Inspection Reports for McCormick’s Creek Rehabilitation and Healthcare
210 STATE HWY 43, SPENCER, IN, 47460
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 1, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a pattern of mostly no deficiencies, with occasional citations primarily involving life safety code compliance and resident care issues such as catheter management and dietary errors. Inspectors cited recurring issues with fire safety system maintenance, fire drill documentation, and some care plan and environmental concerns in prior reports. Complaint investigations were generally unsubstantiated, with one substantiated complaint in early 2024 related to failure to provide a physician-ordered therapeutic diet. The facility appears to have addressed many prior deficiencies, as recent inspections have not identified new issues.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
67% 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 July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 78
Capacity: 87
Deficiencies: 0
Date: Jul 1, 2025
Visit Reason
An investigation of Complaint Number IN00461848 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Complaint Details
Complaint Number IN00461848 was investigated and found to have no deficiencies related to the allegation.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code.
Report Facts
Facility capacity: 87
Census: 78
Inspection Report
Complaint Investigation
Census: 74
Capacity: 74
Deficiencies: 0
Date: Jun 19, 2025
Visit Reason
This visit was conducted for the Investigation of Complaint IN00461841.
Complaint Details
Investigation of Complaint IN00461841 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00461841 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census Bed Type: 74
Census Payor Type - Medicare: 14
Census Payor Type - Medicaid: 50
Census Payor Type - Other: 10
Inspection Report
Complaint Investigation
Census: 72
Capacity: 72
Deficiencies: 0
Date: Jun 9, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00460992 and IN00461142.
Complaint Details
Investigation of Complaints IN00460992 and IN00461142 found no deficiencies related to the allegations; both complaints were not substantiated.
Findings
No deficiencies related to the allegations in complaints IN00460992 and IN00461142 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 these complaints.
Report Facts
Census SNF/NF beds: 72
Census total residents: 72
Census Medicare residents: 10
Census Medicaid residents: 50
Census other payor residents: 12
Inspection Report
Re-Inspection
Census: 73
Capacity: 87
Deficiencies: 0
Date: Apr 15, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 02/19/25 was performed to verify compliance with life safety code requirements.
Findings
At this PSR to the Life Safety Code survey, McCormick's Creek Rehabilitation and Healthcare 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.
Report Facts
Facility capacity: 87
Census: 73
Inspection Report
Complaint Investigation
Census: 74
Capacity: 74
Deficiencies: 0
Date: Apr 10, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00457066.
Complaint Details
Complaint IN00457066 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00457066 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census SNF/NF: 74
Census Payor Type Medicare: 14
Census Payor Type Medicaid: 46
Census Payor Type Other: 14
Inspection Report
Complaint Investigation
Census: 75
Capacity: 75
Deficiencies: 0
Date: Mar 19, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00455700.
Complaint Details
Complaint IN00455700 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00455700 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census Bed Type: 75
Total Census: 75
Census Payor Type - Medicare: 15
Census Payor Type - Medicaid: 45
Census Payor Type - Other: 15
Inspection Report
Complaint Investigation
Census: 75
Capacity: 75
Deficiencies: 0
Date: Mar 6, 2025
Visit Reason
This visit was conducted for the Investigation of Complaint IN00454545.
Complaint Details
Investigation of Complaint IN00454545 found no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census Payor Type - Medicare: 17
Census Payor Type - Medicaid: 44
Census Payor Type - Other: 14
Inspection Report
Life Safety
Census: 80
Capacity: 87
Deficiencies: 10
Date: Feb 19, 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) on 02/19/2025.
Findings
The facility was found not in compliance with several Life Safety Code requirements including staff training on fire suppression systems, fire alarm system testing, sprinkler head maintenance, smoke barrier door functionality, electrical safety, fire drill documentation, fire door inspections, and oxygen equipment storage and safety.
Deficiencies (10)
Failed to ensure staff were instructed in the proper use of the UL 300 hood fire suppression system in the kitchen.
Failed to provide an approved method for returning cooking appliances to approved design location under the kitchen hood extinguishing system.
Failed to ensure documentation was available to show 33 of 92 smoke detectors were sensitivity tested within the past 24 months.
Failed to ensure sprinkler heads in 2 of 3 porch overhangs covered with corrosion were replaced.
Failed to ensure 1 of 6 sets of smoke/fire barrier doors would close to form a smoke resistant barrier.
Failed to ensure 1 of over 10 wet locations was provided with ground fault circuit interrupter (GFCI) protection against electric shock.
Failed to ensure 5 of 12 fire drill reports included complete and accurate documentation of the transmission of a fire alarm signal to the monitoring company/fire department during the past twelve months.
Failed to ensure an annual inspection and testing of 1 of 1 oxygen room fire door assembly was completed.
