Inspection Reports for Holy Cross Village at Notre Dame Inc
54515 STATE ROAD 933 NORTH, NOTRE DAME, IN, 46556
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 9, 2025, found Holy Cross Village at Notre Dame in compliance with Medicare/Medicaid participation and Life Safety Code requirements. Earlier inspections showed a pattern of Life Safety Code deficiencies, mainly involving fire safety issues such as unsecured furniture in corridors, unsealed smoke barrier penetrations, and smoke barrier doors not restricting smoke movement. Complaint investigations were generally unsubstantiated, though prior reports noted an incident involving improper resident transfer resulting in a fall and a deficiency for failure to report an abuse allegation that was later deemed unsubstantiated. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to be improving in Life Safety Code compliance, with the most recent follow-up showing no deficiencies after previous citations.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
12.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
198% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
90% occupied
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Follow-Up
Census: 47
Capacity: 52
Deficiencies: 0
Date: May 9, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey that exited on 04/16/2025 was conducted by the Indiana Department of Health in accordance with 42 CFR Subpart 483.90(a).
Findings
At this PSR, Holy Cross Village at Notre Dame Inc. 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 2019 Therapy Room and dining facility addition to the Murphy Wing were surveyed under Chapter 18, New Health Care Occupancies.
Report Facts
Certified beds: 52
Census: 47
Inspection Report
Life Safety
Census: 47
Capacity: 52
Deficiencies: 3
Date: Apr 16, 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 04/16/2025 to assess compliance with emergency preparedness and life safety requirements.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies included unsecured furniture in a corridor, unsealed penetrations in smoke barrier walls, and smoke barrier doors that did not properly restrict smoke movement.
Deficiencies (3)
Furniture located in a corridor in 1 of 5 smoke compartments was not securely attached to the floor or wall, violating LSC 19.2.3.4(5).
Penetrations caused by the passage of wire and/or conduit through 1 of 4 smoke barrier walls were not protected to maintain smoke resistance, violating LSC Section 19.3.7.5.
One set of smoke barrier doors failed to restrict the movement of smoke for at least 20 minutes, with a 1/4-inch gap measured between doors, violating LSC Section 19.3.7.8 and 8.5.4.
Report Facts
Certified beds: 52
Census: 47
Corridor width: 8
Penetration size: 1
Door gap: 0.25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Armendarz | Director of Nursing | Signed the report. |
| Maintenance Supervisor | Interviewed regarding unsecured furniture and smoke barrier issues. | |
| Maintenance Technician 2 | Interviewed and acknowledged deficiencies related to smoke barrier penetrations and doors. |
Inspection Report
Renewal
Census: 44
Capacity: 85
Deficiencies: 0
Date: Mar 13, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted over multiple days in March 2025.
Findings
Holy Cross Village at Notre Dame was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Recertification and State Licensure Survey.
Report Facts
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 4
Census Payor Type - Other: 32
Census Bed Type - SNF/NF: 25
Census Bed Type - SNF: 19
Census Bed Type - Residential: 41
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 13, 2025
Visit Reason
The inspection was conducted as an annual survey to assess the facility's compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 1
Date: Sep 27, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00442671 at Holy Cross Village at Notre Dame.
Complaint Details
Complaint IN00442671 was investigated and no deficiencies related to the allegations were cited. The unrelated deficiency involved a fall due to improper transfer of Resident E with a mechanical lift.
Findings
No deficiencies related to the complaint allegations were cited. An unrelated deficiency was cited involving failure to transfer a dependent resident with a mechanical lift according to physician orders, resulting in a fall and a left shin fracture. The deficient practice was corrected prior to the survey.
Deficiencies (1)
Facility failed to ensure staff transferred a dependent resident with a mechanical lift in accordance with physician orders and plan of care, resulting in a fall and left shin fracture.
