Inspection Report Summary
The most recent inspection on June 5, 2025, found the facility out of compliance with Life Safety Code requirements due to multiple deficiencies involving fire door closures, fire extinguisher placement, electrical equipment use, and corridor door latching. Earlier inspections showed a pattern of Life Safety Code issues, including problems with door latching, power strip use, and fire extinguisher inspections, as well as some deficiencies related to resident care such as supervision, medication management, and dementia services. Several complaint investigations were substantiated with deficiencies cited, primarily involving elopement prevention, abuse reporting, care planning for behavioral symptoms, and safe mechanical lift transfers, while most other complaints were unsubstantiated. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The inspection history indicates ongoing challenges with fire safety compliance and resident care processes, with some corrective actions implemented but recurring issues noted over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
79% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
69% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Life Safety
Census: 51
Capacity: 74
Deficiencies: 8
Jun 5, 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 06/05/2025 to assess compliance with Medicare/Medicaid participation requirements and fire safety codes.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Multiple deficiencies related to fire door closures, horizontal exit doors, cooking facility equipment placement, portable fire extinguisher installation, corridor door latching, and electrical equipment use and maintenance were identified.
Severity Breakdown
SS=E: 6
SS=D: 1
SS=F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 1 separation fire doors would limit the spread of fire and restrict the movement of smoke; double set of barrier doors separating Assisted Living from Skilled Nursing did not close and latch. | SS=E |
| Failed to ensure 1 of over 3 horizontal exit fire door sets were arranged to automatically close and latch; fire door set into TCU unit was warped and did not latch. | SS=E |
| Failed to provide an approved method for returning cooking appliances to approved design location under kitchen hood extinguishing system. | SS=E |
| Failed to ensure 1 of 1 portable fire extinguishers in maintenance area was installed in accordance with NFPA 10; extinguisher was sitting unsecured on the floor. | SS=D |
| Failed to ensure 1 of over 30 corridor doors had no impediment to closing and latching into the door frame; corridor door from kitchen into dining room did not close and latch due to missing hardware. | SS=E |
| Failed to ensure 2 of 2 power strips were not used as a substitute for fixed wiring to provide power to high current draw equipment; power strips used in salon for hair dryers and curling irons. | SS=E |
| Failed to ensure 1 of 1 flexible cords were not used as a substitute for fixed wiring; extension cord used in 100 hall attic to thaw pipes. | SS=E |
| Failed to conduct required maintenance and maintain complete documentation of inspections for Patient Care Related Electrical Equipment (PCREE); no documentation available for testing of PCREE in use throughout the facility. | SS=F |
Report Facts
Certified beds: 74
Census: 51
Residents potentially affected: 25
Residents potentially affected: 26
Staff potentially affected: 6
Residents potentially affected: 20
Staff potentially affected: 2
Residents potentially affected: 4
Staff potentially affected: 1
Residents potentially affected: all
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Lambert | Area Executive Director | Signed report and present at exit conference |
| Director of Plant Operations | Acknowledged deficiencies related to fire doors, cooking equipment, fire extinguisher, corridor doors, electrical equipment; participated in observations and interviews | |
| Senior Director of Plant Operations | Participated in observations and interviews related to deficiencies | |
| Cooperate Facilities Management Support representative | Participated in observations and interviews related to deficiencies | |
| Executive Director | Present at exit conference and involved in quality assurance performance improvement meetings |
Inspection Report
Annual Inspection
Census: 42
Capacity: 97
Deficiencies: 4
May 13, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey and the Investigation of Complaint IN00457483. The visit included a State Residential Licensure Survey.
Findings
The facility was found to have deficiencies related to discharge process notifications, supervision of cognitively impaired residents, use of psychoactive medications without proper gradual dose reductions or documentation, and failure to offer pneumococcal vaccines per CDC guidance. Complaint allegations were not substantiated. The facility submitted plans of correction for all cited deficiencies and was found in compliance with state licensure requirements.
