Inspection Reports for Bethany Village
3518 Shelby St, Indianapolis, IN 46227, USA, IN, 46227
Back to Facility ProfileDeficiencies per Year
12
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6
3
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High
Moderate
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Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 87
Capacity: 87
Deficiencies: 0
Jun 6, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00459186.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00459186 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 73
Census Payor Type - Other: 13
Inspection Report
Complaint Investigation
Census: 86
Capacity: 86
Deficiencies: 0
Feb 27, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00453177, IN00453234, IN00453348, and IN00453724 at Bethany Village.
Findings
No deficiencies related to the allegations in any of the complaints were cited. Bethany Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the investigation of these complaints.
Complaint Details
Complaints IN00453177, IN00453234, IN00453348, and IN00453724 were investigated and no deficiencies related to the allegations were cited.
Report Facts
Census SNF/NF beds: 86
Total census: 86
Medicare census: 1
Medicaid census: 79
Other payor census: 6
Inspection Report
Complaint Investigation
Census: 85
Capacity: 85
Deficiencies: 1
Jan 28, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00449665, IN00450619, IN00450639, and IN00451657. The investigation focused on allegations related to misappropriation of resident property.
Findings
The facility failed to ensure the safeguarding of resident trust accounts to prevent misappropriation for 6 of 6 residents reviewed. Cash withdrawals from resident trust accounts were unaccounted for, with signatures on withdrawal slips being forged or illegible. The facility replaced the missing funds and implemented a systemic plan of correction including staff education and ongoing monitoring.
Complaint Details
Complaint IN00449665 was substantiated with federal/state deficiencies cited at F602 related to misappropriation of resident property. Complaints IN00450619, IN00450639, and IN00451657 had no deficiencies related to the allegations.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure resident trust accounts were safeguarded to prevent misappropriation for 6 residents; cash withdrawn was unaccounted for and signatures on withdrawal slips were forged or illegible. | SS=E |
Report Facts
Residents reviewed for misappropriation: 6
Census: 85
Total capacity: 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 2 | Licensed Practical Nurse | Named in relation to withdrawal slips for Residents B, E, and G where signatures were forged or denied signing |
| LPN 3 | Licensed Practical Nurse | Named in relation to withdrawal slips for Resident B where signatures were forged or denied signing |
| Business Office Manager | Named in relation to withdrawal slips for Residents B, F, and others with forged or illegible signatures | |
| QMA 3 | Qualified Medication Aide | Named in relation to withdrawal slips for Resident C where signatures were forged or denied signing |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 83
Deficiencies: 0
Dec 12, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00447876.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00447876 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 83
Census Payor Type Medicaid: 66
Census Payor Type Other: 17
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 0
Nov 26, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00446730, IN00446953, and IN00447465.
Findings
No deficiencies related to the allegations in complaints IN00446730, IN00446953, and IN00447465 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaints IN00446730, IN00446953, and IN00447465 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 83
Census Payor Type - Medicaid: 69
Census Payor Type - Other: 14
Total Census: 83
Inspection Report
Re-Inspection
Census: 83
Capacity: 100
Deficiencies: 0
Nov 15, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 09/23/24 was performed to verify compliance with fire safety and licensure requirements.
Findings
Bethany Village 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 was fully sprinklered except for one detached storage shed.
Report Facts
Facility capacity: 100
Census: 83
Inspection Report
Annual Inspection
Deficiencies: 0
Oct 8, 2024
Visit Reason
The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Bethany Village 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
Life Safety
Census: 88
Capacity: 100
Deficiencies: 6
Sep 23, 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 not in compliance with Life Safety Code requirements. Deficiencies were identified related to sprinkler system obstructions, sprinkler system maintenance and testing, smoke barrier wall protection, electrical receptacle maintenance, smoking regulations, and use of non-fused multiplug adapters.
