Inspection Report Summary
The most recent inspection on May 5, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a mixed record with several citations primarily involving fall prevention, abuse investigations, dementia care, medication management, and life safety code compliance. Inspectors frequently noted issues such as failure to follow fall interventions, incomplete abuse investigations, medication errors, and multiple fire safety and building code deficiencies. Several complaints were substantiated with related deficiencies, including abuse prevention training, medication errors, and pressure ulcer care, but fines or enforcement actions were not listed in the available reports. The facility’s recent inspections indicate some improvement in compliance, particularly with no deficiencies cited in the latest reviews following prior issues.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
14.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
240% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
45 residents
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 0
Date: May 5, 2025
Visit Reason
This visit was for the investigation of Complaint IN00456396.
Complaint Details
Complaint IN00456396 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the complaint investigation.
Report Facts
Census SNF/NF beds: 37
Census Residential beds: 8
Total Census: 45
Medicare residents: 3
Medicaid residents: 18
Other payor residents: 24
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 6, 2025
Visit Reason
Paper compliance review related to an unrelated finding during the Investigation of Complaint IN0045116 completed on February 15, 2025.
Findings
The Cedars was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review related to the unrelated complaint investigation.
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 1
Date: Feb 17, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN0451146. The complaint allegations were found to have no related deficiencies cited, but an unrelated deficiency was identified during the investigation.
Complaint Details
Complaint IN0451146 was investigated and found to have no deficiencies related to the allegations. The deficiency cited was unrelated to the complaint.
Findings
The facility failed to ensure fall interventions were followed for 1 of 3 residents reviewed (Resident B), who sustained a fall resulting in a distal fibula fracture. Resident B was left unattended on the toilet despite care plan instructions, indicating a failure in following fall prevention protocols.
Deficiencies (1)
Failed to ensure fall interventions were followed for Resident B, who was left unattended on the toilet and subsequently found on the bathroom floor with a fracture.
Report Facts
Residents reviewed for fall interventions: 3
Resident census: 47
SNF/NF beds: 39
Residential beds: 8
Medicare residents: 1
Medicaid residents: 20
Other payor residents: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Duggan | Administrator | Provided facility reported incident and plan of correction |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 39
Deficiencies: 0
Date: Dec 18, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00447805 and IN00447896.
Complaint Details
Investigation of Complaints IN00447805 and IN00447896 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00447805 and IN00447896 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census Bed Type: 39
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 14
Census Payor Type - Other: 19
Inspection Report
Re-Inspection
Census: 46
Capacity: 65
Deficiencies: 0
Date: Nov 21, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 09/24/24 was performed to verify compliance with previous deficiencies.
Findings
The Cedars 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 sprinklered except for a barn providing facility services.
Report Facts
Facility capacity: 65
Census: 46
Inspection Report
Complaint Investigation
Census: 41
Capacity: 41
Deficiencies: 0
Date: Oct 29, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00445058 and IN00445121.
Complaint Details
Complaint IN00445058 and IN00445121 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00445058 and IN00445121 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 SNF/NF beds: 41
Census total residents: 41
Census Medicare residents: 3
Census Medicaid residents: 21
Census other payor residents: 17
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Oct 3, 2024
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
The Cedars 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: 40
Capacity: 65
Deficiencies: 11
Date: Sep 24, 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).
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Multiple deficiencies were identified including unsealed penetrations in fire barrier walls, obstructed means of egress, improper exit discharge surfaces, non-self-closing stairway doors, improperly installed kitchen hood extinguishing systems, inadequate sprinkler system maintenance, lack of electrically supervised smoke detection in sunrooms, incomplete fire evacuation plans, missing annual fire door inspections, absence of a portable space heater policy, and improper use of extension cords and power strips.
Deficiencies (11)
Failed to ensure penetrations in 1 of 1 fire barrier walls separating healthcare from assisted living were sealed to maintain fire resistance.
Failed to maintain 1 of 4 means of egress free of obstructions; handrail blocked door swing path.
Failed to ensure 1 of 4 exit discharges had an unobstructed level walking surface; ramp transition and obstructions noted.
Failed to ensure 1 of 4 stairway doors were self-closing and latching to keep door closed.
Failed to properly install and maintain kitchen hood extinguishing systems and provide shut off for cooktops.
Failed to maintain sprinkler system storage tanks and spare sprinkler boxes per NFPA 25 requirements.
