Inspection Report Summary
The most recent inspection on January 27, 2025, found no deficiencies related to complaint investigations. Earlier inspections showed a mixed record with several deficiencies primarily involving resident privacy, medication security, emergency preparedness, kitchen sanitation, and notification of condition changes to family and hospice. Notable issues included a substantiated complaint in September 2023 regarding narcotic medication misappropriation by a staff member and a substantiated complaint in April 2023 for failure to notify family and hospice of a resident’s condition change. Most complaint investigations were unsubstantiated, and enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s recent inspections indicate improvement, with the latest surveys showing compliance after addressing prior deficiencies.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
38% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
100% occupied
Based on a January 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 54
Capacity: 54
Deficiencies: 0
Jan 27, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00449561 and IN00450366.
Findings
No deficiencies related to the allegations in complaints IN00449561 and IN00450366 were cited. The facility was found to be in compliance with 42 CFR Parts 483.12 and 483.25.
Complaint Details
Investigation of Complaints IN00449561 and IN00450366 found no deficiencies related to the allegations; both complaints were not substantiated.
Report Facts
Census: 54
Total Capacity: 54
Medicare Census: 1
Medicaid Census: 44
Other Payor Census: 9
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 0
Dec 2, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00448349.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Parts 483.12 and 483.25 regarding the complaint investigation.
Complaint Details
Complaint IN00448349 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 59
Census Bed Type - SNF/NF: 53
Census Bed Type - Residential: 4
Census Bed Type - NCC: 2
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 48
Census Payor Type - Other: 6
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 27, 2024
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey conducted on August 16, 2024.
Findings
Englewood Health 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 for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 53
Capacity: 64
Deficiencies: 0
Sep 10, 2024
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).
Findings
Englewood Health & Rehabilitation Center 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 three detached storage buildings and has a fire alarm system with smoke detection in corridors and resident rooms.
Report Facts
Certified beds: 64
Census: 53
Detached storage buildings not sprinklered: 3
Inspection Report
Annual Inspection
Census: 49
Capacity: 49
Deficiencies: 1
Aug 16, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00440986.
Findings
The facility failed to ensure residents' privacy and dignity by not asking permission prior to entering residents' rooms for 4 of 13 residents reviewed. No deficiency was cited related to the complaint allegation.
Complaint Details
Complaint IN00440986 was investigated and no deficiency related to the allegation was cited.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure residents' privacy and dignity by asking permission prior to entering residents' rooms for 4 of 13 residents reviewed (Residents 18, 17, 34, 40). | SS=E |
Report Facts
Census: 49
Total Capacity: 49
Residents reviewed: 13
Residents with privacy deficiency: 4
Medicare residents: 2
Medicaid residents: 42
Other payor residents: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Hiles | HFA | Facility representative signing the report |
| RN 3 | Named in findings for entering residents' rooms without knocking or asking permission | |
| RN 2 | Interviewed regarding staff expectations for knocking and asking permission before entering rooms |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 51
Deficiencies: 0
Jul 10, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00437227.
Findings
No Federal or State deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00437227 was investigated and found to have no substantiated deficiencies.
Report Facts
Census: 51
Total Capacity: 51
Medicare Census: 5
Medicaid Census: 41
Other Payor Census: 5
Inspection Report
Complaint Investigation
Census: 53
Capacity: 53
Deficiencies: 0
Jun 3, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00432968.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00432968 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 53
Total Capacity: 53
Medicare Census: 2
Medicaid Census: 41
Other Payor Census: 10
Inspection Report
Complaint Investigation
Census: 51
Capacity: 51
Deficiencies: 0
Mar 8, 2024
Visit Reason
This visit was for the investigation of complaints IN00428444 and IN00428925.
Findings
No deficiencies related to the allegations in complaints IN00428444 and IN00428925 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00428444 - No deficiencies related to the allegations are cited. Complaint IN00428925 - No deficiencies related to the allegations are cited.
Report Facts
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 41
Census Payor Type - Other: 3
Inspection Report
Complaint Investigation
Census: 51
Capacity: 51
Deficiencies: 0
Jan 18, 2024
Visit Reason
This visit was conducted as an investigation of Complaint IN00426292.
