Failed to maintain 3 of 4 kitchen corridor doors to ensure cooking facilities serving 30 or more residents were not open to the corridor; doors were propped open or blocked.
Sprinkler heads were obstructed in 4 of 4 closets and 1 of 8 corridors, preventing proper spray pattern coverage.
Facility failed to enforce non-smoking policies; cigarette butts and an ashtray were found outside the 500-hall exit.
Electrical receptacles in 59 of 68 resident sleeping rooms were not tested at least annually as required.
Flexible extension cord was used as a substitute for fixed wiring in the Social Services office.
Report Facts
Facility capacity: 139
Census: 102
Deficient kitchen doors: 3
Obstructed sprinkler locations: 5
Resident rooms with untested receptacles: 59
Resident rooms total: 68
Residents potentially affected by smoking violation: 50
Residents potentially affected by sprinkler obstruction: 10
Residents potentially affected by kitchen door deficiency: 50
Residents potentially affected by extension cord use: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Molly Linder | Administrator | Named in relation to exit conference and review of findings |
| Maintenance Director | Interviewed and involved in observations related to deficiencies |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Oct 13, 2022
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Ashton Creek Health and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 0
Date: Oct 5, 2022
Visit Reason
This visit was conducted for the investigation of Complaints IN00390083 and IN00390888.
Complaint Details
Complaint IN00390083 - Unsubstantiated due to lack of evidence. Complaint IN00390888 - Substantiated. No deficiencies related to the allegations are cited.
Findings
Complaint IN00390083 was unsubstantiated due to lack of evidence. Complaint IN00390888 was substantiated but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 109
Census Bed Type - SNF/NF: 70
Census Bed Type - SNF: 39
Census Payor Type - Medicare: 39
Census Payor Type - Medicaid: 60
Census Payor Type - Other: 10
Inspection Report
Renewal
Census: 98
Capacity: 98
Deficiencies: 7
Date: Sep 13, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from September 7 to 13, 2022.
Findings
The facility was found deficient in multiple areas including failure to assess residents for safe self-administration of medications, inaccurate Minimum Data Set (MDS) assessments, inadequate cleansing during bathing, failure to ensure residents were free from accident hazards related to smoking, improper handling of tube feeding supplies, failure to monitor narcotic medication side effects, and unsanitary food service conditions.
Deficiencies (7)
Failed to ensure a resident was assessed to safely self-administer a topical medication left at bedside.
Failed to ensure accuracy of Minimum Data Set (MDS) assessments for residents.
Failed to cleanse a resident's hands during bathing.
Failed to ensure residents remained free of accident hazards related to smoking.
Failed to maintain proper handling of tube feeding supplies including labeling and capping.
Failed to adequately monitor narcotic pain medication side effects for residents.
Failed to ensure sanitary conditions in food service areas related to debris on dishes, storage of wet cookware and glassware, and handwashing during food service.
Report Facts
Census: 98
Total Capacity: 98
Deficiencies cited: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 9 | Registered Nurse | Interviewed regarding medication self-administration assessment and smoking supervision |
| Director of Nursing | Director of Nursing | Interviewed regarding medication self-administration assessment, MDS accuracy, and narcotic monitoring |
| Dietary Aide 6 | Dietary Aide | Observed during meal service with hand hygiene issues |
| Certified Dietary Manager 7 | Certified Dietary Manager | Interviewed regarding dishwashing and hand hygiene policies |
| Cook 5 | Cook | Observed delivering meals without hand hygiene |
| Licensed Practical Nurse 2 | Licensed Practical Nurse | Interviewed regarding resident smoking practices |
| MDS Coordinator 2 | MDS Coordinator | Interviewed regarding MDS assessment process |
| Administrator | Administrator | Interviewed regarding resident smoking and facility policies |
| Executive Director | Executive Director | Interviewed regarding facility smoking policy |
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