Complaint Details
Complaint IN00457483 was investigated during this visit. No deficiencies related to the allegations were cited.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to provide bed hold policy notifications to residents or their representatives for 2 of 2 residents reviewed for hospitalizations. | SS=D |
| Failed to ensure a resident with cognitive impairment was provided supervision and not left unattended while awaiting a medical appointment. | SS=D |
| Failed to ensure residents who received psychoactive medications had gradual dose reductions or statements of clinical contraindication and had identified and documented targeted behavioral symptoms for the use of psychotropic medications for 2 of 5 residents reviewed. | SS=D |
| Failed to offer and educate residents regarding pneumococcal vaccines per CDC guidance for 2 of 5 residents reviewed for infection control. | SS=D |
Report Facts
Survey dates: 6
Census Bed Type - SNF/NF: 26
Census Bed Type - SNF: 29
Census Bed Type - Residential: 42
Total Capacity: 97
Census Payor Type - Medicare: 21
Census Payor Type - Medicaid: 25
Census Payor Type - Other: 9
Total Census Payor: 55
Number of residents reviewed for bed hold notification deficiency: 2
Number of residents reviewed for supervision deficiency: 1
Number of residents reviewed for unnecessary medication deficiency: 2
Number of residents reviewed for pneumococcal vaccine deficiency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Lambert | Area Executive Director | Signed the report and plan of correction |
| RN 6 | Interviewed regarding bed hold policy notification process | |
| LPN 4 | Interviewed regarding bed hold policy notification process | |
| Administrator | Interviewed regarding missing bed hold policy documentation | |
| DON | Director of Nursing | Interviewed regarding bed hold policy documentation and psychoactive medication management |
| Resident 25's family member | Reported concern about resident being left unattended at hospital appointment | |
| Transport Driver | Interviewed regarding supervision of Resident 25 during hospital transport | |
| CNA 7 | Interviewed regarding Resident 13 and Resident 34 hallucinations and delusions | |
| Infection Preventionist | Interviewed regarding Resident 13 and Resident 34 hallucinations and vaccine education | |
| LPN 9 | Interviewed regarding Resident 13 and Resident 34 hallucinations and delusions |
Inspection Report
Annual Inspection
Deficiencies: 0
May 13, 2025
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure Survey conducted on May 13, 2025.
Findings
Bethany Pointe Health Campus 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 Annual Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 59
Capacity: 99
Deficiencies: 0
Feb 10, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00451755.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00451755 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 59
Total Capacity: 99
Inspection Report
Complaint Investigation
Census: 54
Capacity: 102
Deficiencies: 0
Jan 13, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00449902, IN00449858, and IN00448763.
Findings
No deficiencies related to the allegations in complaints IN00449902, IN00449858, and IN00448763 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaints IN00449902, IN00449858, and IN00448763 found no deficiencies related to the allegations.
Report Facts
Census Bed Type Total: 102
Census Payor Type Total: 54
Census SNF/NF: 23
Census SNF: 31
Census Residential: 48
Census Medicare: 24
Census Medicaid: 22
Census Other: 8
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 0
Nov 25, 2024
Visit Reason
This visit was for the investigation of complaints IN00446732 and IN00446382 at Bethany Pointe Health Campus.
Findings
No deficiencies related to the allegations in complaints IN00446732 and IN00446382 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00446732 - No deficiencies related to the allegations were cited. Complaint IN00446382 - No deficiencies related to the allegations were cited.
Report Facts
Census Bed Type Total: 95
Census Payor Type Total: 49
SNF/NF Beds: 24
SNF Beds: 25
Residential Beds: 46
Medicare Residents: 14
Medicaid Residents: 23
Other Payor Residents: 12
Inspection Report
Complaint Investigation
Census: 51
Capacity: 97
Deficiencies: 0
Oct 30, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00445103 and IN00445385.
Findings
No deficiencies related to the allegations in complaints IN00445103 and IN00445385 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00445103 and IN00445385 were investigated with no deficiencies found related to the allegations.
Report Facts
Census Bed Type: 97
Census Payor Type: 51
Inspection Report
Life Safety
Census: 56
Capacity: 74
Deficiencies: 0
Aug 22, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 07/09/24, in conjunction with a Life Safety Code Preoccupancy Survey that exited on 08/22/24.