Severity Breakdown
SS=D: 4
SS=E: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Spray pattern for sprinkler heads obstructed by combustible boxes in walk-in freezer in the kitchen. | SS=D |
| Failure to maintain automatic sprinkler systems in accordance with NFPA 25, including lack of testing or replacement of sprinklers in harsh environments such as walk-in freezer and cooler. | SS=D |
| One of six smoke barrier walls not protected to maintain fire resistance rating due to unsealed annular space around sprinkler pipe above corridor door by Room 208. | SS=E |
| Electrical receptacles in resident sleeping Room 201 showed signs of overheating and were not maintained properly. | SS=D |
| Smoking materials were not deposited into proper ashtrays or metal containers with self-closing covers in one outdoor staff smoking area. | SS=D |
| Use of non-fused multiplug adapter as a substitute for fixed wiring in resident sleeping Room 302. | SS=E |
Report Facts
Certified beds: 100
Census: 88
Deficiencies cited: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kavita Beri | HFA, ED | Laboratory Director's or Provider/Supplier Representative's signature on report |
Inspection Report
Renewal
Census: 89
Capacity: 89
Deficiencies: 7
Sep 10, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including investigation of two complaints (IN00442889 and IN00441467).
Findings
The facility was found deficient in several areas including reasonable accommodations (call light accessibility), notice requirements before transfer/discharge, accuracy of Minimum Data Set (MDS) assessments, treatment services for pressure ulcers, accident hazard prevention, medication storage security, and maintaining a homelike environment. No deficiencies were cited related to the investigated complaints.
Complaint Details
Complaint IN00442889 and IN00441467 were investigated with no deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 6
SS=E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure reasonable accommodation of needs for 1 of 8 residents; call light was not within reach (Resident 86). | SS=D |
| Failed to provide written notification to the Office of the State Long-Term Care Ombudsman for 1 of 4 residents reviewed for transfer/discharge (Resident 39). | SS=D |
| Failed to ensure accurate Minimum Data Set (MDS) assessments for 2 of 4 residents; falls were not coded correctly (Residents 35 and 92). | SS=D |
| Failed to provide treatment services to prevent/heal pressure ulcer for 1 of 3 residents; wound on right heel was uncovered and not wrapped (Resident 86). | SS=D |
| Failed to ensure facility was free from accident hazards; a rubber hose was located in the middle of a walkway used by residents, creating a trip hazard. | SS=E |
| Failed to ensure treatment cart was locked and secured; unlocked treatment cart with medicated creams was accessible on memory care unit. | SS=D |
| Failed to ensure a homelike atmosphere; drywall was missing with exposed wires in Room 111 (Resident 86). | SS=D |
Report Facts
Survey dates: 5
Census SNF/NF beds: 89
Census Medicaid residents: 73
Census Other residents: 16
Self-mobile residents: 36
Cognitively impaired self-mobile residents: 20
Residents reviewed for transfer notification: 4
Residents reviewed for MDS accuracy: 4
Residents reviewed for pressure ulcers: 3
Rooms observed for homelike setting: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Indicated call light should have been within reach of Resident 86 | |
| Director of Nursing | Provided Resident Bill of Rights policy and transfer notification QA tool | |
| Social Service Director | Indicated lack of notification to Ombudsman for Resident 39 transfers | |
| MDS Coordinator | Indicated MDS assessments for Residents 35 and 92 were inaccurate | |
| Executive Director | Provided policies and acknowledged facility lacked maintenance director | |
| LPN 2 | Observed near trip hazard and unsure about caution signs | |
| LPN 3 | Indicated treatment cart should have been locked |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 91
Deficiencies: 0
May 15, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00427342 and IN00433174.
Findings
No deficiencies related to the allegations in complaints IN00427342 and IN00433174 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaints IN00427342 and IN00433174 found no deficiencies related to the allegations.
Report Facts
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 70
Census Payor Type - Other: 15
Inspection Report
Complaint Investigation
Census: 86
Capacity: 86
Deficiencies: 0
Jan 22, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00426314.
Findings
No deficiencies related to the allegations in Complaint IN00426314 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00426314 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare residents: 2
Medicaid residents: 68
Other payor residents: 16
Inspection Report
Complaint Investigation
Census: 85
Capacity: 85
Deficiencies: 0
Jan 17, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00421863 and IN00425480.
Findings
No deficiencies related to the allegations in complaints IN00421863 and IN00425480 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaints IN00421863 and IN00425480 found no deficiencies related to the allegations; both complaints were not substantiated.
Report Facts
Census SNF/NF beds: 85
Census total residents: 85
Census Medicare residents: 1
Census Medicaid residents: 69
Census other payor residents: 15
Inspection Report
Re-Inspection
Census: 87
Capacity: 100
Deficiencies: 0
Jan 12, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 10/24/23 was performed to verify compliance with fire safety and licensure requirements.
Findings
Bethany Village 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 was fully sprinklered except for one detached storage shed.
