Inspection Report Summary
The most recent inspection on April 3, 2025, found no deficiencies related to the complaint investigated. Prior inspections showed a pattern of deficiencies mostly involving resident care issues such as dignity and timely assistance, medication administration and documentation, and maintaining a safe, sanitary environment. Several complaints were substantiated with citations related to resident rights, discharge planning, medication notification, and infection control, but many complaint investigations were found to be unsubstantiated. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s inspection history shows some improvement in recent months, with the latest inspections indicating compliance following earlier citations.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
19.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
364% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
100% occupied
Based on a April 2025 inspection.
Occupancy over time
Inspection Report
Deficiencies: 1
Date: Nov 13, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards of quality, specifically regarding adherence to physician's orders for resident care.
Findings
The facility failed to follow physician's orders for one resident with a pressure ulcer, resulting in missed antibiotic administration and incomplete wound treatments as ordered. Documentation in medication administration records and treatment records was incomplete or missing.
Deficiencies (1)
Failure to follow physician's orders for antibiotic administration and wound treatment for a resident with a pressure ulcer.
Report Facts
Residents reviewed for quality of care: 4
Antibiotic doses missed: 3
Wound treatment missed shifts: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide 3 | Certified Nurse Aide | Interviewed regarding turning and repositioning of Resident C |
| DON | Director of Nursing | Interviewed confirming Resident C was to be turned every 2 hours and treatments should have been completed |
| Assistant Administrator | Assistant Administrator | Interviewed regarding facility policy on following physician's orders |
Inspection Report
Routine
Deficiencies: 1
Date: Sep 8, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with care standards, specifically focusing on the provision of activities of daily living (ADL) assistance such as showering for residents dependent on staff.
Findings
The facility failed to ensure that residents dependent on staff for ADLs were showered as scheduled or per their preferences, with multiple residents not receiving showers or complete bed baths on numerous scheduled days in August 2025. Observations and record reviews revealed inconsistent bathing care, despite care plans and shower schedules indicating otherwise.
Deficiencies (1)
Failure to provide scheduled showers or complete bed baths to residents dependent on staff for ADLs, affecting 7 of 8 residents reviewed.
Report Facts
Scheduled shower days missed: 3
Scheduled shower days missed: 2
Scheduled shower days missed: 6
Scheduled shower days missed: 7
Scheduled shower days missed: 3
Scheduled shower days missed: 2
Scheduled shower days missed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Indicated shower sheets were part of the clinical record and staff sometimes forgot to transfer information to the POC Response. | |
| Assistant Director of Nursing (ADON) | Indicated residents received at least two showers per week or more if preferred; staff should reattempt showers if refused. | |
| Administrator | Provided Resident Rights policy indicating residents' rights to dignity, respect, and participation in scheduling and activities. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Sep 8, 2025
Visit Reason
The inspection was conducted based on complaints regarding failure to implement a resident's comprehensive care plan for fall prevention, inadequate assistance with activities of daily living (ADLs) including showering, and failure to address medication side effects for mood and behavior management.
Complaint Details
The visit was complaint-related, connected to Intake 2592689, involving concerns about care plan implementation, ADL assistance, and behavioral health medication management.
Findings
The facility failed to ensure a resident's care plan interventions for fall prevention were implemented, seven residents did not receive showers as scheduled according to their care plans, and one resident's medication side effects were not properly addressed following a medication change.
Deficiencies (3)
Failed to ensure a resident's comprehensive care plan interventions were implemented for fall prevention; Dycem was not in use in the wheelchair as ordered.
Failed to provide care and assistance to perform activities of daily living; seven residents did not receive showers as scheduled or per their preferences.
Failed to ensure a resident's medication side effects were addressed after a medication change for mood and behaviors; increased tearfulness was noted but not reported to psychiatric nurse practitioner.
Report Facts
Residents affected: 1
Residents affected: 7
Residents affected: 1
Dates resident did not receive showers: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) 4 | Indicated resident was care planned for Dycem pad but it was not in wheelchair | |
| Director of Nursing (DON) | Indicated shower sheets were part of clinical record and staff sometimes forgot to transfer information | |
| Assistant Director of Nursing (ADON) | Indicated residents should get at least two showers per week or more per preference and side effects would be addressed immediately | |
| Administrator | Provided current policies on care planning, resident rights, and psychotropic management |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 116
Deficiencies: 0
Date: Apr 3, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00454298.
