Inspection Reports for Charlestown Place at New Albany
4915 CHARLESTOWN RD, IN, 47150
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 13, 2025, found no deficiencies related to the complaints investigated. Earlier inspections showed a pattern of deficiencies primarily involving documentation issues, care plan updates, medication administration, and some safety concerns, particularly related to admission paperwork and emergency department communication. Complaint investigations occasionally substantiated deficiencies, but no fines, immediate jeopardy findings, or license actions were listed in the available reports. Most complaints were either unsubstantiated or corrected upon follow-up visits. The facility’s record shows some ongoing challenges in clinical documentation and care coordination, but recent inspections indicate improvements in addressing prior issues.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
19 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
352% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
96% occupied
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: 132
Capacity: 137
Deficiencies: 0
May 13, 2025
Visit Reason
This visit was conducted for the investigation of Nursing Home Complaints IN00457419, IN00457928, and IN00458119.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the investigation of these complaints.
Complaint Details
Complaint IN00457419 - No deficiencies related to the allegations are cited. Complaint IN00457928 - No deficiencies related to the allegations are cited. Complaint IN00458119 - No deficiencies related to the allegations are cited.
Report Facts
Census SNF/NF beds: 132
Census Residential beds: 5
Total licensed capacity: 137
Census Medicare residents: 27
Census Medicaid residents: 48
Census Other payor residents: 57
Total census residents: 132
Inspection Report
Follow-Up
Census: 128
Capacity: 136
Deficiencies: 1
Apr 11, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) for Nursing Home Complaint IN00454370 completed on 3/18/25, conducted in conjunction with investigations of Nursing Home Complaints IN00456144, IN00457155, and IN00457176.
Findings
Complaint IN00454370 was corrected. No deficiencies were cited related to complaints IN00456144 and IN00457176. A federal/state deficiency related to complaint IN00457155 was cited at F620. Overall, the facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the PSR to complaint IN00454370.
Complaint Details
This visit was related to multiple nursing home complaints: IN00454370 (corrected), IN00456144 (no deficiencies), IN00457155 (deficiency cited at F620), and IN00457176 (no deficiencies).
Deficiencies (1)
| Description |
|---|
| Federal/State deficiency related to complaint IN00457155 cited at F620. |
Report Facts
Census SNF/NF: 128
Census Residential: 8
Total Census: 136
Total Capacity: 136
Medicare Census: 32
Medicaid Census: 66
Other Payor Census: 30
Inspection Report
Complaint Investigation
Census: 128
Capacity: 136
Deficiencies: 1
Apr 10, 2025
Visit Reason
This visit was conducted for the investigation of Nursing Home Complaints IN00456144, IN00457155, and IN00457176, in conjunction with a Post Survey Revisit for Complaint IN00454370.
Findings
The facility was found deficient related to Complaint IN00457155 regarding admissions policy, specifically failing to complete a resident's admission paperwork in a timely manner. Other complaints had no deficiencies cited or were corrected.
Complaint Details
Complaint IN00457155 was substantiated with a federal/state deficiency cited at F620. Complaints IN00456144 and IN00457176 had no deficiencies related to allegations. Complaint IN00454370 was corrected.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a resident's admission paperwork was completed in a timely manner for 1 of 3 residents reviewed for admissions. | SS=D |
Report Facts
Census SNF/NF beds: 128
Census Residential beds: 8
Total Capacity: 136
Medicare census: 32
Medicaid census: 66
Other payor census: 30
Total census: 128
Inspection Report
Follow-Up
Census: 135
Capacity: 144
Deficiencies: 1
Mar 18, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) for Complaints IN00453742 and IN00453811, conducted in conjunction with the Investigation of Nursing Home Complaints IN00454370 and IN00454530.
Findings
Complaint IN00453742 and IN00453811 were corrected. Complaint IN00454370 resulted in a Federal/State deficiency cited at F622. Complaint IN00454530 had no deficiencies related to the allegations. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
The visit was complaint-related for Complaints IN00453742, IN00453811, IN00454370, and IN00454530. Complaints IN00453742 and IN00453811 were corrected. Complaint IN00454370 was substantiated with a deficiency cited. Complaint IN00454530 was not substantiated with any deficiencies.
Deficiencies (1)
| Description |
|---|
| Federal/State deficiency related to Complaint IN00454370 cited at F622. |
Report Facts
SNF/NF Census: 135
Residential Census: 9
Total Capacity: 144
Medicare Census: 20
Medicaid Census: 66
Other Payor Census: 49
Total Payor Census: 135
Inspection Report
Complaint Investigation
Census: 136
Capacity: 145
Deficiencies: 1
Mar 17, 2025
Visit Reason
This visit was conducted for the investigation of Nursing Home Complaints IN00454370 and IN00454530, in conjunction with the Post Survey Revisit for Complaints IN00453742 and IN00453811.
Findings
The facility failed to ensure that information was provided to the receiving emergency department for one resident and failed to provide bed hold policies to residents discharged to the hospital for four residents. Some complaints were corrected, while one complaint resulted in a federal/state deficiency citation.