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 2, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00416420 completed on December 1, 2023, which resulted in unrelated deficiencies cited.
Findings
Bethany Village 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 and the unrelated deficiencies.
Complaint Details
Investigation of Complaint IN00416420 completed on December 1, 2023; unrelated deficiencies were cited but compliance was found in the paper review.
Inspection Report
Complaint Investigation
Census: 91
Capacity: 91
Deficiencies: 3
Dec 1, 2023
Visit Reason
This visit was for the investigation of Complaint IN00416420, which involved federal and state deficiencies related to allegations cited at tags F690 and F880.
Findings
The facility was found deficient in providing appropriate care related to urinary catheter management for one resident, proper tube feeding management for another resident, and infection control practices related to glucometer disinfection. Deficiencies included improper catheter bag placement, failure to follow feeding tube protocols, and inadequate disinfection of glucometers used for multiple residents.
Complaint Details
Complaint IN00416420 was investigated, with federal and state deficiencies cited related to the allegations at tags F690 (Bowel/Bladder Incontinence, Catheter, UTI) and F880 (Infection Prevention & Control).
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide care and services to a resident with a suprapubic catheter, including improper placement of the catheter bag leading to potential urinary tract infection risk. | SS=D |
| Failure to provide appropriate care and services for a resident requiring continuous g-tube feedings, including improper management of feeding rates and positioning. | SS=D |
| Failure to ensure that a glucometer used for multiple residents was disinfected before entering a resident's room to test blood sugar. | SS=D |
Report Facts
Census: 91
Total Capacity: 91
Medicare Census: 6
Medicaid Census: 70
Other Payor Census: 15
Tube feeding volume: 900
Tube feeding rate: 50
Water flush rate: 45
Audit frequency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kavita Beri | HFA, ED | Laboratory Director's or Provider/Supplier Representative's signature on report |
| QMA 1 | Qualified Medication Aide | Mentioned in relation to improper catheter bag placement and glucometer disinfection |
| CNA 1 | Certified Nursing Aide | Mentioned in relation to catheter bag placement |
| ADON | Assistant Director of Nursing | Involved in assessment and corrective actions for catheter and tube feeding deficiencies |
| LPN 1 | Licensed Practical Nurse | Mentioned in relation to tube feeding management |
| DON | Director of Nursing | Provided policies and interviewed regarding infection control and glucometer use |
Inspection Report
Annual Inspection
Deficiencies: 0
Oct 31, 2023
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure Survey was completed.
Findings
Bethany Village 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
Life Safety
Census: 88
Capacity: 100
Deficiencies: 7
Oct 24, 2023
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 Life Safety Code standards.
Findings
The facility was found not in compliance with several Life Safety Code requirements including improper latching of hazardous area doors, sprinkler system maintenance issues, fire extinguisher maintenance lapses, corridor door latching failures, smoke barrier door deficiencies, and incomplete fire drills on all shifts.
Severity Breakdown
SS=E: 5
SS=C: 1
SS=B: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure soiled linen room doors were separated by smoke resistant partitions and doors with self-closing and latching mechanisms. | SS=E |
| Failed to maintain ceiling construction around sprinkler heads in one bath, exposing attic space. | SS=E |
| One portable fire extinguisher was not maintained within the required one-year interval. | SS=E |
| One corridor door to resident sleeping room 110 failed to latch properly to resist passage of smoke. | SS=E |
| One set of smoke barrier doors nearest to the salon failed to fully close and latch, restricting smoke movement. | SS=E |
| Fire drills on second and third shifts were not conducted at unexpected times under varying conditions for 3 of 4 quarters. | SS=C |
| One extension cord was used as a substitute for fixed wiring in the nurse station area of Auguste Cottage. | SS=B |
Report Facts
Certified beds: 100
Census: 88
Residents potentially affected: 20
Residents potentially affected: 24
Residents potentially affected: 22
Residents potentially affected: 10
Residents potentially affected: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kavita Beri | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Maintenance Director | Interviewed and involved in confirming deficiencies and corrective actions | |
| Field Maintenance Supervisor | Interviewed and involved in confirming deficiencies and corrective actions | |
| Executive Director | Interviewed and involved in confirming deficiencies and corrective actions |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 91
Deficiencies: 0
Oct 5, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00418789.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00418789 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 4
Medicaid census: 71
Other payor census: 16
Inspection Report
Annual Inspection
Census: 93
Capacity: 93
Deficiencies: 2
Sep 29, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaints IN00417827 and IN00418258.
