Inspection Reports for Belltower Health & Rehabilitation Center
5805 NORTH FIR ROAD, GRANGER, IN, 46530
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 27, 2025, found the facility in compliance with no deficiencies related to the complaint investigated. Prior inspections showed a mixed pattern with some deficiencies noted in areas such as food storage sanitation and staff credentialing, as well as issues with resident care including medication administration and abuse resolution. Earlier reports frequently cited deficiencies related to emergency preparedness, life safety code compliance, care planning, and infection control, but no fines or license actions were listed in the available reports. Most complaint investigations were unsubstantiated, though one in May 2025 was substantiated with deficiencies related to abuse policies and medication orders. The facility’s recent clean inspection suggests some improvement following prior citations, particularly in complaint-related compliance.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
22.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
443% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 27, 2025
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00457672 completed on May 8, 2025.
Complaint Details
Complaint IN00457672 was investigated and the facility was found to be in compliance.
Findings
Belltower Health and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 regarding the paper compliance review of the complaint investigation.
Inspection Report
Renewal
Census: 83
Capacity: 83
Deficiencies: 2
Date: Jun 9, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaints IN00459484, IN00460545, and IN00460971.
Complaint Details
Complaints IN00459484, IN00460545, and IN00460971 were investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies were cited related to the complaints investigated. Two deficiencies were identified: failure to store food in a sanitary manner in the kitchen, and failure to ensure a Certified Nursing Assistant maintained current registration. Both deficiencies had corrective actions planned with compliance dates.
Deficiencies (2)
Facility failed to store food in a sanitary manner related to undated and unlabeled foods and drinks in the main kitchen walk-in cooler and freezer.
Facility failed to ensure a Certified Nursing Assistant (CNA 4) maintained a current registration with the State of Indiana; CNA worked with an expired certificate.
Report Facts
Residents affected: 82
Certified Nursing Assistants reviewed: 38
CNA with expired registration: 1
Census: 83
Total licensed capacity: 83
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marti Carmean | Administrator | Signed the report and involved in education of CNA on certificate renewal. |
| CNA 4 | Certified Nursing Assistant | Named in deficiency for working with expired registration. |
| Dietary Manager | Interviewed regarding food storage deficiencies and provided facility food safety policy. | |
| DON | Director of Nursing | Interviewed regarding CNA registration and facility policies. |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 84
Deficiencies: 2
Date: May 8, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00457672 and IN00458673. Complaint IN00457672 resulted in federal deficiencies related to the allegations, while Complaint IN00458673 had no deficiencies related to the allegations.
Complaint Details
Complaint IN00457672 was substantiated with federal deficiencies cited at F607 related to abuse/neglect policies. Complaint IN00458673 was not substantiated with no deficiencies cited.
Findings
The facility was found deficient for failing to ensure an allegation of abuse resolution regarding care assignments for Resident C, and for failing to follow a physician's order when administering blood pressure medication for Resident E. Resident C was still receiving care from a CNA he preferred not to have, despite the investigation outcome. Resident E received blood pressure medication despite blood pressure readings below the ordered parameters.
Deficiencies (2)
Failed to ensure an allegation of abuse resolution regarding care assignments for Resident C.
Failed to follow a physician's order when administering blood pressure medication for Resident E.
Report Facts
Census: 84
Total Capacity: 84
Residents affected by abuse allegation: 1
Residents affected by blood pressure medication issue: 1
Residents with blood pressure medications with parameters: 2
Dates of blood pressure medication given below parameters: 7
Inspection Report
Complaint Investigation
Census: 88
Capacity: 88
Deficiencies: 0
Date: Apr 2, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00454801.
Complaint Details
Complaint IN00454801 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 relevant regulations.
Report Facts
Medicare census: 21
Medicaid census: 55
Other payor census: 12
Inspection Report
Complaint Investigation
Census: 89
Capacity: 89
Deficiencies: 0
Date: Dec 19, 2024
Visit Reason
This visit was conducted for the investigation of Complaints IN00444070 and IN00439922.
