Inspection Reports for Maple Manor Christian Home Inc
643 W UTICA ST, IN, 47172
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 12, 2025, found the facility in compliance with Life Safety Code requirements and no deficiencies were cited. Prior inspections showed a pattern of deficiencies primarily related to fire safety and emergency preparedness, including issues with fire alarm policies, sprinkler system maintenance, corridor obstructions, and emergency power system testing. Complaint investigations substantiated deficiencies involving resident care concerns such as neglect, abuse, restraint use, and medication administration delays, with corrective actions implemented in each case. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s recent compliance with life safety standards and absence of deficiencies in the latest inspections suggest improvement following earlier issues.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
121% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
88% occupied
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Life Safety
Census: 50
Capacity: 57
Deficiencies: 0
Mar 12, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 01/30/25 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR Life Safety Code survey, Maple Manor Christian Home Inc 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
Annual Inspection
Deficiencies: 0
Mar 4, 2025
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey conducted on January 14, 2025.
Findings
Maple Manor Christian Home Inc. 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: 51
Capacity: 57
Deficiencies: 8
Jan 30, 2025
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) to assess compliance with fire safety and life safety code requirements.
Findings
The facility was found not in compliance with several Life Safety Code requirements including incomplete fire alarm system policies, inadequate fire department connection signage, unsealed gaps around sprinkler heads, corridor doors with holes allowing smoke passage, lack of annual fire door inspections, incomplete testing and documentation of patient care related electrical equipment, and improper storage of oxygen cylinders.
Severity Breakdown
SS=F: 5
SS=E: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to provide a complete written policy for protection of residents when fire alarm system is out of service for four hours or more. | SS=F |
| Did not provide adequate signage for fire department connection (FDC). | SS=F |
| Failed to maintain ceiling construction around sprinkler head causing potential delay in sprinkler activation. | SS=E |
| Failed to provide correct written policies for sprinkler system out-of-service for 10 hours or more. | SS=F |
| Failed to ensure 2 of over 30 corridor doors would resist passage of smoke due to holes in doors. | SS=E |
| Failed to ensure annual inspection and testing of all fire door assemblies with proper documentation. | SS=F |
| Failed to conduct required maintenance and maintain documentation of inspections for Patient Care Related Electrical Equipment (PCREE). | SS=F |
| Failed to ensure oxygen cylinders were properly secured to prevent falling. | SS=E |
Report Facts
Certified beds: 57
Census: 51
Corridor doors with holes: 2
Fire door assemblies: 90
Oxygen cylinders improperly stored: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cullen Istre | Laboratory Director or Provider/Supplier Representative | Signed the report |
| Maintenance Supervisor | Acknowledged findings related to fire watch, sprinkler system, fire door inspections, and oxygen cylinder storage | |
| Administrator | Acknowledged findings related to fire watch and fire alarm system policies | |
| QAPI Coordinator | Responsible for reviewing and maintaining policies and monitoring compliance | |
| Administrative Assistant | Responsible for daily visual audits of oxygen cylinder storage |
Inspection Report
Renewal
Census: 47
Capacity: 47
Deficiencies: 1
Jan 14, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted over January 8, 9, 10, 13, and 14, 2024.
Findings
The facility failed to follow documentation procedures for dispensed medications on the Controlled Drug Record of administered narcotics for 5 of 24 residents observed. Discrepancies were found between medication counts and documentation for residents 16, 15, 13, 49, and 50.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to follow documentation procedures of dispensed medications on the Controlled Drug Record of administered narcotics for 5 of 24 residents observed. | SS=E |
Report Facts
Residents observed for pharmacy services: 24
Residents with documentation discrepancies: 5
Census: 47
Total licensed capacity: 47
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cullen Istre | ADM | Facility representative who signed the report |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 50
Deficiencies: 1
Nov 22, 2024
Visit Reason
The visit was conducted for the investigation of three complaints (IN00446181, IN00446569, and IN00446803) related to the facility.
Findings
The facility was found deficient for failing to ensure a resident (Resident B) was free from physical restraints, specifically being restrained in place by locking wheelchair brakes and positioning arms across the chest. No deficiencies were cited for two of the complaints. The deficiency was corrected by the facility after education and systemic interventions.