Failed to provide electrically supervised automatic smoke detection in 1 of 1 sunrooms open to corridor.
Failed to provide a written fire evacuation plan addressing locations of smoke/fire barriers or cross corridor doors.
Failed to ensure annual inspection and testing of 1 of 17 fire door assemblies; oxygen room fire door not inspected.
Failed to develop a portable space heater policy; facility does not allow space heaters but had no written policy.
Failed to ensure extension cords and power strips were not used as substitutes for fixed wiring; improper use observed.
Report Facts
Residents affected: 25
Residents affected: 20
Deficiencies cited: 11
Facility capacity: 65
Census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Duggan | Health Facility Administrator | Named in relation to findings and plans of correction. |
| Maintenance Director | Interviewed and involved in observations related to multiple deficiencies. |
Inspection Report
Annual Inspection
Census: 46
Deficiencies: 5
Date: Sep 13, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted from September 9 to 13, 2024.
Findings
The facility was found deficient in multiple areas including failure to provide required transfer information for hospital transfers, failure to clarify and follow physician orders related to high-risk medications, inadequate hand hygiene during wound care, improper respiratory care, and poor food labeling and storage practices.
Deficiencies (5)
Failed to ensure the resident was provided with required transfer information for a hospital transfer for 1 of 2 residents reviewed (Resident 37).
Failed to ensure physician orders related to a high-risk medication were clarified and followed for 1 of 2 residents reviewed (Resident 37).
Failed to ensure hand hygiene was performed during wound care for 1 of 2 residents reviewed (Resident 12).
Failed to ensure respiratory care was provided according to physician's orders for 1 of 2 residents reviewed (Resident 29).
Failed to ensure food items were labeled and stored to prevent contamination and hand hygiene was performed consistently for all residents served food prepared in the kitchen.
Report Facts
Census SNF/NF: 39
Census Residential: 7
Total Census: 46
Number of residents served: 39
Number of residents served: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda M Duggan | Health Facility Administrator | Named as contact for plan of correction and administrative representative |
| LPN 27 | Licensed Practical Nurse | Interviewed regarding hospital transfer form and medication administration |
| LPN 5 | Licensed Practical Nurse | Observed and interviewed regarding wound care and respiratory care |
| Cook 2 | Interviewed and observed regarding food storage and hand hygiene | |
| Dietary aide 4 | Observed regarding hand hygiene during dishwashing duties | |
| Dietary Manager | Interviewed regarding hand hygiene and food labeling practices | |
| Director of Nursing | Interviewed regarding hospital transfer policy and wound care procedures |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 4, 2024
Visit Reason
The document is a paper compliance review related to unrelated citations in the complaint investigations IN00438240 and IN00437842 completed on July 22, 2024.
Findings
The Cedars 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 unrelated citation in the complaint investigations.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 4, 2024
Visit Reason
This document serves as a paper compliance report related to the investigation of complaints IN00439941, IN00440684, and IN00440721 completed on August 14, 2024.
Complaint Details
The report addresses complaint investigations and confirms compliance; no deficiencies were cited.
Findings
The Cedars was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigations.
Inspection Report
Complaint Investigation
Census: 40
Capacity: 40
Deficiencies: 2
Date: Aug 12, 2024
Visit Reason
This visit was for the investigation of multiple complaints (IN00439941, IN00440684, IN00440721, IN00440722, and IN00440704) regarding allegations of abuse and pressure ulcer care at the facility.
Complaint Details
Complaints IN00439941, IN00440684, and IN00440721 were substantiated with federal/state deficiencies cited at F610 and F686. Complaints IN00440722 and IN00440704 had no deficiencies related to the allegations.
Findings
The facility failed to conduct a thorough investigation of an allegation of physical abuse for one resident and failed to develop and implement person-centered interventions to promote healing of pressure ulcers for the same resident. The investigation lacked staff and resident interviews, and wound care assessments and treatments were incomplete or missed.
Deficiencies (2)
Failed to conduct a thorough investigation of an allegation of physical abuse for 1 of 3 residents reviewed for abuse.
Failed to develop and implement person-centered interventions to promote healing of pressure ulcers for 1 of 3 residents reviewed for pressure ulcers.
