Inspection Reports for Mason Health Care Center
900 PROVIDENT DRIVE, IN, 46580
Back to Facility ProfileDeficiencies per Year
24
18
12
6
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 68
Capacity: 68
Deficiencies: 1
Jun 17, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00461321 regarding allegations of inadequate feeding tube care at Mason Health Care Center.
Findings
The facility failed to ensure appropriate feeding tube care for 1 of 3 residents reviewed, specifically Resident F, including lack of water flushes before and after medication administration and absence of insertion site care orders. The facility nursing staff was reinstructed on policies and procedures, and monitoring plans were established to ensure compliance.
Complaint Details
Complaint IN00461321 was received by the Indiana Department of Health on 6/11/2025 alleging inadequate cleaning around the feeding tube and improper dressing placement. The complaint was substantiated with deficiencies cited.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure appropriate feeding tube care regarding water flushes before and after medication administration and insertion site care for 1 of 3 residents reviewed (Resident F). | SS=D |
Report Facts
Census: 68
Total Capacity: 68
Medicare Residents: 6
Medicaid Residents: 44
Other Payor Residents: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Sevier | RN, RDQA | Signed the report as Laboratory Director or Provider/Supplier Representative |
| RN 2 | Interviewed on 6/17/2025 regarding feeding tube care orders |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 21, 2025
Visit Reason
The inspection was conducted as a Paper Compliance Review related to the Investigation of Complaints IN00454167 completed on March 5, 2025.
Findings
Mason Health Care 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 to the Complaint Investigation.
Complaint Details
Complaint Investigation IN00454167 was reviewed and found to be in compliance.
Inspection Report
Complaint Investigation
Census: 73
Capacity: 73
Deficiencies: 1
Mar 5, 2025
Visit Reason
This visit was for the investigation of Complaint IN00454167 related to allegations of deficiencies in medication administration at Mason Health Care Center.
Findings
The facility failed to provide scheduled pain medication in a timely manner for 1 of 3 residents reviewed (Resident B). The investigation found delays in administering pain medication beyond the facility's policy of within 60 minutes before or after the scheduled time, affecting Resident B's pain management.
Complaint Details
Complaint IN00454167 was substantiated with federal/state deficiencies cited at F684 related to delayed administration of pain medication to Resident B. Resident B and family reported communication issues with nursing staff, specifically RN 2, who did not inform other staff to administer medications timely. Facility policy requires medication administration within 60 minutes before or after scheduled time.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide scheduled pain medication in a timely manner for Resident B. | SS=D |
Report Facts
Census: 73
Total Capacity: 73
Medicare Residents: 7
Medicaid Residents: 50
Other Payor Residents: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Sevier | RN, RDQA | Signed the report as Laboratory Director or Provider/Supplier Representative |
| RN 2 | Named in findings related to failure to communicate and timely administer Resident B's pain medication | |
| RN 3 | Interviewed regarding communication problems with RN 2 about medication administration |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 77
Deficiencies: 0
Jan 25, 2025
Visit Reason
This visit was conducted to investigate two complaints, IN00443764 and IN00451428, regarding the facility.
Findings
No deficiencies related to the allegations in either complaint were cited. The facility was found to be in compliance with relevant federal and state regulations.
Complaint Details
Investigation of Complaint IN00443764 and Complaint IN00451428 found no deficiencies related to the allegations; both complaints were not substantiated.
Report Facts
Census: 77
Total Capacity: 77
Medicare Census: 5
Medicaid Census: 48
Other Payor Census: 24
Inspection Report
Follow-Up
Census: 79
Capacity: 105
Deficiencies: 0
Oct 24, 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 that exited on 09/17/24.
Findings
At this PSR survey, Mason Health Care Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility was fully sprinklered with a fire alarm system and smoke detection in required areas.