Complaint Details
Complaint IN00446181 was substantiated with a federal/state deficiency cited (F604). Complaints IN00446569 and IN00446803 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a resident was not restrained in place by locking wheelchair brakes and placing arms across the chest. | SS=D |
Report Facts
Census: 50
Total Capacity: 50
Medicare Census: 3
Medicaid Census: 35
Other Payor Census: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Aide (CNA 5) | Observed restraining Resident B by locking wheelchair brakes and placing arms across chest | |
| Executive Director | Interviewed and indicated CNA 5 was trying to keep Resident B from going to her room to prevent falls | |
| Staff Member 6 | Interviewed and indicated it was not appropriate to lock a resident's wheelchair to prevent movement | |
| Director of Nursing | Provided facility policy document titled 'If You See Something Say Something' |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 51
Deficiencies: 1
Jun 3, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00434474 regarding allegations of staff to resident abuse.
Findings
The facility failed to ensure that staff to resident abuse did not occur for one resident (Resident B). Evidence included observation, interviews, record review, and video footage showing inappropriate behavior by a staff member toward the resident. The staff member was terminated and corrective actions were implemented.
Complaint Details
Complaint IN00434474 was substantiated with a Federal/State deficiency cited as F600 related to abuse and neglect. The incident involved CNA 9 verbally and physically abusing Resident B on 5/12/24. The staff member was terminated and the facility implemented a systemic corrective plan including staff education and resident assessments.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure staff to resident abuse did not occur for Resident B, including verbal abuse and inappropriate physical contact. | SS=D |
Report Facts
Census SNF/NF beds: 51
Census total residents: 51
Medicare residents: 2
Medicaid residents: 38
Other payor residents: 11
Date of incident: May 12, 2024
Date of correction completion: May 30, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 9 | Certified Nursing Aide | Named in abuse incident involving Resident B; terminated after investigation |
| CNA 5 | Certified Nursing Aide | Reported the inappropriate behavior of CNA 9 toward Resident B |
| LPN 3 | Licensed Practical Nurse | Received report from CNA 5 about CNA 9's behavior |
| Director of Nursing | Director of Nursing | Interviewed during investigation and confirmed abuse via video review |
Inspection Report
Life Safety
Deficiencies: 0
Feb 21, 2024
Visit Reason
The visit was a Post Survey Revisit (PSR) for the Life Safety Code Recertification and State Licensure Survey following previous surveys that exited on 12/13/23 and 02/08/24.
Findings
Maple Manor Christian Home 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, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Re-Inspection
Census: 51
Capacity: 57
Deficiencies: 1
Feb 8, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 12/13/2023.
Findings
At the PSR survey, the facility was found in compliance with Emergency Preparedness Requirements. However, the facility was found not in compliance with Life Safety Code requirements due to failure to properly enclose two former dumbwaiter shafts with the required fire resistance rating, posing a risk to residents, staff, and visitors. The deficiency was corrected by sealing the openings with drywall and fire caulk.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure the protection of 2 former dumbwaiter shafts with minimum one-hour fire-rated construction at the top of each shaft. | SS=F |
Report Facts
Certified beds: 57
Census: 51
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Steven Cunningham | Administrator | Named in relation to observations and exit conference |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 48
Deficiencies: 1
Feb 1, 2024
Visit Reason
The visit was conducted as an investigation of Complaint IN00424481 regarding allegations of neglect at the facility.
Findings
The facility failed to ensure staff immediately responded and completed a full body assessment when Resident B fell. The RN involved did not assess the resident for injury and delayed assistance, constituting neglect.
Complaint Details
Complaint IN00424481 was substantiated with a Federal/State deficiency cited at F600 for neglect related to failure to respond appropriately to a resident fall.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure staff immediately responded and completed a full body assessment when Resident B fell. | SS=D |
Report Facts
Census SNF/NF: 48
Medicaid Census: 32
Other Payor Census: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN 4 | Registered Nurse | Named in neglect finding for failure to assess Resident B after fall |
| CNA 8 | Certified Nursing Aide | Witnessed fall and attempted to assist Resident B |
| LPN 3 | Licensed Practical Nurse | Conducted assessment after video review of fall |
| Executive Director | Observed video of incident and provided interview | |
| Director of Nursing | Provided facility abuse/neglect policy document |
Inspection Report
Life Safety
Census: 46
Capacity: 57
Deficiencies: 14
Dec 13, 2023
Visit Reason
An Emergency Preparedness and Life Safety Code Recertification Survey was conducted by the Indiana Department of Health to assess compliance with emergency preparedness requirements and life safety codes.