Complaint Details
Complaint IN00454370 resulted in a federal/state deficiency related to the allegations. Complaint IN00454530 had no deficiencies cited. Complaints IN00453742 and IN00453811 were corrected.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure information was provided to the receiving emergency department for Resident B pending arrival and failed to provide bed hold policies to residents discharged to the hospital for Residents B, C, D, and E. | SS=E |
Report Facts
Census SNF/NF beds: 136
Census Residential beds: 9
Total Capacity: 145
Medicare residents: 34
Medicaid residents: 64
Other payor residents: 38
Total residents present: 136
Inspection Report
Complaint Investigation
Census: 135
Capacity: 144
Deficiencies: 3
Feb 20, 2025
Visit Reason
This visit was conducted for the investigation of nursing home complaints IN00452133, IN00452809, IN00453742, and IN00453811.
Findings
The facility was found deficient in ensuring neurological checks were completed after unwitnessed falls for 2 of 4 residents reviewed, respiratory assessments and proper nebulizer equipment storage for 1 of 3 residents, and preventing a significant medication error for 1 of 3 residents reviewed.
Complaint Details
Complaints investigated included IN00452133 (no deficiencies cited), IN00452809 (deficiency cited at F760), IN00453742 (deficiency cited at F684), and IN00453811 (deficiencies cited at F684 and F695).
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure neurological checks were completed on residents with unwitnessed falls (Resident H and Resident K). | SS=D |
| Failed to ensure respiratory assessments were completed and nebulizer equipment was stored appropriately for Resident F. | SS=D |
| Failed to ensure a significant medication error did not occur for Resident C, who received an additional unintended dose of Keppra. | SS=D |
Report Facts
Census SNF/NF beds: 135
Census Residential beds: 9
Total Capacity: 144
Medicare census: 20
Medicaid census: 66
Other payor census: 49
Medication error dose: 2000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Ray | Executive Director | Signed the report |
| LPN 5 | Licensed Practical Nurse | Administered additional unintended dose of medication leading to medication error |
| LPN 6 | Licensed Practical Nurse | Interviewed regarding neurological checks after unwitnessed falls |
| RN 3 | Registered Nurse | Interviewed regarding respiratory assessments for nebulizer treatments |
| RN 4 | Registered Nurse | Interviewed regarding proper storage of respiratory equipment |
| Director of Nursing | Provided policies and information related to neurological assessments, medication administration, and respiratory care |
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 10, 2025
Visit Reason
Paper compliance review to the Investigation of Complaints IN00447226 and IN00449144 completed on December 30, 2024.
Findings
Charlestown Place at New Albany 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 investigations. Both complaints were corrected.
Complaint Details
Complaint IN00447226 and Complaint IN00449144 were investigated and found corrected.
Inspection Report
Complaint Investigation
Census: 123
Capacity: 132
Deficiencies: 6
Dec 30, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00447226, IN00448143, and IN00449144 at Charlestown Place at New Albany.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of changes in resident condition, inaccurate vital sign assessments, incomplete documentation of urine output for residents with indwelling catheters, failure to follow fluid restriction orders, inadequate respiratory equipment maintenance and orders, and failure to implement medication orders properly.
Complaint Details
The investigation was triggered by complaints IN00447226, IN00448143, and IN00449144. Deficiencies related to complaints IN00447226 and IN00449144 were substantiated with cited deficiencies. Complaint IN00448143 had no deficiencies cited.
Severity Breakdown
SS=D: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure physician was notified of Resident K's low blood pressure and shortness of breath. | SS=D |
| Failed to ensure licensed staff accurately assessed and obtained vital signs daily for Resident K. | SS=D |
| Failed to ensure staff documented urine output for residents with indwelling catheters (Residents B, F, and G). | SS=D |
| Failed to ensure staff followed Resident K's fluid restriction order. | SS=D |
| Failed to ensure physician's orders were in place for weekly maintenance of nebulizer equipment and routine oxygen administration for residents (Residents B, H, and K). | SS=D |
| Failed to ensure Resident K's new order for increased Lasix was implemented. | SS=D |
Report Facts
Census SNF/NF: 123
Census Residential: 9
Total Capacity: 132
Medicare Census: 14
Medicaid Census: 60
Other Payor Census: 49
Fluid Intake: 2900
Fluid Intake: 1580
Fluid Intake: 2560
Lasix Dosage: 20
Lasix Dosage: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Ray | Executive Director | Signed the report and plan of correction. |
| RN 4 | Registered Nurse | Interviewed regarding notification of physician for Resident K and nursing practices. |
| Director of Nursing | Provided documentation and interviews regarding policies, deficiencies, and corrective actions. |
Inspection Report
Life Safety
Census: 20
Capacity: 172
Deficiencies: 0
Nov 14, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted due to the lack of a 2 hour fire-rated separation between the skilled care areas and the Assisted Living area.
Findings
The facility was found in compliance with the Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. All resident areas and facility service areas were sprinkled.
Report Facts
Total certified beds: 158
Total capacity: 172
Census: 20
Inspection Report
Life Safety
Census: 141
Capacity: 172
Deficiencies: 11
Oct 8, 2024
Visit Reason
An Emergency Preparedness Recertification and Life Safety Code Recertification and State Licensure Survey was conducted due to lack of a 2 hour fire-rated separation between skilled care and Assisted Living areas.
Findings
The facility was found not in compliance with Life Safety Code requirements including issues with egress doors, cooking facilities, sprinkler system maintenance, fire extinguisher inspections, smoke barrier penetrations, fire drills, fire door inspections, and emergency generator testing.
