Inspection Reports for Freelandville Community Home
310 West Carlisle St, Freelandville, IN 47535, IN, 47535
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Inspection Report
Life Safety
Deficiencies: 0
Mar 4, 2025
Visit Reason
The visit was a Post Survey Revisit (PSR) for the Life Safety Code Recertification and State Licensure Survey that exited on 01/02/25.
Findings
Freelandville Community Home 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 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Re-Inspection
Census: 29
Capacity: 50
Deficiencies: 1
Feb 18, 2025
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on previous Emergency Preparedness and Life Safety Code deficiencies identified during the survey on 01/02/2025.
Findings
The facility was found in compliance with Emergency Preparedness requirements but was not in compliance with Life Safety Code due to a non-operational emergency generator annunciator panel. The deficiency was not corrected by the initial revisit date but was resolved by 02/28/2025 with the annunciator panel tied into the generator and tested weekly.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 1 emergency generator annunciator panel was in proper operating condition, not tied into the annunciator panel at the nurse’s station. | SS=F |
Report Facts
Certified beds: 50
Census: 29
Deficiency completion date: Feb 28, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shannon Williams | Executive Director | Named in relation to exit conference and follow-up on deficiency |
| Maintenance Director | Interviewed regarding generator annunciator panel deficiency |
Inspection Report
Re-Inspection
Census: 32
Capacity: 32
Deficiencies: 0
Jan 17, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 12/9/24.
Findings
Freelandville Community Home 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 Payor Type - Medicare: 1
Census Payor Type - Medicaid: 22
Census Payor Type - Other: 9
Inspection Report
Life Safety
Census: 32
Capacity: 50
Deficiencies: 15
Jan 2, 2025
Visit Reason
Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health to assess compliance with Medicare/Medicaid participation requirements and Life Safety Code standards.
Findings
The facility was found not in compliance with several Life Safety Code and emergency preparedness requirements including failure to annually review and update the Emergency Preparedness Plan, policies, communication plan, and training/testing program; failure to conduct required generator maintenance and testing; failure to maintain proper fire safety equipment and drills; and issues with emergency power systems and electrical safety.
Severity Breakdown
SS=F: 12
SS=D: 2
SS=E: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to review and update the Emergency Preparedness Plan at least annually. | SS=F |
| Failed to review and update Emergency Preparedness Policies and Procedures annually. | SS=F |
| Failed to review and update the Emergency Preparedness Communication Plan annually. | SS=F |
| Failed to review and update the Emergency Preparedness Training and Testing Program annually. | SS=F |
| Failed to implement emergency power system inspection, testing, and maintenance requirements including monthly battery testing. | SS=F |
| Delayed egress locking arrangement failed to release lock within required time. | SS=D |
| Portable fire extinguisher in beauty shop not maintained within one year. | SS=D |
| Failed to conduct quarterly fire drills for 2 of 4 quarters. | SS=F |
| Failed to ensure nonhospital-grade electrical receptacles at resident rooms were tested annually. | SS=F |
| Emergency generator annunciator panel not in proper operating condition. | SS=F |
| Emergency generator failed to document 5 minute cool down time after load test and transfer time to emergency power. | SS=F |
| Failed to maintain complete written record of monthly generator load testing for 3 of last 12 months. | SS=F |
| Failed to maintain written record of weekly emergency generator inspections for all weeks in past year. | SS=F |
| Failed to properly inspect and test all components of emergency generator including monthly battery specific gravity or conductance testing. | SS=F |
| Extension cords used as substitute for fixed wiring in resident rooms. | SS=E |
Report Facts
Certified beds: 50
Census: 32
Deficiency completion date: Jan 17, 2025
Deficiency completion date: Jan 24, 2025
Deficiency completion date: Feb 3, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shannon Williams | Executive Director | Named in relation to emergency preparedness and Life Safety Code findings and exit conference |
| Maintenance Director | Named in relation to multiple findings including emergency preparedness plan review, generator maintenance, fire safety, and electrical system deficiencies |
Inspection Report
Annual Inspection
Census: 32
Capacity: 32
Deficiencies: 5
Dec 9, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from December 3 to December 9, 2024.
Findings
The facility was found deficient in multiple areas including failure to ensure detailed incident reporting, inaccurate Minimum Data Set (MDS) assessments, failure to develop comprehensive care plans for residents on certain medications, inadequate assistance and supervision during mechanical lift transfers leading to resident falls and injuries, and failure to ensure RN coverage for 8 consecutive hours on certain days.