Complaint Details
Complaint IN00454298 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: 116
Total Capacity: 116
Medicare Census: 2
Medicaid Census: 97
Other Payor Census: 17
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 18, 2025
Visit Reason
Paper compliance review related to the Investigation of multiple complaints (IN00452997, IN00453214, IN00453166, IN00453005, IN00453237, IN00452975, IN00453317) and an unrelated deficiency survey completed on February 13, 2025.
Complaint Details
The visit was related to the investigation of multiple complaints as listed; compliance was found based on paper review.
Findings
Columbia Healthcare Center 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 of the investigations and the unrelated deficiency survey.
Inspection Report
Routine
Deficiencies: 5
Date: Feb 13, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with safety, sanitation, and housekeeping standards over a two-day survey period.
Findings
The facility failed to maintain a safe and sanitary environment, with dust and dirt buildup in multiple hallways, unclean linen closets, improperly stored urinals, unclean shower rooms, and pervasive urine odors throughout the facility.
Deficiencies (5)
Resident room halls had a buildup of dust and dirt on multiple units and hallways.
Linen closets were not clean, with debris and a safety razor found on the floor.
Two shower rooms were unclean or not maintained, with cracked tiles, discoloration, and debris.
Urinals were not stored properly in a shared restroom, being uncovered and placed on the bathroom floor.
Strong urine odors were present throughout the facility, including hallways and lobby.
Report Facts
Dates of facility concern/grievance forms: 2
Survey days: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper 4 | Housekeeper | Interviewed regarding cleaning practices and observed cleaning deficiencies. |
| Resident D | Resident | Reported issues with urinal storage in shared bathroom. |
| CNA 9 | Certified Nursing Assistant | Interviewed regarding proper storage of resident urinals. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 12, 2025
Visit Reason
The inspection was conducted as a paper compliance review of the Investigation of Complaint IN00449174 completed on December 31, 2024.
Complaint Details
Complaint IN00449174 was investigated and found to be corrected.
Findings
Columbia Healthcare Center 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 complaint investigation.
Inspection Report
Complaint Investigation
Census: 117
Capacity: 117
Deficiencies: 1
Date: Feb 12, 2025
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00452997, IN00453214, IN00453166, IN00453005, IN00453237, IN00452975, IN00453317) regarding the facility.
Complaint Details
The investigation covered seven complaints (IN00452997, IN00453214, IN00453166, IN00453005, IN00453237, IN00452975, IN00453317). No deficiencies related to the allegations in these complaints were cited.
Findings
No deficiencies were found related to the specific complaints investigated; however, an unrelated deficiency was cited regarding the facility's failure to maintain a safe, sanitary, and comfortable environment, including dust and dirt buildup, unclean linen closets and shower rooms, improper storage of urinals, and persistent urine odors throughout the facility.
Deficiencies (1)
Facility failed to ensure a safe, sanitary environment with dust and dirt buildup on multiple halls, unclean linen closets and shower rooms, improper storage of urinals, and urine odors present throughout the survey.
Report Facts
Census: 117
Total Capacity: 117
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 98
Census Payor Type - Other: 18
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 31, 2024
Visit Reason
The inspection was conducted in response to complaint IN00449174 regarding failure to follow nebulizer treatment policies and incomplete medication administration documentation.
Complaint Details
This citation relates to complaint IN00449174.
Findings
The facility failed to follow nebulizer treatment policies for one resident, resulting in a critical incident where the resident was found without respirations or pulse during treatment. Additionally, documentation for insulin administration and nebulizer treatments was incomplete or missing for multiple residents.
Deficiencies (2)
Failure to follow nebulizer policy for one resident, including lack of assessment before treatment and staff not staying at bedside during treatment.
Incomplete and inaccurate documentation of insulin administration and nebulizer treatments for four residents.
Report Facts
Residents affected: 1
Residents affected: 4
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 5 | Registered Nurse | Interviewed regarding the incident with Resident D during nebulizer treatment |
| Director of Nursing | Director of Nursing (DON) | Initiated CPR for Resident D and provided information on assessment and documentation policies |
| Administrator | Administrator | Provided information about nebulizer treatment policy and documentation |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 111
Deficiencies: 2
Date: Dec 30, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00449174 related to federal/state deficiencies cited at F695 and F842.
Complaint Details
Complaint IN00449174 was substantiated with federal/state deficiencies cited at F695 (respiratory/tracheostomy care and suctioning) and F842 (resident records - identifiable information).
Findings
The facility failed to follow nebulizer treatment policy for one resident, resulting in a resident found without respirations or pulse during treatment. Additionally, the facility failed to ensure complete and accurate documentation for insulin administration and nebulizer treatments for multiple residents.