Report Facts
Census: 40
Total Capacity: 40
Complaint IDs: 5
Dates of Survey: 2024-08-12 to 2024-08-14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda M Duggan | Health Facility Administrator | Named in relation to plan of correction and interview regarding investigation procedures |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 48
Deficiencies: 1
Date: Jul 22, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00437842 and IN00438240. No deficiencies related to the allegations of these complaints were cited, but an unrelated deficiency was identified.
Complaint Details
Complaint IN00437842 and IN00438240 were investigated. No deficiencies related to the allegations were cited for either complaint.
Findings
The facility failed to ensure there was an assessment and documentation of a resident's dislodged PICC line and PICC line site in 1 of 1 resident reviewed (Resident C). The PICC line was found dislodged on 7/17/24, but no assessment or documentation was completed as required by facility policy and professional standards.
Deficiencies (1)
Failure to assess and document the dislodged PICC line and PICC line site for Resident C.
Report Facts
Census: 48
Total Capacity: 48
Survey Dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda M Duggan | Health Facility Administrator | Signed report and referenced in plan of correction |
| LPN 4 | Reported PICC line dislodgement to physician but did not document assessment | |
| CNA 2 | Certified Nursing Aide | Noticed and reported the dislodged PICC line |
| Director of Nursing | Indicated the dislodged PICC line and site should have been assessed and documented but was not |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 38
Deficiencies: 0
Date: Apr 29, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00431171 and IN00432825.
Complaint Details
Complaint IN00431171 and Complaint IN00432825 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00431171 and IN00432825 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF beds: 38
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 23
Census Payor Type - Other: 11
Total Census: 38
Inspection Report
Complaint Investigation
Census: 33
Capacity: 33
Deficiencies: 0
Date: Dec 28, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00422533.
Complaint Details
Complaint IN00422533 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Report Facts
Census SNF/NF beds: 33
Census Payor Type Medicaid: 25
Census Payor Type Other: 8
Inspection Report
Re-Inspection
Census: 46
Capacity: 65
Deficiencies: 1
Date: Dec 12, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 10/19/2023.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements due to failure to ensure 2-hour fire rated barriers between the skilled nursing unit and the independent living unit. The facility is awaiting installation of new 2-hour fire rated doors to correct the deficiency.
Deficiencies (1)
Failed to ensure 2 of 2 vertical occupancy separations between the skilled nursing unit and the independent living unit contained a 2-hour fire rated barrier.
Report Facts
Facility capacity: 65
Census: 46
Deficiency correction timeframe: 90
Estimated delay: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda M Duggan | Health Facility Administrator | Contact person for questions and plan of correction |
| Maintenance Director | Interviewed regarding fire rated door deficiency and installation plans |
Inspection Report
Life Safety
Census: 46
Capacity: 65
Deficiencies: 12
Date: Oct 19, 2023
Visit Reason
A Life Safety Code (LSC) Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) to assess compliance with fire safety and life safety code requirements.
Findings
The facility was found not in compliance with several life safety code requirements including failure to maintain a 2-hour fire rated barrier between the skilled nursing and independent living units, obstruction in means of egress, inadequate fire safety signage, improper hazardous area protections, improper placement of alcohol-based hand sanitizer dispensers near ignition sources, and improper use of power strips and extension cords.
Deficiencies (12)
Failed to review and update the Emergency Preparedness Plan (EPP) at least annually.
Failed to review and update the EPP Policy and Procedures at least annually.
Failed to review and update the EPP Communication Program at least annually.
Failed to test and train on the updated EPP Communication Program at least annually.
Failed to ensure 2 of 2 vertical occupancy separations between the skilled nursing unit and the independent living unit contained a 2-hour fire rated barrier.
Failed to ensure 1 of 5 means of egress were continuously maintained free of all obstructions or impediments to full instant use in case of fire or emergency.
Failed to meet the clear width requirement for 3 of 3 Independent Living corridors due to furniture not securely attached and encroaching into corridor space.
Failed to ensure 1 of 1 sunroom courtyard doors were posted with a 'NO EXIT' sign to prevent mistaken exit.
Failed to ensure 2 of 7 storage rooms with large amounts of combustible storage were protected as hazardous areas with self-closing doors.
Failed to ensure 1 of over 20 alcohol-based hand sanitizer dispensers were not near an ignition source where sanitizer was splashing on the ignition source.
Failed to ensure 1 of 1 fire alarm systems was installed in accordance with NFPA 72; smoke detector was located less than three feet from an air return vent.
Failed to ensure 1 of 1 extension cords and 4 of 4 power strips were not used as a substitute for fixed wiring and met UL rating requirements in patient care locations.