Findings
No deficiencies related to the allegations in Complaint IN00426292 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
Investigation of Complaint IN00426292 found no deficiencies related to the allegations; complaint was not substantiated.
Report Facts
Census: 51
Total Capacity: 51
Medicare Census: 2
Medicaid Census: 44
Other Payor Census: 5
Inspection Report
Re-Inspection
Census: 50
Capacity: 67
Deficiencies: 0
Sep 8, 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 08/03/23.
Findings
At this PSR survey, Englewood Health & Rehabilitation Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility was determined to be fully sprinklered except for two detached storage buildings and had a fire alarm system with smoke detection in all resident areas.
Report Facts
Certified beds: 67
Census: 50
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 6, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00416564 and the Focused Infection Control Survey.
Findings
Englewood Health 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 complaint investigation and focused infection control survey.
Complaint Details
Investigation of Complaint IN00416564 was reviewed for paper compliance.
Report Facts
Complaint Investigation Number: 416564
Inspection Report
Complaint Investigation
Census: 51
Capacity: 51
Deficiencies: 1
Sep 5, 2023
Visit Reason
This visit was for the investigation of complaints IN00415356, IN00415766, and IN00416564, including a focused infection control survey.
Findings
The facility was found deficient related to complaint IN00416564 involving failure to securely handle narcotic medications for 4 residents. The investigation revealed narcotic count discrepancies, missing controlled substance sign-out sheets, and documentation failures. LPN 1 admitted to misappropriating narcotic medication and was terminated. The facility implemented corrective actions including staff education and enhanced auditing procedures.
Complaint Details
Complaint IN00416564 was substantiated with federal and state deficiencies cited at F 602 related to misappropriation and exploitation of narcotic medications. Complaints IN00415356 and IN00415766 had no deficiencies related to the allegations.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure narcotic medications were handled securely for 4 residents, including misappropriation of Percocet by LPN 1. | SS=E |
Report Facts
Residents reviewed for narcotic handling: 4
Facility census: 51
Total licensed capacity: 51
Dates of survey: September 5 and 6, 2023
Completion date for corrective actions: October 22, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Admitted to misappropriating narcotic medication; terminated following investigation |
| Molly Linder | Administrator | Signed report |
| Nurse Manager 3 | Provided information about pharmacy shipments and controlled substance records | |
| Nurse Manager 4 | Participated in investigation and interview regarding narcotic discrepancies | |
| AIT | Administrator in Training | Provided incident report and participated in investigation |
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 8, 2023
Visit Reason
The visit was a paper compliance review related to the Annual Recertification and State Licensure survey conducted on July 20, 2023.
Findings
Englewood Health 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 for the Recertification and State Licensure survey.
Inspection Report
Routine
Census: 50
Capacity: 67
Deficiencies: 6
Aug 3, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with federal and state regulations including emergency preparedness requirements and fire safety codes.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements due to failure to ensure staff demonstrated knowledge of emergency procedures and failure to conduct required emergency preparedness exercises. Life Safety Code deficiencies included a resident room door with excessive gap, electrical splices not contained in a junction box, blocked electrical panels, and combustible shelving near oxygen storage.
Severity Breakdown
SS=C: 1
SS=F: 1
SS=D: 1
SS=E: 3
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure staff could demonstrate knowledge of emergency procedures in accordance with 42 CFR 483.73(d)(1). | SS=C |
| Failed to conduct required emergency preparedness exercises at least twice per year including unannounced staff drills. | SS=F |
| Resident room corridor door 212 had a ½ inch gap between the top of the door and the door frame, not resisting passage of smoke as required. | SS=D |
| Electrical splices were not contained inside a junction box in the breakroom above ceiling tiles. | SS=E |
| Access and working space was blocked for two electrical panels in the Fire Control Panel mechanical room. | SS=E |
| Combustible wooden shelves were stored within five feet of stationary liquid oxygen containers in the oxygen storage and trans-filling room. | SS=E |
Report Facts
Certified beds: 67
Census: 50
Residents affected by door gap: 2
Residents potentially affected by electrical splice: 8
Residents potentially affected by blocked electrical panels: 30
Residents potentially affected by combustible shelving near oxygen: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rose Smalley | Regulatory Compliance Director | Signed the report |
| Maintenance Director | Interviewed and involved in findings related to emergency preparedness training, door gap, electrical splices, and electrical panel access | |
| Administrator | Interviewed and involved in exit conference for findings |
Inspection Report
Renewal
Census: 53
Capacity: 53
Deficiencies: 5
Jul 17, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted over July 17-20, 2023.