Complaint Details
Complaint IN00444070 - No deficiencies related to the allegations are cited. Complaint IN00439922 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations in Complaints IN00444070 and IN00439922 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type: 89
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 67
Census Payor Type - Other: 17
Inspection Report
Follow-Up
Census: 79
Capacity: 96
Deficiencies: 0
Date: Sep 24, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted for the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey following the exit of the initial surveys on 08/13/24.
Findings
At this Post Survey Revisit, Belltower Health & Rehabilitation Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Participation in Medicare and Medicaid.
Report Facts
Certified beds: 96
Census: 79
Inspection Report
Routine
Census: 83
Capacity: 96
Deficiencies: 8
Date: Aug 13, 2024
Visit Reason
Routine Emergency Preparedness and Life Safety Code Recertification survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Emergency Preparedness Requirements, Life Safety Code, and related NFPA standards. Deficiencies included failure to conduct required emergency plan exercises twice per year, missing documentation for emergency generator load testing, incomplete kitchen hood suppression coverage, missing quarterly sprinkler inspection documentation, incomplete fire door inspections, presence of prohibited portable space heaters, and inadequate staff training and ventilation in oxygen transfilling rooms.
Deficiencies (8)
Failed to conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using emergency procedures.
Failed to implement emergency power system inspection, testing, and maintenance requirements; generator lacked required 3-year, 4-hour load exercise documentation.
Kitchen hood extinguishing system did not provide complete coverage for cooking equipment producing grease-laden vapors.
Failed to provide documentation for quarterly sprinkler system inspection and testing for one quarter.
Failed to ensure annual inspection and testing of two oxygen storage/transfilling fire door assemblies.
Portable space heaters were present and in use in staff areas where prohibited.
Failed to maintain emergency power standby system testing documentation within required 36 months.
Failed to ensure staff were properly trained on oxygen transfilling procedures and failed to provide adequate mechanical ventilation in oxygen transfilling room.
Report Facts
Certified beds: 96
Census: 83
Deficiencies cited: 8
Emergency generator load test interval: 36
Emergency plan exercises required: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marti Carmean | Administrator | Named in relation to findings and plan of correction |
Inspection Report
Annual Inspection
Census: 76
Capacity: 76
Deficiencies: 3
Date: Jul 29, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00438379.
Complaint Details
Complaint IN00438379 was investigated with no deficiencies related to the allegations cited.
Findings
The facility was found deficient in developing comprehensive care plans for residents' communication needs and accident hazards, maintaining a safe environment free of accident hazards, and ensuring food safety standards including proper food storage and cookware condition. No deficiencies were related to the complaint allegations.
Deficiencies (3)
Failed to develop a care plan regarding communication needs for Resident 39 and accident hazards for Resident 56.
Failed to ensure Resident 56's environment was free of potential accident hazards related to use of an air fryer in her room.
Failed to store and prepare food in a sanitary manner related to expired leftovers, open and undated food in the walk-in cooler, and skillets with missing Teflon.
Report Facts
Survey dates: 6
Census: 76
Total capacity: 76
Medicare residents: 8
Medicaid residents: 50
Other payor residents: 18
Residents affected: 69
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marti Carmean | Administrator | Signed the report as facility administrator |
| CNA 6 | Interviewed regarding Resident 39's communication needs and call light usage | |
| Unit Manager 2 | Interviewed regarding call light use and care plan for Resident 39 | |
| Executive Director | Interviewed regarding facility policies and care plan deficiencies | |
| CNA 4 | Interviewed regarding Resident 56 cooking in room | |
| CNA 5 | Interviewed regarding Resident 56 cooking and staff awareness | |
| Unit Manager 3 | Interviewed regarding Resident 56's noncompliance with cooking policy | |
| Corporate Regulation Specialist | Interviewed regarding electric device testing and air fryer inspection | |
| Maintenance Director | Interviewed regarding inspection of air fryer safety | |
| Certified Dietary Manager | Interviewed regarding food storage, labeling, and cookware condition |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 29, 2024
Visit Reason
Paper Compliance Review to the Recertification and Licensure Survey and Complaint Investigation completed on July 29, 2024.
Findings
Belltower Health and Rehabilitation 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 Licensure Survey and Complaint Investigation.