Report Facts
Facility capacity: 65
Census: 46
Deficiencies cited: 12
Fire rated door installation timeframe: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda M Duggan | Health Facility Administrator | Named in relation to findings and exit conference |
Inspection Report
Re-Inspection
Census: 46
Deficiencies: 0
Date: Oct 19, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 2023-09-08, including the PSR to the State Residential Licensure Survey completed on the same date.
Findings
The Cedars 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.
Report Facts
Census SNF/NF: 39
Census Residential: 7
Total Census: 46
Census Medicare: 2
Census Medicaid: 18
Census Other: 26
Inspection Report
Annual Inspection
Census: 7
Capacity: 40
Deficiencies: 8
Date: Sep 8, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted on September 5-8, 2023.
Findings
The facility was found deficient in multiple areas including failure to maintain resident privacy, failure to provide timely transfer/discharge notices, inadequate discharge planning, failure to provide scheduled showers, insufficient RN coverage, delayed pharmacy recommendation implementation, and poor kitchen sanitation.
Deficiencies (8)
Failure to ensure privacy was maintained for 1 of 6 residents reviewed (Resident 23) due to posting of a POST form with personal information above the bed.
Failure to provide written explanation of Notice of Transfer or Discharge and Bed Hold Policy within 24 hours of hospital transfer for 1 of 2 residents reviewed (Resident 25).
Failure to provide an effective discharge planning process including provision of discharge summary for 1 of 7 residents reviewed (Resident 30).
Failure to ensure provision of scheduled showers at resident preference for 1 of 7 residents reviewed (Resident 10).
Failure to ensure a Registered Nurse worked 8 consecutive hours in the facility on 11 of 60 days reviewed.
Failure to ensure pharmacy recommendations were addressed timely for 1 of 5 residents reviewed (Resident 12).
Failure to maintain kitchen sanitation including expired food items, unlabeled food containers, dirty shelves and drip pans, and incomplete temperature logs.
Failure to evaluate residents' ability to self-administer medications for 2 of 2 residents reviewed (Residents 200 and 201).
Report Facts
Census: 7
Total Capacity: 40
Days RN coverage less than 8 consecutive hours: 11
Residents reviewed for privacy: 6
Residents reviewed for transfer notice: 2
Residents reviewed for discharge planning: 7
Residents reviewed for shower provision: 7
Residents reviewed for pharmacy recommendations: 5
Residents reviewed for self-medication evaluation: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Duggan | Health Facility Administrator | Named in relation to plan of correction and facility administration |
| RN 4 | Registered Nurse | Interviewed regarding pharmacy recommendations and RN coverage |
| QMA 3 | Qualified Medication Aide | Interviewed regarding kitchen sanitation and resident medication setup |
| Cook 2 | Interviewed regarding kitchen sanitation and food storage |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 29, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00413820 completed on August 9, 2023.
Complaint Details
Investigation of Complaint IN00413820 completed on August 9, 2023; facility found in compliance.
Findings
The Cedars was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Inspection Report
Complaint Investigation
Census: 29
Capacity: 29
Deficiencies: 1
Date: Aug 8, 2023
Visit Reason
This visit was for the investigation of Nursing Home Complaint IN00413820 and Residential Complaint IN00413976.
Complaint Details
Complaint IN00413820 was substantiated with federal/state deficiencies cited at F744 related to dementia care and behavior management. Complaint IN00413976 was found to have no deficiencies related to the allegations.
Findings
The facility failed to provide appropriate dementia care and services for 2 of 3 residents reviewed, resulting in physical injuries and inadequate behavior management. Deficiencies were cited related to dementia care and behavior management protocols, documentation, and individualized interventions.
Deficiencies (1)
Failure to provide appropriate treatment and services for residents with dementia, resulting in bruising and combative behaviors not properly managed.
Report Facts
Census: 29
Total Capacity: 29
Medicare Census: 2
Medicaid Census: 15
Other Payor Census: 12
Residential Census: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Duggan | Health Facility Administrator | Named in plan of correction and contact person for compliance |
| CNA 3 | Involved in care incident with Resident F leading to bruising and combative behavior | |
| CNA 5 | Assisted CNA 3 with Resident F and reported behavior and bruises to charge nurse | |
| Social Services Director | SSD | Interviewed regarding behavior documentation and management |
| Director of Nursing | DON | Provided CNA assignment sheet and interviewed about behavior documentation |
Inspection Report
Complaint Investigation
Census: 31
Capacity: 31
Deficiencies: 0
Date: Jun 30, 2023
Visit Reason
This visit was conducted as an investigation of Complaint IN00411163.