Report Facts
Census Bed Type - Total Residents: 92
Census Payor Type - Total: 47
Residents requiring mechanical lift: 1
Incident report number: 344
Dates of survey: 2024-09-26 to 2024-09-27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 2 | Licensed Practical Nurse | Provided handwritten statement and was given corrective action for not notifying management of Resident E's fall |
| CNA 3 | Certified Nursing Assistant | Failed to transfer Resident E with mechanical lift and lowered resident to floor, resulting in fall and injury; received final corrective action |
| CNA 4 | Certified Nursing Assistant | Interviewed regarding availability of mechanical lift slings |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 27, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure staff transferred a dependent resident (Resident E) with a mechanical lift according to physician orders and the plan of care, which resulted in a fall and injury.
Complaint Details
The complaint investigation found that on 7/27/24, Resident E was lowered to the floor during a transfer without use of the mechanical lift as ordered. The resident sustained a fracture to the left distal tibial metaphysis and fibular shaft. Staff failed to notify management promptly. Corrective actions were taken including staff discipline and education.
Findings
The facility failed to follow the mechanical lift transfer protocol for Resident E, resulting in a fall and a left shin fracture. The incident was self-reported, and corrective actions including staff education and disciplinary measures were implemented prior to the survey date, resolving the deficiency.
Deficiencies (1)
Failed to ensure staff transferred a dependent resident with a mechanical lift in accordance with physician orders and plan of care, resulting in a fall and left shin fracture.
Report Facts
Incident report number: 344
Date of incident: Jul 27, 2024
Date of corrective action: Jul 31, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 2 | Licensed Practical Nurse | Did not notify management of Resident E's fall, received corrective action |
| CNA 3 | Certified Nursing Assistant | Did not transfer Resident E with mechanical lift as per plan of care, received corrective action |
| CNA 4 | Certified Nursing Assistant | Interviewed regarding mechanical lift sling availability |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 11, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00435850 completed on June 26, 2024.
Complaint Details
Complaint IN00435850 was investigated and found to be corrected.
Findings
Holy Cross Village at Notre Dame 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 Complaint IN00435850.
Inspection Report
Complaint Investigation
Census: 92
Capacity: 92
Deficiencies: 1
Date: Jun 26, 2024
Visit Reason
The visit was conducted for the investigation of Complaint IN00435850 regarding an allegation of abuse at the facility.
Complaint Details
Complaint IN00435850 was related to an allegation of physical abuse by a staff member toward Resident C. The facility investigated the allegation but did not substantiate it and did not report it as abuse, consulting lawyers who believed it was not abuse but gossip.
Findings
The facility failed to report an allegation of abuse for one resident (Resident C). The allegation was investigated and deemed unsubstantiated within two hours, and the facility did not report it as abuse based on legal consultation.
Deficiencies (1)
Failed to report an allegation of abuse for 1 of 3 residents reviewed for abuse (Resident C).
Report Facts
Census: 92
Total Capacity: 92
Residents reviewed for abuse: 3
Residents affected: 1
Completion date for corrective action: Jul 9, 2024
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 26, 2024
Visit Reason
The inspection was conducted due to a complaint alleging physical abuse of a resident by a staff member.
Complaint Details
This citation relates to Complaint IN00435850. The allegation involved a staff member purposely pushing a resident out of bed causing the resident to hit her head. The facility did not substantiate or report the abuse, consulting lawyers who concluded it was not abuse.
Findings
The facility failed to report an allegation of abuse for one resident after investigating and determining there was no abuse, consulting lawyers who also concluded it was not abuse but gossip. The facility did not follow its policy requiring timely reporting of alleged abuse to proper authorities.
Deficiencies (1)
Failed to timely report suspected abuse and report the results of the investigation to proper authorities.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON | Director of Nursing | Interviewed regarding the abuse allegation and facility's investigation and reporting procedures. |
| Administrator | Interviewed along with the DON regarding the abuse allegation and facility's investigation and reporting procedures. |
Inspection Report
Follow-Up
Census: 48
Capacity: 52
Deficiencies: 0
Date: Jun 14, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 04/18/24 was performed by the Indiana Department of Health in accordance with 42 CFR Subpart 483.90(a).
Findings
At this Life Safety Code PSR, Holy Cross Village at Notre Dame Inc. was found in compliance with 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 and had appropriate fire alarm and smoke detection systems.