Findings
Bethany Pointe Health Campus was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility is fully sprinkled with a fire alarm system and smoke detection throughout resident areas.
Report Facts
Facility capacity: 74
Census: 56
Inspection Report
Life Safety
Census: 60
Capacity: 74
Deficiencies: 0
Aug 22, 2024
Visit Reason
A Life Safety Code Preoccupancy Survey was conducted for the legacy building memory care to add ten beds, increasing licensed beds from 112 to 138.
Findings
Bethany Pointe Health Campus was found in compliance with Medicare/Medicaid participation requirements and the 2012 NFPA 101 Life Safety Code. Both the main and legacy buildings were fully sprinkled with appropriate fire alarm and smoke detection systems.
Report Facts
Licensed beds increase: 26
Legacy building assisted living census: 20
Legacy building Medicare/Medicaid census: 0
Inspection Report
Life Safety
Census: 55
Capacity: 74
Deficiencies: 1
Jul 9, 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
The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements due to failure to maintain ceiling construction around a sprinkler escutcheon in one corridor, which could affect up to 12 residents, 4 staff, and 2 visitors.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to maintain the ceiling construction around the sprinkler escutcheon in 1 of 5 corridors, leaving a one-half inch annular space around the sprinkler head escutcheon outside resident room #106. | SS=E |
Report Facts
Certified beds: 74
Census: 55
Potentially affected individuals: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Lambert | Area Executive Director | Signed the report and participated in exit conference |
| Senior Director of Plant Operations | Acknowledged the annular space around the sprinkler escutcheon during observation and exit conference | |
| Facilities Maintenance Support Director | Participated in observation and exit conference regarding the sprinkler escutcheon deficiency |
Inspection Report
Annual Inspection
Census: 60
Capacity: 106
Deficiencies: 2
Jun 19, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure survey conducted on June 12, 13, 14, 17, 18, and 19, 2024.
Findings
The facility was found in compliance with state residential licensure requirements. However, deficiencies were cited related to respiratory care including oxygen therapy management for one resident, and failure to provide appropriate dementia services including meaningful activities and sensory items for residents on the dementia unit.
Severity Breakdown
SS=D: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to properly monitor oxygen use, maintain oxygen equipment, and follow physician orders for oxygen therapy for 1 of 3 residents reviewed for respiratory care. | SS=D |
| Failure to offer dementia services to enhance quality of life regarding sensory items and purposeful activities for 4 of 4 residents reviewed for dementia services. | SS=E |
Report Facts
Survey dates: 6
Census Bed Type - SNF/NF: 26
Census Bed Type - SNF: 34
Census Bed Type - Residential: 46
Total Capacity: 106
Census Payor Type - Medicare: 25
Census Payor Type - Medicaid: 25
Census Payor Type - Other: 10
Total Census: 60
Oxygen liter flow: 4
Matching cards: 36
Activity audit frequency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Lambert | Executive Director | Signed the report |
| RN 3 | Provided information about Resident 5's oxygen humidification canister | |
| RN 4 | Observed Resident 5's oxygen concentrator and portable tank issues | |
| CNA 8 | Indicated portable oxygen tanks should be refilled and managed properly | |
| Corporate Nurse Consultant | Provided guidance on oxygen humidification and physician order compliance | |
| LPN 7 | Provided information about oxygen titration limits | |
| LPN 5 | Legacy Leader / Charge Nurse | Provided information about oxygen titration and dementia unit resident needs |
| Activity Assistant 9 | Conducted dementia unit activities and was interviewed about activity modifications | |
| Administrator | Dementia Unit Director | Provided information about dementia unit programming and policies |
Inspection Report
Annual Inspection
Deficiencies: 0
Jun 19, 2024
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey.
Findings
Bethany Pointe Health Campus 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: 49
Deficiencies: 1
May 2, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00432702 regarding allegations of failure to prevent elopement of a cognitively impaired resident from a secured dementia care unit.
