Inspection Reports for Community Nursing and Rehabilitation Center
IN, 46218
Back to Facility ProfileDeficiencies per Year
20
15
10
5
0
Moderate
Low
Census Over Time
Census
Capacity
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 8, 2025
Visit Reason
Paper compliance review to the Post Survey Revisit (PSR) completed on June 10, 2025, related to the Annual Recertification and State Licensure survey completed on April 25, 2025.
Findings
Community Nursing and Rehabilitation 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 PSR to the Recertification and State Licensure survey.
Inspection Report
Re-Inspection
Census: 55
Capacity: 55
Deficiencies: 2
Jun 10, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on April 25, 2025, including a PSR to the Investigation of Complaint IN00456672 completed on April 25, 2025.
Findings
The facility failed to ensure cleanliness of the kitchen and failed to provide a homelike environment for 3 of 5 residents reviewed. Deficiencies included dirty kitchen floors, food debris in the dishwasher drain, dust on walls, ceiling, and shelves, missing paint and holes in call light box coverings in resident rooms, and dust on a resident's fan. The facility had not implemented systemic plans of correction to prevent recurrence.
Complaint Details
Complaint IN00456672 was investigated and corrected.
Severity Breakdown
SS=F: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure cleanliness of the kitchen, including dirty floors, food debris in dishwasher drain, and dust on walls and shelves. | SS=F |
| Failed to provide a homelike environment for 3 of 5 residents, including missing paint, holes in call light box coverings, and dust on resident's fan. | SS=D |
Report Facts
Residents affected by kitchen cleanliness deficiency: 55
Residents reviewed for physical environment: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paige Metzler | Executive Director | Interviewed regarding kitchen cleanliness and homelike environment policies; named in findings and corrective action plans. |
| Culinary Manager | Culinary Manager | Conducted kitchen tour and observations related to cleanliness deficiencies. |
Inspection Report
Life Safety
Census: 55
Capacity: 115
Deficiencies: 15
May 20, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 05/20/2025.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Multiple deficiencies were identified including obstructed means of egress, improperly secured stairwell exit doors, storage in stairwells, emergency lighting documentation issues, lack of preventative maintenance on battery-operated smoke alarms, sprinkler system obstructions and maintenance issues, smoke barrier door malfunctions, fire drills not conducted at varying times, malfunctioning rolling fire door, incomplete emergency generator battery testing records, and improper use of extension cords.
Severity Breakdown
SS=F: 3
SS=E: 8
SS=D: 2
SS=C: 2
Deficiencies (15)
| Description | Severity |
|---|---|
| Means of egress were obstructed by stored items in corridors. | SS=F |
| Stairwell exit door on second floor had incorrect keypad code posted. | SS=E |
| Items stored in first floor exit stairwell interfered with egress. | SS=E |
| Failed to document monthly testing for 1 of 4 battery backup emergency lights. | SS=D |
| Failed to ensure preventative maintenance for all battery operated smoke alarms in resident rooms. | SS=C |
| Stairwell door on second floor did not latch properly, compromising smoke barrier. | SS=E |
| Curtain obstructed sprinkler spray pattern in second floor Activities Office. | SS=E |
| Rusted sprinkler head in visitor's restroom behind reception desk not replaced. | SS=D |
| Therapy room door lacked positive latching mechanism to secure door closed. | SS=E |
| Corridor walls near mechanical room did not resist transfer of smoke due to HVAC return not flush with grill. | SS=E |
| One set of smoke barrier doors failed to fully self-close due to malfunctioning door coordinator. | SS=E |
| Failed to conduct quarterly fire drills at unexpected times on third shift for four calendar quarters. | SS=C |
| Rolling steel fire door in kitchen did not operate automatically and was awaiting repair/replacement. | SS=E |
| Incomplete written record of monthly testing of emergency generator starting batteries for 11 of 12 months. | SS=F |
| Extension cord used as substitute for fixed wiring in first floor dining room. | SS=E |
Report Facts
Certified beds: 115
Census: 55
Third shift fire drills: 10
Third shift fire drills: 12
Battery backup lights: 4
Battery backup lights: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and involved in findings and corrective actions throughout the report | |
| Executive Director | Interviewed and involved in exit conferences and corrective action plans |
Inspection Report
Annual Inspection
Census: 54
Capacity: 54
Deficiencies: 15
Apr 25, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00456672.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, grievance follow-up, abuse prevention and investigation, timely PASARR assessments, ADL care, medication administration, food temperature and storage, infection control, and environmental maintenance.