Inspection Report
Complaint Investigation
Census: 85
Capacity: 85
Deficiencies: 0
Date: Jun 5, 2024
Visit Reason
This visit was conducted for the investigation of Complaints IN00435406 and IN00433217.
Complaint Details
Complaint IN00435406 - No deficiencies related to the allegations are cited. Complaint IN00433217 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations in Complaints IN00435406 and IN00433217 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census SNF/NF beds: 85
Census total residents: 85
Census Medicare residents: 17
Census Medicaid residents: 49
Census other payor residents: 19
Inspection Report
Life Safety
Census: 83
Capacity: 96
Deficiencies: 0
Date: Jan 9, 2024
Visit Reason
A 2nd Post Survey Revisit (PSR) to the 1st PSR conducted on 12/05/23 for the Life Safety Code Recertification and State Licensure Survey conducted on 09/05/23 was conducted by the Indiana Department of Health.
Findings
At this Life Safety Code PSR, Belltower 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, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Report Facts
Facility capacity: 96
Census: 83
Inspection Report
Complaint Investigation
Census: 82
Capacity: 82
Deficiencies: 0
Date: Dec 6, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00423139, IN00422000, IN00422396, and IN00421576 at Belltower Health & Rehabilitation Center.
Complaint Details
Complaints IN00423139, IN00422000, IN00422396, and IN00421576 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the four 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.
Report Facts
Census: 82
Total Capacity: 82
Medicare Census: 9
Medicaid Census: 53
Other Payor Census: 20
Inspection Report
Life Safety
Census: 82
Capacity: 96
Deficiencies: 3
Date: Dec 5, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and Life Safety Code standards.
Findings
The facility was found not in compliance with Life Safety Code requirements including deficiencies in kitchen fire suppression system inspection, sprinkler system maintenance and testing, and fire damper inspections. Corrective actions and education plans were implemented with compliance dates in December 2023.
Deficiencies (3)
Failed to ensure 1 of 1 kitchen fire suppression system was inspected semiannually as required by NFPA 96.
Failed to maintain 2 of 2 automatic sprinkler systems in accordance with NFPA 25, including overdue air test, hydrostatic test, internal check valve inspection, and missing automatic drain/ball check.
Failed to ensure 46 of 46 fire dampers were inspected and maintained after the first year and at least every four years per NFPA 90A and NFPA 80 standards.
Report Facts
Facility capacity: 96
Census: 82
Deficiencies cited: 3
Fire dampers: 46
Kitchen suppression system inspections missed: 1
Sprinkler system deficiencies: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marti Carmean | Administrator | Named in relation to findings and exit conference |
| Maintenance Director | Interviewed regarding deficiencies and corrective actions | |
| Dietary Manager | Educated on kitchen suppression system inspection requirements |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 77
Deficiencies: 0
Date: Sep 12, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00416565.
Complaint Details
Complaint IN00416565 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
Medicare census: 10
Medicaid census: 52
Other payor census: 15
Inspection Report
Annual Inspection
Census: 78
Capacity: 96
Deficiencies: 10
Date: Sep 5, 2023
Visit Reason
An annual Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health to assess compliance with Medicare/Medicaid participation requirements and fire safety codes.
Findings
The facility was found not in compliance with several Life Safety Code requirements including means of egress obstructions, corridor width issues, kitchen fire suppression inspection lapses, fire alarm system testing deficiencies, sprinkler system maintenance failures, portable fire extinguisher maintenance lapses, smoke damper inspection omissions, smoking area maintenance issues, and unauthorized use of a portable space heater.
Deficiencies (10)
Failed to ensure 1 of 8 corridor means of egresses were continuously maintained free of obstructions affecting approximately 20 residents and staff in C-Hall.
Failed to meet clear width requirement for 1 of 8 corridors due to unfixed furniture in memory care wing corridor affecting approximately 12 residents and staff.
Failed to ensure kitchen fire suppression system was inspected semi-annually; last inspection was over six months old affecting staff and 25 residents.
Failed to maintain fire alarm system with required semi-annual visual inspections; no documentation of inspection six months after annual inspection affecting all occupants.
