Inspection Reports for Miller’s at Oak Pointe
411 N WOLF RD, COLUMBIA CITY, IN, 46725
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 10, 2024, found the facility in compliance with Emergency Preparedness and Life Safety Code requirements, with no deficiencies noted. Earlier inspections showed some deficiencies related mainly to medication security, food safety practices, respiratory care planning, and employee recordkeeping. Complaint investigations conducted during this period were all unsubstantiated, with no deficiencies related to the allegations. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. The facility’s record shows improvement over time, with the latest inspection meeting all applicable standards.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
2.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
40% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
50% occupied
Based on a December 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Life Safety
Census: 41
Capacity: 82
Deficiencies: 0
Date: Dec 10, 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 and Life Safety Code requirements for Medicare and Medicaid Participating Providers and Suppliers. The facility is fully sprinklered with a fire alarm system and smoke detection in required areas. A detached barn used for storage was not sprinklered.
Report Facts
Facility capacity: 82
Census: 41
Inspection Report
Renewal
Census: 52
Capacity: 52
Deficiencies: 2
Date: Nov 14, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted on November 12, 13, and 14, 2024.
Findings
The facility was found deficient in securing medications and treatment supplies, proper labeling and discarding of insulin, safe storage of chemicals, and food safety practices including labeling leftovers, equipment cleanliness, gloving, and hand hygiene during food preparation and serving. The ice machine was found with residue but was subsequently cleaned and maintained per policy.
Deficiencies (2)
Failed to ensure medications and treatment supplies were secured, insulin was dated upon opening and discarded upon expiration for 4 of 11 reviewed residents.
Failed to ensure leftovers were labeled, equipment was cleaned, gloving and hand hygiene were observed during tray pass.
Report Facts
Census: 52
Total Capacity: 52
Deficiencies cited: 2
Dates of survey: November 12, 13, and 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephen C. Baker | Administrator | Signed the report |
| Licensed Practical Nurse 6 | Interviewed regarding medication administration and storage | |
| Director of Nursing | DON | Provided interviews and inserviced staff on medication administration and storage |
| Licensed Practical Nurse 5 | Interviewed regarding insulin storage and expiration | |
| Registered Nurse 7 | Interviewed regarding insulin expiration and administration | |
| Dietary Manager 3 | Addressed food safety concerns and provided education | |
| Maintenance 2 | Performed cleaning and maintenance of ice machine | |
| Dietary Aide 4 | Observed with improper gloving and hand hygiene during food preparation |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Nov 14, 2024
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure survey was conducted.
Findings
Miller's at Oak Pointe 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: 53
Deficiencies: 0
Date: Aug 23, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00440764.
Complaint Details
Complaint IN00440764 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 applicable regulations.
Report Facts
Census: 53
Census Bed Type: 45
Census Bed Type: 8
Census Payor Type: 4
Census Payor Type: 24
Census Payor Type: 25
Inspection Report
Life Safety
Census: 48
Capacity: 82
Deficiencies: 0
Date: Feb 20, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code (LSC) 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).
Findings
The facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements for Medicare and Medicaid Participating Providers and Suppliers. The facility is fully sprinklered with a fire alarm system and smoke detection in required areas.
Report Facts
Facility capacity: 82
Census: 48
Inspection Report
Annual Inspection
Census: 46
Capacity: 46
Deficiencies: 0
Date: Jan 17, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00424200.
Complaint Details
Complaint IN00424200 was investigated and no deficiencies related to the allegations were cited.
Findings
Miller's at Oak Pointe 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 and the Investigation of Complaint IN00424200. No deficiencies related to the complaint allegations were cited.
Report Facts
Census: 46
Total Capacity: 46
Census Bed Type - SNF: 4
Census Bed Type - SNF/NF: 42
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 18
Census Payor Type - Other: 27
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 0
Date: Oct 20, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00418654.
Complaint Details
Complaint IN00418654 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations of Complaint IN00418654 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 50
Census Bed Type - SNF: 6
Census Bed Type - SNF/NF: 44
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 20
Census Payor Type - Private: 26
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 10, 2023
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure survey was conducted.
Findings
Miller's at Oak Pointe 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: 39
Capacity: 82
Deficiencies: 0
Date: Jan 31, 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 and Life Safety Code Requirements for Participation in Medicare/Medicaid. The facility is fully sprinklered with a fire alarm system and smoke detection in required areas.
Report Facts
Facility capacity: 82
Census: 39
Inspection Report
Renewal
Census: 39
Capacity: 39
Deficiencies: 3
Date: Jan 11, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted on January 11, 12, 13, and 17, 2023.
Findings
The facility was found deficient in developing and implementing respiratory care plans for residents requiring oxygen, maintaining kitchen cleanliness and food safety standards, and ensuring accurate and complete employee personnel records.
Deficiencies (3)
Failed to ensure care plans were developed and implemented for residents requiring respiratory care including oxygen use.
Failed to ensure cleanliness of the kitchen, sanitary storage of cookware, and proper labeling of opened food items.
Failed to maintain current and accurate personnel records for employees, including incomplete orientation checklists and missing background checks.
Report Facts
Survey dates: 4
Residents present: 39
Total licensed capacity: 39
Residents reviewed for respiratory care: 5
Residents with deficient care plans: 2
Employees files reviewed: 5
Employees with deficient personnel records: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephen C. Baker | Administrator | Signed the report and interviewed regarding kitchen cleanliness and personnel records |
| Housekeeping Employee #3 | Had incomplete orientation checklist and Mantoux test reading issues | |
| Housekeeping Employee #4 | Had incomplete orientation checklist and missing background check | |
| Director of Nursing | DON | Interviewed regarding respiratory care plans and Mantoux test procedures |
| Certified Dietary Manager | CDM | Interviewed and responsible for kitchen cleanliness and food safety corrective actions |
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