Deficiencies (2)
Failed to follow nebulizer policy for 1 of 1 resident reviewed; resident was not assessed prior to treatment and staff did not stay at bedside during nebulizer treatment, resulting in resident found without respirations or pulse.
Failed to ensure documentation was complete and accurate for 4 of 8 resident records reviewed; insulin administration and nebulizer treatments were not marked as complete on the Medication Administration Record.
Report Facts
Census: 111
Total Capacity: 111
Survey Dates: December 30 and 31, 2024
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Beran | Laboratory Director or Provider/Supplier Representative | Signed the report |
| RN 5 | Registered Nurse | Named in nebulizer treatment deficiency and interview regarding resident found unresponsive |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding nebulizer treatment assessments and documentation |
| Administrator | Facility Administrator | Interviewed regarding nebulizer treatment policy and staffing |
Inspection Report
Re-Inspection
Census: 114
Capacity: 114
Deficiencies: 0
Date: Dec 12, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on November 1, 2024, conducted in conjunction with the Investigation of Complaint IN00447581.
Complaint Details
Investigation of Complaint IN00447581 was conducted in conjunction with this visit.
Findings
Columbia Healthcare Center 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: 114
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 96
Census Payor Type - Other: 17
Inspection Report
Complaint Investigation
Census: 114
Capacity: 114
Deficiencies: 0
Date: Dec 12, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00447581 and was conducted in conjunction with the Post Survey Revisit to the Recertification and State Licensure Survey completed on November 1, 2024.
Complaint Details
Complaint IN00447581 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. Columbia Healthcare Center 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: 114
Total Capacity: 114
Payor Type Census: 1
Payor Type Census: 96
Payor Type Census: 17
Inspection Report
Life Safety
Census: 109
Capacity: 171
Deficiencies: 0
Date: Nov 20, 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 and Life Safety Code requirements for Medicare and Medicaid Participating Providers and Suppliers. The facility is a two-story, fully sprinklered building with a fire alarm system and smoke detectors in corridors and resident rooms, except for one detached wood shed used for storage.
Report Facts
Facility capacity: 171
Census: 109
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Nov 1, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to notify physicians of abnormal blood glucose levels, inadequate care planning for urinary tract infections, pressure ulcer care, pain management, medication administration errors, infection control, and documentation deficiencies.
Complaint Details
The visit was complaint-related due to allegations of failure to notify physicians of abnormal blood glucose levels, inadequate care planning, medication errors, infection control breaches, and documentation issues. Substantiation status is not explicitly stated.
Findings
The facility failed to notify physicians timely of critical blood glucose levels, did not implement appropriate care plans for residents with recurrent UTIs, failed to provide effective treatment for elevated blood glucose resulting in hospitalization, did not monitor skin properly to prevent pressure ulcers, failed to administer pain management appropriately, had medication administration errors including failure to prime insulin pens, had unlabeled and expired medications in medication carts, and failed to maintain complete and accurate medical records. Infection control practices were also inadequate, including failure to use enhanced barrier precautions and proper hand hygiene.
Deficiencies (9)
Failed to notify physician of blood glucose levels outside parameters for 1 of 2 residents reviewed for insulin administration (Resident 59).
Failed to ensure a resident had a care plan implemented related to frequent urinary tract infections with multidrug resistant organisms (Resident 85).
Failed to ensure effective services to treat elevated blood glucose levels in accordance with physician and NP orders, resulting in emergent hospital transport for diabetic ketoacidosis (Resident 59).
Failed to ensure a resident did not develop an avoidable pressure ulcer by monitoring skin under a knee immobilizer (Resident 89).
Failed to administer non-pharmacological or pharmacological pain interventions prior to wound care (Resident 104).
Failed to ensure medications were administered according to manufacturer and professional standards; insulin pens were not primed prior to administration (Resident 89).
Failed to ensure medications and biologicals were properly dated, labeled, and not expired in medication and treatment carts.
Failed to ensure documentation was complete and accurate for insulin use, including lack of documentation of physician notification and insulin administration (Resident 59).
Failed to implement infection prevention and control program including failure to use enhanced barrier precautions during wound care and failure to sanitize hands and change gloves between soiled and clean tasks (Residents 64, 85, and 86).