Failed to maintain 2 of 2 automatic sprinkler systems; multiple deficiencies noted including overdue tests and missing inspections affecting all occupants.
Failed to document weekly gauge checks for dry sprinkler system for two weeks affecting all occupants.
Failed to ensure 18 of 18 portable fire extinguishers were maintained annually; some extinguishers expired or missing inspection tags affecting all residents, staff, and visitors.
Failed to inspect and maintain 46 of 46 fire dampers as required; no documentation of inspections available affecting all staff, residents, and visitors.
Failed to maintain smoking area by disposing cigarette butts in a metal or noncombustible container with self-closing cover devices affecting approximately 5 staff and unknown number of residents.
Failed to prohibit use of portable space heater in facility contrary to policy affecting approximately 3 staff and unknown number of residents.
Report Facts
Certified beds: 96
Census: 78
Residents affected by corridor obstruction: 20
Residents affected by corridor width issue: 12
Residents affected by kitchen suppression deficiency: 25
Portable fire extinguishers: 18
Fire dampers: 46
Smoking area staff affected: 5
Space heaters found: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marti Carmean | Administrator | Named in relation to exit conference and oversight of findings |
| Maintenance Director | Interviewed and involved in findings related to corridor obstructions, fire suppression, fire alarm, sprinkler system, fire extinguishers, smoke dampers, smoking area, and space heater | |
| Dietary Manager | Educated on kitchen fire suppression system inspection requirements |
Inspection Report
Recertification
Census: 82
Capacity: 82
Deficiencies: 15
Date: Aug 14, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey including the Investigation of Complaint IN00411784 and IN00414532.
Complaint Details
Complaint IN00411784 - Federal/state deficiencies related to the allegations are cited at F686. Complaint IN00414532 - No deficiencies related to the allegations are cited.
Findings
The facility was found deficient in multiple areas including ensuring physician orders matched advanced directives, proper transfer/discharge notification and paperwork, comprehensive and accurate resident assessments, care planning, pressure ulcer prevention, medication management, respiratory care, medication storage, and food safety.
Deficiencies (15)
Failed to ensure Physician Orders for Scope of Treatment (POST) matched physician order for code status for Resident 232.
Failed to ensure transfer and discharge paperwork was completed and Ombudsman notified timely for Resident 76.
Failed to ensure comprehensive assessments were accurate and complete for dental status and bowel/bladder continence for Residents 1 and 51.
Failed to ensure MDS assessment accurately reflected oxygen use for Resident 68.
Failed to develop and implement comprehensive care plans for Residents 1 and 15 addressing dental care, diabetes, medications, and equipment needs.
Failed to conduct timely care plan meetings and revise care plans for Residents 15, 39, 58, and 179.
Failed to provide nail care for Resident 20.
Failed to ensure coordinated care with Hospice for Resident 15 including timely documentation and therapy services.
Failed to prevent development of deep tissue injury to left heel for Resident 39 and implement timely interventions.
Failed to ensure appropriate care of nephrostomy tube and foley catheter for Resident 179 including physician orders and dressing changes.
Failed to ensure respiratory equipment was stored and maintained per professional standards and signage was on the door for Residents 68.
Failed to ensure medication regimen was free from unnecessary medications and timely implementation of pharmacy recommendations for Resident 39 and 51.
Failed to ensure gradual dose reduction of psychotropic medication was implemented timely for Resident 15.
Failed to ensure medications were dated when opened, stored properly, medication carts free of loose pills, and resident alcohol bottles labeled for 3 medication carts and 1 medication room.
Failed to ensure food was stored in accordance with professional standards for food safety including proper dating, sealing, and temperature monitoring.