Complaint Details
Complaint IN00456672 was investigated with federal/state deficiencies cited related to allegations of dignity, abuse, grievance follow-up, ADL care, medication administration, and infection control.
Severity Breakdown
SS=E: 2
SS=D: 10
SS=F: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to ensure residents' respect and dignity were maintained for multiple residents during care and dining. | SS=E |
| Failed to follow up on grievances for 2 residents reviewed. | SS=D |
| Failed to protect residents' right to be free from abuse for 2 residents reviewed. | SS=D |
| Failed to maintain evidence that an allegation of abuse was thoroughly investigated for 2 residents reviewed. | SS=D |
| Failed to timely refer a resident with a new psychiatric diagnosis for a Level 2 PASARR assessment. | SS=D |
| Failed to timely pull a resident up in bed as requested and provide consistent showers per resident preference. | SS=D |
| Failed to ensure resident's oxygen was provided as ordered. | SS=D |
| Failed to provide adequate pain control for 2 residents reviewed for pain medication. | SS=D |
| Failed to timely document behaviors and initiate new interventions for a resident with dementia exhibiting wandering and inappropriate urination. | SS=D |
| Failed to timely follow-up on pharmacy recommendations for a resident reviewed for unnecessary medications. | SS=D |
| Failed to ensure insulin medications had open and/or expiration dates on medication carts. | SS=D |
| Failed to ensure food was served at palatable temperatures for multiple residents and resident council attendees. | SS=E |
| Failed to ensure kitchen was clean and in good repair, staff contained hair, food was properly covered, labeled, dated, and trash cans were covered when not in use. | SS=F |
| Failed to ensure infection control was maintained by utilizing hand hygiene prior to administering eye drops, timely removing feces and urine from bedside table, and wearing gown while disposing bodily fluids for residents on Enhanced Barrier Precautions. | SS=D |
| Failed to promote a homelike environment by not repairing broken blinds, addressing urine odor, and repairing scraped paint in resident rooms. | SS=D |
Report Facts
Survey dates: 5
Residents present: 54
Residents Medicare: 1
Residents Medicaid: 44
Residents Other: 9
Deficiency counts: 14
Missed medication doses: 10
Insulin doses missed: 6
Food temperature: 126.3
Food temperature: 153
Food temperature: 50.7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keshia Polston | Regional Vice President of Operations | Signed report cover page |
| CNA 2 | Named in abuse and dignity findings related to resident care and attitude | |
| LPN 5 | Licensed Practical Nurse | Named in delayed pain medication administration |
| LPN 25 | Licensed Practical Nurse | Named in delayed pain medication administration |
| QMA 10 | Qualified Medication Aide | Named in infection control and oxygen administration findings |
| RN 24 | Registered Nurse | Named in insulin medication labeling deficiency |
| DA 15 | Dietary Aide | Named in food storage and hygiene deficiencies |
| DA 17 | Dietary Aide | Named in food service temperature and hygiene deficiencies |
| DM | Dietary Manager | Named in food storage and hygiene deficiencies |
| WS 8 | Weekend Supervisor | Named in abuse and resident wandering incident |
| SSD | Social Service Director | Named in grievance and behavior management findings |
| DON | Director of Nursing | Named in multiple findings including abuse, medication, and infection control |
| NC 13 | Nurse Consultant | Named in abuse and infection control findings |
| DNS | Director of Nursing Services | Named in medication and infection control corrective actions |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 55
Deficiencies: 0
Jan 16, 2025
Visit Reason
This visit was for the investigation of complaints IN00436227 and IN00451332.
Findings
No deficiencies related to the allegations in complaints IN00436227 and IN00451332 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 these complaints.
Complaint Details
Complaint IN00436227 - No deficiencies related to the allegations are cited. Complaint IN00451332 - No deficiencies related to the allegations are cited.
Report Facts
Census SNF/NF beds: 55
Total census: 55
Medicare census: 1
Medicaid census: 47
Other payor census: 7
Inspection Report
Life Safety
Census: 51
Capacity: 115
Deficiencies: 0
Jul 11, 2024
Visit Reason
A second Post Survey Revisit (PSR) to the Post Survey Revisit conducted on 06/10/24 to the Life Safety Code Recertification and State Licensure Survey conducted on 05/14/24 was conducted by the Indiana Department of Health.
Findings
At this PSR survey, Community Nursing and Rehabilitation Center 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 (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinklered except for two detached buildings used for storage which were not sprinklered.
Report Facts
Facility capacity: 115
Census: 51
Inspection Report
Re-Inspection
Census: 55
Capacity: 115
Deficiencies: 2
Jun 10, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 05/14/24 was performed to verify correction of previously cited deficiencies.