Report Facts
Certified beds: 105
Census: 79
Inspection Report
Life Safety
Census: 68
Capacity: 105
Deficiencies: 21
Sep 17, 2024
Visit Reason
Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with multiple Life Safety Code requirements including emergency preparedness, means of egress, fire alarm system maintenance, sprinkler system installation and maintenance, portable fire extinguisher placement, electrical safety, and fire drills. Deficiencies affected residents, staff, and visitors with corrective actions planned or underway.
Severity Breakdown
SS=F: 11
SS=E: 6
SS=D: 1
Deficiencies (21)
| Description | Severity |
|---|---|
| Failed to maintain an emergency preparedness plan based on a documented, facility-based and community-based risk assessment and strategies for addressing emergency events. | SS=F |
| Failed to ensure emergency preparedness plan addressed resident population, including persons at-risk and continuity of operations. | SS=F |
| Failed to include process for cooperation and collaboration with local, tribal, regional, State, or Federal emergency preparedness officials. | SS=F |
| Failed to ensure emergency preparedness communication plan included primary and alternate means for communication with staff and emergency agencies. | SS=F |
| Failed to conduct required emergency preparedness exercises at least twice per year including unannounced staff drills. | SS=F |
| Failed to ensure emergency generator had a reliable source of fuel with proper documentation. | SS=F |
| Means of egress through 5 exit doors were not readily accessible; doors were magnetically locked with codes not clearly understood by residents and visitors. | SS=F |
| Failed to maintain headroom clearance in activity dining rooms due to hanging light fixtures below required height. | SS=F |
| Failed to provide approved method for returning cooking appliances to approved design location after maintenance or cleaning. | SS=E |
| Failed to maintain kitchen extinguishing system with remote pull station mounted too high above floor. | SS=E |
| Fire alarm system had a trouble signal due to faulty sprinkler sensor that was not corrected at time of survey. | SS=F |
| Fire control panel time was incorrect. | — |
| Sprinkler head in activity supplies closet was obstructed by supplies stacked too high. | SS=E |
| Sprinkler heads in laundry room were covered with lint and not cleaned or replaced. | SS=E |
| Two portable fire extinguishers in maintenance office were improperly placed on the floor. | SS=D |
| Failed to ensure emergency generator had reliable fuel source documentation meeting regulatory requirements. | SS=F |
| Electrical receptacles within 18 inches of sink in medication room lacked required GFCI protection. | SS=F |
| Failed to conduct quarterly fire drills at varying times and conditions; drills clustered at end of month and similar times. | SS=F |
| Used multi-plug adaptors and power strips improperly as substitutes for fixed wiring in resident rooms and staff areas. | SS=E |
| Power strip used in patient care vicinity did not meet UL rating requirements. | SS=E |
| Flexible cord used as substitute for fixed wiring powering microwave oven in staff pantry. | SS=E |
Report Facts
Facility capacity: 105
Census: 68
Fire drills conducted: 12
Exit doors with deficient egress: 5
Activity dining rooms with deficient headroom: 2
Sprinkler heads covered with lint: 2
Portable fire extinguishers improperly placed: 2
Power strips removed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rukiya Brooks | Administrator | Named in multiple findings and exit conference |
Inspection Report
Annual Inspection
Census: 72
Capacity: 72
Deficiencies: 6
Aug 30, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from August 26 to August 30, 2024.
Findings
The facility was found deficient in multiple areas including care plan revisions, communication devices for non-English speaking residents, respiratory equipment maintenance, medication storage and security, food sanitation and safety, and infection prevention practices. Plans of correction were submitted for each deficiency with monitoring and re-education protocols.