Severity Breakdown
SS=E: 8
SS=F: 4
Deficiencies (11)
| Description | Severity |
|---|---|
| Egress exit doors did not have door codes posted and lacked 15-second delayed egress function. | SS=E |
| Staff lacked access to shutoff switch for stove/oven in therapy room; cooking appliances not returned to approved design location under kitchen hood extinguishing system. | SS=E |
| Ceiling construction near sprinkler head outside room 403 was not maintained; sprinkler escutcheon missing. | SS=E |
| Backflow prevention device in sprinkler system was not tested annually as required. | SS=F |
| Multiple ceiling penetrations in various areas were not sealed properly to maintain smooth ceiling for sprinkler operation. | SS=E |
| Sprinkler heads in laundry area, behind dryers, and porch near therapy were covered with lint or foreign substances and not replaced or cleaned as required. | SS=E |
| Fire extinguishers in copy room and 400 hall nurse's station med room were not inspected monthly as required. | SS=E |
| Penetrations through smoke barrier walls near north dining room and 300 hall were not protected to maintain smoke resistance. | SS=E |
| Quarterly fire drills were not conducted at unexpected times under varying conditions on all shifts. | SS=F |
| Annual inspection and testing of all fire door assemblies, including oxygen room door, was not completed as required. | SS=F |
| 36-month emergency generator testing for 4 continuous hours was not documented for the main building generator. | SS=F |
Report Facts
Residents potentially affected by egress door deficiency: 31
Residents potentially affected by cooking facility deficiency: 5
Residents potentially affected by sprinkler head deficiency: 4
Residents potentially affected by backflow prevention deficiency: all
Residents potentially affected by ceiling penetrations: all
Residents potentially affected by sprinkler head cleaning deficiency: 3
Staff potentially affected by fire extinguisher inspection deficiency: 5
Residents potentially affected by smoke barrier penetration deficiency: 20
Residents potentially affected by fire drill deficiency: all
Residents potentially affected by fire door inspection deficiency: all
Residents potentially affected by emergency generator testing deficiency: all
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Ray | Executive Director | Named in relation to exit conference and findings review |
| Maintenance Director | Participated in observations, interviews, and exit conference regarding deficiencies | |
| Senior Vice President of Facilities | Participated in observations, interviews, and exit conference regarding deficiencies |
Inspection Report
Re-Inspection
Census: 127
Deficiencies: 0
Sep 12, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to multiple complaints and was conducted in conjunction with the Recertification and State Licensure Survey, a State Residential Licensure Survey, and investigations of several complaints completed on September 12, 2024.
Findings
Charlestown Place at New Albany 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 investigation of multiple complaints. Several complaints were corrected as of this visit.
Complaint Details
The visit addressed complaints IN00435623, IN00439316, IN00439663, IN00439706, IN00441570, IN00441712, IN00442755, and IN00442598. Complaints IN00435623, IN00439316, IN00439663, and IN00439706 were corrected.
Report Facts
Census Bed Type - SNF/NF: 118
Census Bed Type - Residential: 9
Total Census: 127
Census Payor Type - Medicare: 11
Census Payor Type - Medicaid: 65
Census Payor Type - Other: 42
Total Census Payor: 118
Inspection Report
Annual Inspection
Census: 127
Capacity: 127
Deficiencies: 7
Sep 12, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey including investigation of multiple complaints and post-survey revisits.
Findings
The facility had deficiencies related to resident accommodations, medication documentation and storage, expired and discontinued medications, and kitchen sanitation. Corrective actions and education were implemented to address these issues.
Complaint Details
This visit included investigation of Complaints IN00441570, IN00441712, IN00442755, IN00442598, and post-survey revisits to Complaints IN00435623, IN00439316, IN00439663, and IN00439706. All complaints were either corrected or had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 1
SS=E: 3
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure a resident was provided a bed and mattress that could accommodate his height comfortably. | SS=D |
| Failed to ensure documentation on the Controlled Drug Receipt/Record/Disposition Form of administered narcotics for multiple residents. | SS=E |
| Failed to ensure discontinued and expired medications were promptly disposed of during medication storage. | SS=E |
| Failed to ensure kitchen equipment, ceiling vents and the kitchen floor were free from food debris and grease build up. | SS=E |
| Failed to ensure documentation on the Controlled Drug Receipt/Record/Disposition Form of administered narcotics for 2 residents in Residential 100 Hall medication cart. | — |
| Failed to ensure kitchen equipment, ceiling vents and the kitchen floor were free from food debris and grease build up affecting Residential residents. | — |
| Failed to ensure discontinued and expired medications were promptly disposed of in Residential 100 Hall medication cart. | — |
Report Facts
Census SNF/NF: 118
Census Residential: 9
Total Census: 127
Residents affected by bed accommodation deficiency: 1
Residents observed for medication storage: 64
Residents with controlled medication documentation issues: 12
Residents observed for discontinued/expired medication storage: 7
Residents observed for kitchen sanitation: 118
Residents observed for residential kitchen sanitation: 9
Residents observed for residential medication documentation: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Ray | Laboratory Director or Provider/Supplier Representative | Signed the report |
| RN 5 | Observed resident's feet touching footboard and assessed skin condition | |
| Maintenance Director | Adjusted bed footboard and interviewed residents about bed accommodations | |
| Executive Director | Provided education to maintenance staff and dietary staff; involved in auditing | |
| LPN 4 | Licensed Practical Nurse | Administered medications and interviewed regarding narcotic documentation |
| LPN 6 | Licensed Practical Nurse | Interviewed about narcotic documentation |
| QMA 7 | Qualified Medication Aide | Interviewed about narcotic documentation |
| LPN 5 | Licensed Practical Nurse | Interviewed about returning discontinued medications to pharmacy |
| LPN 8 | Licensed Practical Nurse | Interviewed about expired/discontinued medication disposal |
| DON | Director of Nursing | Interviewed about narcotic documentation and medication disposal procedures |
| Dietary Manager | Conducted kitchen tours, provided cleaning schedules, and re-education to staff | |
| Regional District Manager | Accompanied dietary manager during kitchen observations |
Inspection Report
Renewal
Deficiencies: 0
Sep 12, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey.