Report Facts
Certified beds: 52
Census: 48
Inspection Report
Life Safety
Census: 49
Capacity: 52
Deficiencies: 4
Date: Apr 18, 2024
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 NFPA 101 standards.
Findings
The facility was found not in compliance with Life Safety Code requirements, including deficiencies related to sprinkler system installation and maintenance, fire hydrant inspections, ground fault circuit interrupter (GFCI) maintenance, and improper use of extension cords. Corrective actions were taken during the survey and systemic changes were planned to prevent recurrence.
Deficiencies (4)
Failed to maintain the ceiling construction around a sprinkler head in resident room 134, missing escutcheon plate.
Failed to ensure 3 private fire hydrants were continuously maintained and inspected periodically; last inspection dated 06/01/22 and documentation incomplete.
Failed to ensure 1 ground fault circuit interrupter (GFCI) in restroom of room 134 was properly maintained; GFCI did not trip when tested.
Failed to ensure 2 flexible cords were not used as a substitute for fixed wiring; extension cords found in rooms 134 and 113.
Report Facts
Certified beds: 52
Census: 49
Fire hydrants inspected: 5
Deficiencies completion date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jen Armendariz | Director of Nursing (DON) | Signed the report |
| Maintenance Director | Involved in observations and interviews related to sprinkler and electrical deficiencies | |
| Director of Plant Operations | Involved in observations and interviews related to sprinkler, fire hydrants, and electrical deficiencies | |
| Executive Director | Participated in exit conference discussing findings |
Inspection Report
Routine
Deficiencies: 5
Date: Mar 25, 2024
Visit Reason
The inspection was conducted as a routine regulatory oversight visit to assess compliance with healthcare facility regulations, including care planning, pressure ulcer prevention, medication storage, and food safety.
Findings
The facility was found deficient in revising care plans timely, preventing pressure ulcers, providing timely incontinent care, ensuring proper medication storage and labeling, and maintaining food safety and sanitation standards in the kitchen and pantry.
Deficiencies (5)
Failed to revise a care plan for an anti-anxiety medication for 1 of 15 residents reviewed (Resident 8).
Failed to prevent development of pressure areas for 1 of 3 residents reviewed for pressure areas (Resident 9).
Failed to provide timely incontinent care for 1 of 2 residents reviewed for urinary incontinence (Resident 9).
Failed to ensure medication storage areas were free of expired medications and properly labeled, and failed to maintain medication refrigerator in a safe/sanitary manner.
Failed to ensure food items in cooler were sealed securely, failed to maintain clean cooking utensils and skillets, failed to clean microwaves, failed to remove expired foods, and failed to date foods when opened in kitchen and pantry.
Report Facts
Residents reviewed for care plans: 15
Residents reviewed for pressure areas: 3
Residents reviewed for urinary incontinence: 2
Pressure ulcer measurement: 3
Pressure ulcer measurement: 1.5
Pressure ulcer measurement: 0.5
Braden Scale score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Indicated care plan should have been updated and provided medication storage and administration policies |
| Assistant Director of Nursing | Assistant Director of Nursing | Indicated resident should have been checked more for incontinence and provided incontinence and pressure injury prevention policies |
| LPN 2 | Licensed Practical Nurse | Observed expired medications, medication storage issues, and pantry conditions |
| CNA 6 | Certified Nursing Assistant | Observed resident's brief saturated and indicated resident should have been checked more |
| Regional Manager | Regional Manager | Provided food and supply storage and cleaning policies and acknowledged expired food items |
| Regional Staff | Regional Staff | Acknowledged issues with skillets and utensils in kitchen |
Inspection Report
Renewal
Census: 43
Capacity: 91
Deficiencies: 7
Date: Mar 25, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey including a State Residential Licensure Survey conducted on March 19, 20, 21, 22, and 25, 2024.
Findings
The facility was found deficient in multiple areas including care plan revisions, pressure ulcer prevention, incontinent care, medication storage and labeling, food safety and sanitation, fire and disaster preparedness drills, and semi-annual resident evaluations.
Deficiencies (7)
Failed to revise a care plan for an anti-anxiety medication for 1 of 15 residents reviewed (Resident 8).