Findings
The facility failed to respond promptly to an external door alarm, resulting in Resident B eloping from the secured unit and being found unsupervised outside the facility. The alarm system did not alert throughout the facility, and staffing at the time was limited to one QMA and one CNA. The facility submitted a plan of correction and implemented measures including staff education and increased alarm sounders.
Complaint Details
Complaint IN00432702 was substantiated with state deficiencies cited related to failure to prevent elopement of Resident B. The investigation included interviews, record reviews, and video surveillance confirming the incident and delayed staff response to the alarm.
Deficiencies (1)
| Description |
|---|
| Failed to prevent the elopement of a cognitively impaired resident from a secured dementia care unit by failing to respond to an external door alarm. |
Report Facts
Residential Census: 49
Time from alarm to staff alert: 7
Estimated time Resident B was outside: 10
Elopement drills frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Lambert | Executive Director | Signed as facility representative and involved in plan of correction. |
| CNA 2 | Observed exiting building during elopement event and involved in resident care. | |
| QMA 3 | Observed disabling alarm and involved in resident care during elopement event. | |
| CNA 4 | Conducted perimeter search and located Resident B outside. |
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 0
Feb 1, 2024
Visit Reason
The visit was conducted to investigate Nursing Home Complaints IN00424284 and IN00427095, as well as Residential Complaint IN00426141.
Findings
No deficiencies related to the allegations were cited for any of the complaints investigated. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00424284 - No deficiencies related to the allegations are cited. Complaint IN00426141 - No deficiencies related to the allegations are cited. Complaint IN00427095 - No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type Total: 108
Census Payor Type Total: 58
Census Bed Type SNF/NF: 24
Census Bed Type SNF: 34
Census Bed Type Residential: 50
Census Payor Type Medicare: 23
Census Payor Type Medicaid: 11
Census Payor Type Other: 24
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 0
Dec 6, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00422267.
Findings
No deficiencies related to the allegations in Complaint IN00422267 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Complaint Details
Complaint IN00422267 was investigated and found to have no deficiencies related to the allegations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 1, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00420416 completed on October 31, 2023.
Findings
Bethany Pointe Health Campus 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.
Complaint Details
Investigation of Complaint IN00420416 completed on October 31, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 1
Oct 31, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00420416 regarding federal and state deficiencies related to the allegation.
Findings
The facility failed to develop and implement a comprehensive care plan for targeted behaviors for 1 of 3 residents reviewed (Resident C), specifically lacking individualized interventions for behaviors such as yelling.
Complaint Details
Complaint IN00420416 was substantiated with federal/state deficiencies cited at F656 related to the allegation. Resident C was affected by alleged insufficient practice but continues to reside at the facility with no psychosocial distress related to the event.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to develop and implement a care plan for targeted behaviors for Resident C. | SS=D |
Report Facts
Census: 111
SNF/NF beds: 26
SNF beds: 33
Residential beds: 52
Medicare residents: 20
Medicaid residents: 23
Other payor residents: 16
Total payor residents: 59
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 0
Sep 20, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00417779.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Complaint Details
Investigation of Complaint IN00417779 found no deficiencies related to the allegations; the complaint was not substantiated.
Inspection Report
Life Safety
Census: 48
Capacity: 74
Deficiencies: 0
Sep 13, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 06/14/23 and 08/08/23 by the Indiana Department of Health.
Findings
At this Life Safety Code Survey, Bethany Pointe Health Campus was found in compliance with the Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 483.90(a).
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 2
Sep 5, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00415137, which alleged deficiencies related to resident safety and abuse at Bethany Pointe Health Campus.
Findings
The facility failed to implement interventions to prevent the elopement of a cognitively impaired resident and failed to report in a timely manner an allegation of resident-to-resident sexual abuse. The investigation confirmed insufficient practices related to securing entrance codes and delayed reporting of abuse allegations.
Complaint Details
Complaint IN00415137 was substantiated with state deficiencies cited related to allegations of elopement risk and delayed abuse reporting. Resident B was affected by insufficient practice related to elopement prevention and is currently at an inpatient psychiatric hospital. Resident C was affected by delayed reporting of sexual abuse and continues to reside at the facility.