Findings
The facility was found not in compliance with Life Safety Code requirements, specifically regarding corridor door latching and ground fault circuit interrupter (GFCI) maintenance. Deficiencies from the prior survey were not fully corrected, indicating failure to implement systemic corrective actions.
Severity Breakdown
SS=E: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure 1 of over 40 corridor doors had no impediment to closing and latching into the door frame, affecting 4 residents. | SS=E |
| Failed to ensure all ground fault circuit interrupters (GFCI) were properly maintained for protection against electric shock, specifically in resident room 139. | SS=D |
Report Facts
Facility capacity: 115
Census: 55
Corridor doors inspected: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paige Metzler | Executive Director | Interviewed regarding door latching and GFCI deficiencies; also contact for desk review |
Inspection Report
Renewal
Deficiencies: 0
May 22, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the Recertification and State Licensure of the facility.
Findings
Community Nursing and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 during the paper compliance review for Recertification and State Licensure.
Inspection Report
Life Safety
Census: 50
Capacity: 115
Deficiencies: 3
May 14, 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.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies included corridor doors that failed to latch properly, smoke barrier doors that did not close to form a smoke resistant barrier, and a ground fault circuit interrupter (GFCI) receptacle that did not trip when tested.
Severity Breakdown
SS=E: 2
SS=D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 2 of over 40 corridor doors had no impediment to closing and latching into the door frame and would resist the passage of smoke, potentially affecting 4 residents. | SS=E |
| Failed to ensure 1 of 6 sets of smoke barrier doors would close to form a smoke resistant barrier, potentially affecting 40 residents, staff, and visitors. | SS=E |
| Failed to ensure all ground fault circuit interrupter (GFCI) receptacles were properly maintained; one GFCI receptacle in resident room 139 did not trip when tested, potentially affecting one resident and staff. | SS=D |
Report Facts
Certified beds: 115
Census: 50
Corridor doors with deficiency: 2
Smoke barrier door sets with deficiency: 1
GFCI receptacle with deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paige Metzler | Executive Director | Named as Executive Director and contact for desk review |
| Maintenance Director | Interviewed and confirmed deficiencies related to door latching and smoke barrier door coordination | |
| Field Maintenance Supervisor | Participated in observations and interviews regarding deficiencies | |
| Director of Property Management | Present at exit conference reviewing findings |
Inspection Report
Annual Inspection
Census: 55
Capacity: 55
Deficiencies: 7
Apr 22, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00432069, IN00431934, and IN00432753.
Findings
The facility was found deficient in multiple areas including timely assistance with dressing, medication administration errors, inadequate skin assessments, failure to monitor bowel movements, improper oral and gastrostomy tube care, behavioral health monitoring deficiencies, medication error rate exceeding 5%, serving food at safe temperatures, and environmental maintenance issues such as a leaking pipe and unclean shower room.
Complaint Details
Complaints IN00432069, IN00431934, and IN00432753 were investigated with no deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 5
SS=E: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to timely provide assistance with dressing for 1 of 1 resident reviewed for ADL care (Resident 6). | SS=D |
| Failed to assess a resident's skin condition; clarify medication dosage and administration time; administer insulin as ordered; and monitor bowel movements for residents (Residents B and 27). | SS=D |
| Failed to provide oral care as ordered and timely obtain physician's order for gastrostomy tube site care for 1 resident (Resident 23). | SS=D |
| Failed to adequately monitor and document behaviors for 1 resident reviewed for mood and behaviors and 2 residents reviewed for unnecessary medications (Residents 38 and 45). | SS=D |
| Medication error rate exceeded 5 percent with 2 errors in 34 opportunities involving 1 resident (Resident 43). | SS=D |
| Failed to serve breakfast at safe and palatable temperatures affecting 54 of 55 residents. | SS=E |
| Failed to maintain the first-floor shower room in good condition and timely repair a leaking pipe in the kitchen affecting all residents. | SS=E |
Report Facts
Census: 55
Total Capacity: 55
Medication error rate: 5.88
Insulin dosage: 22
Insulin dosage: 12
Food temperature: 86
Food temperature: 100
Food temperature: 109
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paige Metzler | Executive Director | Signed report and contact for desk review |
| LPN 3 | Observed administering insulin and blood sugar checks with errors | |
| DNS | Director of Nursing Services | Interviewed regarding medication errors, skin assessments, and behavioral health |
| CNA 2 | Certified Nursing Assistant | Interviewed regarding Resident 6's dressing assistance |
| FC 5 | Facility Cook | Observed serving cold food |
| DM | Dietary Manager | Observed food temperatures and kitchen pipe leak |
| IPF | Infection Preventionist Float | Provided policies and observations on bowel management and food temperatures |
| ED | Executive Director | Provided investigative files and interviewed about behavioral incidents and environmental issues |
| SSD | Social Services Director | Interviewed regarding behavioral incidents and resident interviews |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 55
Deficiencies: 0
Apr 22, 2024
Visit Reason
The visit was conducted for the investigation of Complaint IN00432753 and included the investigation of Complaints IN00432069 and IN00431934, in conjunction with the Recertification and State Licensure Survey.