Report Facts
Survey dates: 8
Census: 82
Total Capacity: 82
Deficiencies cited: 14
Medication doses: 200
Pressure ulcer size: 2.2
Pressure ulcer size: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marti Carmean | Administrator | Signed the inspection report |
| Employee 12 | Reviewed Resident 232's chart and identified code status discrepancy | |
| Employee 10 | Indicated code status location in resident chart | |
| Employee 9 | Indicated transfer and discharge paperwork issues | |
| Employee 16 | OT1 | Reported Broda chair removed by Hospice for Resident 15 |
| CNA 13 | Reported Resident 51's continence status | |
| CNA 14 | Observed Resident 1's denture care supplies | |
| CNA 7 | Described shower procedure for Resident 20 | |
| CNA 4 | Described nail care and oxygen tubing handling | |
| CNA 8 | Described shower procedure | |
| LPN 3 | Provided information on Resident 179 nephrostomy tube care | |
| LPN 2 | Reported medication storage issues on B Hall medication cart | |
| QMA 5 | Reported medication storage issues on F/D Hall cart and Long Term Care medication room | |
| QMA 6 | Reported medication storage issues on Memory Care medication cart | |
| Dietary Manager | Reported food storage and labeling issues | |
| Unit Manager 14 | Reported oxygen equipment maintenance issues | |
| Unit Manager 15 | Reported oxygen signage issues | |
| Director of Nursing | Provided policies and acknowledged deficiencies | |
| Social Service Director | Discussed care plan meetings and medication order implementation | |
| Infectious Preventionist | Discussed antibiotic order error for Resident 51 |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 14, 2023
Visit Reason
Paper Compliance Review to the Recertification and Licensure Survey and Complaint Investigation of IN00411784 completed on August 14, 2023.
Findings
Belltower Health and Rehabilitation 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 Licensure Survey and Complaint Investigation.
Inspection Report
Complaint Investigation
Census: 82
Capacity: 82
Deficiencies: 1
Date: Aug 14, 2023
Visit Reason
The visit was conducted for the investigation of Complaint IN00414532 and Complaint IN00411784, in conjunction with the Recertification and State Licensure Survey.
Complaint Details
Complaint IN00414532 was not substantiated with deficiencies. Complaint IN00411784 had Federal/State deficiencies cited.
Findings
No deficiencies related to Complaint IN00414532 were cited. Federal and State deficiencies related to Complaint IN00411784 were cited at F686.
Deficiencies (1)
Deficiencies related to Complaint IN00411784 cited at F686
Report Facts
Census SNF/NF: 82
Total Capacity: 82
Medicare Census: 17
Medicaid Census: 53
Other Payor Census: 12
Inspection Report
Complaint Investigation
Census: 86
Capacity: 86
Deficiencies: 0
Date: May 23, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00408518.
Complaint Details
Complaint IN00408518 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 Payor Type - Medicare: 16
Census Payor Type - Medicaid: 52
Census Payor Type - Other: 18
Inspection Report
Follow-Up
Census: 85
Capacity: 85
Deficiencies: 0
Date: May 4, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00396966, IN00396990, IN00399975, IN00400935, and IN00402732 completed March 23, 2023, and was conducted in conjunction with an Investigation of Complaint IN00407132.
Complaint Details
Complaints IN00396966, IN00396990, IN00399975, IN00400935, and IN00402732 were corrected. Complaint IN00407132 had no deficiencies related to the allegations cited.
Findings
The facility was found to be in compliance with relevant regulations regarding the complaints investigated. Complaints IN00396966, IN00396990, IN00399975, IN00400935, and IN00402732 were corrected, and no deficiencies related to Complaint IN00407132 were cited.
Report Facts
Census Bed Type: 85
Census Payor Type - Medicare: 11
Census Payor Type - Medicaid: 63
Census Payor Type - Other: 11
Inspection Report
Complaint Investigation
Census: 85
Capacity: 85
Deficiencies: 0
Date: May 4, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00407132 and in conjunction with a Post Survey Revisit (PSR) to the investigation of multiple prior complaints completed on March 23, 2023.
Complaint Details
Complaint IN00407132 was investigated with no deficiencies cited. Complaints IN00396966, IN00396990, IN00399975, IN00400935, and IN00402732 were found corrected upon Post Survey Revisit.
Findings
No deficiencies related to Complaint IN00407132 were cited. All other complaints investigated during this visit were found to be corrected. The facility was found to be in compliance with applicable federal and state regulations.