Report Facts
Blood glucose level: 490
Blood glucose level: 526
Blood glucose level: 548
Blood glucose level: 582
Blood glucose level: 742
Pressure ulcer size: 4.8
Pressure ulcer size: 1.3
Pressure ulcer size: 0.1
Pressure ulcer size: 8.8
Pressure ulcer size: 8
Pressure ulcer size: 1.3
Medication error rate: 7.69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 6 | Licensed Practical Nurse | Named in failure to notify physician of critical blood glucose level and lack of documentation of insulin administration |
| Registered Nurse 15 | Registered Nurse | Administered insulin lispro without proper documentation |
| Nurse Practitioner | Nurse Practitioner | Involved in communication failures regarding elevated blood glucose levels |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan and documentation deficiencies |
| Administrator | Administrator | Provided policies and interviewed regarding documentation and communication practices |
| Licensed Practical Nurse 13 | Licensed Practical Nurse | Observed medication administration error for insulin priming |
| Registered Nurse 12 | Registered Nurse | Observed failing to provide pain medication prior to wound care |
| Certified Nurses Aide 3 | Certified Nurses Aide | Observed failing to sanitize hands and changing gloves properly during incontinence care |
| Certified Nurses Aide 7 | Certified Nurses Aide | Observed failing to change gloves and sanitize hands during incontinence care |
| Qualified Medication Aide 5 | Qualified Medication Aide | Observed failing to sanitize hands during incontinence care |
| Licensed Practical Nurse 4 | Licensed Practical Nurse | Observed failing to wear gown during wound care |
Inspection Report
Annual Inspection
Census: 111
Capacity: 111
Deficiencies: 9
Date: Nov 1, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00440519, IN00440582, IN00441713, and IN00445070.
Complaint Details
This visit included the investigation of complaints IN00440519, IN00440582, IN00441713, and IN00445070. No deficiencies related to the allegations were cited for these complaints.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of abnormal blood glucose levels, incomplete care plans for residents with frequent UTIs, inadequate treatment of elevated blood glucose resulting in hospitalization, failure to monitor skin under immobilizers leading to pressure ulcers, inadequate pain management prior to wound care, medication administration errors including failure to prime insulin pens, improper medication storage and labeling, incomplete documentation of insulin use, and lapses in infection prevention and control practices.
Deficiencies (9)
Failed to notify physician of blood glucose levels outside parameters for 1 of 2 residents reviewed for insulin administration.
Failed to ensure a resident had a care plan implemented related to frequent urinary tract infections with multidrug resistant organisms.
Failed to ensure effective services to treat elevated blood glucose levels were provided in accordance with physician orders, resulting in hospitalization for diabetic ketoacidosis.
Failed to monitor skin for pressure ulcers under a knee immobilizer for 1 of 3 residents reviewed.
Failed to administer pain interventions prior to wound care for 1 of 2 residents observed.
Failed to prime insulin injection pens prior to administration for 1 of 5 residents observed during medication pass.
Failed to ensure medications were properly dated, labeled, and not expired in multiple medication and treatment carts.
Failed to ensure documentation was complete and accurate for insulin use for 1 of 2 residents reviewed.
Failed to ensure infection control practices including hand hygiene, glove changes, and use of enhanced barrier precautions during wound and incontinence care.
Report Facts
Survey dates: 7
Census: 111
Total capacity: 111
Medication administration opportunities: 26
Blood glucose levels: 600
Pressure ulcer size: 8.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 6 | LPN | Named in failure to notify physician of critical blood glucose level and insulin administration documentation. |
| Licensed Practical Nurse 13 | LPN | Named in medication administration error for failure to prime insulin pens. |
| Registered Nurse 12 | RN | Observed administering wound care without adequate pain management. |
| Registered Nurse 15 | RN | Named in incomplete documentation of insulin administration. |
| Director of Nursing | DON | Provided interviews regarding insulin administration, documentation, and care plan expectations. |
| Nurse Practitioner | NP | Interviewed regarding communication and orders for elevated blood glucose levels. |
| Certified Nurses Aide 3 | CNA | Observed failing to change gloves and sanitize hands during incontinence care. |
| Certified Nurses Aide 7 | CNA | Observed failing to change gloves and sanitize hands during incontinence care. |
| Qualified Medication Aide 5 | QMA | Observed failing to change gloves and sanitize hands during incontinence care. |
| Licensed Practical Nurse 4 | LPN | Observed performing wound care without wearing gown as required by enhanced barrier precautions. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 14, 2024
Visit Reason
Paper compliance review related to the Investigation of Complaints IN00432722 survey ending on May 9, 2024.
Complaint Details
Investigation of Complaints IN00432722 survey was reviewed for paper compliance.
Findings
Columbia Health Care Center 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 Investigation of Complaints IN00432722 survey.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 9, 2024
Visit Reason
The inspection was conducted due to a complaint (IN00432722) regarding the facility's failure to properly implement the discharge process for a resident who lacked the ability to care for herself and was discharged without proper arrangements or documentation.