Findings
The facility was found not in compliance with emergency preparedness training requirements, emergency power system maintenance, means of egress obstructions, door locking arrangements, hazardous area enclosures, sprinkler system installation, fire extinguisher maintenance, electrical receptacle standards, and use of extension cords. Corrective actions and plans of correction were provided for each deficiency.
Severity Breakdown
SS=F: 6
SS=E: 4
SS=D: 3
SS=C: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to ensure emergency preparedness training and testing program included annual training and documentation. | SS=F |
| Failed to implement emergency power system inspection, testing, and maintenance requirements including weekly inspections and 36-month load testing. | SS=F |
| Failed to maintain means of egress free of obstructions; furniture and carts blocked corridors reducing egress width. | SS=F |
| Failed to ensure exit door keypad code was posted for residents without specialized security needs. | SS=E |
| Failed to ensure vertical shafts (former dumbwaiters) were enclosed with minimum 1-hour fire resistance construction. | SS=F |
| Failed to ensure hazardous areas such as laundry and combustible storage rooms were separated by smoke resistant partitions and doors; laundry doors were propped open. | SS=F |
| Failed to maintain sprinkler system installation; missing escutcheon ring on ceiling sprinkler in main dining room. | SS=E |
| Failed to maintain portable fire extinguisher pressure gauge in acceptable range and secure extinguisher properly. | SS=D |
| Failed to ensure corridor doors had no impediment to closing and latching; wedge used to prop open Activity Room door. | SS=E |
| Failed to provide combustion air intake from outside for fuel fired equipment in basement. | SS=D |
| Failed to conduct quarterly fire drills on third shift at unexpected times under varying conditions. | SS=C |
| Failed to ensure nonhospital-grade electrical receptacles were replaced with hospital-grade receptacles in resident room 200. | SS=D |
| Failed to maintain weekly emergency generator inspection documentation and label remote manual stop button for emergency generator. | SS=F |
| Failed to ensure extension cords and power strips were not used as substitutes for fixed wiring; refrigerator and microwave plugged into power strip in nurse's station. | SS=E |
Report Facts
Certified beds: 57
Census: 46
Deficiencies cited: 14
Emergency generator rating: 35
Fire drills missing: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Steven Cunningham | Administrator | Named in relation to emergency preparedness training and exit conference |
Inspection Report
Renewal
Census: 46
Capacity: 46
Deficiencies: 0
Nov 17, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted over November 13-17, 2023.
Findings
Maple Manor Christian Home was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the Recertification and State Licensure Survey.
Report Facts
Census payor type - Medicare: 2
Census payor type - Medicaid: 33
Census payor type - Other: 11
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 12, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00416292 completed on September 12, 2023.
Findings
Maple Manor Christian Home INC 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 to the Complaint Investigation.
Complaint Details
Investigation of Complaint IN00416292 completed with paper compliance; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 52
Capacity: 52
Deficiencies: 1
Sep 11, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00416292 regarding a federal/state deficiency related to quality of care at the facility.
Findings
The facility failed to ensure timely blood sugar level checks and insulin administration for a diabetic resident admitted on 8/23/23. The resident did not receive insulin orders entered into the system timely, resulting in delayed treatment and a high blood sugar reading of 600 mg/dl. The facility implemented new procedures to audit admission medication orders and educate staff on insulin and accu check order entry.
Complaint Details
Complaint IN00416292 was substantiated with a federal/state deficiency cited at F684 related to quality of care involving delayed insulin administration and blood sugar monitoring for Resident B.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a resident admitted with diabetes received timely blood sugar checks and insulin administration. | SS=D |
Report Facts
Census: 52
Total Capacity: 52
Insulin doses: 32
Blood sugar reading: 600
Insulin doses: 20
Toujeo insulin dose: 15
Humalog insulin dose: 5
Admissions/readmissions audited: 4
Audit timeframe: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Steven Cunningham | Laboratory Director or Provider/Supplier Representative | Signed the report |
| RN 2 | Registered Nurse | Interviewed regarding admission process and insulin administration for Resident B |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding agency nurse performance and education on insulin orders |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 50
Deficiencies: 0
Jun 26, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00410849.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00410849 was investigated and found to have no deficiencies related to the allegation.