Failed to prevent development of pressure areas for 1 of 3 residents reviewed for pressure areas (Resident 9).
Failed to provide timely incontinent care for 1 of 2 residents reviewed for urinary incontinence (Resident 9).
Failed to ensure medication storage areas were free of expired medications, expired glucose testing solution, medications had resident identifiers, and stored properly in medication refrigerator (Dujarie Medication Cart and Storage Room).
Failed to ensure food items in cooler were sealed securely after opening, failed to have clean cooking utensils and skillets without missing Teflon, failed to ensure microwaves were clean and free of food debris, failed to remove expired foods, and failed to date foods when opened in kitchen and pantry.
Failed to ensure 12 fire and evacuation drills were completed throughout the year, specifically one drill per shift per quarter.
Failed to complete semi-annual evaluations for 2 of 7 resident records reviewed (Residents 5 and 7).
Report Facts
Survey dates: 5
Census: 43
Total capacity: 91
Fire drills required: 12
Fire drills missing: 2
Residents reviewed for care plans: 15
Residents reviewed for pressure areas: 3
Residents reviewed for urinary incontinence: 2
Residents reviewed for semi-annual evaluations: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jen Armendariz | Director of Nursing | Provided policies and indicated care plan revision requirements |
| CNA 6 | Interviewed regarding incontinent care for Resident 9 | |
| LPN 2 | Licensed Practical Nurse | Observed medication cart and storage room deficiencies |
| Assistant Director of Nursing | ADON | Interviewed regarding care plan and incontinent care deficiencies |
| Regional Manager | Provided food and supply storage policies and observations | |
| Maintenance Director | Interviewed regarding fire drill scheduling and documentation | |
| Assisted Living Manager | Interviewed regarding semi-annual evaluations and policies |
Inspection Report
Renewal
Deficiencies: 0
Date: Mar 25, 2024
Visit Reason
Paper Compliance to the Recertification and State Licensure survey completed on March 25, 2024.
Findings
Holy Cross Village at Notre Dame 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
Complaint Investigation
Census: 50
Capacity: 93
Deficiencies: 0
Date: Sep 20, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00410681 and included the investigation of Residential Complaint IN00412059.
Complaint Details
Complaint IN00410681 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00410681 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.
Report Facts
Census SNF/NF beds: 30
Census SNF beds: 20
Census Residential beds: 43
Total licensed capacity: 93
Census Medicare residents: 13
Census Medicaid residents: 10
Census Other payor residents: 27
Total census residents: 50
Inspection Report
Follow-Up
Census: 45
Capacity: 52
Deficiencies: 0
Date: May 15, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 03/24/23 was performed to verify compliance with Life Safety Code and state licensure requirements.
Findings
At this Life Safety Code PSR, Holy Cross Village at Notre Dame Inc. 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 was fully sprinklered and had appropriate fire alarm and smoke detection systems.
Report Facts
Certified beds: 52
Census: 45
Inspection Report
Life Safety
Census: 43
Capacity: 52
Deficiencies: 7
Date: Mar 24, 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 on March 24, 2023.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies included obstructions in means of egress, incomplete preventative maintenance documentation for smoke alarms, incomplete fire pump system maintenance, doors lacking positive latching hardware, missing annual fire door inspections, combustible materials stored too close to oxygen storage, and other fire safety code violations.
Deficiencies (7)
Failed to ensure 1 of 6 means of egress were continuously maintained free of all obstructions or impediments to full instant use in case of emergency.
Failed to ensure documentation for preventative maintenance of 2 battery operated smoke alarms in the main dining room were complete.
Failed to maintain 1 of 1 fire pump system in accordance with NFPA 25; monthly inspections incomplete and no annual inspection documentation.
Failed to ensure 3 of 40 corridor doors had positive latching hardware and would resist passage of smoke.
Failed to ensure annual inspection and testing of 1 of 5 fire door assemblies were completed.
Failed to ensure annual inspection for the oxygen storage/transfilling room fire door was completed.
Failed to ensure a minimum distance of at least five feet separated combustible materials from oxygen storage equipment in 1 oxygen storage area.