Complaint Details
This citation relates to Complaint IN00432722. The complaint involved failure to properly discharge Resident B, who left the facility AMA without proper documentation or education, and the facility did not notify Adult Protective Services despite concerns for the resident's safety.
Findings
The facility failed to ensure the resident's discharge process was properly implemented, as Resident B was discharged home without arranged home health services and without completing required discharge documentation. The resident left against medical advice without proper education or AMA observation documentation, and the facility did not contact Adult Protective Services despite concerns.
Deficiencies (1)
Failure to implement the resident's discharge process according to facility policy, including incomplete discharge documentation and lack of arranged home health services.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SS 4 | Social Service | Interviewed regarding discharge process and documentation for Resident B. |
| Administrator | Interviewed regarding Resident B's discharge and hospice evaluation. |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 116
Deficiencies: 1
Date: May 8, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00434200, IN00433145, and IN00432722. Deficiencies related to complaint IN00432722 were cited at F660, while no deficiencies were cited for the other complaints.
Complaint Details
Complaint IN00432722 was substantiated with deficiencies cited related to discharge planning. Complaints IN00433145 and IN00434200 had no deficiencies related to the allegations.
Findings
The facility failed to ensure the proper implementation of the discharge planning process for one resident (Resident B) who was discharged home without arrangements for home health services and without proper documentation according to facility policy. Resident B left the facility against medical advice without appropriate education or documentation, and the facility did not contact Adult Protective Services despite concerns about the resident's safety.
Deficiencies (1)
Failure to implement the resident's discharge process for 1 of 3 residents reviewed, including discharging a resident home without arranging home health services and without proper documentation.
Report Facts
Census SNF/NF beds: 116
Census total residents: 116
Medicare residents: 3
Medicaid residents: 91
Other payor residents: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Beran | Administrator | Administrator interviewed regarding Resident B's discharge and facility policies |
| SS 4 | Social Service | Social Service staff interviewed regarding discharge process and Resident B's case |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 26, 2024
Visit Reason
The inspection was conducted in response to complaints regarding delayed assistance with care, lack of respect and dignity towards residents, and failure to timely respond to call lights.
Complaint Details
This citation relates to Complaint IN00429431. Complaints included residents waiting over two hours for care, call lights not being answered timely, disrespectful staff behavior, and failure to provide requested items such as ice packs and pillows. Department head reviews and actions included written warnings and staff education.
Findings
The facility failed to ensure dignity and timely care for residents, with documented instances of residents waiting over two hours for assistance, staff turning off call lights without providing care, and residents being spoken to disrespectfully. Several grievances were reviewed, confirming these issues, and staff education was completed to address call light response times.
Deficiencies (1)
Failed to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights, including timely assistance with care and respectful treatment.
Report Facts
Residents affected: 3
Wait time: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Indicated staff members can answer call lights and should notify appropriate staff if unable to provide care |
| Administrator | Administrator | Provided information on complaint handling and call light monitoring policy |
Inspection Report
Complaint Investigation
Census: 117
Capacity: 117
Deficiencies: 1
Date: Mar 26, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00429431 regarding allegations of deficient care related to resident rights and dignity.
Complaint Details
Complaint IN00429431 was substantiated with federal/state deficiencies cited at F550 related to resident rights and dignity. The complaint included reports of residents waiting hours for care, call lights being turned off without care, and disrespectful staff behavior.
Findings
The facility failed to ensure dignity and timely care for 3 of 3 residents reviewed. Residents were not assisted promptly, call lights were ignored or turned off without providing care, and residents were treated without respect.
Deficiencies (1)
Failed to ensure dignity and timely assistance for residents, including ignoring call lights and disrespectful treatment.
Report Facts
Census: 117
Total Capacity: 117
Residents affected: 3
Survey dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Beran | Administrator | Signed the report and provided statements regarding complaint handling |
| LPN 1 | Licensed Practical Nurse | Provided information on call light response procedures |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 26, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaints IN00429431 survey ending on March 26, 2024.
Complaint Details
Investigation of Complaints IN00429431; paper compliance review; facility found in compliance.
Findings
Columbia Health Care Center 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 Investigation of Complaints IN00429431 survey.
Inspection Report
Complaint Investigation
Census: 115
Capacity: 115
Deficiencies: 0
Date: Feb 8, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00427810.