Severity Breakdown
SS=D: 5
SS=E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure a care plan regarding activities was revised and updated for 1 of 21 residents reviewed (Resident 6). | SS=D |
| Failed to provide appropriate communication devices for a Spanish speaking resident (Resident 29). | SS=D |
| Failed to ensure respiratory equipment was changed per Physician orders for 1 resident reviewed for oxygen use (Resident 14). | SS=D |
| Failed to ensure medication storage carts were locked when not in use; failed to store medications appropriately; failed to remove expired medications; and failed to ensure medication refrigerator freezer was free from ice buildup. | SS=D |
| Failed to store, prepare and serve food in a sanitary manner in the kitchen and nutrition pantries, including unsealed and expired food items, and improper food handling by staff. | SS=E |
| Failed to ensure staff used appropriate PPE when emptying a Foley catheter drainage bag for 1 resident reviewed for catheters (Resident 14). | SS=D |
Report Facts
Census: 72
Total Capacity: 72
Survey Dates: 5
Medicare Residents: 7
Medicaid Residents: 48
Other Payor Residents: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Sevier | RN, RDQA | Signed the report as Laboratory Director or Provider/Supplier Representative |
| QMA 12 | Observed emptying Foley catheter drainage bag without appropriate PPE | |
| RN 14 | Interviewed regarding communication with Resident 29 and Spanish communication board availability | |
| LPN 3 | Interviewed regarding oxygen tubing and medication storage deficiencies | |
| Director of Nursing | Provided multiple facility policies and interviewed regarding deficiencies | |
| Dietary Manager | Interviewed regarding food sanitation and safety deficiencies |
Inspection Report
Renewal
Deficiencies: 0
Aug 30, 2024
Visit Reason
Paper Compliance to the Recertification and State Licensure Survey completed on August 30, 2024.
Findings
Mason Health Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 in regard to the Paper Compliance Review to the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 74
Capacity: 74
Deficiencies: 0
May 15, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00433810.
Findings
No deficiencies related to the allegations in Complaint IN00433810 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00433810 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 74
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 49
Census Payor Type - Other: 22
Inspection Report
Complaint Investigation
Census: 69
Capacity: 69
Deficiencies: 0
Apr 18, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00430593 and IN00429946.
Findings
No deficiencies related to the allegations in complaints IN00430593 and IN00429946 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaints IN00430593 and IN00429946 found no deficiencies related to the allegations.
Report Facts
Medicare census: 11
Medicaid census: 49
Other payor census: 9
Inspection Report
Complaint Investigation
Census: 71
Capacity: 71
Deficiencies: 0
Feb 6, 2024
Visit Reason
This visit was for the investigation of complaints IN00426233 and IN00425270.
Findings
No deficiencies related to the allegations in complaints IN00426233 and IN00425270 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00426233 - No deficiencies related to the allegations are cited. Complaint IN00425270 - No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type: 71
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 48
Census Payor Type - Other: 15
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 1, 2024
Visit Reason
The visit was conducted as a paper compliance review related to the investigation of complaints IN00423083 and IN00423682 completed on December 28, 2023.
Findings
Mason Health Care 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 to the complaint investigation.
Complaint Details
The investigation was related to complaints IN00423083 and IN00423682 and was completed with the facility found in compliance.
Inspection Report
Complaint Investigation
Census: 71
Capacity: 71
Deficiencies: 2
Dec 27, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00422660, IN00423083, and IN00423682 regarding allegations of misappropriation of resident property and pharmacy service deficiencies.
Findings
The facility failed to ensure thorough investigations were completed for allegations of misappropriation of resident property for two residents and failed to maintain proper accountability for medications awaiting final disposition for four residents. Some medication packets were not labeled with disposition reasons. The facility provided lock boxes to affected residents and initiated investigations but was unable to confirm theft in the cases reviewed.
Complaint Details
Complaint IN00422660 - No deficiencies related to the allegations were cited. Complaint IN00423083 - Federal/state deficiencies related to misappropriation of resident property were cited at F610. Complaint IN00423682 - Federal/state deficiencies related to pharmacy services were cited at F755.
