Inspection Report Summary
The most recent inspection on December 19, 2024, was a complaint investigation that found no deficiencies related to the allegations. Earlier inspections showed a mixed pattern with several citations primarily involving Life Safety Code issues such as fire alarm system maintenance, unsecured oxygen cylinders, and door safety, as well as deficiencies in resident notification policies, infection control practices, and employee testing. Complaint investigations were mostly unsubstantiated, with one substantiated complaint that did not result in cited deficiencies. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows some recurring Life Safety and procedural issues, but recent inspections indicate compliance and improvement in key areas.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
90% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
148 residents
Based on a December 2024 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 148
Deficiencies: 0
Dec 19, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00444642.
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 regarding the complaint investigation.
Complaint Details
Complaint IN00444642 - No deficiencies related to allegations are cited.
Report Facts
Census: 148
Medicare census: 9
Medicaid census: 82
Other payor census: 57
Inspection Report
Annual Inspection
Deficiencies: 0
Oct 28, 2024
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Compass Park 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
Life Safety
Deficiencies: 0
Oct 22, 2024
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey that exited on 2024-10-07 was completed on 2024-10-22.
Findings
Compass Park was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 18, New Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Life Safety
Census: 142
Capacity: 167
Deficiencies: 3
Oct 7, 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 Emergency Preparedness Survey found Compass Park in compliance with requirements. The Life Safety Code survey found the facility not in compliance due to deficiencies including incorrect fire alarm system time and date, incomplete documentation of fire alarm signal transmission during fire drills, and unsecured oxygen cylinders in the storage room.
Severity Breakdown
SS=C: 1
SS=F: 1
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to maintain the fire alarm system to assure accurate time and date information on the fire alarm control panel. | SS=C |
| Failed to ensure 12 of 12 fire drills included verification of transmission of the fire alarm signal to the monitoring station. | SS=F |
| Failed to ensure 2 of 4 cylinders of nonflammable gases such as oxygen were properly secured from falling. | SS=E |
Report Facts
Certified beds: 167
Census: 142
Fire drills reviewed: 12
Oxygen cylinders unsecured: 2
Potentially affected residents: 18
Potentially affected staff: 4
Potentially affected visitors: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| William Pierce | Administrator | Signed the report |
| Campus C.E.O. | Participated in observation and exit conference | |
| Maintenance Director | Participated in observation, interview, and exit conference; involved in corrective actions |
Inspection Report
Renewal
Census: 147
Capacity: 147
Deficiencies: 5
Sep 20, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from September 16 to 20, 2024.
Findings
The facility was found deficient in multiple areas including failure to provide written notification of transfer/discharge and bed hold policies to residents and their representatives, incomplete baseline care plans for new admissions, failure to implement infection prevention and control practices for residents on Enhanced Barrier Precautions, and incomplete two-step tuberculin skin testing for new employees.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure written notification of transfer/discharge was provided to residents, their representatives, and the Long-Term Care Ombudsman for 3 of 5 residents reviewed. | SS=D |
| Failed to ensure written bed hold notification was provided to residents and their representatives for 3 of 5 residents reviewed. | SS=D |
| Failed to ensure a baseline care plan was developed including Enhanced Barrier Precautions for 1 of 5 residents reviewed for new admissions. | SS=D |
| Failed to ensure infection control practices were implemented for 1 of 8 residents observed with Enhanced Barrier Precautions; PPE was not used initially during medication administration via feeding tube. | SS=D |
| Failed to ensure staff completed a two-step tuberculin skin test prior to employment for 2 of 3 employees reviewed. | SS=D |
Report Facts
Census SNF/NF beds: 145
Census SNF beds: 2
Total census: 147
Medicare census: 9
Medicaid census: 84
Other payor census: 54
Deficiencies cited: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marissa Meahl | RN Director of Nursing | Signed the report and involved in findings related to infection control and tuberculin skin testing |
| NA 5 | Nurse Aide | Employee file reviewed for two-step tuberculin skin test compliance |
| NA 7 | Nurse Aide | Employee file reviewed for two-step tuberculin skin test compliance |
Inspection Report
Complaint Investigation
Census: 144
Deficiencies: 0
Jun 28, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00431962.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00431962 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 144
Medicare Census: 10
Medicaid Census: 83
Other Payor Census: 51
Inspection Report
Complaint Investigation
Census: 141
Capacity: 141
Deficiencies: 0
Jan 11, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00423148.
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.