Complaint Details
Complaint IN00411163 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 Bed Type: 31
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 19
Census Payor Type - Other: 11
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 13, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00405571 completed on May 8, 2023.
Complaint Details
Investigation of Complaint IN00405571 completed with findings of compliance.
Findings
The Cedars 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.
Report Facts
Complaint Investigation ID: 4005571
Inspection Report
Complaint Investigation
Census: 32
Capacity: 32
Deficiencies: 1
Date: May 8, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00405571, IN00405877, and IN00405891. The investigation focused on allegations related to resident care and facility compliance.
Complaint Details
Complaint IN00405571 was substantiated with federal/state deficiencies cited at F656. Complaints IN00405877 and IN00405891 were not substantiated with deficiencies.
Findings
The facility was found deficient for failing to address the use of a quarter siderail in the care plan for one resident (Resident G), which impacted the resident's safety and sense of security. Other complaints were found to have no deficiencies related to the allegations.
Deficiencies (1)
Facility failed to address siderail use in the care plan for Resident G, who required a quarter siderail on the right side of the bed for safety and security due to paralysis and dizziness.
Report Facts
Census: 32
Total Capacity: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Kruse | Director of Nursing | Interviewed regarding Resident G's care plan and siderail use; provided facility policy on care plans. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 12, 2023
Visit Reason
Paper compliance review related to the Investigation of Complaint IN00402379 completed on March 13, 2023.
Complaint Details
Investigation of Complaint IN00402379 completed on March 13, 2023; facility found in compliance.
Findings
The Cedars was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 38
Capacity: 38
Deficiencies: 2
Date: Mar 9, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00402374 regarding allegations of abuse at the facility.
Complaint Details
Complaint IN00402374 was substantiated with federal/state deficiencies cited related to allegations of abuse. The investigation included interviews, record reviews, and physical assessments confirming abuse and neglect issues.
Findings
The facility was found to have failed to prevent physical abuse for one resident, Resident P, who reported abuse by staff resulting in bruises and skin tears. Additionally, the facility failed to ensure showers were provided to Resident T as scheduled. Corrective actions including staff in-service and monitoring were planned.
Deficiencies (2)
Failure to implement interventions to prevent physical abuse for 1 of 3 residents reviewed (Resident P).
Failure to ensure showers were provided for 1 of 1 residents reviewed (Resident T).
Report Facts
Census: 38
Total Capacity: 38
Survey Dates: 2
Medicaid Residents: 26
Other Payor Residents: 12
Medicare Residents: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chad Forth | Administrator | Signed the report |
| RN 2 | Registered Nurse | Agency nurse on night shift during alleged abuse incident |
| CNA 5 | Certified Nurse Assistant | Staff involved in alleged abuse incident |
| CNA 7 | Certified Nurse Assistant | Staff involved in alleged abuse incident |
| RN 9 | Registered Nurse | Charge nurse interviewed regarding shower issues for Resident T |
| Director of Nursing | Interviewed regarding abuse allegations and shower issues | |
| Social Service Director | Present during interview of Resident P |
Inspection Report
Follow-Up
Census: 38
Capacity: 65
Deficiencies: 0
Date: Mar 8, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 12/07/22 was performed to verify compliance with previous deficiencies.
Findings
The Cedars 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 was fully sprinklered except for a barn providing facility services.
Report Facts
Facility capacity: 65
Census: 38
Inspection Report
Complaint Investigation
Census: 37
Capacity: 37
Deficiencies: 0
Date: Feb 3, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00399067.
Complaint Details
Complaint IN00399067 was investigated and found unsubstantiated due to lack of evidence.
Findings
The complaint was found to be unsubstantiated due to lack of evidence, and the facility was found to be in compliance with relevant regulations.
Report Facts
Census: 37
Total Capacity: 37
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 26
Census Payor Type - Other: 10
Inspection Report
Complaint Investigation
Census: 37
Capacity: 37
Deficiencies: 0
Date: Jan 3, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00396437.
Complaint Details
Complaint IN00396437 was substantiated; however, no deficiencies related to the allegation were cited.