Severity Breakdown
SS=D: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure investigations were completed for misappropriation of resident property for 2 residents. | SS=D |
| Failed to provide pharmaceutical services with accurate procedures for acquiring, receiving, dispensing, and administering drugs, including lack of accountability for medications awaiting final disposition for 4 residents. | SS=E |
Report Facts
Residents affected by misappropriation allegations: 2
Residents affected by medication disposition deficiencies: 4
Missing money reported for Resident B: 27
Missing money reported for Resident F: 40
Total census: 71
Total capacity: 71
Inspection Report
Life Safety
Census: 73
Capacity: 115
Deficiencies: 0
Oct 30, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR Subpart 483.90(a).
Findings
At this Life Safety Code Survey, Mason Health Care Center was found in compliance with the Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 483.90(a).
Inspection Report
Complaint Investigation
Census: 81
Capacity: 115
Deficiencies: 0
Oct 10, 2023
Visit Reason
A Post Survey Revisit (PSR) of Complaint Number IN00415890 was conducted to verify compliance following a complaint investigation.
Findings
At this PSR Complaint survey, Mason Health Care 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 was fully sprinklered except for two detached sheds used for storage.
Complaint Details
Complaint Number IN00415890 was corrected as of the survey date.
Report Facts
Facility capacity: 115
Census: 81
Inspection Report
Life Safety
Census: 77
Capacity: 115
Deficiencies: 3
Oct 2, 2023
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).
Findings
The facility was found not in compliance with Life Safety Code requirements, including failure to protect a hazardous storage area, failure to replace or test sprinkler system gauges every 5 years, and failure to post required signage in the liquid oxygen transfilling room.
Severity Breakdown
SS=E: 2
SS=F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure the activity office storage room with combustible materials over 50 square feet was protected as a hazardous area; the corridor door did not self-close and latch. | SS=E |
| Failed to ensure one of three sprinkler system gauges was replaced or tested every 5 years; one gauge was dated 2016 with no recalibration documentation. | SS=F |
| Failed to ensure the liquid oxygen storage/transfer room was provided with a sign indicating that transferring is occurring and that smoking is prohibited. | SS=E |
Report Facts
Facility capacity: 115
Census: 77
Number of sprinkler system gauges: 3
Number of sprinkler system gauges not replaced/tested within 5 years: 1
Number of residents potentially affected by hazardous storage room deficiency: 10
Number of residents potentially affected by oxygen room signage deficiency: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rukiya Brooks | Administrator | Reviewed findings and exit conference |
| Director of Plant Operations | Interviewed and involved in observations and corrective actions |
Inspection Report
Annual Inspection
Census: 79
Capacity: 79
Deficiencies: 9
Sep 22, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00416862 and IN00417481.
Findings
The facility was found deficient in multiple areas including resident dignity during dining, privacy violations, failure to report abuse allegations timely, inadequate assistance with activities of daily living, insufficient foot care, lack of individualized contracture management, improper IV therapy management, inadequate staffing levels, and kitchen sanitation issues.
Complaint Details
Complaint IN00416862 - No deficiencies related to the allegations are cited. Complaint IN00417481 - Deficiencies related to the allegations are cited at F550, F677, and F725.