Report Facts
Census SNF/NF: 85
Total Capacity: 85
Medicare Census: 11
Medicaid Census: 63
Other Payor Census: 11
Inspection Report
Complaint Investigation
Census: 91
Capacity: 91
Deficiencies: 4
Date: Mar 21, 2023
Visit Reason
This visit was for the investigation of multiple complaints (IN00396966, IN00396990, IN00399975, IN00400935, IN00401058, and IN00403732) regarding care and treatment at the facility.
Complaint Details
This investigation was triggered by complaints IN00396966, IN00396990, IN00399975, IN00400935, IN00401058, and IN00403732. Deficiencies were cited related to complaints IN00400935, IN00401058, IN00403932, and IN00399975. Complaints IN00396966 and IN00396990 had no deficiencies related to the allegations.
Findings
The facility was found deficient in multiple areas including failure to obtain timely physician orders for wound care, inconsistent implementation of pressure ulcer prevention and treatment, inadequate nephrostomy tube care, and improper PICC line management. Several residents had active wounds or devices that were not managed according to physician orders or professional standards.
Deficiencies (4)
Failed to ensure a physician's order for a diabetic ulcer was obtained timely for 1 of 3 residents reviewed for wounds (Resident E).
Failed to ensure preventative pressure ulcer measures were implemented consistently and pressure ulcer treatments were completed as ordered for 2 of 3 residents reviewed for pressure ulcers and/or skin issues (Residents D and F).
Failed to ensure 1 of 1 residents reviewed for nephrostomy tubes received care as ordered (Resident D).
Failed to ensure orders for PICC line care and discontinuation were implemented for 1 of 1 residents reviewed for intravenous needs (Resident D).
Report Facts
Census: 91
Total Capacity: 91
Medicare Census: 15
Medicaid Census: 59
Other Payor Census: 17
Deficiency Count: 4
Date of Compliance: Apr 19, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marti Carmean | Administrator | Signed the report and is referenced as facility administrator |
| LPN 5 | Licensed Practical Nurse | Involved in wound care and treatment order issues for Resident E |
| Director of Nursing | Director of Nursing | Provided interviews and education plans related to wound care, nephrostomy, and PICC line deficiencies |
| Wound Nurse | Involved in wound care observations and interviews for Residents D and F | |
| RN 2 | Registered Nurse | Interviewed regarding PICC line removal and care for Resident D |
| LPN 6 | Licensed Practical Nurse | Interviewed regarding medication and treatment cart for Resident D |
Inspection Report
Life Safety
Census: 85
Capacity: 96
Deficiencies: 0
Date: Feb 2, 2023
Visit Reason
A 3rd Post Survey Revisit (PSR) was conducted for the 2nd PSR survey related to the Life Safety Code Recertification survey originally done on 10/03/22 by the Indiana Department of Health.
Findings
At this Life Safety Code PSR, Belltower Health and Rehabilitation Center was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), 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.
Report Facts
Facility capacity: 96
Census: 85
Inspection Report
Re-Inspection
Census: 90
Capacity: 96
Deficiencies: 1
Date: Jan 9, 2023
Visit Reason
A 2nd Post Survey Revisit (PSR) was conducted for the 1st PSR survey related to Emergency Preparedness and Life Safety Code Surveys conducted previously due to deficiencies found.
Findings
At the Emergency Preparedness PSR, the facility was found in compliance. However, at the Life Safety Code PSR, the facility was found not in compliance due to a fire alarm system malfunction, specifically a yellow trouble light on the fire alarm control panel and incorrect time display, which had not been corrected since prior citations.
Deficiencies (1)
Failed to ensure 1 of 1 fire alarm systems was continuously in proper operating condition; yellow trouble light illuminated on fire alarm control panel and incorrect time displayed.
Report Facts
Facility capacity: 96
Census: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marti Carmean | Administrator | Signed report and mentioned in relation to education of Maintenance Director |
| Maintenance Director | Interviewed regarding fire alarm system deficiencies and corrective actions |
Inspection Report
Follow-Up
Census: 82
Capacity: 96
Deficiencies: 4
Date: Nov 23, 2022
Visit Reason
Post Survey Revisit (PSR) for Emergency Preparedness and Life Safety Code Recertification conducted by the Indiana Department of Health to verify correction of previous deficiencies.