Failed to ensure cylinders of nonflammable gases such as oxygen were properly secured from falling in 1 of 1 oxygen storage/transfilling room.
Failed to ensure 1 of 1 oxygen storage rooms where oxygen transfilling takes place was provided with a door that closed completely and latched.
Report Facts
Certified beds: 87
Census: 80
Smoke detectors tested: 59
Smoke detectors not tested: 33
Sprinkler heads corroded: 6
Fire drills lacking documentation: 5
Oxygen cylinders unsecured: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sara Hatfield | Executive Director | Named in relation to exit conference and survey oversight |
| Senior Maintenance Director | Named in relation to multiple findings including fire suppression system, smoke detectors, sprinkler heads, smoke doors, and oxygen equipment | |
| Director of Plant Operations | Named in relation to multiple findings including fire suppression system, smoke detectors, sprinkler heads, smoke doors, and oxygen equipment | |
| Kitchen Manager | Named in relation to fire suppression system training deficiency |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 18, 2025
Visit Reason
The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
McCormick's Creek Rehabilitation and Healthcare 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
Complaint Investigation
Census: 78
Capacity: 78
Deficiencies: 0
Date: Feb 6, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00452749.
Complaint Details
Complaint IN00452749 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00452749 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census SNF/NF: 78
Total Capacity: 78
Census Payor Type Medicare: 18
Census Payor Type Medicaid: 50
Census Payor Type Other: 10
Inspection Report
Renewal
Census: 75
Capacity: 75
Deficiencies: 1
Date: Jan 31, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from January 27 to January 31, 2025.
Findings
The facility was found deficient for failing to keep the urinary catheter drainage bag and tubing from touching the floor for one resident being treated for a urinary tract infection. Immediate corrective actions were taken, and staff were re-educated on proper catheter care.
Deficiencies (1)
Failed to keep the urinary catheter drainage bag and tubing from touching the floor for a resident being treated for a urinary tract infection.
Report Facts
Census: 75
Total Capacity: 75
Medicare Residents: 15
Medicaid Residents: 50
Other Payor Residents: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sara Hatfield | Administrator | Signed the report and provided facility policy |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 83
Deficiencies: 0
Date: Nov 12, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00446607.
Complaint Details
Complaint IN00446607 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census SNF/NF: 83
Census Payor Type Medicare: 15
Census Payor Type Medicaid: 58
Census Payor Type Other: 10
Inspection Report
Complaint Investigation
Census: 84
Capacity: 84
Deficiencies: 0
Date: Oct 30, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00445220 and IN00446259.
Complaint Details
Investigation of Complaints IN00445220 and IN00446259 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00445220 and IN00446259 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 84
Total Capacity: 84
Medicare Census: 3
Medicaid Census: 57
Other Payor Census: 24
Inspection Report
Complaint Investigation
Census: 80
Capacity: 80
Deficiencies: 0
Date: Aug 19, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00440871.
Complaint Details
Complaint IN00440871 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations 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: 80
Total Capacity: 80
Medicare Census: 13
Medicaid Census: 58
Other Payor Census: 9
Inspection Report
Complaint Investigation
Census: 71
Capacity: 71
Deficiencies: 0
Date: May 15, 2024
Visit Reason
This visit was conducted for the investigation of three complaints: IN00434017, IN00433125, and IN00433580.
Complaint Details
Complaints IN00434017, IN00433125, and IN00433580 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with relevant federal and state regulations regarding the complaints investigated.
Report Facts
Census: 71
Total Capacity: 71
Medicare Census: 10
Medicaid Census: 48
Other Payor Census: 13
Inspection Report
Re-Inspection
Census: 72
Capacity: 87
Deficiencies: 0
Date: Apr 16, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 03/04/24 was performed to verify compliance with prior deficiencies.
Findings
The facility 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 is fully sprinklered with a fire alarm system and smoke detection throughout.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 2, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00428670 completed on March 11, 2024.
Complaint Details
Paper compliance review to the Investigation of Complaint IN00428670 completed on March 11, 2024; facility found in compliance.
Findings
McCormick's Creek Rehabilitation and Healthcare was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 74
Capacity: 74
Deficiencies: 1
Date: Mar 11, 2024
Visit Reason
The visit was conducted for the investigation of Complaint IN00428670 regarding allegations related to residents not receiving physician ordered therapeutic diets.
Complaint Details
Complaint IN00428670 was substantiated with federal/state deficiencies cited related to the allegations at F800.
Findings
The facility failed to ensure that residents received the physician ordered therapeutic diet, specifically one resident was served regular syrup instead of sugar free syrup as ordered. The facility acknowledged the issue and implemented corrective actions including purchasing sugar free syrup and staff education.
Deficiencies (1)
Failed to ensure residents received the physician ordered therapeutic diet, specifically serving regular syrup instead of sugar free syrup to a resident on a controlled carbohydrate diet.