Severity Breakdown
SS=D: 8
SS=F: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure dignity was maintained during assisted dining for 3 residents. | SS=D |
| Failed to ensure privacy for 3 residents and confidentiality of personal and medical records. | SS=D |
| Failed to report and investigate allegations of abuse for 2 residents. | SS=D |
| Failed to respond to a request with positioning and personal care for 1 resident. | SS=D |
| Failed to develop and implement preventative foot care interventions for 1 resident with diabetes and foot complications. | SS=D |
| Failed to ensure individualized contracture management interventions for 1 resident with decline in range of motion. | SS=D |
| Failed to ensure intravenous therapy was maintained and discontinued properly for 1 resident. | SS=D |
| Failed to maintain adequate staffing levels to provide assistance with repositioning and personal care for 2 residents. | SS=D |
| Failed to ensure kitchen sanitation including cleanliness of pans, cabinetry, floors, proper food storage and labeling, and hand hygiene of staff. | SS=F |
Report Facts
Census: 79
Total Capacity: 79
Medicare Census: 6
Medicaid Census: 54
Other Payor Census: 19
Deficiency Counts: 9
Staffing Hours - Licensed Nurses: 48
Staffing Hours - CNAs: 124
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rukiya Brooks | Administrator | Named as Administrator signing report and interviewed regarding staffing and abuse reporting |
| LPN 6 | Licensed Practical Nurse | Interviewed regarding IV placement and computer screen privacy |
| QMA 5 | Qualified Medication Aide | Observed assisting residents during dining and interviewed about staffing |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including dignity, privacy, abuse reporting, IV therapy, and contracture management |
| Physical Therapy Assistant 8 | Physical Therapy Assistant | Observed entering resident room without knocking |
| Cook 3 | Cook | Observed with poor hand hygiene and contaminated uniform during food preparation |
| Dietary Manager | Dietary Manager | Interviewed and observed during kitchen sanitation inspection |
Inspection Report
Renewal
Deficiencies: 0
Sep 22, 2023
Visit Reason
Paper Compliance to the Recertification and State Licensure Survey completed on September 22, 2023.
Findings
Mason Health Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 in regard to the Paper Compliance Review to the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 81
Capacity: 115
Deficiencies: 1
Aug 23, 2023
Visit Reason
An investigation of Complaint Number IN00415890 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) related to Life Safety Code compliance.
Findings
The facility was found not in compliance with Life Safety Code requirements due to failure to maintain 50 of 50 Packaged Terminal Air Conditioners (PTACs) in a safe operational condition, which could cause overheating and fire. The PTAC units were found dirty and had not been cleaned for two to three years, posing a fire risk.
Complaint Details
Complaint IN00415890 was substantiated with a federal/state deficiency cited at K100 related to the allegation of unsafe PTAC units causing smoke and fire risk.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure 50 of 50 Packaged Terminal Air Conditioners (PTAC) were maintained in a safe operational condition to prevent fire due to motor overheating and debris buildup. | SS=F |
Report Facts
Facility capacity: 115
Census: 81
PTAC units inspected: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rukiya Brooks | Administrator | Named during interview and exit conference regarding findings |
Inspection Report
Renewal
Deficiencies: 1
Jun 7, 2023
Visit Reason
The inspection was conducted as an offsite Licensure Investigation Survey to review the facility's compliance with timely renewal of its license to operate as a health care facility.
Findings
The facility failed to timely renew its license before the expiration date of May 31, 2023, as the renewal application and payment were submitted on June 1, 2023, which was not at least 45 days prior to license expiration as required by state regulations.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure timely renewal of license to operate before expiration on May 31, 2023. |
Report Facts
Days prior to license expiration required for renewal application: 45
Date license expired: May 31, 2023
Date renewal application submitted: Jun 1, 2023
Date systemic changes to prevent recurrence will be completed: Jun 16, 2023
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: 71
Capacity: 71
Deficiencies: 0
Jun 7, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00409182.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00409182 found no deficiencies related to the allegations.
Report Facts
Census Bed Type: 71
Medicare Census: 3
Medicaid Census: 52
Other Payor Census: 16
Inspection Report
Complaint Investigation
Census: 73
Capacity: 73
Deficiencies: 0
Dec 21, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00395108.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00395108 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Census SNF/NF beds: 73
Census total residents: 73
Census Medicare residents: 10
Census Medicaid residents: 49
Census other payor residents: 14
Inspection Report
Re-Inspection
Census: 86
Capacity: 115
Deficiencies: 0
Dec 8, 2022
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 11/02/22.
Findings
At this PSR survey, Mason Health and Rehabilitation was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Report Facts
Certified beds: 115
Census: 86
Inspection Report
Re-Inspection
Census: 79
Capacity: 79
Deficiencies: 0
Nov 29, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on September 26, 2022.