Complaint Details
Complaint IN00427810 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 SNF/NF: 115
Total Capacity: 115
Medicare Census: 1
Medicaid Census: 92
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 29, 2023
Visit Reason
Paper compliance review to the Investigation of Complaints IN00420692, IN00422524, and IN00422380 survey ending on November 28, 2023.
Complaint Details
Investigation of Complaints IN00420692, IN00422524, and IN00422380; facility found in compliance.
Findings
Columbia Health Care Center 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 investigations.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 28, 2023
Visit Reason
The inspection was conducted in response to complaints regarding the facility's failure to notify physicians about unavailable medications and failure to provide adequate assistance with activities of daily living, specifically bathing, to residents.
Complaint Details
This citation relates to Complaint IN00422524, IN00420692, IN00422380. The complaints involved failure to notify physicians about medication availability and failure to provide bathing care to residents.
Findings
The facility failed to notify the physician when ordered medications were unavailable or not administered to Resident B, and failed to provide bathing assistance to Resident D as required. Documentation issues and lack of specific policies for notifying physicians and bathing care were noted.
Deficiencies (2)
Facility failed to notify the physician of medications not available or given as ordered for Resident B.
Facility failed to provide activities of daily living care, specifically bathing, to Resident D.
Report Facts
Medication doses not available: 26
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Provided information about medication delivery and facility processes regarding medication availability and prior authorization. | |
| Administrator in Training | Provided pharmacy services and procedures document and resident care/ADL document; indicated lack of specific policies for medication notification and bathing. | |
| CNA 1 | Certified Nursing Assistant | Provided information about bathing documentation and procedures for resident refusals. |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 114
Deficiencies: 2
Date: Nov 28, 2023
Visit Reason
This visit was conducted for the investigation of three complaints (IN00420692, IN00422524, and IN00422380) related to allegations of deficiencies in medication notification and ADL care.
Complaint Details
The investigation was triggered by complaints IN00420692, IN00422524, and IN00422380. Deficiencies related to these complaints were substantiated with citations at F580 (Notification of Changes) and F677 (ADL Care Provided for Dependent Residents).
Findings
The facility failed to notify the physician of unavailable or not administered medications for Resident B and failed to provide bathing care to Resident D. Deficiencies were cited related to notification of changes and ADL care for dependent residents.
Deficiencies (2)
Failed to notify the physician of medications not available or given as ordered for Resident B.
Failed to provide activities of daily living (ADL) care, specifically bathing, to Resident D.
Report Facts
Census: 114
Total Capacity: 114
Medicare Census: 2
Medicaid Census: 94
Other Payor Census: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert O'Niones | Health Facility Administrator/ED | Signed the report |
| Director of Nursing (DON) | Interviewed regarding medication administration and bathing care | |
| Administrator in Training | Provided pharmacy services document and interview about policies | |
| CNA 1 | Interviewed regarding bathing procedures and documentation |
Inspection Report
Re-Inspection
Census: 121
Capacity: 171
Deficiencies: 0
Date: Nov 6, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 09/18/23 was performed to verify compliance with life safety and state licensure requirements.
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. The facility was fully sprinklered except for one detached wood shed used for storage.
Report Facts
Facility capacity: 171
Census: 121
Inspection Report
Complaint Investigation
Census: 117
Capacity: 117
Deficiencies: 0
Date: Oct 10, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00415871.
Complaint Details
Investigation of Complaint IN00415871 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00415871 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 3
Medicaid census: 97
Other payor census: 17
Inspection Report
Renewal
Deficiencies: 0
Date: Oct 3, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey ending on August 14, 2023.
Findings
Columbia Health Care Center was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Recertification and State Licensure Survey.
Inspection Report
Life Safety
Census: 121
Capacity: 171
Deficiencies: 9
Date: Sep 18, 2023
Visit Reason
Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the 2012 NFPA 101 Life Safety Code. Deficiencies included lint accumulation in laundry dryer enclosure, fire rating tags obscured by paint on stairway doors, missing self-closing devices on hazardous area doors, cooktop not deactivated when not in use, fire alarm system trouble light, incomplete sprinkler coverage, sprinkler heads covered with foreign substances, combustible decorations without fire retardant treatment, and missing annual inspection documentation for stairway and laundry chute fire door assemblies.
Deficiencies (9)
Laundry area dryer room enclosure was substantially covered with dryer lint.
One stairway door's fire rating tag was covered with paint.
One hazardous area door (Central Supply Room) lacked a self-closing device.
Cooktop stove/oven in The Cottage was not shut off at the switch when not in use.
Fire alarm control panel had a 'Supervisory' yellow trouble light indicating dialer trouble.
Sprinkler system failed to provide complete coverage in a storage area behind walk-in cooler.