Findings
The facility was found deficient in developing and implementing comprehensive person-centered care plans for residents using wanderguards and C-PAP machines, and failed to date and label oxygen tubing for several residents receiving oxygen therapy.
Complaint Details
Complaint IN00417827 and Complaint IN00418258 were investigated with no deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure a resident-centered comprehensive care plan was developed for 1 of 3 residents reviewed for wanderguards and 1 of 5 residents reviewed for oxygen therapy. | SS=D |
| Failed to date and label oxygen tubing for 4 of 5 residents reviewed for oxygen therapy. | SS=E |
Report Facts
Residents reviewed for wanderguards: 3
Residents reviewed for oxygen therapy: 5
Residents affected by unlabeled oxygen tubing: 4
Residents census: 93
Total licensed capacity: 93
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kavita Beri | Laboratory Director or Provider/Supplier Representative | Signed the inspection report |
| Memory Care Coordinator | Interviewed regarding residents' care plans and wanderguard and C-PAP use | |
| Director of Nursing | Director of Nursing | Provided policy documents and described corrective actions for oxygen tubing labeling |
| License Practical Nurse 2 | LPN | Interviewed regarding oxygen tubing labeling practices |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 85
Deficiencies: 0
Aug 1, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00411969.
Findings
No deficiencies related to the allegations in Complaint IN00411969 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 IN00411969 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 85
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 69
Census Payor Type - Other: 13
Inspection Report
Complaint Investigation
Census: 87
Capacity: 87
Deficiencies: 0
May 18, 2023
Visit Reason
This visit was conducted for the investigation of three complaints: IN00407322, IN00408055, and IN00408425.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaints IN00407322, IN00408055, and IN00408425 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 87
Medicare Census: 6
Medicaid Census: 71
Other Payor Census: 10
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 0
Mar 23, 2023
Visit Reason
This visit was conducted for the investigation of Complaints IN00402482 and IN00404003 and included a COVID-19 Focused Infection Control Survey.
Findings
No deficiencies related to the allegations in Complaints IN00402482 and IN00404003 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 the COVID-19 Focused Infection Control Survey.
Complaint Details
Complaints IN00402482 and IN00404003 were investigated and no deficiencies related to the allegations were cited.
Report Facts
Census SNF/NF: 88
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 75
Census Payor Type - Other: 11
Total Census: 88
Inspection Report
Complaint Investigation
Census: 92
Capacity: 92
Deficiencies: 0
Mar 3, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00402982.
Findings
Bethany Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the investigation of Complaint IN00402982.
Complaint Details
Investigation of Complaint IN00402982 resulted in a finding of compliance.
Report Facts
Census: 92
Total Capacity: 92
Medicare Census: 4
Medicaid Census: 75
Other Payor Census: 13
Inspection Report
Follow-Up
Census: 86
Capacity: 100
Deficiencies: 0
Dec 9, 2022
Visit Reason
A Post Survey Revisit (PSR) was conducted to the previous PSR on 11/07/22 related to the Life Safety Code Recertification and State Licensure Survey conducted on 09/20/22 by the Indiana Department of Health.
Findings
At this PSR survey, Bethany Village 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 was fully sprinklered except for one detached storage shed.
Report Facts
Facility capacity: 100
Census: 86
Inspection Report
Re-Inspection
Census: 83
Capacity: 100
Deficiencies: 2
Nov 7, 2022
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 09/20/22 was performed to verify compliance with fire safety and licensure requirements.
Findings
The facility was found not in compliance with Medicare/Medicaid participation requirements related to Life Safety Code and fire safety. Deficiencies included failure to perform a full hydrostatic flush on one of two sprinkler piping systems due to debris obstruction, and failure to maintain proper operation of two rolling steel fire doors which failed annual testing.