Findings
Mason Health Care Center 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: 8
Census Payor Type - Medicaid: 51
Census Payor Type - Other: 20
Inspection Report
Routine
Census: 86
Capacity: 115
Deficiencies: 8
Nov 2, 2022
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification 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 including failure to annually review and update the Emergency Preparedness Plan, Policies and Procedures, Communication Plan, and Training and Testing Plan. Additionally, the facility failed to ensure exit doors were accessible without special tools or keys, failed to provide staff access to the cooktop shutoff switch in the therapy gym, and failed to maintain proper mechanical ventilation in the oxygen storage room.
Severity Breakdown
SS=F: 5
SS=E: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to review and update the Emergency Preparedness Plan at least annually. | SS=F |
| Failed to review and update the Emergency Preparedness Policies and Procedures at least annually. | SS=F |
| Failed to review and update the Emergency Preparedness Communication Plan at least annually. | SS=F |
| Failed to review and update the Emergency Preparedness Training and Testing Plan at least annually. | SS=F |
| Failed to conduct annual emergency preparedness training for all staff. | SS=F |
| Exit doors on 100, 300, and 400 halls were magnetically locked and required a code not posted at the exits, restricting egress. | SS=E |
| Staff did not have access to the shutoff switch for the cooktop in the therapy gym. | SS=E |
| Oxygen storage/transfer room ventilation fan motor was not working, failing to provide required mechanical ventilation. | SS=E |
Report Facts
Certified beds: 115
Census: 86
Deficiency count: 8
Residents potentially affected: 55
Residents potentially affected: 5
Residents potentially affected: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rukiya Brooks | Administrator | Named in relation to emergency preparedness findings and exit conference |
| Maintenance Director | Named in relation to emergency preparedness findings, exit door lock issues, cooktop shutoff, and oxygen room ventilation |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 80
Deficiencies: 0
Oct 25, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00392142.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00392142 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Medicare residents: 16
Medicaid residents: 45
Other payor residents: 19
Inspection Report
Annual Inspection
Census: 81
Capacity: 81
Deficiencies: 9
Sep 26, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from September 19 to 26, 2022.
Findings
The facility was found deficient in multiple areas including care planning, pressure ulcer prevention and treatment, urinary catheter care, respiratory care, dialysis communication, psychotropic medication monitoring, food safety, and infection control practices.
Severity Breakdown
SS=D: 5
SS=E: 4
SS=G: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to provide a comprehensive care plan for skin condition and oxygen use for 2 residents. | SS=D |
| Failed to revise care plan timely for a resident on a weight loss regimen. | SS=D |
| Failed to implement pressure relieving interventions to prevent an unstageable pressure wound for 1 resident. | SS=G |
| Failed to provide dignity cover for urinary catheter drainage bag for 1 resident. | SS=D |
| Failed to ensure respiratory equipment was dated, tracked, and changed properly; non-nursing staff improperly changed oxygen tubing for 4 residents. | SS=E |
| Failed to complete post dialysis assessments and dialysis communication for 1 resident. | SS=D |
| Failed to monitor for adverse side effects of psychotropic medications and complete AIMS assessments timely for 4 residents. | SS=E |
| Failed to ensure food items were dated, sealed, labeled, and refrigerators clean in kitchen and pantries. | SS=E |
| Failed to ensure proper infection control practices including PPE use during aerosol generating procedures, medication administration without touching medication with bare hands, and proper hand hygiene and glove use during wound care. | SS=E |
Report Facts
Survey dates: 6
Residents reviewed for care planning: 24
Residents reviewed for pressure ulcers: 3
Residents reviewed for respiratory care: 4
Residents reviewed for psychotropic medication monitoring: 5
Food items undated or unsealed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant | Entered resident room without proper PPE during aerosol generating procedure | |
| Qualified Medication Aide | Entered resident room without proper PPE during aerosol generating procedure | |
| Licensed Practical Nurse | Did not wash hands or change gloves properly during wound care | |
| Registered Nurse | Opened medication capsules with bare hands |
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