Findings
The complaint was substantiated, but no deficiencies related to the allegation were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type: 37
Medicare Census: 3
Medicaid Census: 25
Other Payor Census: 9
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 22, 2022
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00394592 completed on November 22, 2022.
Complaint Details
Investigation of Complaint IN00394592 completed with the facility found in compliance.
Findings
The Cedars was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Dec 22, 2022
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
The Cedars 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: 38
Capacity: 65
Deficiencies: 2
Date: Dec 7, 2022
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies included failure to ensure rolling fire doors/windows in smoke barriers were kept closed and released by fire alarms, and a soiled utility room door was blocked from latching due to paper in the strike plate.
Deficiencies (2)
Failed to ensure 2 of 2 rolling fire doors/windows located in smoke barriers were kept in a closed position and released by fire alarm system.
Failed to ensure the corridor door to 1 of 3 soiled utility rooms was provided with a self-closing device that would cause the door to automatically close and latch into the door frame.
Report Facts
Facility capacity: 65
Census: 38
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chad Forth | Administrator | Named in exit conference and report signature |
| Maintenance Director | Interviewed regarding fire door deficiencies and door latch issue |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 37
Deficiencies: 1
Date: Nov 22, 2022
Visit Reason
This visit was for the investigation of three complaints: IN00394592, IN00395367, and IN00395265. Complaint IN00394592 was substantiated, while the other two complaints were unsubstantiated due to lack of sufficient evidence.
Complaint Details
Complaint IN00394592 was substantiated with federal/state deficiencies cited at F600. Complaints IN00395367 and IN00395265 were unsubstantiated due to lack of sufficient evidence.
Findings
The facility failed to ensure a resident (Resident B) was free from abuse. Resident B had bruising consistent with suspected deep tissue injuries, and staff interviews and documentation confirmed an incident involving physical abuse. The facility took corrective actions including staff interviews, physical assessments of residents, staff in-service on abuse policy, and removal of an agency nurse involved.
Deficiencies (1)
Failed to ensure a resident was free from abuse for 1 of 3 residents reviewed (Resident B).
Report Facts
Residents present: 37
Total licensed capacity: 37
Medicare residents: 2
Medicaid residents: 23
Private pay residents: 12
Bruising areas on Resident B: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chad Forth | Administrator | Signed report and provided facility policy |
| LPN 3 | Licensed Practical Nurse | Agency nurse involved in abuse incident and removed from facility |
| CNA 4 | Certified Nursing Assistant | Reported bruising on Resident B and involved in abuse incident |
| Director of Nursing | Interviewed regarding abuse incident and advised removal of agency nurse | |
| Social Services Director | Interviewed Resident B and noted history of trauma |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 0
Date: Nov 9, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00393389, conducted in conjunction with a Recertification and State Licensure Survey and a State Residential Licensure Survey.
Complaint Details
Complaint IN00393389 was investigated and found unsubstantiated due to lack of evidence.
Findings
The complaint IN00393389 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with 42 CFR Parts 483.10, 483.12, 483.25, and 483.35 related to the complaint investigation.
Report Facts
Census SNF/NF beds: 32
Census Residential beds: 8
Total Census: 40
Census Payor Medicare: 1
Census Payor Medicaid: 23
Census Payor Other: 16
Inspection Report
Complaint Investigation
Census: 40
Capacity: 40
Deficiencies: 6
Date: Nov 9, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey, conducted in conjunction with the Investigation of Complaint IN00393389.
Complaint Details
The visit was conducted in conjunction with the Investigation of Complaint IN00393389.
Findings
The facility was found deficient in ensuring residents' rights, specifically regarding adequate meal time for Resident 7, monitoring of psychotropic medication side effects for three residents, staffing with certified first aid personnel, current service plans and pre-admission screenings for residents, physician notification of pharmacy medication reviews, and annual health statements and flu vaccinations for residents.
Deficiencies (6)
Failed to ensure Resident 7 had adequate time to finish her meal.
Failed to ensure side effects of psychotropic medications were monitored for 3 residents (Resident 17, Resident 20, Resident 34).
Failed to always have a certified first aid staff member on site.
Failed to ensure 5 residents had current service plans and 1 resident had pre-admission screening.
Failed to ensure physician was notified regarding pharmacy medication reviews for 1 resident (Resident B).
Failed to ensure 4 residents had annual health statements and 1 resident had annual flu vaccination.