Report Facts
Census: 74
Total Capacity: 74
Medicare Residents: 6
Medicaid Residents: 44
Other Residents: 24
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 6, 2024
Visit Reason
The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure Survey.
Findings
McCormick's Creek Rehabilitation and Healthcare 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: 74
Capacity: 87
Deficiencies: 4
Date: Mar 4, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements. However, the Life Safety Code survey identified deficiencies including an exit door with a locking code not posted, lack of semi-annual visual fire alarm inspections, failure to conduct fire drills at unexpected times on some shifts, and generator transfer times exceeding 10 seconds during monthly load tests.
Deficiencies (4)
Exit door in therapy was magnetically locked with a code not posted at the exit, affecting egress accessibility.
Facility failed to maintain fire alarm system with required semi-annual visual inspections.
Facility failed to conduct quarterly fire drills at unexpected times under varying conditions on first and second shifts for 3 of 4 quarters.
Generator transfer time to emergency power exceeded 10 seconds during monthly load tests in 2 of 12 months reviewed.
Report Facts
Certified beds: 87
Census: 74
Fire drills not conducted at unexpected times: 3
Generator transfer time: 30
Generator transfer time: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sara Hatfield | Executive Director | Named during exit conference and signature on report |
| Director of Maintenance | Interviewed and involved in observations and corrective actions related to deficiencies |
Inspection Report
Annual Inspection
Census: 72
Capacity: 72
Deficiencies: 4
Date: Feb 15, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaints IN00426703 and IN00428164.
Complaint Details
Complaints IN00426703 and IN00428164 were investigated with no deficiencies related to the allegations cited.
Findings
The facility was found deficient in several areas including failure to provide RN coverage for at least 8 consecutive hours 7 days a week, failure to label eye drop bottles with open dates, improper positioning of urinary drainage bags touching the floor, and unsecured biohazard/soiled linen room. No deficiencies were cited related to the complaints investigated.
Deficiencies (4)
Failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week based on payroll and staffing data for Q4 FY 2023.
Failed to label eye drop bottles with an open date on 2 of 3 medication carts observed.
Failed to ensure urinary drainage bag attached to Foley catheter was positioned off the floor for 1 resident reviewed.
Failed to ensure a room containing soiled linens and biohazard materials was secured when unattended by staff.
Report Facts
Census: 72
Total Capacity: 72
RN coverage missing days: 4
Deficiency citations: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sara Hatfield | Executive Director | Signed report and involved in interviews |
| Assistant Director of Nursing | Interviewed regarding medication labeling and urinary drainage bag positioning | |
| Director of Nursing | Provided policies and involved in corrective action plans | |
| Certified Nursing Assistant 1 | Interviewed about urinary drainage bag positioning | |
| Certified Nursing Assistant 2 | Interviewed about urinary drainage bag positioning |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 64
Deficiencies: 0
Date: Dec 12, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00423164.
Complaint Details
Complaint IN00423164 was investigated and found to have no related deficiencies.
Findings
No deficiencies related to the allegations in Complaint IN00423164 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 8
Medicaid census: 41
Other payor census: 15
Inspection Report
Complaint Investigation
Census: 72
Capacity: 72
Deficiencies: 0
Date: Nov 2, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00420432 and IN00420668.
Complaint Details
Investigation of Complaints IN00420432 and IN00420668 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00420432 and IN00420668 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 10
Medicaid census: 45
Other payor census: 17
Inspection Report
Complaint Investigation
Census: 67
Capacity: 67
Deficiencies: 0
Date: Oct 3, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00418621 and included a COVID-19 Focused Infection Control Survey.
Complaint Details
Complaint IN00418621 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations 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 and the COVID-19 survey.
Report Facts
Census: 67
Total Capacity: 67
Medicare Census: 11
Medicaid Census: 49
Other Payor Census: 7
Inspection Report
Complaint Investigation
Census: 71
Capacity: 71
Deficiencies: 0
Date: Aug 2, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00413916.
Complaint Details
Complaint IN00413916 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census SNF/NF: 71
Census Payor Type Medicare: 10
Census Payor Type Medicaid: 43
Census Payor Type Other: 18
Inspection Report
Complaint Investigation
Census: 67
Capacity: 67
Deficiencies: 0
Date: Jul 24, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00413360.
Complaint Details
Complaint IN00413360 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00413360 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 55
Census Payor Type - Other: 7
Inspection Report
Complaint Investigation
Census: 73
Capacity: 73
Deficiencies: 0
Date: Jul 10, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00409278, IN00411039, and IN00412245.
Complaint Details
Investigation of Complaints IN00409278, IN00411039, and IN00412245 found no deficiencies related to the allegations; all complaints were unsubstantiated.
Findings
No deficiencies related to the allegations in complaints IN00409278, IN00411039, and IN00412245 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 these complaints.