Findings
No deficiencies related to the allegations of any of the complaints were cited. The facility was found to be in substantial compliance with 42 CFR Part 483, Subpart B regarding the investigation of Complaint IN00432753.
Complaint Details
Complaint IN00432069 - No deficiencies related to the allegations are cited. Complaint IN00431934 - No deficiencies related to the allegations are cited. Complaint IN00432753 - No deficiencies related to the allegations are cited.
Report Facts
Census SNF/NF beds: 55
Total census: 55
Medicare census: 1
Medicaid census: 47
Other payor census: 7
Inspection Report
Complaint Investigation
Census: 44
Capacity: 44
Deficiencies: 0
Sep 7, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00413637 and IN00416066.
Findings
No deficiencies related to the allegations in complaints IN00413637 and IN00416066 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaints IN00413637 and IN00416066 found no deficiencies related to the allegations.
Report Facts
Census Bed Type: 44
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 39
Census Payor Type - Other: 4
Total Census: 44
Inspection Report
Re-Inspection
Census: 44
Capacity: 115
Deficiencies: 0
Jul 6, 2023
Visit Reason
This was a Post Survey Revisit (PSR) to the Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey conducted on 05/16/23.
Findings
The facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements, including fire safety and sprinkler systems. The facility is fully sprinklered except for two detached storage buildings.
Report Facts
Certified beds: 115
Census: 44
Inspection Report
Follow-Up
Census: 42
Capacity: 42
Deficiencies: 0
Jun 21, 2023
Visit Reason
This visit was for the Post Survey Revisit (PSR) to the Recertification and State Licensure Survey and the investigation of Complaints IN00402254, IN00400685, and IN00399680.
Findings
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 the Recertification and State Licensure Survey and the PSR to the Investigation of the three complaints, all of which were corrected.
Complaint Details
Complaints IN00400685, IN00399680, and IN00402254 were investigated and found to be corrected.
Report Facts
Census SNF/NF: 42
Total Capacity: 42
Census Medicaid: 33
Census Other: 9
Inspection Report
Annual Inspection
Census: 46
Capacity: 115
Deficiencies: 5
May 16, 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 federal regulations and state codes.
Findings
The facility was found in substantial compliance with Emergency Preparedness Requirements but had multiple deficiencies related to Life Safety Code including missing generator testing documentation, lack of self-closing device on a medical records office door, smoke barrier doors not closing completely, improper use of power strips, and missing fire rating identification on an oxygen storage room door.
Severity Breakdown
SS=C: 1
SS=E: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to maintain complete weekly generator inspection documentation for a five-week period. | SS=C |
| Corridor door to Medical Records office lacked a self-closing device. | SS=E |
| Smoke barrier doors in Administration Hall did not close completely, leaving a one-inch gap. | SS=E |
| Power strip used as an extension cord in the Executive Director's office. | SS=E |
| Door to oxygen transfilling room had fire rating sticker painted over and illegible. | SS=E |
Report Facts
Certified beds: 115
Census: 46
Missing generator testing documentation weeks: 5
Residents potentially affected by smoke barrier door deficiency: 16
Staff potentially affected by smoke barrier door deficiency: 4
Visitors potentially affected by smoke barrier door deficiency: 2
Residents potentially affected by power strip deficiency: 10
Staff potentially affected by power strip deficiency: 6
Visitors potentially affected by power strip deficiency: 1
Residents potentially affected by oxygen room door deficiency: 16
Staff potentially affected by oxygen room door deficiency: 4
Visitors potentially affected by oxygen room door deficiency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Davis | Senior Executive Director | Signed the report and educated Maintenance Director on generator testing and other deficiencies |
| Maintenance Director | Acknowledged deficiencies and was educated on corrective actions including generator testing, self-closing doors, power strip usage, and fire rating door identification |
Inspection Report
Recertification
Census: 46
Deficiencies: 18
May 11, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00402254, IN00400685, and IN00399680.