Severity Breakdown
SS=D: 2
SS=E: 2
SS=G: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure detailed reporting of incidents for 2 of 3 incident reports reviewed (Resident 2 and Resident 137). | SS=D |
| Failed to ensure accurate Minimum Data Set (MDS) assessments for 2 of 5 residents reviewed, including incorrect coding of restraints, diagnoses, and medications. | SS=E |
| Failed to develop care plans for 2 of 5 residents reviewed related to unnecessary medications including diuretics, insulin, anticoagulants, opioids, and antiplatelets. | SS=D |
| Failed to ensure adequate assistance and proper use of mechanical lift during transfers, and failed to implement immediate interventions after falls resulting in fractures for two residents (Resident 137 and Resident 2). | SS=G |
| Failed to ensure RN services were available for at least 8 consecutive hours on two days reviewed (November 28 and 29, 2024). | SS=E |
Report Facts
Census: 32
Total Capacity: 32
Incident Reports Reviewed: 3
Residents Reviewed for MDS Accuracy: 5
Residents Reviewed for Care Plans: 5
Days without 8-hour RN coverage: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shannon Williams | Executive Director | Signed the inspection report |
| CNA 20 | Certified Nurse Aide | Involved in fall incident with Resident 137 and failed to follow mechanical lift policy |
| LPN 5 | Licensed Practical Nurse | Witnessed Resident 2 fall due to unsecured toilet seat riser |
| LPN 25 | Licensed Practical Nurse | Resident 137's nurse during fall incident on 8/29/24 |
| Administrator | Provided information about fall incidents and facility policies | |
| Director of Nursing | DON | Provided interviews and education related to findings |
| MDS Coordinator | Provided information on MDS assessment coding and policies |
Inspection Report
Complaint Investigation
Census: 31
Capacity: 31
Deficiencies: 0
Aug 7, 2024
Visit Reason
This visit included the investigation of complaints IN00440505, IN00440234, and IN00439483.
Findings
No deficiencies related to the allegations were cited for any of the three complaints investigated. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaints IN00440505, IN00440234, and IN00439483 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 31
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 20
Census Payor Type - Other: 10
Inspection Report
Re-Inspection
Census: 33
Capacity: 50
Deficiencies: 0
Jan 18, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey originally conducted on 12/04/23.
Findings
At this PSR survey, Freelandville Community Home was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility was fully sprinklered except for a detached garage and wood shed used for storage.
Inspection Report
Life Safety
Census: 35
Capacity: 50
Deficiencies: 12
Dec 4, 2023
Visit Reason
Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health to assess compliance with Medicare/Medicaid participation requirements and Life Safety Code standards.
Findings
The facility was found not in compliance with several Life Safety Code requirements including emergency preparedness exercises, emergency generator functionality and testing, emergency lighting maintenance, smoke barrier door functionality, sprinkler system maintenance, fire extinguisher maintenance, fire drill conduct and documentation, fuel-fired water heater inspections, and electrical safety related to power cords and multi plug adaptors.
Severity Breakdown
SS=F: 7
SS=E: 2
SS=D: 3
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to conduct emergency preparedness exercises at least twice per year including unannounced staff drills. | SS=F |
| Emergency generator was not functioning properly; annunciator panel showed 'Overcrank' light and generator failed to start during survey. | SS=F |
| Failed to maintain complete written record of monthly generator load testing including 5-minute cool down and load percentage documentation. | SS=F |
| Battery powered emergency light on exterior by generator failed to function properly. | SS=D |
| Failed to maintain protection of interior stairwell door; self-closing device was not functioning and door did not latch properly to resist smoke passage. | SS=D |
| Missing ceiling section in Nurses Supply room, potentially affecting sprinkler system operation. | SS=E |
| Fire extinguisher in Beauty Shop had not received maintenance for over one year. | SS=D |
| Smoke barrier doors at dining room entrance with astragal had a non-functioning coordinator causing doors not to close properly. | SS=E |
| Failed to maintain current inspection certificates for fuel fired water heaters. | SS=F |
| Fire drills were not conducted on unexpected days and times; documentation lacked transmission confirmation to monitoring company and staff signatures on some reports. | SS=F |
| Emergency generator and associated equipment failed to start properly during survey; repairs and rental generator arranged. | SS=F |
| Multi plug adaptor used in resident room as substitute for fixed wiring. | SS=D |
Report Facts
Certified beds: 50
Census: 35
Fire drills reviewed: 12
Fire drills with missing transmission documentation: 4
Fire drills with incomplete staff signatures: 1
Generator load tests missing cool down documentation: 2
Generator load tests missing load percentage documentation: 3
Generator lead time: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Le Ann Petit | Health Facility Administrator | Signed report and involved in exit conference |
| Maintenance Director | Interviewed regarding generator, fire drills, emergency lighting, smoke barrier doors, fire extinguisher maintenance, and electrical safety | |
| Business Office Manager | Interviewed regarding generator replacement and emergency preparedness | |
| Director of Nursing | Interviewed regarding compliance and findings during exit conference |
Inspection Report
Annual Inspection
Census: 33
Capacity: 33
Deficiencies: 8
Nov 16, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted November 13-16, 2023.