Findings
The facility failed to ensure sanitary practices in the kitchen, including slippery oily floors, unclean oven trays with crumbs, unlabeled hamburgers in the refrigerator, and improper hair net use by dietary staff. The walk-in freezer had an unidentified black substance under a rack.
Severity Breakdown
SS=E: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Floor was slippery with an oily substance from in front of the oven to beyond the stove top range. | SS=E |
| Top of the oven had trays and multiple crumbs varying in size and color. | SS=E |
| Two hamburgers in the refrigerator were covered with cellophane but had no date labeling. | SS=E |
| Dietary aide had hair uncovered despite wearing a hair net covering only the bun. | SS=E |
| Black substance approximately 1 inch high by ½ inch wide by 9 inches long found under rack in walk-in freezer. | SS=E |
Report Facts
Residents eating food prepared in kitchen: 53
Census: 53
Total capacity: 53
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christian Livingston | Administrator | Administrator who indicated kitchen staff were to be in-serviced and was informed of cleaning issues. |
| Dietary Aide 3 | Observed with hair uncovered despite hair net; unable to determine hamburger preparation date. |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 56
Deficiencies: 0
Jun 7, 2023
Visit Reason
This visit was conducted for the investigation of three complaints: IN00409647, IN00410100, and IN00410293.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaints IN00409647, IN00410100, and IN00410293 were investigated with no deficiencies related to the allegations cited.
Report Facts
Census: 56
Total Capacity: 56
Medicare Census: 4
Medicaid Census: 48
Other Payor Census: 4
Inspection Report
Renewal
Deficiencies: 1
Jun 7, 2023
Visit Reason
The inspection was an offsite Licensure Investigation Survey conducted to review the facility's compliance with license renewal requirements.
Findings
The facility failed to timely renew their license to operate as a health care facility before the expiration date of May 31, 2023, as the renewal application and payment were submitted less than 45 days prior to license expiration.
Deficiencies (1)
| Description |
|---|
| Facility failed to submit a renewal application at least 45 days prior to license expiration. |
Report Facts
Days prior to license expiration for renewal application submission: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rose Smalley | Regulatory Compliance Director | Signed as Laboratory Director's or Provider/Supplier Representative's Signature on the report. |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 51
Deficiencies: 0
May 26, 2023
Visit Reason
This visit was conducted for the investigation of four complaints: IN00407569, IN00408219, IN00408255, and IN00408523.
Findings
No deficiencies related to the allegations in any of the four complaints were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaints IN00407569, IN00408219, IN00408255, and IN00408523 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 51
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 44
Census Payor Type - Other: 6
Inspection Report
Complaint Investigation
Deficiencies: 0
May 15, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00406404 completed on April 18, 2023.
Findings
Englewood Health 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
Complaint IN00406404 was investigated and found to be in compliance as of the review date May 19, 2023.
Inspection Report
Complaint Investigation
Census: 48
Capacity: 48
Deficiencies: 1
Apr 18, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00406404 regarding failure to notify family and hospice services of a condition change for a resident.
Findings
The facility failed to notify the Power of Attorney and hospice services of a significant condition change for Resident C, who vomited and later passed away. Documentation and notification attempts were incomplete or absent, violating notification policies.