Deficiencies (2)
| Description |
|---|
| Failed to implement interventions to prevent the elopement of a cognitively impaired resident by failing to secure entrance codes to secure doors. |
| Failed to report in a timely manner an allegation of resident to resident sexual abuse between a moderately cognitively impaired resident and a severely cognitively impaired resident. |
Report Facts
Residential Census: 56
BIMS Score Resident B: 11
BIMS Score Resident C: 1
Time delay for reportable submission: 2.8
Inspection Report
Re-Inspection
Census: 49
Capacity: 74
Deficiencies: 2
Aug 8, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 06/14/23 by the Indiana Department of Health.
Findings
The facility was found not in compliance with Life Safety Code requirements related to egress door signage and hazardous area door latching. Deficiencies included missing signage on delayed egress doors affecting memory care residents and a self-closing door to the oxygen storage room that did not latch properly.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Delayed egress locks lacked proper signage indicating doors can be opened in 15 seconds by pushing on the door. | SS=E |
| Corridor door to oxygen storage room, a hazardous area, had a self-closing device that did not latch into the door frame. | SS=E |
Report Facts
Certified beds: 74
Census: 49
Residents affected by delayed egress signage deficiency: 20
Residents affected by hazardous door latch deficiency: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Lambert | Executive Director | Named in relation to review of findings at exit conference. |
| Director of Plant Operations | Interviewed and acknowledged deficiencies related to door signage and door latching. |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 0
Aug 7, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00413805 and IN00414518.
Findings
No deficiencies related to the allegations in complaints IN00413805 and IN00414518 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaints IN00413805 and IN00414518 found no deficiencies related to the allegations; facility was in compliance.
Report Facts
Residential Census: 47
Inspection Report
Annual Inspection
Deficiencies: 0
Jul 3, 2023
Visit Reason
The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure survey completed on June 6, 2023.
Findings
Bethany Pointe Health Campus 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: 74
Deficiencies: 0
Jun 29, 2023
Visit Reason
An investigation of Complaint Number IN00410869 was conducted by the Indiana Department of Health.
Findings
Bethany Pointe Health Campus was found in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 in regard to the investigation of Complaint Number IN00410869.
Complaint Details
Investigation of Complaint Number IN00410869; facility found in compliance.
Report Facts
Census: 74
Inspection Report
Annual Inspection
Census: 45
Capacity: 74
Deficiencies: 4
Jun 14, 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 and Life Safety Code requirements.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies included improper use of power strips in resident rooms, unsecured oxygen cylinders, malfunctioning delayed egress locking, and failure to inspect portable fire extinguishers monthly.
Severity Breakdown
SS=D: 1
SS=E: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Power strip in resident sleeping room 620 did not meet UL 1363 requirements and was removed. | SS=D |
| Three 'E' type oxygen cylinders were not properly secured from falling in the oxygen storage room. | SS=E |
| One of six delayed egress locking arrangements in the Assisted Living living room was not functioning properly and required repair. | SS=E |
| One portable fire extinguisher by the Assisted Living Nursing Office lacked documentation of monthly inspections from February 2023 to May 2023. | SS=E |
Report Facts
Residents potentially affected: 2
Residents potentially affected: 10
Residents potentially affected: 10
Residents potentially affected: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Lambert | Executive Director | Reviewed findings and exit conference participant |
| Director of Plant Operations | Interviewed and acknowledged deficiencies related to power strips, oxygen cylinders, delayed egress locking, and fire extinguisher inspections |
Inspection Report
Recertification
Census: 49
Capacity: 101
Deficiencies: 2
Jun 6, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey and Investigation of Residential Complaint IN00409999.
Findings
No deficiencies related to the complaint allegations were cited. Two deficiencies were identified: failure to resolve resident grievances regarding shower provision for one resident, and failure to obtain and administer ordered medications from the emergency drug kit for one resident.