Findings
Charlestown Place at New Albany 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 for the Recertification and State Licensure Survey.
Inspection Report
Re-Inspection
Census: 127
Deficiencies: 0
Sep 12, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to Complaint IN00435623 completed on June 27, 2024, conducted in conjunction with the Recertification and State Licensure Survey, a State Residential Licensure Survey, and investigations of multiple complaints completed on September 12, 2024, as well as PSRs to other complaints completed on August 15, 2024.
Findings
Charlestown Place at New Albany 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 Investigation of Complaint IN00435623. Multiple complaints were corrected as of this visit.
Complaint Details
This visit addressed multiple complaints including IN00435623, IN00439316, IN00439663, IN00439706, IN00441570, IN00441712, IN00442755, and IN00442598. Complaints IN00435623, IN00439316, IN00439663, and IN00439706 were corrected.
Report Facts
Census Bed Type - SNF/NF: 118
Census Bed Type - Residential: 9
Total Census: 127
Census Payor Type - Medicare: 11
Census Payor Type - Medicaid: 65
Census Payor Type - Other: 42
Total Census Payor: 118
Inspection Report
Complaint Investigation
Census: 118
Deficiencies: 3
Aug 11, 2024
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00437974, IN00438638, IN00439105, IN00439316, IN00439663, IN00439706, IN00440360, and IN00441040) at Charlestown Place at New Albany.
Findings
The facility was found to have deficiencies related to cleanliness of resident toilets, medication administration errors including failure to hold medication based on heart rate parameters, and inaccurate medication and controlled substance records. Some complaints were substantiated with federal/state deficiencies cited, while others had no deficiencies related to the allegations.
Complaint Details
Complaints IN00439105, IN00439316, IN00439663, and IN00439706 were substantiated with federal/state deficiencies cited at tags F602 and F842. Complaints IN00437974, IN00438638, IN00440360, and IN00441040 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure residents' toilets were clean and sanitary for 2 of 4 residents reviewed. | SS=D |
| Facility failed to follow medication administration hold parameters related to a resident's heart rate for 1 of 3 residents reviewed. | SS=D |
| Facility failed to ensure medication administration records and controlled substance records accurately reflected administration of narcotic medication for 3 of 4 residents reviewed. | SS=D |
Report Facts
Census Bed Type - SNF/NF: 111
Census Bed Type - Residential: 7
Total Census: 118
Census Payor Type - Medicare: 22
Census Payor Type - Medicaid: 57
Census Payor Type - Other: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Ray | Executive Director | Signed the report as facility representative |
| LPN 5 | Licensed Practical Nurse | Interviewed regarding medication administration and resident care |
| Assistant Housekeeping Supervisor | Interviewed regarding housekeeping practices and cleanliness of resident bathrooms | |
| Housekeeping Supervisor | Interviewed regarding housekeeping procedures and toilet cleaning frequency | |
| Director of Nursing | Director of Nursing | Interviewed regarding resident care, medication administration, and sliding scale insulin refusal |
| In-house wound physician | Interviewed regarding wound care orders and treatment discontinuation |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 113
Deficiencies: 1
Jun 27, 2024
Visit Reason
This visit was conducted for the investigation of multiple nursing home complaints (IN00435044, IN00435623, IN00436560, IN00436635, IN00436650, and IN00436866).
Findings
The facility was found deficient related to Complaint IN00435623 for failing to ensure nursing staff followed medication parameters for 1 of 4 residents reviewed (Resident C). No deficiencies were cited for the other complaints. Resident C was discharged with no negative outcomes related to the deficient practice.
Complaint Details
Complaint IN00435623 was substantiated with a federal/state deficiency cited at F684. Other complaints (IN00435044, IN00436560, IN00436635, IN00436650, IN00436866) had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure nursing staff followed medication parameters for Resident C regarding Lisinopril administration. | SS=D |
Report Facts
Census SNF/NF: 106
Census Residential: 7
Total Census: 113
Medicare Census: 6
Medicaid Census: 55
Deficiencies cited: 1
Audit duration: 4
Additional audit duration: 8
Residents reviewed in audit: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Ray | Laboratory Director or Provider/Supplier Representative | Signed the report |
| RN 5 | Interviewed regarding medication parameters and administration | |
| Director of Nursing | Provided policy document and outlined corrective actions and audits |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 13, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00430915 completed on May 3, 2024.
Findings
Charlestown Place at New Albany 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 IN00430915 completed on May 3, 2024; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 128
Capacity: 128
Deficiencies: 2
May 2, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00430915 regarding alleged deficiencies at the facility.