Findings
The facility was found not in compliance with Emergency Preparedness training and testing requirements, failing to conduct annual staff training and biannual emergency plan exercises. Additionally, the fire alarm system had a trouble signal and incorrect date/time, and the facility had not completed required smoke damper inspections. Plans of correction were submitted with compliance dates.
Deficiencies (4)
Failed to conduct annual emergency preparedness training and demonstrate staff knowledge.
Failed to conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills.
Fire alarm system was not continuously in proper operating condition; trouble light illuminated and incorrect date/time on panel.
Failed to inspect and maintain fire damper systems after first year and at least every four years as required.
Report Facts
Facility capacity: 96
Census: 82
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marti Carmean | Administrator | Signed report and involved in plan of correction |
| Maintenance Director | Interviewed regarding emergency preparedness training, fire alarm system issues, and smoke damper inspections |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 82
Deficiencies: 0
Date: Oct 27, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00392742.
Complaint Details
Complaint IN00392742 was substantiated; however, no deficiencies related to the allegations were cited.
Findings
The complaint 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: 82
Total Capacity: 82
Medicare Census: 12
Medicaid Census: 54
Other Payor Census: 16
Inspection Report
Routine
Census: 85
Capacity: 96
Deficiencies: 19
Date: Oct 3, 2022
Visit Reason
Routine Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health.
Findings
The facility was found not in compliance with Emergency Preparedness requirements, Life Safety Code, and other regulatory standards including fire alarm system maintenance, sprinkler system inspections, HVAC compliance, evacuation plan completeness, smoking regulations, and storage of oxygen cylinders.
Deficiencies (19)
Failed to review and update the Emergency Preparedness Plan annually as required.
Failed to review and update Emergency Preparedness Policies and Procedures annually.
Failed to ensure emergency preparedness policies include subsistence needs for staff and residents.
Failed to review and update Emergency Preparedness Communication Plan annually.
Failed to review and update Emergency Preparedness Training and Testing Program annually.
Failed to conduct annual emergency preparedness training for staff.
Failed to conduct exercises to test the emergency plan at least twice per year including unannounced staff drills.
Fire alarm system was not continuously in proper operating condition; trouble light illuminated and incorrect time/date on panel.
Fire alarm system smoke detector improperly located near air return vent, impairing operation.
Fire alarm system testing and maintenance past due; missing annual inspection and sensitivity testing.
Failed to provide documentation of quarterly sprinkler system inspection for one quarter.
Failed to inspect and maintain fire damper systems as required.
Laundry room fuel-fired dryer louvers did not open automatically to provide combustion air.
Fire safety plan did not address isolation of fire, evacuation of immediate area, preparation of floors/building for evacuation, or evacuation of smoke compartment.
Staff smoking area not maintained; cigarette butts disposed on ground instead of metal container with self-closing cover.
Trash/linen receptacles in corridors exceeded 32 gallons capacity limit.
Portable space heater used in resident accessible area without policy and unknown max temperature.
Hospital-grade electrical receptacles in resident rooms not tested after installation, replacement, or servicing.
Oxygen cylinders stored mixed full and empty without proper separation or marking.
Report Facts
Facility capacity: 96
Census: 85
Deficiencies cited: 18
Trash/linen carts: 9
Cigarette butts: 30
Resident rooms with hospital-grade receptacles: 17
Residents affected by smoke detector placement: 20
Residents affected by oxygen cylinder storage: 30
Residents affected by smoking area issue: 10
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 29, 2022
Visit Reason
The document relates to paper compliance for the Recertification and Licensure Survey and Investigation of Complaint IN00382390 completed on 2022-08-18.
Complaint Details
Investigation of Complaint IN00382390 was completed on 2022-08-18; facility found in compliance.
Findings
Belltower Health & Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 regarding the Recertification and Licensure survey and Complaint Investigation.
Inspection Report
Complaint Investigation
Census: 85
Capacity: 85
Deficiencies: 19
Date: Aug 18, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00382390.
Complaint Details
Complaint IN00382390 was substantiated with federal deficiencies cited at F657 and F677.