Report Facts
Survey dates: 5
Census SNF/NF beds: 32
Census Residential beds: 8
Total census: 40
Total capacity: 40
Residents on Medicare: 1
Residents on Medicaid: 23
Residents on Other payor: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chad Forth | Administrator | Signed the report. |
| CNA 1 | Certified Nursing Assistant | Involved in the incident with Resident 7 regarding meal time. |
| Director of Nursing | Director of Nursing | Interviewed regarding Resident 7 incident and psychotropic medication monitoring. |
| Social Services Director | Social Services Director | Interviewed regarding resident assessments and documentation. |
| Executive Director | Executive Director | Interviewed regarding policies and procedures. |
| Assisted Living Coordinator | Assisted Living Coordinator | Interviewed regarding service plans and certifications. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 21, 2022
Visit Reason
Paper compliance review related to the Investigation of Complaints IN00387360 and IN00390573 completed on September 21, 2022.
Complaint Details
Investigation of Complaints IN00387360 and IN00390573; paper compliance review found the facility in compliance.
Findings
The Cedars was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Inspection Report
Complaint Investigation
Census: 34
Capacity: 34
Deficiencies: 1
Date: Sep 20, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00387360 and IN00390573. Complaint IN00387360 was unsubstantiated due to lack of evidence, while complaint IN00390573 was substantiated with related deficiencies cited.
Complaint Details
Complaint IN00387360 was unsubstantiated due to lack of evidence. Complaint IN00390573 was substantiated with federal/state deficiencies cited at F689 related to fall prevention failures.
Findings
The facility failed to implement fall interventions to prevent accidents, identify root causes of falls, and update care plans for 3 residents reviewed for accidents. There was a failure to follow the fall protocol checklist, complete root cause analyses, update care plans, and conduct follow-up assessments after falls.
Deficiencies (1)
Failure to implement fall interventions to prevent accidents, identify root causes of falls, and update care plans for residents O, R, and S.
Report Facts
Census: 34
Total Capacity: 34
Number of residents reviewed for accidents: 3
Survey dates: September 20 and 21, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding fall protocols and care plan compliance | |
| Certified Nurse Assistant (CNA 3) | Involved in transferring Resident O without required assistance | |
| Certified Nurse Assistant (CNA 5) | Involved in transferring Resident O without required assistance |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 31, 2022
Visit Reason
Paper compliance review to the Investigation of Complaints IN00386007 and IN00386937 completed on August 2, 2022.
Complaint Details
The visit was related to complaint investigations IN00386007 and IN00386937; the facility was found in compliance.
Findings
The Cedars was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 31, 2022
Visit Reason
Paper compliance review to the Complaint Investigation IN00384697 completed on July 20, 2022.
Complaint Details
Complaint Investigation IN00384697 was reviewed and found to be in compliance.
Findings
The Cedars was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Inspection Report
Complaint Investigation
Census: 43
Capacity: 43
Deficiencies: 2
Date: Aug 2, 2022
Visit Reason
This visit was conducted for the investigation of two complaints, IN00386007 and IN00386937, both of which were substantiated with related federal/state deficiencies cited.
Complaint Details
Complaint IN00386007 was substantiated with deficiencies related to abuse prevention training. Complaint IN00386937 was substantiated with deficiencies related to medication errors involving insulin pens.
Findings
The facility failed to ensure all staff received annual abuse prevention and resident rights training, and failed to ensure residents were free of significant medication errors involving multi-dose insulin pens, resulting in cross-contamination risks.
Deficiencies (2)
Failure to ensure all staff received annual abuse prevention and resident rights training.
Failure to ensure residents were free of significant medication errors involving multi-dose insulin pens.
Report Facts
Census: 43
Total Capacity: 43
Residents reviewed: 6
Residents reviewed: 5
Medication error monitoring frequency: 10
Medication error monitoring frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 2 | Certified Nursing Assistant | Named in deficiency for lack of annual abuse and resident rights training |
| LPN 8 | Licensed Practical Nurse | Named in medication error involving insulin pen administration |
| RN 5 | Registered Nurse | Named in medication error involving insulin pen administration |
| Administrative Assistant 7 | Administrative Assistant | Provided training documentation and interview regarding abuse training |
| Director of Nursing | Director of Nursing | Interviewed regarding training policies and medication error response |
| Administrator | Facility Administrator | Interviewed and provided statements related to deficiencies |
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