Sprinkler heads in maintenance shop and laundry dryer enclosure were covered with foreign substances.
Combustible decorations (picture collage and coloring pictures) in 2300 Unit corridors lacked fire retardant treatment.
Annual inspection and testing documentation missing for 15 stairway fire door assemblies and 3 laundry chute fire door assemblies.
Report Facts
Deficiency count: 9
Facility capacity: 171
Census: 121
Storage area size: 10
Storage area size: 3
Picture collage size: 12
Picture collage size: 3
Coloring picture size: 10
Coloring picture size: 2
Number of stairway fire door assemblies: 15
Number of laundry chute fire door assemblies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert O'Niones | Health Facility Administrator/ED | Signed the report |
| Maintenance Supervisor | Interviewed and involved in observations and findings | |
| Maintenance Assistant | Interviewed and involved in observations and findings | |
| Senior Maintenance Supervisor | Interviewed and involved in observations and findings | |
| Administrator-in-Training | Present during exit conference and findings review |
Inspection Report
Annual Inspection
Census: 116
Capacity: 116
Deficiencies: 14
Date: Aug 14, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from August 7 to August 14, 2023.
Findings
The facility was found deficient in multiple areas including reasonable accommodations for residents, ADL care for dependent residents, fall prevention, catheter care, urostomy care, respiratory care, medication administration, medication storage, dietary support and food safety, meal/snack provision, and environmental conditions on the dementia unit.
Deficiencies (14)
Failed to accommodate residents with call lights within reach for 4 of 4 residents reviewed.
Failed to ensure dependent residents received necessary services to maintain grooming and personal hygiene for 3 of 4 residents reviewed.
Failed to provide adequate supervision and assistance devices to prevent falls for 2 of 3 residents reviewed.
Failed to ensure residents with catheters received appropriate treatment to prevent urinary tract infections; catheter bag observed on floor.
Failed to provide urostomy care consistent with professional standards for 1 resident with a urostomy.
Failed to provide respiratory care consistent with professional standards for 1 resident requiring oxygen therapy.
Failed to post accurate nurse staffing data including total number and actual hours worked for licensed and unlicensed nursing staff for 6 of 6 days reviewed.
Medication error rate exceeded 5% with 3 errors observed during 35 medication administration opportunities for 1 resident.
Failed to properly label and store drugs and biologicals; loose pills and unlabeled medications found in multiple medication and treatment carts.
Failed to employ staff with appropriate competencies and skills to prepare pureed diets according to dietician's nutritional requirements.
Failed to provide food and drink that are palatable, attractive, and at a safe and appetizing temperature; residents complained of cold food and poor quality.
Failed to provide nourishing bedtime snacks for 5 residents and failed to provide meals at times comparable to normal mealtimes in the community.
Failed to store, prepare, distribute, and serve food in accordance with professional food service safety standards; issues with cleanliness, expired and unlabeled food items, and damaged kitchen infrastructure.
Failed to maintain a safe, clean, comfortable, and homelike environment on the locked dementia unit; multiple maintenance and cleanliness issues observed.
Report Facts
Survey dates: August 7-14, 2023
Census: 116
Total capacity: 116
Medication error rate: 8.57
Fall count: 13
Audit frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| QMA 10 | Qualified Medication Aide | Named in medication administration error finding |
| LPN 5 | Licensed Practical Nurse | Named in urostomy care deficiency and medication storage |
| LPN 11 | Licensed Practical Nurse | Named as wound nurse observing urostomy care |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including falls, urostomy care, oxygen therapy, and medication policies |
| Dietary Manager | Dietary Manager | Interviewed regarding food service deficiencies and meal/snack provision |
| Assistant Dietary Manager | Assistant Dietary Manager | Interviewed regarding kitchen sanitation and food storage |
| RN 12 | Registered Nurse | Observed medication administration and interviewed about insulin storage |
| LPN 14 | Licensed Practical Nurse | Interviewed regarding dementia unit bathroom and bathtub conditions |
Inspection Report
Annual Inspection
Deficiencies: 13
Date: Aug 14, 2023
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements for nursing home care and facility operations.
Findings
The facility was found deficient in multiple areas including failure to accommodate residents' needs for call lights, inadequate assistance with activities of daily living, insufficient supervision to prevent falls, improper catheter care, unsafe medication storage, poor food service quality and timing, and failure to maintain a safe and clean environment in the dementia unit.
Deficiencies (13)
Failed to accommodate residents with the use of call lights to summon help for 4 of 4 residents reviewed.