Complaint Details
Complaint IN00423148 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 141
Census Payor Type: 141
Medicare residents: 10
Medicaid residents: 72
Other residents: 59
Inspection Report
Annual Inspection
Deficiencies: 0
Dec 7, 2023
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure Survey completed on November 8, 2023.
Findings
Compass Park 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
Life Safety
Deficiencies: 0
Dec 7, 2023
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey that exited on 11/20/23 was completed on 12/07/23.
Findings
Compass Park was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 18, New Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Life Safety
Census: 142
Capacity: 167
Deficiencies: 2
Nov 20, 2023
Visit Reason
The visit was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 standards.
Findings
The facility was found not in compliance with Life Safety Code requirements due to two deficiencies: a corridor door to one resident sleeping room had impediments preventing it from closing and latching properly, and extension cords including power strips were used as substitutes for fixed wiring in the nursing office. No residents were found to be directly affected, but multiple residents had the potential to be affected.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Corridor door to resident sleeping Room 2108 had hooks preventing the door from closing and latching, failing to resist the passage of smoke. | SS=E |
| Use of 2 extension cords including power strips as substitutes for fixed wiring in the Nursing Office (Room 2123) near the second floor nurse's station. | SS=E |
Report Facts
Certified beds: 167
Census: 142
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| William Pierce | Administrator | Signed the report and participated in exit conference |
| Director of Facilities | Interviewed regarding door and power strip deficiencies |
Inspection Report
Annual Inspection
Census: 146
Capacity: 146
Deficiencies: 3
Nov 8, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted on November 1, 2, 3, 6, and 8, 2023.
Findings
The facility was found deficient in maintaining secure electrical hazard doors, posting accurate nurse staffing information, and ensuring sanitary food service practices, specifically staff hair covering in the kitchen. Plans of correction were submitted addressing these deficiencies.
Severity Breakdown
SS=D: 1
SS=C: 1
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure potentially hazardous materials were kept secure behind locked doors to prevent resident access (Electrical Closet door was ajar). | SS=D |
| Failed to post daily nurse staffing information reflecting actual hours worked and failed to ensure the post was easily accessible for staff and guests for 3 of 5 days during the survey period. | SS=C |
| Failed to ensure food was served in a sanitary manner; staff hair was not covered while in the kitchen during 2 of 3 kitchen observations. | SS=E |
Report Facts
Census: 146
Licensed capacity: 146
Residents cognitively impaired and independently mobile: 8
Days of survey: 5
Days with nurse staffing posting deficiencies: 3
Kitchen observations: 3
Kitchen observations with hair covering deficiencies: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| William Pierce | Administrator | Signed the report as Laboratory Director's or Provider/Supplier Representative |
| Director of Nursing | Interviewed regarding electrical closet door security and nurse staffing postings | |
| Director of Dining Services | Interviewed regarding kitchen staff hair covering policy | |
| Dietary Manager | Provided facility policy and conducted in-service on hairnet compliance |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 143
Deficiencies: 0
Oct 20, 2023
Visit Reason
This visit was conducted for the investigation of Complaints IN00419220 and IN00419398.
Findings
No deficiencies related to the allegations in Complaints IN00419220 and IN00419398 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00419220 - No deficiencies related to the allegations are cited. Complaint IN00419398 - No deficiencies related to the allegations are cited.
Report Facts
Census: 143
Total Capacity: 143
Medicare Census: 7
Medicaid Census: 73
Other Payor Census: 63
Inspection Report
Complaint Investigation
Census: 140
Capacity: 140
Deficiencies: 0
Jul 31, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00412744.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00412744 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 140
Census total residents: 140
Census Medicare residents: 5
Census Medicaid residents: 76
Census other payor residents: 59
Inspection Report
Complaint Investigation
Census: 138
Deficiencies: 0
May 25, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00405731.
Findings
No deficiencies related to the allegations in Complaint IN00405731 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00405731 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type Total: 138
Census Payor Type Total: 138
Medicare Census: 12
Medicaid Census: 79
Other Payor Census: 47
Inspection Report
Complaint Investigation
Census: 146
Capacity: 146
Deficiencies: 0
Mar 29, 2023
Visit Reason
This visit was conducted for the investigation of three complaints: IN00402568, IN00403161, and IN00404092.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with applicable federal and state regulations.
