Inspection Report
Life Safety
Census: 54
Capacity: 86
Deficiencies: 0
Nov 15, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively on 11/15/2024.
Findings
Christian Care Retirement Community was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Participation in Medicare/Medicaid. The facility was fully sprinklered with appropriate fire alarm and smoke detection systems, and the building construction met the required standards.
Report Facts
Facility capacity: 86
Census: 54
Inspection Report
Annual Inspection
Census: 63
Capacity: 105
Deficiencies: 1
Oct 22, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted from October 16 to 22, 2024.
Findings
The facility failed to ensure physician orders were in place related to code status for 2 of 3 residents reviewed. Corrective actions included entering the missing orders, auditing all residents for code status orders, and providing mandatory training to nursing staff.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure physician orders were in place related to code status for 2 of 3 residents reviewed (Residents 62 and 166). | SS=D |
Report Facts
Census Bed Type - SNF/NF: 47
Census Bed Type - SNF: 16
Census Bed Type - Residential: 42
Total Capacity: 105
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 32
Census Payor Type - Other: 24
Total Census: 63
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Austin Smith | Executive Director, HFA | Signed the report as facility representative |
| Registered Nurse 5 | Interviewed regarding code status documentation | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding code status orders and corrective actions |
Inspection Report
Annual Inspection
Deficiencies: 0
Oct 22, 2024
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Christian Care Retirement Community was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 1
Aug 5, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00434869 regarding allegations of deficient care related to elopement risk.
Findings
The facility failed to ensure interventions were implemented to prevent elopement for 1 of 4 residents reviewed (Resident B). Resident B exited an unsecured courtyard gate unattended, triggering a code alert alarm that was disarmed by staff. The gate itself did not have an alarm. Corrective actions included enhanced supervision protocols, staff re-education, installation of a code alert on the gate, and relocation of Resident B to a secured memory care unit.
Complaint Details
Complaint IN00434869 was substantiated with federal/state deficiencies cited at F689 related to failure to prevent elopement of Resident B.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure interventions were implemented to prevent elopement for 1 of 4 residents reviewed (Resident B). | SS=D |
Report Facts
Census: 102
SNF beds: 12
SNF/NF beds: 51
Residential beds: 39
Medicare residents: 7
Medicaid residents: 33
Other payor residents: 62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Austin Smith | Executive Director, HFA | Named as facility representative signing the report |
| Activity Aide 2 | Named in findings related to leaving Resident B unattended in courtyard | |
| Registered Nurse 3 | Registered Nurse | Provided interview regarding Resident B's wanderguard/code alert and supervision |
| Director of Nursing | Director of Nursing (DON) | Provided interview about elopement incident and code alert system |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 5, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00434869 completed on August 5, 2024.
Findings
Christian Care Retirement Community 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 IN00434869; paper compliance review found facility in compliance.
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 0
Apr 24, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00431702.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00431702 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 101
Census Bed Type - SNF/NF: 50
Census Bed Type - SNF: 10
Census Bed Type - Residential: 41
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 34
Census Payor Type - Other: 64
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 0
Feb 20, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00427371.
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.
Complaint Details
Complaint IN00427371 - No deficiencies related to the allegations are cited.
Report Facts
Census: 104
Census Bed Type - SNF/NF: 52
Census Bed Type - SNF: 12
Census Bed Type - Residential: 40
Census Payor Type - Medicare: 11
Census Payor Type - Medicaid: 36
Census Payor Type - Other: 57
Inspection Report
Census: 57
Capacity: 86
Deficiencies: 0
Nov 8, 2023
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
Christian Care Retirement Community was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, as well as with Life Safety Code requirements for participation in Medicare/Medicaid. The facility was fully sprinklered with appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 86
Census: 57
Inspection Report
Renewal
Census: 53
Capacity: 53
Deficiencies: 0
Oct 11, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted over October 4, 5, 6, 10, and 11, 2023.
Findings
Christian Care Retirement Community was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Recertification and State Licensure Survey.
Report Facts
Census Bed Type: 53
Census Payor Type: 53
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 0
Dec 20, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00396679.
Findings
The complaint was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00396679 was substantiated; however, no deficiencies related to the allegations were cited.
Report Facts
Census Bed Type Total: 77
Census Bed Type SNF/NF: 49
Census Bed Type SNF: 2
Census Bed Type Residential: 26
Census Payor Type Medicare: 6
Census Payor Type Medicaid: 27
Census Payor Type Other: 44
Inspection Report
Life Safety
Census: 52
Capacity: 86
Deficiencies: 0
Dec 19, 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
Christian Care Retirement Community was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Participation in Medicare/Medicaid. The facility was fully sprinklered except for attic spaces constructed of non-combustible material, and had appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 86
Census: 52
Inspection Report
Renewal
Census: 80
Capacity: 80
Deficiencies: 0
Nov 18, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted over November 14-18, 2022.
Findings
Christian Care Retirement Community was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Recertification and State Licensure Survey.
Report Facts
Census Bed Type Total: 80
Census Payor Type Total: 80
Inspection Report
Complaint Investigation
Census: 51
Capacity: 77
Deficiencies: 0
Oct 5, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00391314 at Christian Care Retirement Community.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00391314 was substantiated, but no deficiencies related to the allegations were cited.
Report Facts
Census Bed Type - SNF/NF: 49
Census Bed Type - SNF: 2
Census Bed Type - Residential: 26
Census Bed Type - Total: 77
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 23
Census Payor Type - Other: 25
Census Payor Type - Total: 51
Inspection Report
Complaint Investigation
Census: 53
Capacity: 79
Deficiencies: 1
Aug 31, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00388316, which was substantiated with federal deficiencies cited related to the allegations.
Findings
The facility failed to ensure safety devices, specifically gait belts, were used with a resident known to be at high risk of falls, resulting in a fall with injury. The investigation focused on Resident B, who had multiple documented falls including one with a head laceration requiring hospital treatment. The facility implemented corrective actions including care plan updates, staff education, audits, and policy revisions to prevent recurrence.
Complaint Details
Complaint IN00388316 was substantiated. The deficiency related to failure to use safety devices (gait belts) for a resident at fall risk, leading to a fall with injury.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure safety devices were used with a resident known to be a fall risk, resulting in a fall with injury. | SS=D |
Report Facts
Census Bed Type - SNF/NF: 51
Census Bed Type - SNF: 2
Census Bed Type - Residential: 26
Total Licensed Capacity: 79
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 24
Census Payor Type - Other: 24
Total Census: 53
Fall Risk Assessment Score: 26
Fall Risk Assessment Score: 7
Laceration Size: 3
Laceration Width: 0.2
Staples Applied: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nurses Assistant | Named in the finding related to failure to use gait belt during Resident B's fall |
| Director of Nursing | DON | Spoke with CNA 1 about gait belt usage and involved in corrective actions |
| Administrator-In-Training | AIT | Provided hospital records and interviewed regarding the fall incident |
| CNA 2 | Certified Nurses Assistant | Interviewed about fall prevention and gait belt usage |
| CNA 3 | Certified Nurses Assistant | Interviewed about fall prevention and gait belt usage |
| RN 4 | Registered Nurse | Interviewed about fall risk assessments and gait belt policy |
| CNA 5 | Certified Nurses Assistant | Interviewed about gait belt availability and usage |
| CNA 6 | Certified Nurses Assistant | Interviewed about fall risk and gait belt usage |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 31, 2022
Visit Reason
Paper compliance review to the Investigation of Complaint IN00388316 completed on August 31, 2022.
Findings
Christian Care Retirement Community 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 IN00388316 was investigated and found to be in compliance.
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