Inspection Reports for
Cloverleaf of Knightsville
9325 N CRAWFORD ST, KNIGHTSVILLE, IN, 47857
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
210% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
100% occupied
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 63
Capacity: 63
Deficiencies: 0
Date: Apr 17, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00454279.
Complaint Details
Complaint IN00454279 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations are cited. Cloverleaf of Knightsville was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Investigation of Complaint IN00454279.
Report Facts
Census SNF/NF: 63
Census Payor Type Medicare: 13
Census Payor Type Medicaid: 44
Census Payor Type Other: 6
Inspection Report
Re-Inspection
Census: 68
Capacity: 102
Deficiencies: 0
Date: Feb 27, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 01/13/25 was performed to verify compliance with fire safety and licensure requirements.
Findings
At this PSR survey, Cloverleaf of Knightsville 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 the detached laundry building.
Report Facts
Facility capacity: 102
Census: 68
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 4, 2025
Visit Reason
Paper compliance to the Annual Recertification and State Licensure review completed on December 18, 2024.
Findings
Cloverleaf of Knightsville was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance to the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 64
Capacity: 102
Deficiencies: 2
Date: Jan 13, 2025
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and the 2012 edition of the NFPA 101 Life Safety Code.
Findings
The facility was found not in compliance with Life Safety Code requirements due to failure to maintain documentation for preventative maintenance of 51 battery operated smoke alarms in resident rooms and failure to provide an approved method to ensure kitchen cooking appliances are returned to their approved design location after maintenance or cleaning.
Deficiencies (2)
Failed to ensure documentation for the preventative maintenance of 51 battery operated smoke alarms in resident rooms was complete.
Failed to provide an approved method for returning cooking appliances to their approved design location after maintenance or cleaning.
Report Facts
Certified beds: 102
Census: 64
Battery operated smoke alarms: 51
Residents potentially affected: 32
Staff potentially affected: 6
Visitors potentially affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alexa Abbott | Laboratory Director or Provider/Supplier Representative | Signed the report |
| Maintenance Director | Named in relation to findings about smoke alarm maintenance and kitchen appliance compliance | |
| Facility Administrator | Named in relation to findings and exit conference |
Inspection Report
Annual Inspection
Census: 65
Deficiencies: 11
Date: Dec 18, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey including investigation of two complaints (IN00446893 and IN00449471).
Complaint Details
Complaint IN00446893 and IN00449471 were investigated with no deficiencies related to the allegations cited.
Findings
The facility was found deficient in multiple areas including resident dignity during meal assistance, weight monitoring, catheter care, dialysis assessments, behavioral health monitoring, medication administration errors, medication labeling, dietary preferences, food storage, antibiotic stewardship, and bedroom square footage compliance with waivers in place.
Deficiencies (11)
Facility failed to ensure residents were addressed in a dignified manner and assisted during meal service in a dignified manner for 2 of 3 dining observations.
Facility failed to monitor a resident's weight as ordered for 1 of 4 reviewed for nutrition.
Facility failed to ensure a resident's indwelling urinary catheter drainage bag and tubing were maintained off the floor for 1 of 2 residents reviewed for urinary catheters.
Facility failed to assess a resident's condition for complications before and after hemodialysis treatments for 1 of 2 residents reviewed for dialysis.
Facility failed to ensure behavior monitoring was completed for 1 of 5 residents reviewed for unnecessary medications.
Facility failed to ensure a medication error rate of less than 5 percent with an error rate of 21.43 percent for 3 of 4 residents reviewed for medication administration.
Facility failed to ensure medication storage insulin pens were labeled with date opened and expiration for 3 of 4 medication carts reviewed.
Facility failed to honor food preferences of 1 of 1 resident reviewed for dietary preferences.
Facility failed to ensure undated and expired foods were disposed of for 1 of 2 kitchen observations.
Facility failed to follow the antibiotic stewardship protocol program for 1 of 5 residents reviewed for antibiotics.
Facility failed to provide at least 80 square feet per resident in multiple occupancy resident rooms (Rooms 14 and 15) with waivers granted.