Complaint Details
Complaint IN00409999 was investigated with no deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to resolve resident grievances regarding the provision of showers for 1 of 1 residents reviewed for resolution of grievances (Resident 5). | SS=D |
| Failure to obtain and administer ordered medications, available from the facility emergency drug kit, for 1 of 5 residents reviewed for unnecessary medications (Resident 19). | SS=D |
Report Facts
Census: 49
Total Capacity: 101
Shower frequency: 15
Medication doses missed: 7
Survey dates: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Lambert | Executive Director | Signed the report and is mentioned as facility representative |
| Director of Nursing (DON) | Involved in addressing Resident 5's shower concerns and medication administration issues | |
| LPN 3 | Interviewed regarding medication administration procedures | |
| LPN 5 | Interviewed regarding medication administration procedures |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 55
Deficiencies: 1
May 17, 2023
Visit Reason
This visit was conducted for the investigation of four complaints (IN00403374, IN00403665, IN00403553, and IN00407878) regarding the facility's compliance with regulations.
Findings
The investigation found no deficiencies related to three of the complaints, but federal and state deficiencies were cited related to complaint IN00403665 concerning failure to process and implement physician treatment orders for one resident (Resident D).
Complaint Details
Complaint IN00403665 was substantiated with federal/state deficiencies cited. Complaints IN00403374, IN00403553, and IN00407878 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to process and implement physician treatment orders for 1 of 3 residents reviewed (Resident D). | SS=D |
Report Facts
Census: 55
Total Capacity: 55
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Lambert | Executive Director | Signed the report and provided facility policy |
| LPN 44 | Licensed Practical Nurse | Interviewed regarding medication order processing |
| LPN 15 | Licensed Practical Nurse | Interviewed regarding review and input of medication orders |
| RN 33 | Registered Nurse | Interviewed regarding processing pulmonologist orders and chart documentation |
| DON | Director of Nursing | Interviewed regarding nurse responsibilities for processing orders after resident appointments |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 17, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00403665 completed on May 17, 2023.
Findings
Bethany Pointe Health Campus 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 complaint investigation.
Complaint Details
Investigation of Complaint IN00403665; paper compliance review found facility in compliance.
Inspection Report
Complaint Investigation
Census: 49
Capacity: 92
Deficiencies: 0
Feb 16, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00400700 and IN00401381.
Findings
Both complaints were substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00400700 - Substantiated with no deficiencies cited. Complaint IN00401381 - Substantiated with no deficiencies cited.
Report Facts
Census Bed Type Total: 92
Census Payor Type Total: 49
Inspection Report
Complaint Investigation
Census: 52
Capacity: 98
Deficiencies: 0
Jan 20, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00399027 and IN00399061.
Findings
Complaint IN00399027 was substantiated but no deficiencies related to the allegations were cited. Complaint IN00399061 was unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00399027 - Substantiated with no deficiencies cited. Complaint IN00399061 - Unsubstantiated due to lack of evidence.
Report Facts
Census Bed Type - SNF/NF: 27
Census Bed Type - NF: 25
Census Bed Type - Residential: 46
Total Capacity: 98
Census Payor Type - Medicare: 17
Census Payor Type - Medicaid: 25
Census Payor Type - Other: 10
Total Census: 52
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 13, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00392796 completed on November 3, 2022.
Findings
Bethany Pointe Health Campus 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.
Complaint Details
Investigation of Complaint IN00392796 completed on November 3, 2022; facility found in compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 16, 2022
Visit Reason
The visit was conducted as a paper compliance review related to the Investigation of Complaint IN00394562 completed on November 17, 2022.
Findings
Bethany Pointe Health Campus 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.
Complaint Details
Investigation of Complaint IN00394562 completed on November 17, 2022; paper compliance review found the facility in compliance.
Inspection Report
Complaint Investigation
Census: 51
Capacity: 95
Deficiencies: 1
Nov 17, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00394562, which was substantiated with a federal/state deficiency cited related to the allegation.
Findings
The facility failed to report suspicions of emotional abuse by a staff member towards a resident immediately to the facility Administrator as required by policy. Interviews and record reviews confirmed inappropriate statements made by a nurse to a resident and delayed reporting by staff.