Findings
The facility was found deficient for failing to notify a physician about a resident's multiple loose stools and for failing to ensure a resident's room was free of accident hazards, resulting in a burn injury. Corrective actions and education were initiated to address these issues.
Complaint Details
Complaint IN00430915 was substantiated with federal/state deficiencies cited related to failure to notify physician of resident's condition and failure to maintain a safe environment.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure the physician was notified of a resident's multiple loose stools indicating a change of condition. | SS=D |
| Failed to ensure a resident's room was free of potential hazards, resulting in a burn from a melted phone charger cord plugged into an unapproved power strip. | SS=D |
Report Facts
Census SNF/NF beds: 123
Census Residential beds: 5
Total Census: 128
Medicare residents: 30
Medicaid residents: 66
Other payor residents: 27
Dates of survey: 2024-05-02 to 2024-05-03
Resident B discharge date: Nov 25, 2023
Resident D burn wound measurements: 2 cm x 3 cm
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Ray | Laboratory Director or Provider/Supplier Representative | Signed the report |
| RN 5 | Registered Nurse | Observed and documented Resident D's burn injury and provided education |
| LPN 3 | Licensed Practical Nurse | Interviewed regarding physician notification for change of condition |
| Maintenance Director | Provided education and conducted electrical safety audits | |
| Director of Nursing | Provided policy documents and described corrective actions | |
| Unit Manager | Interviewed and documented resident education and observations |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 5, 2024
Visit Reason
Paper compliance review to the unrelated deficiencies from the Investigation of Complaint IN00427985 completed on February 22, 2024.
Findings
Charles Town Place 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 deficiency from the Complaint Investigation.
Inspection Report
Complaint Investigation
Census: 126
Capacity: 126
Deficiencies: 2
Feb 22, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00427985. The complaint investigation found no deficiencies related to the allegations, but unrelated deficiencies were cited.
Findings
The facility failed to ensure a comprehensive care plan was in place for a resident's refusal of care and failed to ensure treatments for pressure ulcers were completed as ordered for two residents. Documentation and care plan updates were lacking for refusal of turning and repositioning, and treatment administration records showed missed treatments for pressure ulcers.
Complaint Details
Complaint IN00427985 was investigated with no deficiencies related to the allegations cited. Unrelated deficiencies were identified during the investigation.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure a plan of care was in place for a resident's refusal of care related to turning and repositioning. | SS=D |
| Failed to ensure residents' treatments for pressure ulcers were completed as ordered by the physician. | SS=D |
Report Facts
Census SNF/NF beds: 116
Census Residential beds: 10
Total Census: 126
Medicare census: 25
Medicaid census: 68
Other payor census: 23
Missed treatment dates for Resident D left and right buttocks: 5
Missed treatment dates for Resident D coccyx: 4
Missed treatment date for Resident D coccyx (new treatment): 1
Missed treatment dates for Resident E coccyx: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Ray | Laboratory Director or Provider/Supplier Representative | Signed the report |
| RN 7 | Registered Nurse | Interviewed regarding resident refusal of care and treatment documentation |
| CNA 6 | Certified Nursing Aide | Interviewed regarding resident non-compliance with turning and repositioning |
| CNA 8 | Certified Nursing Aide | Interviewed regarding resident refusal to turn and reposition |
Inspection Report
Complaint Investigation
Census: 115
Capacity: 125
Deficiencies: 1
Jan 25, 2024
Visit Reason
This visit was conducted for the investigation of nursing home complaints IN00424248, IN00425390, and IN00426633.
Findings
The facility was found to have a deficiency related to misappropriation of resident property involving missing narcotic medication for one resident (Resident B). No deficiencies were found related to the other two complaints. The facility implemented corrective actions including audits, education, and staff changes.
Complaint Details
Complaint IN00424248 was substantiated with a federal/state deficiency cited at F602. Complaints IN00425390 and IN00426633 were not substantiated with any deficiencies.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure misappropriation of resident property did not occur for 1 of 3 residents reviewed for abuse related to missing narcotic medication. | SS=D |
Report Facts
Census SNF/NF beds: 115
Census Residential beds: 10
Total licensed capacity: 125
Medicare census: 7
Medicaid census: 66
Other payor census: 42
Oxycodone tablets delivered: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 4 | Licensed Practical Nurse | Signed in 90 Oxycodone tablets and involved in investigation of missing medication |
| Director of Nursing | Provided information on investigation and staffing actions related to missing narcotic medication | |
| Executive Director | Provided the facility's 'Freedom from Abuse and Neglect Policy' document |
Inspection Report
Complaint Investigation
Census: 126
Capacity: 135
Deficiencies: 0
Dec 13, 2023
Visit Reason
This visit was conducted to investigate three nursing home complaints identified as IN00421989, IN00422117, and IN00422573.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with applicable federal and state regulations regarding the investigation of complaints.
Complaint Details
Complaint IN00421989 - No deficiencies related to the allegation is cited. Complaint IN00422117 - No deficiencies related to the allegation is cited. Complaint IN00422573 - No deficiencies related to the allegations are cited.
Report Facts
Census SNF/NF: 126
Census Residential: 9
Total Capacity: 135
Census Payor Type Medicare: 29
Census Payor Type Medicaid: 61
Census Payor Type Other: 36
Total Census Payor Type: 126
Inspection Report
Complaint Investigation
Census: 127
Deficiencies: 0
Nov 8, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00420626.