Report Facts
Census: 65
Total Capacity: 65
Medication error rate: 21.43
Room 14 square footage: 225
Room 15 square footage: 225.63
Square footage per resident in room 14: 75
Square footage per resident in room 15: 75.21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alexa Abbott | Laboratory Director or Provider/Supplier Representative | Signed the report |
| John Smith | Director of Nursing | Named in findings related to resident dignity and catheter care education |
| Employee 7 | Dietary staff interviewed about resident food preferences | |
| Employee 6 | Dietary staff interviewed about resident food preferences | |
| RN 15 | Registered Nurse | Observed medication administration errors and interviewed about insulin pen labeling |
| RN 17 | Registered Nurse | Observed insulin administration and interviewed about insulin pen priming and labeling |
| Cook 3 | Observed food storage and interviewed about food labeling | |
| LPN 8 | Licensed Practical Nurse | Interviewed about dialysis access site monitoring |
| QMA 18 | Qualified Medication Aide | Interviewed about insulin pen labeling |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 74
Deficiencies: 0
Date: Jun 3, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00435062.
Complaint Details
Complaint IN00435062 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
Medicare residents: 10
Medicaid residents: 48
Other payor residents: 16
Inspection Report
Complaint Investigation
Census: 70
Capacity: 70
Deficiencies: 0
Date: Apr 4, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00426986.
Complaint Details
Complaint IN00426986 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
Medicare residents: 8
Medicaid residents: 48
Other residents: 14
Inspection Report
Re-Inspection
Census: 72
Capacity: 102
Deficiencies: 0
Date: Jan 2, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 11/27/2023.
Findings
At this PSR survey, Cloverleaf of Knightsville was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Report Facts
Certified beds: 102
Census: 72
Inspection Report
Re-Inspection
Census: 73
Capacity: 73
Deficiencies: 0
Date: Dec 8, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on November 3, 2023.
Findings
Cloverleaf of Knightsville 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: 73
Census Payor Type Medicare: 7
Census Payor Type Medicaid: 54
Census Payor Type Other: 12
Inspection Report
Life Safety
Census: 69
Capacity: 102
Deficiencies: 11
Date: Nov 27, 2023
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on November 27, 2023.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code requirements including staff emergency preparedness training, exit discharge construction, illumination of means of egress, interior wall and ceiling finish, sprinkler system maintenance, corridor door functionality, electrical safety, HVAC combustion air intake, and portable space heater policy violations.
Deficiencies (11)
Failed to ensure staff were trained in emergency preparedness policies and procedures with no documentation of training or staff knowledge.
Failed to ensure 1 of 13 exit discharges was constructed to prevent elevation changes exceeding code requirements.
Failed to ensure lighting for 1 of 13 exit means of egress was properly maintained and would not leave the area in darkness.
Failed to ensure materials used as interior finish on 1 of 6 smoke compartments had a flame spread rating of Class A or B.
Failed to maintain ceiling construction in 1 of 6 smoke compartments with missing ceiling tiles and open grill tiles exposing ceiling above.
Failed to ensure 2 corridor doors were provided with means suitable for keeping the door closed, had no impediment to closing, latching, and would resist passage of smoke.
Failed to ensure 1 of over 5 wet locations was provided with ground fault circuit interrupter (GFCI) protection against electric shock.
Failed to ensure all fire dampers were inspected and maintained at least every four years with documentation of repairs missing.
Failed to ensure two mechanical rooms were provided with intake combustion air from outside for rooms containing fuel fired equipment.
Failed to follow the facility's portable space heater policy by having a portable space heater in the Therapy area.
Failed to ensure 2 flexible cords were installed properly and used in a safe manner; power strips were unsecured and dangling.
Report Facts
Certified beds: 102
Census: 69
Exit discharges inspected: 13
Residents potentially affected: 30
Residents potentially affected: 30
Suspended ceiling tiles missing: 12
Corridor doors inspected: 100
Residents potentially affected: 15
Wet locations inspected: 5
Residents potentially affected: 1
Fire dampers inspected: 4
Residents potentially affected: 40
Power strips audited: 4
Inspection Report
Annual Inspection
Census: 68
Capacity: 68
Deficiencies: 8
Date: Nov 3, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00417201.
Complaint Details
Complaint IN00417201 was investigated with no deficiencies related to the allegations cited.
Findings
The facility was found deficient in multiple areas including failure to notify dialysis center of changes in resident condition, inadequate nail care for dependent residents, incomplete pharmacy medication regimen review follow-up, improper medication labeling and storage, uncovered food delivery and poor hand hygiene during meal assistance, inadequate infection control practices including COVID-19 outbreak management, incomplete antibiotic stewardship tracking, and insufficient bedroom square footage for licensed beds in two rooms.