Report Facts
Certified beds: 52
Census: 43
Dually certified beds: 30
Medicare only beds: 22
Number of corridor doors inspected: 40
Number of fire door assemblies: 5
Number of battery operated smoke alarms: 2
Fire pump systems: 1
Cardboard boxes: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jack Mueller | Administrator | Named in relation to findings and exit conference |
| Maintenance Technician #1 | Interviewed and involved in observations and findings related to maintenance and fire safety | |
| Maintenance Director | Interviewed and involved in observations and findings related to maintenance and fire safety | |
| Plant Operations Director | Responsible for reporting to QAPI committee on corrective actions |
Inspection Report
Annual Inspection
Census: 39
Capacity: 76
Deficiencies: 11
Date: Feb 27, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey including a State Residential Licensure Survey conducted from February 20 to 27, 2023.
Findings
The facility was found deficient in multiple areas including resident dignity and self-determination, care plan updates, ADL care, accident prevention, respiratory care, food service sanitation, emergency record completeness, and maintenance of building systems.
Deficiencies (11)
Failed to provide adequate clothing for 1 of 2 residents reviewed for dignity (Resident 32).
Failed to provide showers per resident's choice for 1 of 1 resident reviewed for preferences (Resident 6).
Failed to update care plans for 2 of 17 residents reviewed for care planning (Residents 32 & 24).
Failed to ensure residents received showers/bathing twice a week and fingernails were cleaned for dependent residents (Residents 9 & 19).
Failed to ensure safety measures were followed for residents receiving haircuts in the beauty shop while on oxygen (Residents 9 & 32).
Failed to ensure proper storage of nasal cannula tubing and CPAP mask when not in use for 2 of 4 residents reviewed for respiratory care (Residents 9 & 28).
Failed to provide sanitary food service in 1 of 2 dining rooms observed for food delivery service (main dining room).
Failed to provide sanitary food service to 8 of 8 residents observed for food delivery service in the residential main dining room.
Failed to ensure yearly inspection was performed on the heating and ventilation system, potentially affecting 39 residents.
Failed to provide required documentation of photographs for 3 of 5 residents and advanced directive for 1 of 5 residents in the emergency file (Residents C, D, G, & F).
Failed to ensure a Certified First Aid employee was working every shift in Assisted Living.
Report Facts
Survey dates: 6
Census: 39
Total capacity: 76
Residents shower schedule: 2
Weight loss percentage: 11.1
Oxygen liters: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jen Armendariz | Director of Nursing | Signed the report |
| CNA 5 | Interviewed regarding resident dignity and shower preferences | |
| Assistant Director of Nursing | ADON | Provided policies and interviews regarding resident care and facility practices |
| Dietary Supervisor 15 | Provided food service policy and interview | |
| Memory Care Manager | Interviewed regarding shower documentation and resident care | |
| Certified Nurse Aide 11 | Interviewed regarding shower and nail care practices | |
| Certified Nurse Aide 12 | Interviewed regarding shower and nail care practices | |
| Licensed Practical Nurse 16 | Interviewed regarding oxygen tubing storage | |
| Nurse Supervisor | Interviewed regarding photographs and advanced directives | |
| Director of Plant Operations | Interviewed regarding HVAC maintenance | |
| Administrator | Interviewed regarding salon services and oxygen use |
Inspection Report
Renewal
Deficiencies: 0
Date: Feb 27, 2023
Visit Reason
Paper Compliance to the Recertification and State Licensure survey completed on February 27, 2023.
Findings
Holy Cross Village at Notre Dame 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
Routine
Deficiencies: 7
Date: Feb 27, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, activities of daily living, fall prevention, respiratory care, and food service sanitation at Holy Cross Village at Notre Dame Inc.
Findings
The facility was found deficient in multiple areas including failure to provide adequate clothing and dignity for residents, failure to provide showers per resident preferences, failure to update care plans timely, inadequate assistance with activities of daily living such as bathing and nail care, failure to ensure safety measures during salon services for residents on oxygen, improper storage of respiratory equipment, and unsanitary food service practices.