Findings
The facility was found deficient in multiple areas including timely completion of quarterly MDS assessments, care plan implementation, restorative therapy services, RN staffing coverage, psychotropic medication management, infection control practices, environmental safety, and programming for residents with intellectual and/or developmental disabilities.
Severity Breakdown
SS=D: 4
SS=E: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure timely completion of quarterly MDS assessments for 3 of 23 residents. | SS=D |
| Failed to implement care plans for urinary catheter use and antidepressant medication for 2 residents. | SS=D |
| Failed to ensure residents with limited mobility received appropriate restorative therapy services for 3 of 6 residents. | SS=D |
| Failed to ensure RN coverage for at least 8 consecutive hours a day, 7 days a week on 4 days reviewed in Q3 2023. | SS=E |
| Failed to ensure residents using psychotropic medications received gradual dose reductions or documented clinical contraindications for 2 of 5 residents. | SS=D |
| Failed to follow infection control practices during urinary catheter care and lacked Legionella water testing program. | SS=E |
| Failed to maintain a safe, functional, sanitary, and comfortable environment including water temperatures above 120°F, uncovered items on bathroom floors, damaged privacy curtains, and peeling paint. | SS=E |
| Failed to provide a specialized program and designate a Qualified Intellectual Disability Professional (QIDP) for residents with intellectual and/or developmental disabilities. | — |
Report Facts
Census: 33
Total Capacity: 33
RN coverage missing days: 4
Residents with intellectual/developmental disability: 3
Water temperature: 125
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cathy Parker | Administrator | Signed plan of correction and correspondence |
| Brenda Buroker | Deputy Director, Long Term Care Division, Indiana State Department of Health | Recipient of plan of correction |
| Cathy Jo Parker | HFA | Submitted plan of correction |
| Director of Nursing | Director of Nursing | Interviewed regarding care plans, restorative therapy, RN coverage, and medication management |
| MDS Coordinator | Licensed Practical Nurse | Interviewed regarding MDS assessments and restorative therapy |
| CNA 6 | Certified Nurse Aide | Observed during catheter care and interviewed regarding restorative care |
| CNA 8 | Certified Nurse Aide | Observed during catheter care and interviewed regarding restorative care |
| Maintenance Director | Maintenance Director | Interviewed regarding water testing, environmental conditions, and maintenance responsibilities |
| Kitchen Manager | Kitchen Manager | Interviewed regarding water testing |
| Business Office Manager | Business Office Manager | Interviewed regarding PBJ staffing data submission |
Inspection Report
Renewal
Deficiencies: 0
Nov 16, 2023
Visit Reason
The inspection was a paper compliance review related to the Recertification and State Licensure Survey completed on November 16, 2023.
Findings
Freelandville Community Home was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 based on the paper compliance review.
Inspection Report
Complaint Investigation
Census: 30
Capacity: 30
Deficiencies: 0
Apr 27, 2023
Visit Reason
The visit was conducted to investigate Complaint IN00405914 at Freelandville Community Home.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00405914 found no deficiencies related to the allegation; complaint was not substantiated.
Report Facts
Census Bed Type: 30
Medicare Census: 2
Medicaid Census: 20
Other Census: 8
Total Census: 30
Inspection Report
Complaint Investigation
Census: 50
Capacity: 50
Deficiencies: 0
Jan 5, 2023
Visit Reason
This visit included the investigation into complaint IN00381609.
Findings
Complaint IN00381609 was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations regarding the complaint investigation.
Complaint Details
Complaint IN00381609 - Substantiated. No deficiencies related to the allegations were cited.
Report Facts
Census: 50
Total Capacity: 50
Medicare Census: 4
Medicaid Census: 20
Other Payor Census: 3
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