Deficiencies (8)
Failure to notify dialysis center nurse of changes of condition related to low blood pressures for 1 of 1 resident reviewed for dialysis.
Failure to ensure nail care was provided to dependent residents for 2 of 24 residents reviewed for activities of daily living.
Failure to ensure pharmacy recommendations were completed for 1 of 5 residents reviewed for unnecessary medications.
Failure to ensure expired insulin medications were disposed of properly and medications and biologicals were labeled and stored according to policy.
Failure to ensure food was covered when delivered to the units and failure to ensure hand hygiene was completed when assisting residents to eat.
Failure to establish and maintain an adequate infection prevention and control program including failure to implement infection control precautions timely, follow COVID-19 testing protocols, and ensure tracking for a COVID-19 outbreak.
Failure to review and track facility wide antibiotic stewardship for 4 of 12 months reviewed.
Failure to provide at least 80 square feet per resident in multiple occupancy resident rooms for 2 of 50 resident rooms observed (Rooms 14 and 15).
Report Facts
Census: 68
Total Capacity: 68
Blood Pressure Readings: 12
Deficiency Count: 8
Residents with Nail Care Deficiency: 2
Residents Reviewed for Medication Regimen: 5
Residents with Medication Labeling Issues: 5
Residents in Rooms with Insufficient Square Footage: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alexa Abbott | Facility Representative | Signed the report |
| Registered Nurse 16 | Registered Nurse | Interviewed regarding dialysis notification |
| Director of Nursing | Director of Nursing | Provided plan of correction and interview regarding pharmacy recommendations and infection control |
| Dialysis Manager | Dialysis Manager | Interviewed regarding dialysis communication |
| Registered Nurse 18 | Registered Nurse | Interviewed regarding nail care |
| Certified Nursing Assistant 3 | CNA | Observed during dining and infection control practices |
| Certified Nursing Assistant 6 | CNA | Observed entering isolation room without PPE |
| Housekeeper 8 | Housekeeper | Observed cleaning isolation rooms without PPE |
| Certified Nursing Assistant 21 | CNA | Observed during dining and infection control practices |
| Certified Nursing Assistant 22 | CNA | Observed during infection control practices |
| Licensed Practical Nurse 23 | LPN | Observed providing care without face shield |
| Housekeeper 24 | Housekeeper | Interviewed regarding cleaning procedures |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 102
Deficiencies: 0
Date: Oct 6, 2023
Visit Reason
An investigation of Complaint Number IN00419040 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a).
Complaint Details
Complaint IN00419040 was investigated and found to have no deficiencies related to the allegation.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code standards.
Report Facts
Certified beds: 102
Census: 63
Inspection Report
Complaint Investigation
Census: 74
Capacity: 74
Deficiencies: 0
Date: Aug 31, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00412669.
Complaint Details
Complaint IN00412669 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
Medicare census: 10
Medicaid census: 60
Other payor census: 4
Inspection Report
Complaint Investigation
Census: 73
Capacity: 73
Deficiencies: 0
Date: Jun 15, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00408293.
Complaint Details
Complaint IN00408293 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 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census SNF/NF beds: 73
Total census: 73
Medicare census: 6
Medicaid census: 57
Other payor census: 10
Inspection Report
Complaint Investigation
Census: 83
Capacity: 83
Deficiencies: 0
Date: Dec 16, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00388884.
Complaint Details
Complaint IN00388884 was investigated and found unsubstantiated due to lack of evidence.
Findings
The complaint IN00388884 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare residents: 17
Medicaid residents: 50
Other payor residents: 16
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Oct 27, 2022
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey completed on August 4, 2022.
Findings
Cloverleaf of Knightsville 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
Follow-Up
Census: 80
Capacity: 102
Deficiencies: 0
Date: Oct 6, 2022
Visit Reason
A Post Survey Revisit (PSR) to the Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey conducted on 08/30/22 was conducted to verify compliance with federal regulations.
Findings
At this PSR survey, Cloverleaf of Knightsville was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements for Medicare and Medicaid Participating Providers and Suppliers. The facility was fully sprinklered except for the detached laundry building and had appropriate fire alarm systems in place.