Findings
The facility was found to have multiple deficiencies including failure to maintain resident dignity related to uncovered urinary catheter bags, failure to notify physician of significant weight loss, incomplete assessments for bowel and bladder incontinence, delayed significant change MDS assessment for hospice enrollment, inaccurate MDS assessments, failure to develop baseline and comprehensive care plans, inadequate assistance with ADLs, failure to monitor and address weight loss, improper medication handling, and infection control issues.
Deficiencies (19)
Failure to maintain resident dignity by leaving urinary catheter bags uncovered for 2 residents.
Failure to notify physician of significant weight loss for 1 resident.
Failure to ensure thorough bowel and bladder incontinence assessments for 2 residents.
Failure to complete significant change MDS assessment for hospice enrollment for 1 resident.
Failure to accurately complete MDS assessments for psychotropic medication use and pressure ulcers for 2 residents.
Failure to develop and implement baseline and comprehensive care plans for multiple residents.
Failure to provide assistance with ADLs including fingernail care and bathing for 3 residents.
Failure to assist resident with hearing evaluation and treatment for significant hearing loss.
Failure to ensure weekly skin assessments and wound measurements for a resident with pressure ulcers.
Failure to ensure timely care and interventions after a fall and failure to ensure wheelchair safety features.
Failure to provide consistent catheter care and maintain catheter bag dignity coverings for a resident with Foley catheter.
Failure to identify and prevent significant weight loss for 2 residents.
Failure to ensure proper handling of oxygen tubing and nasal cannula storage.
Failure to ensure medication/treatment carts and medication storage areas were locked, organized, and free from loose or unlabeled medications.
Failure to complete timely pharmacist recommendations related to psychotropic medications for 2 residents.
Failure to ensure food was stored, prepared and served in a sanitary manner in the kitchen and nourishment pantries.
Failure to implement proper infection control practices including hand hygiene, glove use, and oxygen tubing storage.
Failure to ensure the dementia unit environment was free of hazardous hygiene items and chemicals.
Failure to ensure a Registered Nurse was on duty for at least 8 consecutive hours on a weekend day.
Report Facts
Census: 85
Total Capacity: 85
Weight loss percentage: 10.18
Weight loss percentage: 9.47
Number of residents on Medicare: 16
Number of residents on Medicaid: 54
Number of residents on other payor: 15
Number of days with missed catheter care: 15
Number of days with missed showers or bed baths: 20
Number of days with missed weekly skin assessments: 7
Number of licensed practical nurses on duty: 4
Number of qualified medication aides on duty: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Certified Nursing Assistant | Observed and interviewed regarding catheter dignity bag coverage |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding weight loss, care plans, pharmacy recommendations, infection control, and other findings |
| LPN 12 | Licensed Practical Nurse | Interviewed regarding incomplete bladder incontinence assessment |
| CNA 20 | Certified Nursing Assistant | Interviewed regarding Resident 48 care and hearing communication |
| Occupational Therapist 4 | Occupational Therapist | Interviewed regarding Resident 60 hand splint and care plan |
| CNA 6 | Certified Nursing Assistant | Observed providing catheter care without handwashing after |
| LPN 11 | Licensed Practical Nurse | Observed providing wound care without changing gloves or handwashing between residents |
| RN 16 | Registered Nurse | Observed medication pass with ungloved hands |
| CNA 10 | Certified Nursing Assistant | Observed providing catheter care without handwashing after |
| QMA 18 | Qualified Medication Aide | Interviewed regarding catheter care documentation |
| QMA 19 | Qualified Medication Aide | Interviewed regarding medication cart storage |
| Cook 50 | Cook | Observed food preparation with poor hygiene and food safety practices |
| Food Service Supervisor | Food Service Supervisor | Interviewed regarding food preparation and thermometer use |
| RN 14 | Registered Nurse | Observed nourishment pantry and noted unsanitary conditions |
| QMA 27 | Qualified Medication Aide | Interviewed regarding storage of cleaning chemicals |
| Resident Council Member Resident 10 | Resident | Reported fall from wheelchair and sliding out of wheelchair |
| Rehab Director Employee 24 | Rehab Director | Interviewed regarding wheelchair evaluation referral |
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