Complaint Details
Complaints IN00402568, IN00403161, and IN00404092 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 146
Census Payor Type - Medicare: 14
Census Payor Type - Medicaid: 83
Census Payor Type - Other: 49
Total Census: 146
Inspection Report
Re-Inspection
Census: 145
Capacity: 167
Deficiencies: 0
Feb 16, 2023
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 12/19/22.
Findings
At this PSR survey, Indiana Masonic Home Health Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Participation in Medicare/Medicaid. The facility was fully sprinklered except for the attic and had a fire alarm system with smoke detection in all required areas.
Report Facts
Certified beds: 167
Census: 145
Inspection Report
Complaint Investigation
Census: 138
Capacity: 138
Deficiencies: 0
Jan 23, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00397154.
Findings
Complaint IN00397154 was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00397154 - Substantiated. No deficiencies related to the allegations are cited.
Report Facts
Census: 138
Total Capacity: 138
Medicare Census: 11
Medicaid Census: 82
Other Payor Census: 45
Inspection Report
Life Safety
Census: 141
Capacity: 167
Deficiencies: 8
Dec 19, 2022
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 multiple Life Safety Code requirements including emergency preparedness plan deficiencies, emergency power system maintenance, sprinkler system inspection documentation, and improper storage of soiled linen and trash receptacles.
Severity Breakdown
SS=F: 7
SS=E: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to maintain an emergency preparedness plan reviewed and updated at least annually. | SS=F |
| Failed to maintain an emergency preparedness plan based on a documented facility and community-based risk assessment reviewed within the most recent twelve month period. | SS=F |
| Failed to review and update emergency preparedness policies and procedures to include emerging infectious diseases annually. | SS=F |
| Failed to develop and maintain an emergency preparedness communication plan reviewed and updated at least annually. | SS=F |
| Failed to develop and maintain an emergency preparedness training and testing program reviewed and updated at least annually. | SS=F |
| Failed to implement emergency power system inspection, testing, and maintenance requirements including lack of weekly inspection documentation, unlabeled remote emergency stop buttons, missing annual fuel quality test, and missing 36-month continuous load test documentation. | SS=F |
| Failed to document sprinkler system inspections in accordance with NFPA 25 including missing monthly sprinkler gauge and control valve inspection documentation. | SS=F |
| Failed to ensure mobile soiled linen or trash receptacles greater than 32 gallons were stored in a room protected as a hazardous area when unattended. | SS=E |
Report Facts
Certified beds: 167
Census: 141
Emergency generators: 2
Sprinkler system inspection missing months: 11
Soiled linen/trash receptacles: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| William Pierce | Administrator | Named as facility administrator involved in exit conference and plan of correction. |
Inspection Report
Annual Inspection
Deficiencies: 3
Nov 21, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations related to resident care, clinical record accuracy, and dialysis services.
Findings
The facility was found deficient in notifying physicians of changes when orders could not be implemented, completing required pre- and post-dialysis assessments, and maintaining accurate clinical records, specifically regarding the use and documentation of a brace and edema glove for a resident.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to notify the physician when a physician's order for a positioning device (brace and edema glove) was unable to be implemented for Resident 246. | SS=D |
| Failure to complete pre and post dialysis assessments as ordered for Resident 54. | SS=D |
| Failure to ensure clinical records were accurate for Resident 246 regarding documentation of brace and edema glove use which were not present or applied. | SS=D |
Report Facts
Deficiencies cited: 3
Dates of missing dialysis assessments: 18
Brace/splint audit frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| William Pierce | Administrator | Signed the inspection report |
| Director of Nursing Services | DNS | Interviewed regarding brace order and documentation deficiencies for Resident 246 |
| LPN 4 | Licensed Practical Nurse | Interviewed regarding Resident 246's brace and edema glove order and availability |
| CNA 2 | Certified Nursing Assistant | Interviewed regarding care of Resident 246 and absence of brace and edema glove |
| RN 3 | Registered Nurse | Interviewed regarding change in Resident 246's physician order |
| Director of Nursing | DON | Interviewed regarding missing dialysis assessments for Resident 54 |
Inspection Report
Annual Inspection
Deficiencies: 0
Nov 21, 2022
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure survey was conducted.
Findings
Indiana Masonic Home Health 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.
Inspection Report
Complaint Investigation
Census: 135
Capacity: 135
Deficiencies: 0
Sep 30, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00391081.
Findings
The complaint was substantiated; however, no deficiencies related to the allegation were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00391081 was substantiated but no deficiencies related to the allegation were cited.
Report Facts
Census Bed Type: 135
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 84
Census Payor Type - Other: 48
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