Report Facts
Census Bed Type: 50
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 33
Census Payor Type - Other: 16
Inspection Report
Complaint Investigation
Census: 49
Capacity: 49
Deficiencies: 0
Jun 2, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00404747.
Findings
No deficiencies related to the allegations in Complaint IN00404747 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaint IN00404747 found no deficiencies related to the allegations.
Report Facts
Medicare census: 3
Medicaid census: 37
Other payor census: 9
Inspection Report
Re-Inspection
Census: 43
Capacity: 57
Deficiencies: 0
Jan 24, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 11/29/22 was performed to verify compliance with fire safety and licensure requirements.
Findings
The facility 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. The facility is fully sprinkled with appropriate smoke detection systems in place.
Report Facts
Facility capacity: 57
Census: 43
Inspection Report
Renewal
Census: 42
Capacity: 57
Deficiencies: 6
Nov 29, 2022
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 an Emergency Preparedness Survey in accordance with 42 CFR 483.73.
Findings
The facility was found in compliance with Emergency Preparedness Requirements. However, several Life Safety Code deficiencies were identified including corridor obstructions, outdated smoke alarms, cooktop safety issues, missing flame spread rated panel on attic access, lack of semi-annual fire alarm visual inspections, a malfunctioning fire alarm pull station, and incomplete sprinkler system inspections and maintenance.
Severity Breakdown
SS=E: 4
SS=F: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Storing recliners and a side table in the 200 hall egress corridor obstructed means of egress. | SS=E |
| Failure to replace battery operated smoke alarms in 33 resident sleeping rooms that were outdated beyond 10 years. | SS=E |
| Cooktops in Physical Therapy and Activity rooms were not deactivated when not in use. | SS=E |
| Attic access panel in the 200 hall linen closet lacked a flame spread rated panel. | SS=E |
| Fire alarm system lacked documentation of semi-annual visual inspections and a pull station was broken and unrepaired. | SS=F |
| Sprinkler system was not inspected and tested during 2 of 4 quarters in 2022 and a sprinkler head escutcheon was missing in the Physical Therapy room. | SS=F |
Report Facts
Certified beds: 57
Census: 42
Resident rooms with outdated smoke alarms: 33
Residents potentially affected by corridor obstruction: 15
Residents potentially affected by outdated smoke alarms: 30
Sprinkler system inspection quarters missed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Steven Cunningham | Administrator | Named in relation to findings and exit conference |
Inspection Report
Renewal
Census: 41
Capacity: 41
Deficiencies: 3
Nov 7, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from October 31 to November 7, 2022.
Findings
The facility was found deficient in accurate skin assessments, timely care plan revisions, and proper treatment and monitoring of pressure ulcers and skin impairments, including issues related to a soft helmet fitting and monitoring. Several residents had pressure ulcers or skin breakdowns that were not properly documented or treated in a timely manner.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure weekly skin assessments accurately reflected residents' current skin status and therapy evaluation for helmet assessment were documented for 2 of 13 residents reviewed for skin impairments. | SS=D |
| Failed to ensure timely revision of a resident's care plan to reflect new pressure wound interventions for 1 of 13 residents reviewed. | SS=D |
| Failed to ensure that a resident received care to prevent pressure ulcers and received necessary treatment to promote healing and prevent infection for 3 residents reviewed. | SS=D |
Report Facts
Census: 41
Total Capacity: 41
Deficiencies cited: 3
Dates of survey: 2022-10-31 to 2022-11-07
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Steven Cunningham | Laboratory Director or Provider/Supplier Representative | Signed the inspection report |
| Rehabilitation Manager | Interviewed regarding helmet fitting and monitoring | |
| Wound Nurse | Interviewed regarding wound care and skin assessments | |
| Director of Nursing | DON | Interviewed regarding assessment coding and care plan revisions |
| LPN 1 | Licensed Practical Nurse | Interviewed regarding weekly skin checks |
Inspection Report
Renewal
Deficiencies: 0
Nov 7, 2022
Visit Reason
Paper compliance review to the Recertification and State Licensure survey.
Findings
Maple Manor Christian Home Inc. 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 to the Recertification and State Licensure survey.
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