Findings
No deficiencies related to the allegations in Complaint IN00420626 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00420626 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 119
Census Bed Type - Residential: 8
Census Total: 127
Census Payor Type - Medicare: 23
Census Payor Type - Medicaid: 71
Census Payor Type - Other: 25
Census Payor Type - Total: 119
Inspection Report
Re-Inspection
Census: 118
Capacity: 172
Deficiencies: 0
Oct 24, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 08/24/23 was performed to verify compliance with fire safety and licensure requirements.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 NFPA 101 Life Safety Code. All resident areas and facility service areas were fully sprinkled.
Inspection Report
Complaint Investigation
Census: 126
Deficiencies: 0
Oct 19, 2023
Visit Reason
This visit was conducted for the investigation of Nursing Home Complaints IN00418341, IN00419466, and IN00419631.
Findings
No deficiencies related to the allegations in complaints IN00418341, IN00419466, and IN00419631 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 investigation of these complaints.
Complaint Details
Complaints IN00418341, IN00419466, and IN00419631 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 118
Census Bed Type - Residential: 8
Census Bed Type - Total: 126
Census Payor Type - Medicare: 15
Census Payor Type - Medicaid: 76
Census Payor Type - Other: 27
Census Payor Type - Total: 118
Inspection Report
Follow-Up
Census: 117
Capacity: 125
Deficiencies: 0
Sep 15, 2023
Visit Reason
This was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on July 31, 2023, including a PSR to the State Residential Licensure Survey. The visit was also in conjunction with the PSR to the Investigation of Complaint IN00414596 completed on August 21, 2023.
Findings
Charlestown Place at New Albany 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
Complaint IN00414596 was investigated and found to be corrected.
Report Facts
Census SNF/NF: 117
Census Residential: 8
Total Capacity: 125
Census Medicare: 19
Census Medicaid: 72
Census Other Payor: 26
Total Census Payor: 117
Inspection Report
Follow-Up
Census: 117
Capacity: 125
Deficiencies: 0
Sep 14, 2023
Visit Reason
This visit was for the Post Survey Revisit (PSR) to the Investigation of Complaint IN00414596 completed on August 21, 2023, conducted in conjunction with the PSR to the Recertification and State Licensure Survey completed on July 31, 2023, including a PSR to the State Residential Licensure Survey.
Findings
Charlestown Place at New Albany 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 for the Investigation of Complaint IN00414596.
Complaint Details
Complaint IN00414596 was investigated and found to be corrected.
Report Facts
Census SNF/NF: 117
Census Residential: 8
Total Capacity: 125
Census Medicare: 19
Census Medicaid: 72
Census Other Payor: 26
Inspection Report
Routine
Census: 118
Capacity: 172
Deficiencies: 16
Aug 24, 2023
Visit Reason
An Emergency Preparedness Recertification and Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health due to lack of a 2 hour fire-rated separation between skilled care and Assisted Living areas.
Findings
The facility was found not in compliance with several Life Safety Code requirements including corridor doors not closing and latching, means of egress obstructions, improper locking arrangements on exit doors, corridor width obstructions, emergency lighting testing deficiencies, hazardous area separations, kitchen fire suppression inspection delays, fire alarm system testing and sensitivity testing deficiencies, sprinkler system obstructions and inspection gaps, fire alarm and sprinkler system out-of-service policies incomplete, portable fire extinguisher inspection deficiencies, corridor doors impeded from closing, incomplete fire drill documentation, and unattended soiled linen and trash receptacles improperly stored.
Severity Breakdown
Level 1: 8
Level 2: 5
Level 3: 2
Deficiencies (16)
| Description | Severity |
|---|---|
| Corridor doors to 6 rooms would not close and latch into the door frame. | Level 1 |
| 2 of 11 means of egress were obstructed by furniture and equipment. | Level 1 |
| Means of egress through 2 of 8 exits were not readily accessible due to keypad lock codes not posted. | Level 1 |
| Failed to meet clear corridor width requirements due to furniture obstructing corridors. | Level 1 |
| Failed to document monthly testing for all battery backup emergency lights; 2 of 4 battery lights failed to illuminate. | Level 1 |
| Failed to ensure 2 hazardous areas were separated by smoke resistant partitions and doors. | Level 1 |
| Kitchen fire suppression system was not inspected semi-annually as required. | Level 2 |
| Fire alarm system testing did not include all initiating devices within the most recent 12 months; smoke detector sensitivity testing documentation missing. | Level 2 |
| Sprinkler spray pattern obstructed by storage in Activities Storage room. | Level 1 |
| Failed to provide documentation for quarterly sprinkler system inspections for one quarter; missing weekly dry sprinkler gauge and valve inspections. | Level 2 |
| Failed to provide complete written policy for fire alarm system out-of-service procedures including notification methods. | Level 3 |
| Failed to provide complete written policy for sprinkler system out-of-service procedures including notification methods. | Level 3 |
| One portable fire extinguisher had not been inspected annually; missing monthly inspection documentation for 8 months. | Level 2 |
| Five corridor doors had impediments preventing closing and latching, including propped open doors and missing latching hardware. | Level 1 |
| Fire drill documentation missing for third shift in one quarter; fire alarm activation not documented for one drill conducted between 6am and 9pm. | Level 2 |
| Unattended soiled linen and trash receptacles stored in corridors exceeding allowed capacity and not in hazardous area. | Level 1 |
Report Facts
Total beds: 172
Certified beds: 158
Census: 118
Doors with closing/latching issues: 6
Means of egress obstructed: 2
Battery emergency lights: 4
Battery lights failed: 2
Hazardous areas deficient: 2
Kitchen fire suppression inspections missing: 1
Fire alarm system inspections missing: 1
Sprinkler inspection quarters missing: 1
Portable fire extinguisher missing annual inspection: 1
Corridor doors with impediments: 5
Fire drills missing: 1
Soiled linen and trash receptacles improperly stored: 2
Inspection Report
Complaint Investigation
Census: 114
Capacity: 114
Deficiencies: 1
Aug 21, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00414596 regarding a federal/state deficiency related to dementia care.