Deficiencies (7)
Failed to provide adequate clothing for 1 of 2 residents reviewed for dignity (Resident 32).
Failed to provide showers per the resident's choice for 1 of 1 resident reviewed for preferences (Resident 6).
Failed to update the plan of care for 2 of 17 residents reviewed for care planning (Residents 32 & 24).
Failed to ensure residents received showers/bathing twice a week and fingernails were cleaned for dependent residents for 2 out of 3 residents reviewed for activities of daily living (Residents 9 & 19).
Failed to ensure safety measures were followed for a resident receiving a hair cut in the beauty shop while wearing oxygen for 2 out of 3 residents reviewed for accidents (Residents 9 & 32).
Failed to ensure proper storage of nasal cannula tubing and CPAP mask when not in use for 2 out of 4 residents reviewed for respiratory care (Residents 9 & 28).
Failed to provide sanitary food service in 1 of 2 dining rooms residents observed for food delivery service (main dining room).
Report Facts
Shower frequency: 2
Weight loss percentage: 11.1
Weight loss percentage: 8.6
Weight loss percentage: 18.8
Oxygen liters: 2.5
Dates of showers for Resident 6: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Observed leaving Resident 32's room with resident inadequately dressed |
| CNA 5 | Certified Nursing Assistant | Interviewed regarding shower schedules and resident dignity |
| Assistant Director of Nursing | ADON | Provided policies and interviews regarding resident rights, care planning, showering, nail care, and respiratory care |
| Registered Dietician | Interviewed regarding nutritional care and care plan updates for Resident 32 | |
| Certified Nurse Aide 11 | CNA | Interviewed about showering and nail care practices |
| Certified Nurse Aide 12 | CNA | Interviewed about showering and nail care practices |
| Memory Care Manager | Interviewed about showering schedules and documentation | |
| Dietary Supervisor 15 | Provided policy and interview about dining room service | |
| Administrator | Interviewed regarding salon services and hair dryer use with oxygen | |
| CNA 6 | Certified Nursing Assistant | Interviewed about respiratory equipment storage |
| Licensed Practical Nurse 16 | LPN | Interviewed about oxygen tubing storage |
| Beautician | Observed and interviewed regarding hair dryer use with resident on oxygen |
Inspection Report
Follow-Up
Census: 45
Capacity: 50
Deficiencies: 0
Date: Dec 16, 2022
Visit Reason
A Post Survey Revisit (PSR) was conducted on 12/16/22 for the Emergency Preparedness Survey and the Life Safety Code Preoccupancy survey that exited on 10/21/22, conducted by the Indiana Department of Health.
Findings
At this Emergency Preparedness PSR, the facility was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. At the Life Safety Code PSR survey, the facility was found in compliance with Requirements for Participation in Medicare/Medicaid and Life Safety Code standards.
Report Facts
Facility capacity: 50
Census: 45
Inspection Report
Deficiencies: 2
Date: Oct 21, 2022
Visit Reason
A preoccupancy Emergency Preparedness and Life Safety Code survey was conducted for the addition of resident rooms and renovation of facility spaces, including corridor expansion and addition of licensed beds, to ensure compliance with federal and state regulations.
Findings
The facility was found not in compliance with Emergency Preparedness requirements due to lack of an evacuation policy and procedure, and not in compliance with Life Safety Code requirements due to a corridor door that did not latch properly and had excessive clearance at the bottom, potentially affecting staff safety.
Deficiencies (2)
Emergency Preparedness plan did not include an evacuation policy and procedure addressing safe evacuation, staff responsibilities, transportation, evacuation locations, and communication.
One corridor door on the Dujaire House wing did not latch properly and had a gap exceeding 1 inch between the door bottom and floor, failing to resist passage of smoke.
Report Facts
Licensed beds added: 2
Corridor doors inspected: 12
Gap size: 1.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jack Mueller | Administrator | Named in relation to Emergency Preparedness plan review and exit conference. |
| Maintenance Technician #1 | Interviewed regarding Emergency Preparedness plan and corridor door deficiency. | |
| Maintenance Director | Interviewed regarding corridor door deficiency and corrective actions. |
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