Report Facts
Census SNF/NF: 73
Total Capacity: 73
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 48
Census Payor Type - Other: 18
Inspection Report
Complaint Investigation
Census: 75
Capacity: 75
Deficiencies: 0
Date: Mar 14, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00398709, IN00403170, IN00403867, and IN00403959 at McCormick's Creek Rehabilitation and Healthcare.
Complaint Details
Complaints IN00398709, IN00403170, IN00403867, and IN00403959 were investigated and no deficiencies related to the allegations were cited.
Findings
No deficiencies were cited related to the allegations in any of the four complaints investigated. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census: 75
Total Capacity: 75
Medicare Census: 10
Medicaid Census: 53
Other Payor Census: 12
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 31, 2023
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey, including a Complaint Investigation.
Complaint Details
Complaint Investigation IN00396323 was reviewed as part of the inspection and found to be in compliance.
Findings
McCormick's Creek Rehabilitation and Healthcare 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 of the Recertification, State Licensure survey, and Complaint Investigation.
Inspection Report
Life Safety
Census: 72
Capacity: 87
Deficiencies: 2
Date: Jan 9, 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 in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements. However, deficiencies were found related to fire alarm system maintenance and documentation of fire and smoke damper inspections. Specifically, the fire alarm system batteries had failed and had not yet been replaced, and complete documentation for fire/smoke damper inspections was not available.
Deficiencies (2)
Failed to ensure fire alarm system was maintained in accordance with NFPA 70 and NFPA 72; batteries in the Fire Alarm Control Panel failed and repairs were not documented.
Failed to provide complete documentation of all fire and smoke dampers inspection and testing in accordance with NFPA 90A and NFPA 80.
Report Facts
Certified beds: 87
Census: 72
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sara Mitchell | Administrator | Signed the report |
| Director of Maintenance | Interviewed regarding fire alarm system and fire damper inspection deficiencies | |
| Executive Director | Participated in exit conference reviewing findings |
Inspection Report
Life Safety
Deficiencies: 0
Date: Jan 9, 2023
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey conducted on 01/09/23 was completed on 01/24/23.
Findings
McCormick's Creek Rehabilitation and Healthcare 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
Census: 71
Capacity: 71
Deficiencies: 6
Date: Jan 4, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00396323 and IN00395252.
Complaint Details
Complaint IN00396323 was substantiated with related Federal/State deficiencies cited at F676. Complaint IN00395252 was unsubstantiated due to lack of evidence.
Findings
The facility was found to have deficiencies related to notice requirements before transfer/discharge, notice of bed hold policy before/after transfer, development and implementation of comprehensive care plans, provision of necessary care for activities of daily living, posting of nurse staffing information, and environmental safety and maintenance issues.
Deficiencies (6)
Failed to ensure Notice of Transfer or Discharge were provided to residents or representatives for 2 of 2 residents reviewed.
Failed to ensure that a bed hold policy was provided to residents transferred to the hospital for 2 of 2 residents reviewed.
Failed to ensure the resident had a care plan developed for insulin and antipsychotic medication use for 1 of 5 residents reviewed for unnecessary medications.
Failed to ensure staff provided necessary care and services consistent to the resident's needs and choices for activities of daily living for 1 of 1 resident reviewed.
Failed to ensure the daily posted nurse staffing sheet had the name of the facility and the actual hours worked by staff for 9 of 9 days reviewed.
Failed to ensure wheelchair arm pads were in good repair, call light and overbed light cords were repaired, and a resident wall was clean for 8 of 24 residents reviewed for environmental conditions.
Report Facts
Census Bed Type: 71
Survey dates: 6
Residents Medicare: 8
Residents Medicaid: 47
Residents Other: 16
Days without shower: 12
Audit frequency: 5
Compliance monitoring duration: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sara Mitchell | Administrator | Signed the report and interviewed regarding transfer/discharge notices |
| Executive Director | Interviewed regarding transfer/discharge notices, bed hold policy, and staffing postings | |
| Director of Nursing | DON | Interviewed regarding care plans, education, and monitoring corrective actions |
| MDS Coordinator | Interviewed regarding care plans and shower documentation |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 73
Deficiencies: 0
Date: Oct 19, 2022
Visit Reason
This visit was for the Investigation of Complaints IN00392389 and IN00392445 and included a COVID-19 Focused Infection Control Survey.
Complaint Details
Complaint IN00392389 - Unsubstantiated due to lack of evidence. Complaint IN00392445 - Unsubstantiated due to lack of evidence.
Findings
Both complaints IN00392389 and IN00392445 were found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaints and the COVID-19 Focused Infection Control Survey.
Report Facts
Census SNF/NF beds: 73
Census total residents: 73
Census Medicare residents: 17
Census Medicaid residents: 45
Census Other payor residents: 11
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