Findings
The facility failed to implement and update a resident's plan of care after aggressive behaviors and a resident-to-resident altercation involving one resident with dementia. The care plan lacked documentation of the altercation and appropriate interventions were not updated timely.
Complaint Details
Complaint IN00414596 was substantiated with a federal/state deficiency cited at F744 related to dementia care and failure to update care plans after aggressive behaviors and altercation.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to implement and update a resident's plan of care after aggressive behaviors and resident-to-resident altercation for 1 of 3 residents reviewed for Dementia Care. | SS=D |
Report Facts
Census: 114
Total Capacity: 114
Medicare Census: 17
Medicaid Census: 67
Other Payor Census: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Ray | Laboratory Director or Provider/Supplier Representative | Signed the report |
| Lacy Beyl | Social Services Consultant | Contracted to provide monthly social services support and oversight |
Inspection Report
Renewal
Census: 7
Deficiencies: 10
Jul 31, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey including a State Residential Licensure Survey.
Findings
The facility was found deficient in multiple areas including failure to inform resident's family and obtain physician orders for psychiatric services, failure to ensure prompt physician notification of rectal bleeding, inaccurate behavioral assessments, inadequate pressure ulcer prevention, improper fluid status management, insufficient behavioral health services, failure to provide pneumococcal vaccinations per CDC guidelines, inadequate first aid coverage, and dishwasher temperature below required levels.
Complaint Details
Complaint survey completed on July 31, 2023. Plan of correction submitted for complaint survey.
Severity Breakdown
SS=D: 4
SS=G: 2
SS=E: 3
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to inform resident's family in advance of psychiatric treatment risks and obtain physician order for psychiatric services for 1 of 24 residents. | SS=D |
| Failed to ensure prompt physician notification of rectal bleeding for a resident on anticoagulants resulting in hospitalization for anemia and acute blood loss for 1 of 3 residents. | SS=G |
| Failed to ensure Minimum Data Set assessments accurately reflected behaviors for 1 of 25 residents. | SS=D |
| Failed to ensure pressure ulcer prevention interventions were provided as indicated in the care plan for 1 of 7 residents. | SS=D |
| Failed to ensure appropriate fluid status management including administration of diuretics, clarification of duplicate orders, and weight monitoring for 1 of 3 residents. | — |
| Failed to provide necessary behavioral health services to attain or maintain highest practicable well-being for 1 of 3 residents with behavioral health needs. | SS=G |
| Failed to provide adequate social services follow-up after unwanted and inappropriate behavior interactions for 8 of 9 residents reviewed. | SS=E |
| Failed to ensure dishwashing equipment was at appropriate temperature to disinfect dishes, with temperatures below 120 degrees F. | SS=E |
| Failed to ensure residents were offered pneumococcal vaccinations as recommended by CDC for 3 of 5 residents reviewed. | SS=E |
| Failed to ensure coverage by staff with current First Aid certification 24 hours a day in Assisted Living. | — |
Report Facts
Survey dates: 2023-07-24 to 2023-07-31
Census Bed Type: 7
Dishwasher temperature: 110
Dishwasher temperature: 109
Dishwasher temperature: 108
Dishwasher temperature: 112
Dishwasher temperature: 100
Resident census: 115
Resident census: 122
Pneumococcal vaccine dose: 1
Weight: 263
Weight gain: 8.1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 29 | Licensed Practical Nurse | Named as staff with current First Aid certification. |
| LPN 30 | Licensed Practical Nurse | Named as staff with current First Aid certification. |
| Vice President of Clinical Operations | Provided education and interviews regarding multiple deficiencies including pneumococcal vaccination, dishwasher temperature, and social services. | |
| Director of Nursing | Interviewed regarding First Aid coverage and social services. | |
| District Manager | Interviewed regarding dishwasher temperature and staff education. | |
| Environmental Manager | Interviewed regarding dishwasher temperature and kitchen hot water supply. | |
| Social Service Assistant | Interviewed regarding social services rounds and follow-up. | |
| Social Service Director | Interviewed regarding social services documentation and job description. |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 10, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00399561 completed on January 27, 2023.
Findings
Charlestown Place at New Albany 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 IN00399561 completed on January 27, 2023; paper compliance review found the facility in compliance.
Inspection Report
Complaint Investigation
Census: 123
Deficiencies: 3
Jan 26, 2023
Visit Reason
This visit was for the investigation of complaints IN00398549 and IN00399561. Complaint IN00398549 was unsubstantiated due to lack of sufficient evidence, while complaint IN00399561 was substantiated with related federal/state deficiencies cited.