Complaint Details
Complaint IN00394562 was substantiated. The investigation found that RN 3 made inappropriate statements to Resident B and that CNA 1 and CNA 2 failed to report the incident immediately to the Administrator as required by facility policy.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report suspicions of emotional abuse immediately to the facility Administrator as required by policy. | SS=D |
Report Facts
Census total residents present: 51
Total licensed capacity: 95
Census by bed type SNF/NF: 26
Census by bed type SNF: 25
Census by bed type Residential: 44
Census by payor type Medicare: 15
Census by payor type Medicaid: 25
Census by payor type Other: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN 3 | Registered Nurse | Named in emotional abuse finding for making inappropriate statements to Resident B |
| CNA 1 | Certified Nursing Aide | Witnessed abuse and delayed reporting of incident |
| CNA 2 | Certified Nursing Aide | Witnessed abuse and failed to report the incident |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 1
Nov 2, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00389479 and IN00392796. Complaint IN00389479 was substantiated with no deficiencies cited, and complaint IN00392796 was substantiated with federal/state deficiencies cited.
Findings
The facility failed to ensure safe mechanical lift transfers for one resident (Resident B), resulting in a humeral neck fracture after a sit to stand lift incident. The resident was transferred with one staff member instead of two, and the lift sling was improperly positioned, causing the resident's foot to slip multiple times. The resident was sent to the ER and diagnosed with a minimally displaced humeral neck fracture. The facility updated care plans, educated staff on proper mechanical lift use, and implemented audits to ensure compliance.
Complaint Details
Complaint IN00389479 was substantiated with no deficiencies cited. Complaint IN00392796 was substantiated with federal/state deficiencies cited at tag F689 related to unsafe mechanical lift transfers causing injury to Resident B.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure safe mechanical lift transfers for Resident B, resulting in injury. | SS=D |
Report Facts
Census: 51
SNF/NF beds: 26
SNF beds: 25
Medicare residents: 15
Medicaid residents: 24
Other payor residents: 12
Audit frequency: 5
Audit frequency: 3
Audit frequency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jenny McCurdy | RN, Clinical support nurse | Signed the report |
| CNA 9 | Involved in transferring Resident B during the incident | |
| QMA 5 | Observed Resident B hanging in sling and assisted lowering him to floor | |
| LPN 12 | Nurse on opposite hall during incident, did not assess resident before lifting from floor | |
| NP | Nurse Practitioner | Provided medical evaluation and ordered x-rays for Resident B |
| Executive Director | Provided care sheets, policy, and user manual for mechanical lifts | |
| ADON | Provided nursing notes and interview information regarding incident |
Inspection Report
Life Safety
Census: 52
Capacity: 74
Deficiencies: 0
Aug 30, 2022
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
Bethany Pointe Health Campus 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. The facility is fully sprinkled with a fire alarm system and smoke detection in required areas. Resident rooms 125 through 610 housed quarantined and isolated residents due to a COVID-19 surge and were excluded from the original survey.
Report Facts
Facility capacity: 74
Census: 52
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 0
Aug 23, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00388129.
Findings
Complaint IN00388129 was substantiated, but no State Residential Findings related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Complaint Details
Complaint IN00388129 was substantiated. No State Residential Findings related to the allegations were cited.
Inspection Report
Follow-Up
Census: 32
Deficiencies: 0
Aug 4, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00380533 completed on 6/6/22, conducted in conjunction with the PSR to the Annual Recertification and State Licensure Survey.
Findings
Bethany Pointe Health Campus was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of Complaint IN00380533.
Complaint Details
Complaint IN00380533 was corrected.
Report Facts
Residential Census: 32
Inspection Report
Re-Inspection
Census: 46
Capacity: 78
Deficiencies: 0
Aug 4, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 2022-06-29, conducted in conjunction with the PSR for the investigation of Complaint IN00380533.
Findings
Bethany Pointe Health Campus was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey.
Complaint Details
Investigation of Complaint IN00380533 was conducted in conjunction with this Post Survey Revisit.
Report Facts
Census by Payor Type: 19
Census by Payor Type: 19
Census by Payor Type: 8
Census Bed Type: 23
Census Bed Type: 32
Total Capacity: 78
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