Severity Breakdown
SS=F: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure a full hydrostatic flush was performed on one of two automatic sprinkler piping systems which failed a three-year trip test due to debris obstruction. | SS=F |
| Failed to ensure proper operation was maintained for two rolling steel fire doors; doors failed annual testing due to rust and inability to test. | SS=E |
Report Facts
Facility capacity: 100
Census: 83
Sprinkler pipe length: 631
Deficiency completion date: Mar 15, 2023
Deficiency completion date: Nov 11, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paige Metzler | Executive Director | Named as facility representative during exit conference and in report signature |
| Director of Property Management | Interviewed regarding sprinkler system and fire door deficiencies | |
| Field Maintenance Supervisor | Interviewed regarding sprinkler system and fire door deficiencies | |
| Maintenance Director | Interviewed and observed during record review and facility tour regarding deficiencies |
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 21, 2022
Visit Reason
The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure survey completed on August 11, 2022.
Findings
Bethany Village 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
Life Safety
Census: 82
Capacity: 100
Deficiencies: 9
Sep 20, 2022
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 Life Safety Code standards.
Findings
The facility was found not in compliance with several Life Safety Code requirements including means of egress door locking, hazardous area enclosure, fire alarm system testing, sprinkler system maintenance, corridor door latching, smoke barrier integrity, smoking regulations, soiled linen storage, and rolling fire door operation.
Severity Breakdown
SS=E: 7
SS=F: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure means of egress doors were readily accessible; exit door codes were not posted at three exit doors. | SS=E |
| Failed to ensure hazardous areas such as laundries were separated by smoke resistant partitions and doors; laundry room door was propped open. | SS=E |
| Failed to ensure all fire alarm system initiating devices, specifically duct detectors, were inspected and tested as required. | SS=F |
| Failed to perform a full hydrostatic flush on dry sprinkler system after failed three year trip test due to debris obstruction. | SS=F |
| Failed to ensure corridor door to resident room 102 latched properly to resist passage of smoke. | SS=E |
| Failed to maintain fire resistance rating of smoke barriers due to holes in ceiling near therapy exit door and shower room closet. | SS=E |
| Failed to ensure smoking materials were properly disposed of in ashtrays or metal containers with self-closing covers in outdoor staff smoking area. | SS=E |
| Failed to ensure unattended soiled linen receptacles were stored in rooms protected as hazardous areas; a 55 gallon soiled linen cart was stored in corridor. | SS=E |
| Failed to ensure proper operation of two rolling steel fire doors in kitchen; doors failed annual testing and had rusted parts. | SS=E |
Report Facts
Certified beds: 100
Census: 82
Exit doors with unposted codes: 3
Hazardous areas with deficient enclosure: 1
Duct detectors inspected: 0
Dry sprinkler system trip tests failed: 3
Corridor doors with latching failure: 1
Holes in smoke barrier ceiling: 2
Cigarette butts counted: 50
Soiled linen cart capacity: 55
Rolling fire doors failed testing: 2
Inspection Report
Renewal
Census: 87
Capacity: 87
Deficiencies: 4
Aug 11, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from August 7 to August 11, 2022.
Findings
The facility was found deficient in several areas including failure to implement a comprehensive care plan for a high-risk fall resident, incomplete dialysis assessments, inadequate RN coverage for 8 continuous hours 7 days a week, and unsanitary food handling practices in the kitchen.
Severity Breakdown
SS=D: 2
SS=E: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to implement a care plan for a high risk fall, cognitively impaired resident (Resident 39). | SS=D |
| Failed to ensure pre and post dialysis assessments were completed for Resident 50. | SS=D |
| Failed to provide 8 continuous hours of Registered Nursing services seven days a week for 6 of 30 days reviewed. | SS=E |
| Failed to ensure food was served in a sanitary manner; dietary staff's hair was not restrained, food was not covered or dated, and perishable foods were not discarded. | SS=E |
Report Facts
Census: 87
Total Capacity: 87
Days lacking 8 hours RN coverage: 6
Dialysis Appointment Assessments missing: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 4 | Observed assisting Resident 39 and acknowledged body pillow was removed and should have been replaced | |
| CNA 6 | Indicated staff use task sheets to care for residents | |
| LPN 5 | Licensed Practical Nurse | Indicated dialysis assessments should be completed each dialysis day for Resident 50 |
| Director of Nursing | DON | Acknowledged missing dialysis assessments and RN coverage issues |
| Cook 1 | Observed with uncovered hair and facial hair in kitchen | |
| Dietary Aide 2 | Observed with uncovered facial hair and improper food handling | |
| Dietary Aide 3 | Observed with uncovered hair and facial hair in kitchen | |
| Business Office Manager | BOM | Observed with loose hairs outside hair net in kitchen |
| Administrator | Provided policies and acknowledged deficiencies |
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