Findings
The facility failed to ensure treatments for pressure ulcers were completed as ordered for 2 of 3 residents reviewed, catheter care was not provided or documented as ordered for 2 of 3 residents, and gastrostomy tube site care was not provided or documented for 1 of 2 residents reviewed for enteral feeding.
Complaint Details
Complaint IN00398549 was unsubstantiated due to lack of sufficient evidence. Complaint IN00399561 was substantiated with federal/state deficiencies cited at F686, F690, and F693.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure treatments were completed as ordered by the physician for residents with pressure ulcers. | SS=D |
| Failed to ensure catheter care was provided and documented as ordered for residents with indwelling catheters. | SS=D |
| Failed to ensure care was provided to a resident's gastrostomy tube site as ordered. | SS=D |
Report Facts
Census: 123
SNF/NF beds: 72
SNF beds: 47
Residential beds: 4
Medicare residents: 14
Medicaid residents: 59
Other payor residents: 46
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Ray | Administrator | Signed the report and plan of correction |
| LPN 5 | Licensed Practical Nurse | Interviewed regarding wound and catheter care procedures |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 23, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00395587 completed on December 21, 2022.
Findings
Diversicare of Providence 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
Complaint Investigation IN00395587 was reviewed for paper compliance and found to be in compliance.
Report Facts
Complaint Investigation Number: 395587
Inspection Report
Complaint Investigation
Census: 124
Capacity: 128
Deficiencies: 1
Dec 21, 2022
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00392244, IN00395550, IN00395587, IN00395974, IN00396407, and IN00397149) regarding the facility.
Findings
The investigation substantiated one complaint (IN00395587) with a federal/state deficiency cited related to failure to notify a resident's family member prior to a hospital transfer. Other complaints were either unsubstantiated or substantiated with no deficiencies cited. The facility provided a plan of correction addressing the notification deficiency.
Complaint Details
Complaint IN00395587 was substantiated with a deficiency cited at F580. Complaints IN00392244 and IN00395550 were unsubstantiated due to lack of sufficient evidence. Complaints IN00395974, IN00396407, and IN00397149 were substantiated with no deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to notify a resident's family member prior to a hospital transfer for 1 of 3 residents reviewed for notification of change. | SS=D |
Report Facts
Census Bed Type - SNF/NF: 61
Census Bed Type - SNF: 63
Census Bed Type - Residential: 4
Total Capacity: 128
Census Payor Type - Medicare: 29
Census Payor Type - Medicaid: 56
Census Payor Type - Other: 39
Inspection Report
Re-Inspection
Census: 132
Capacity: 172
Deficiencies: 0
Sep 22, 2022
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Recertification and State Licensure Survey and the Life Safety Code Recertification and State Licensure Survey due to previous deficiencies noted on 07/26/22.
Findings
At this Post Survey Revisit, Diversicare of Providence was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements. The entire facility was surveyed due to the lack of a 2 hour fire-rated separation between the skilled care areas and the Assisted Living areas.
Report Facts
Total beds: 172
Certified beds: 158
Census: 132
Inspection Report
Re-Inspection
Census: 128
Capacity: 132
Deficiencies: 0
Aug 25, 2022
Visit Reason
This visit was a Post Survey Revisit to the Recertification and State Licensure Survey completed on July 12, 2022.
Findings
Diversicare of Providence was found to be in compliance with 410 IAC 16.2-5 in regard to the Post Survey Revisit to the Recertification and Licensure survey.
Report Facts
Census Payor Type - Medicare: 15
Census Payor Type - Medicaid: 61
Census Payor Type - Other: 52
Census Bed Type - SNF/NF: 65
Census Bed Type - SNF: 63
Census Bed Type - Residential: 4
Inspection Report
Annual Inspection
Census: 131
Capacity: 172
Deficiencies: 5
Jul 26, 2022
Visit Reason
An Emergency Preparedness Recertification and State Licensure Survey was conducted due to the lack of a 2 hour fire-rated separation between the skilled care areas and the Assisted Living areas.
Findings
The facility was found in substantial compliance with Emergency Preparedness Requirements but had deficiencies related to emergency generator load testing documentation, smoke detector sensitivity testing, sprinkler heads covered with paint, smoke barrier door coordinators, and generator monthly load test logs missing a 5 minute cool down time.
Severity Breakdown
SS=C: 2
SS=F: 1
SS=E: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to maintain a complete written record of monthly generator load testing for 1 of 1 generator during the past 12 months, missing documentation of a 5 minute cool down time. | SS=C |
| Failed to ensure documentation was available to show that all resident room and several staff offices smoke detectors were sensitivity tested within the past 24 months. | SS=F |
| Sprinkler heads in 2 of 14 smoke compartments were partially covered with paint and needed replacement. | SS=E |
| Failed to ensure 2 of 2 sets of smoke barrier doors which swing in the same direction and equipped with an astragal had a properly functioning coordinator. | SS=E |
| Failed to maintain a complete written record of monthly generator load testing including a 5 minute cool down time for 1 of 1 generator during the past 12 months. | SS=C |
Report Facts
Total beds: 172
Certified beds: 158
Census: 131
Deficiencies cited: 5
Generator load test interval: 12
Generator load test last date: Aug 5, 2022
Smoke detector sensitivity test frequency: 24
Sprinkler heads inspected: 14
Sprinkler heads with paint: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in relation to generator load test documentation and smoke detector sensitivity testing findings | |
| Administrator | Named in relation to review and education regarding deficiencies |
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