Failed to ensure residents received necessary services to maintain grooming and personal hygiene for 3 of 4 residents reviewed.
Failed to provide adequate supervision and interventions to reduce fall risk for 2 of 3 residents reviewed for falls with major injuries.
Failed to ensure appropriate catheter care and prevent urinary tract infections; catheter bag observed on floor.
Failed to provide urostomy care consistent with professional standards and care plan for 1 resident with a urostomy.
Failed to provide safe and appropriate respiratory care; oxygen tubing not dated and portable oxygen tank empty.
Failed to post accurate total number of staff and actual hours worked for licensed and unlicensed nursing staff for 6 of 6 days.
Failed to provide proper storage of medications; loose pills and unlabeled biologicals/medications found in medication and treatment carts.
Failed to employ staff with appropriate competencies and skills to prepare pureed diets for residents.
Failed to provide food and drink that are palatable, attractive, and at safe and appetizing temperatures; residents complained of cold and poor quality food.
Failed to provide nourishing bedtime snacks for residents and failed to provide meals at times comparable to normal mealtimes.
Failed to store, prepare, distribute, and serve food in accordance with professional standards; multiple food safety violations observed including expired and unlabeled food items.
Failed to maintain a safe, clean, comfortable, and homelike environment in the locked dementia unit; multiple maintenance issues observed.
Report Facts
Medication error rate: 8.57
Resident falls: 13
Residents affected: 4
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 6
Residents affected: 4
Residents affected: 8
Residents affected: 5
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| QMA 9 | Qualified Medication Aide | Assisted Resident 26 during toileting and cleaning bowel movement. |
| CNA 6 | Certified Nursing Assistant | Assisted Resident 26 during toileting and cleaning bowel movement. |
| Director of Nursing | Director of Nursing | Provided information on fall interventions, nurse staffing, medication reorder policy, and urostomy care. |
| LPN 5 | Licensed Practical Nurse | Provided urostomy care for Resident 72. |
| LPN 11 | Licensed Practical Nurse | Observed urostomy care for Resident 72. |
| QMA 10 | Qualified Medication Aide | Administered medications to Resident 1 and reported medication availability issues. |
| Registered Nurse 12 | Registered Nurse | Changed dressing for Resident 49's catheter and explained catheter bag handling. |
| Dietary Manager | Dietary Manager | Oversaw pureed food preparation and discussed meal/snack policies. |
| Kitchen Staff 17 | Kitchen Staff | Prepared pureed food for residents. |
| Assistant Dietary Manager | Assistant Dietary Manager | Discussed spice labeling and food storage practices. |
| LPN 14 | Licensed Practical Nurse | Provided information about bathtub and bathroom conditions on dementia unit. |
Inspection Report
Complaint Investigation
Census: 115
Capacity: 115
Deficiencies: 0
Date: May 4, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00399271.
Complaint Details
Complaint IN00399271 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 to be in compliance with applicable regulations.
Report Facts
Census SNF/NF: 115
Census Medicare: 5
Census Medicaid: 101
Census Other: 9
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 15, 2022
Visit Reason
Paper compliance review to the Investigation of Complaint IN00393930 survey ending on December 15, 2022.
Complaint Details
Investigation of Complaint IN00393930; facility found in compliance.
Findings
Columbia Health Care Center was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 126
Capacity: 126
Deficiencies: 1
Date: Dec 14, 2022
Visit Reason
This visit was conducted for the investigation of three complaints (IN00393930, IN00391496, and IN00378261) concerning resident care and rights at Columbia Healthcare Center.
Complaint Details
Complaint IN00393930 was substantiated with federal/state deficiencies cited at F550. Complaints IN00391496 and IN00378261 were unsubstantiated due to lack of evidence.
Findings
The facility was found to have failed to ensure dignity for one resident (Resident B) by not taking him to the restroom and telling him to soil his brief, including taking his call light away. Complaint IN00393930 was substantiated with related federal/state deficiencies cited at F550. Two other complaints were unsubstantiated due to lack of evidence.
Deficiencies (1)
Failure to ensure dignity for 1 of 3 residents reviewed for quality of care; resident was told to soil his brief and call light was taken from his hand.
Report Facts
Census: 126
Total Capacity: 126
Medicare Census: 5
Medicaid Census: 104
Other Payor Census: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lana Ballard | Executive Director | Signed the report and referenced in the document |
| CNA 1 | Staff member involved in the incident with Resident B; suspended and terminated for resident abuse | |
| CNA 2 | Staff member who stated she never told residents to soil briefs and takes residents to bathroom when needed |
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