Findings
The facility was found deficient in multiple areas including medication self-administration evaluations, reasonable accommodations, resident self-determination, notification of changes, grievance handling, abuse prevention and investigation, care planning, discharge summaries, activities of daily living, nutrition, pain management, infection control, environmental safety, and staffing requirements.
Complaint Details
This inspection included investigations of Complaints IN00402254, IN00400685, and IN00399680. Deficiencies related to these complaints were cited throughout the report including medication self-administration, grievance handling, abuse, notification of changes, and quality of care.
Severity Breakdown
SS=D: 14
SS=E: 3
SS=F: 1
SS=C: 1
Deficiencies (18)
| Description | Severity |
|---|---|
| Failed to have interdisciplinary team determine and document clinical appropriateness of self-administration of medications for 2 residents. | SS=D |
| Failed to ensure reasonable accommodations for a resident whose roommate blocked sink access. | SS=D |
| Failed to promote and facilitate resident self-determination including shower preferences, nail care, and timely assistance to wheelchair for breakfast. | SS=D |
| Failed to notify physician of a resident's fall and complete post-fall assessment. | SS=D |
| Failed to address resident grievances promptly and document resolutions. | SS=D |
| Failed to protect resident from verbal abuse by staff and failed to timely report and investigate abuse allegations. | SS=D |
| Failed to develop comprehensive person-centered care plans for hospice and skin care needs. | SS=D |
| Failed to provide 8 consecutive hours of RN coverage daily on multiple days. | SS=F |
| Failed to store, prepare, distribute, and serve food in accordance with food safety standards including dishwasher not reaching adequate temperature, improper food storage, and poor personal hygiene of kitchen staff. | SS=E |
| Failed to accurately submit payroll based journal staffing data for licensed personnel to CMS. | SS=C |
| Failed to ensure medication administration infection control practices including hand hygiene and disposal of dropped medication. | SS=D |
| Failed to ensure antibiotic stewardship by providing antibiotic without infection criteria and without proper follow-up. | SS=D |
| Failed to maintain a safe, sanitary, and homelike environment including broken window, black substance on vents, peeling paint, loose toilet, missing light covers, dirty equipment, and missing handrail. | SS=E |
| Failed to provide pain management including timely pain assessments, documentation of pain intensity, effectiveness of medications, and nonpharmacological interventions. | SS=D |
| Failed to provide trauma-informed care for a resident with PTSD including care planning and staff education. | SS=D |
| Failed to provide communication materials in reach and in good condition for a resident with aphasia. | SS=D |
| Failed to develop comprehensive discharge summaries including recap of resident's stay for discharged residents. | SS=D |
| Failed to follow physician order to hold medication when pulse below 65 and to perform pulse assessments prior to medication administration. | SS=D |
Report Facts
Residents present: 46
Deficiency counts: 19
Days without 8 hour RN coverage: 8
Weight loss: 11
Medication doses held: 7
Antibiotic days: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Davis | Senior Executive Director | Signed report and involved in corrective actions and interviews |
| LPN 3 | Licensed Practical Nurse | Witnessed verbal abuse incident and reported it |
| CNA 4 | Certified Nursing Assistant | Involved in verbal abuse incident with Resident 17 |
| CNA 21 | Certified Nursing Assistant | Alleged verbal abuse by Resident 35, suspended pending investigation |
| RNC | Regional Nurse Consultant | Provided policies, interviewed staff, and reviewed investigations |
| DNS | Director of Nursing Services | Interviewed regarding multiple findings including abuse, falls, and pain management |
| FDNS | Float Director of Nursing Services | Interviewed regarding falls and staffing |
| QMA 22 | Qualified Medication Aide | Observed medication administration with dropped pill |
| RN 31 | Registered Nurse | Observed medication administration and hand hygiene deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 17, 2022
Visit Reason
The inspection was a paper compliance review related to the investigation of multiple complaints (IN00383511, IN00375446, IN00372383, and IN00382973) completed on June 30, 2022.
Findings
Community Nursing and Rehabilitation 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 complaint investigation.
Complaint Details
The visit was related to complaint investigations IN00383511, IN00375446, IN00372383, and IN00382973. The facility was found to be in compliance based on the paper review.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 26, 2022
Visit Reason
The visit was a paper compliance review related to the investigation of Complaint IN00382284 completed on June 10, 2022.
Findings
Community Nursing and Rehabilitation 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 complaint investigation.
Complaint Details
The complaint investigation IN00382284 was completed on June 10, 2022, and the facility was found in compliance during the paper review.
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