Complaint Details
Complaint IN00406404 was substantiated with federal/state deficiencies cited at F580 related to failure to notify family and hospice of condition changes.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure family and hospice services were notified of a condition change for Resident C. | SS=D |
Report Facts
Census: 48
Total Capacity: 48
Medicare Census: 2
Medicaid Census: 43
Other Payor Census: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christian Livingston | Administrator | Signed the report |
| RN 2 | Registered Nurse | Named in findings related to failure to notify POA and hospice |
| LPN 4 | Licensed Practical Nurse | Notified POA and hospice upon finding Resident C unresponsive |
| NP 3 | Nurse Practitioner | Contacted for medication orders for Resident C |
Inspection Report
Life Safety
Census: 53
Capacity: 67
Deficiencies: 0
Dec 14, 2022
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 10/24/22 by the Indiana Department of Health in accordance with 42 CFR Subpart 483.90(a).
Findings
Englewood Health & Rehabilitation Center was found in compliance with Medicare/Medicaid participation requirements, Life Safety From Fire, and the 2012 Edition of the NFPA 101 Life Safety Code. The facility is fully sprinklered except for two detached storage buildings and has appropriate fire alarm and smoke detection systems.
Inspection Report
Annual Inspection
Deficiencies: 0
Oct 24, 2022
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure survey, including investigation of Complaint IN00389138.
Findings
Englewood Health 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 for the Recertification and State Licensure survey. The complaint IN00389138 was corrected.
Complaint Details
Complaint IN00389138 was investigated and found to be corrected.
Inspection Report
Life Safety
Census: 53
Capacity: 67
Deficiencies: 5
Oct 24, 2022
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC).
Findings
The facility was found not in compliance with Life Safety Code requirements, with deficiencies including obstructed means of egress, missing placard on a portable fire extinguisher, corridor door damage compromising smoke resistance, lack of GFCI protection on an electrical receptacle near a sink, and use of extension cords as substitutes for fixed wiring.
Severity Breakdown
SS=E: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 6 means of egress were continuously maintained free of all obstructions; over 20 boxes of supplies stored in corridor near Memory Care exit door. | SS=E |
| Failed to maintain 1 of 1 portable fire extinguishers in kitchen with required placard stating fire protection system activation prior to extinguisher use. | SS=E |
| Failed to ensure 1 of 35 resident room corridor doors resist passage of smoke and fire for at least 20 minutes; corridor door to room 306 had a quarter inch hole. | SS=E |
| Failed to ensure 1 of 1 receptacles within 6 feet from a sink had ground fault circuit interrupter (GFCI) protection; receptacle near dining room sink did not disconnect when tested. | SS=E |
| Failed to ensure 2 of 2 flexible cords were not used as substitutes for fixed wiring; microwave and air-conditioner powered by extension cords. | SS=E |
Report Facts
Certified beds: 67
Census: 53
Residents potentially affected by means of egress obstruction: 15
Staff potentially affected by missing fire extinguisher placard: 5
Residents potentially affected by corridor door deficiency: 2
Residents potentially affected by extension cord use: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christian Livingston | Administrator | Named as facility administrator and present at exit conference |
| Maintenance Director | Interviewed and involved in observations and corrective actions |
Inspection Report
Annual Inspection
Census: 49
Capacity: 49
Deficiencies: 3
Sep 13, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00388046 and IN00389138.
Findings
The facility was found deficient in wound care and assessments for pressure ulcers, fall risk assessments, and catheter care. One complaint was substantiated related to pressure ulcer care. Deficiencies included failure to complete wound care as ordered, incomplete fall risk assessments, and incomplete catheter care documentation.
Complaint Details
Complaint IN00388046 was unsubstantiated. Complaint IN00389138 was substantiated with federal/state deficiencies cited at F686 related to pressure ulcer care.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure wound care and assessments for pressure wounds were completed as ordered for 1 of 2 residents reviewed (Resident T). | SS=D |
| Failed to ensure fall risk assessments were completed timely on 2 of 2 residents reviewed (Resident 14 and Resident 151). | SS=D |
| Failed to ensure catheter care was completed on every shift for 1 of 1 resident reviewed (Resident 19). | SS=D |
Report Facts
Survey dates: 5
Census: 49
Total Capacity: 49
Fall incidents: 9
Fall risk assessment date: 2022
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