Report Facts
Certified beds: 102
Census: 80
Inspection Report
Life Safety
Census: 77
Capacity: 102
Deficiencies: 11
Date: Aug 30, 2022
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal regulations.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code requirements including generator testing documentation, battery operated smoke alarm maintenance, interior wall finish flame spread rating, fire alarm detector sensitivity, sprinkler head corrosion, smoke barrier door closure, fire drill documentation, fire door inspection, rolling fire door maintenance, generator load testing and transfer time, and improper use of power strips in patient care vicinity.
Deficiencies (11)
Failed to maintain complete written record of monthly generator load testing for 1 of 1 generator during past 12 months.
Failed to ensure transfer time to alternate power source on monthly load test supplied service within 10 seconds for 1 of 1 emergency generator during past 12 months.
Failed to ensure documentation for preventative maintenance of battery operated smoke alarms in 15 of 50 resident rooms was complete.
Failed to ensure 1 of 5 smoke compartments was provided with complete interior finish with flame spread rating of Class A or B.
Failed to ensure 4 of 57 smoke detectors that failed sensitivity test were replaced or repaired.
Failed to ensure sprinkler heads covered with corrosion in 2 of 6 smoke compartments were replaced.
Failed to ensure 1 of 5 sets of smoke barrier doors would close to form a smoke resistant barrier.
Failed to ensure 6 of 12 fire drills performed during past 12 months were listed as correct designated shift time frame.
Failed to ensure annual inspection and testing of 1 of 1 oxygen room fire door assembly was completed.
Failed to maintain 1 of 1 rolling fire door in accordance with NFPA 80; rolling fire door not working properly.
Failed to ensure power strip was not used as substitute for fixed wiring in 1 of 1 staff conference room.
Report Facts
Certified beds: 102
Census: 77
Deficiencies cited: 12
Fire drills: 12
Fire drills with incorrect shift designation: 6
Smoke detectors tested: 57
Smoke detectors failed sensitivity test: 4
Inspection Report
Annual Inspection
Census: 84
Capacity: 84
Deficiencies: 9
Date: Aug 4, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted over July 28, 29, August 1, 2, 3, and 4, 2022.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' dignity during dining assistance, inaccurate care plans for dialysis access, lack of restorative nursing program services, significant unaddressed weight loss in a resident, missing physician rationale for psychotropic medication dose reductions, improper medication storage labeling, sanitary violations in kitchen staff attire and hand hygiene, and inadequate room size for licensed bed capacity.
Deficiencies (9)
Failed to ensure residents' dignity while dining was provided in a timely manner and staff did not sanitize hands before assisting residents with eating.
Failed to ensure a resident's dialysis access site was accurately documented on the care plan.
Failed to ensure a restorative nursing program was in place to provide range of motion exercises to a resident with contracture.
Failed to ensure a resident did not experience significant weight loss without physician and responsible party notification and appropriate interventions.
Failed to ensure physician documentation of rationale for declination of gradual dose reductions for psychotropic medications for 3 residents.
Failed to ensure an opened multi-dose vial of tuberculin protein derivative solution had documentation of the date opened.
Failed to ensure staff wore beard or hair restraints in the kitchen and failed to perform hand hygiene prior to assisting residents or pureeing food.
Failed to provide at least 80 square feet per resident in multiple occupancy resident rooms (Rooms 14 and 15).
Failed to ensure staff members did not work with expired certifications (Qualified Medication Aide certification expired).
Report Facts
Census: 84
Total Capacity: 84
Weight loss percentage: 12.1
Weight loss percentage: 5
Room 14 square footage per resident: 75.4
Room 15 square footage per resident: 75.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| QMA 17 | Qualified Medication Aide | Worked with expired certification and passed medications |
| CNA 6 | Certified Nursing Assistant | Observed failing to sanitize hands before assisting resident with eating |
| Dietary Aide 5 | Dietary Aide | Observed wearing hairnet but no beard cover and improper mask use in kitchen |
| Cook 18 | Cook | Observed failing to sanitize hands before pureeing food |
| Director of Nursing | Director of Nursing | Provided policy and interview responses regarding deficiencies |
| Administrator | Administrator | Provided policy and interview responses regarding deficiencies |
| Human Resources Director | Human Resources Director | Observed in kitchen without hair restraint |
Report
December 18, 2024
Report
November 3, 2023
Report
August 4, 2022
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