Inspection Report Summary
The most recent inspection on February 24, 2025, found the facility in compliance with no deficiencies cited. Earlier inspections showed a pattern of deficiencies primarily related to resident care, including supervision leading to a resident fall and fracture, pressure ulcer treatment, and issues with food preparation and kitchen sanitation. Complaint investigations were mostly unsubstantiated or corrected, though some prior complaints were substantiated with deficiencies related to care planning, medication management, and environmental cleanliness. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility appears to have made improvements recently, with the latest inspections showing compliance following correction of earlier issues.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
18.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
336% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
100% occupied
Based on a February 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 147
Capacity: 147
Deficiencies: 0
Date: Feb 24, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00452734.
Complaint Details
Complaint IN00452734 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00452734 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type: 147
Census Payor Type - Medicare: 18
Census Payor Type - Medicaid: 106
Census Payor Type - Other: 23
Inspection Report
Re-Inspection
Census: 144
Capacity: 144
Deficiencies: 0
Date: Jan 14, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the PSR completed on 12/5/24 related to the Recertification and State Licensure Survey completed on 10/22/24, including investigations of multiple complaints.
Complaint Details
This visit included investigations of Complaints IN00444806, IN00444914, IN00445179, IN00448523, and IN00448529. All complaints were corrected.
Findings
Munster Med Inn 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 PSR to the Recertification and State Licensure Survey and the PSR to the PSR to the Investigation of Complaints IN00444806, IN00444914, and IN00445179. All complaints investigated during this visit were corrected.
Report Facts
Census SNF/NF: 144
Medicare census: 16
Medicaid census: 107
Total licensed capacity: 144
Inspection Report
Re-Inspection
Census: 144
Capacity: 144
Deficiencies: 0
Date: Jan 14, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00448523 and IN00448529 completed on 12/5/24, conducted in conjunction with a PSR to the Recertification and State Licensure Survey and Investigation of Complaints IN00444806, IN00444914, and IN00445179 completed on 10/22/24.
Complaint Details
Complaints IN00444806, IN00444914, IN00445179, IN00448523, and IN00448529 were investigated and found to be corrected.
Findings
The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the PSR to the Investigations of Complaints IN00448523 and IN00448529. All complaints investigated during this and prior visits were corrected.
Report Facts
Census SNF/NF: 144
Total Capacity: 144
Medicare Census: 16
Medicaid Census: 107
Other Payor Census: 21
Inspection Report
Complaint Investigation
Census: 142
Capacity: 142
Deficiencies: 0
Date: Jan 6, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00449679, IN00450282, and IN00450421.
Complaint Details
Investigation of complaints IN00449679, IN00450282, and IN00450421 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00449679, IN00450282, and IN00450421 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: 142
Total Capacity: 142
Census Medicare: 12
Census Medicaid: 111
Census Other: 19
Inspection Report
Re-Inspection
Census: 137
Capacity: 225
Deficiencies: 0
Date: Dec 30, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey that exited on 11/07/24 was conducted by the Indiana Department of Health.
Findings
At this PSR survey, Munster Med-Inn 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.
Report Facts
Facility capacity: 225
Census: 137
Inspection Report
Re-Inspection
Census: 152
Capacity: 152
Deficiencies: 4
Date: Dec 5, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey and the Investigation of Complaints IN00444806, IN00444914, and IN00445179 completed on 10/22/24, as well as complaints IN00448523 and IN00448529.
Complaint Details
Complaints IN00444806, IN00444914, and IN00445179 were not corrected. Complaints IN00448523 and IN00448529 had federal/state deficiencies cited at F689 related to the allegations.
Findings
The facility was found deficient in multiple areas including failure to provide adequate supervision resulting in a resident fall and fracture, improper preparation of pureed diets, and poor kitchen sanitation and cleanliness. Systemic plans of correction were not fully implemented to prevent recurrence of these deficiencies.
Deficiencies (4)
Failed to ensure adequate supervision and assistance for a dependent resident requiring total assistance for bed mobility, resulting in a fall and left femur fracture.
Failed to correctly prepare a pureed diet as per recipe, potentially affecting 10 residents.
Failed to keep the kitchen clean and in good repair, including dirty convection ovens, dirty reach-in cooler vent, and improper stacking of wet plates and dome lids.
Failed to keep the kitchen clean related to food splattered on walls, dirty floors, and dirty drains under the dish machine.
Report Facts
Census: 152
Total Capacity: 152
Residents on Medicare: 11
Residents on Medicaid: 113
Residents on Other Payor: 28
Deficiency Completion Date: Dec 13, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| shanika Willhite | Administrator | Signed the report |
| CNA 1 | Named in fall incident involving Resident B | |
| QMA 1 | Named in fall incident involving Resident B | |
| Director of Nursing | Director of Nursing (DON) | Provided interview regarding fall incident and staff actions |
| Assistant Food Service Manager | Interviewed regarding pureed diet preparation and kitchen sanitation | |
| Dietary Aide 1 | Interviewed regarding kitchen sanitation practices |
Inspection Report
Complaint Investigation
Census: 152
Capacity: 152
Deficiencies: 1
Date: Dec 4, 2024
Visit Reason
This visit was for the investigation of complaints IN00448523 and IN00448529, in conjunction with a Post Survey Revisit to the Recertification and State Licensure Survey and the Investigation of Complaints IN00444806, IN00444914, and IN00445179 completed on 10/22/24.
Complaint Details
Complaints IN00448523 and IN00448529 were substantiated with federal/state deficiencies cited at F689. Complaints IN00444806, IN00444914, and IN00445179 were not corrected as of this survey.
Findings
The facility failed to ensure adequate supervision and assistance were provided to a dependent resident requiring total assistance for bed mobility, resulting in a fall and a left femur fracture. The resident was left with only one staff member during repositioning, which led to the fall and injury. The facility initiated corrective actions including staff education and audits to prevent recurrence.
Deficiencies (1)
Failed to ensure adequate supervision and assistance for a dependent resident requiring total assistance for bed mobility, resulting in a fall and left femur fracture.
Report Facts
Census: 152
Total Capacity: 152
Medicare Residents: 11
Medicaid Residents: 113
Other Residents: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding the fall incident and staff actions | |
| Second Floor Unit Manager | Interviewed about awareness of resident fall and staff assignments | |
| CNA 1 | Staff involved in resident care during fall incident | |
| QMA 1 | Staff involved in resident care during fall incident |
Inspection Report
Life Safety
Census: 155
Capacity: 225
Deficiencies: 4
Date: Nov 7, 2024
Visit Reason
The survey 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 NFPA 101 standards.
Findings
The facility was found not in compliance with several Life Safety Code requirements including staff training on UL 300 hood fire suppression system use, lack of approved method for returning cooking appliances to their designed location, failure to maintain wet sprinkler system antifreeze solution at required temperature, and failure to maintain proper latching on corridor doors on two floors.
Deficiencies (4)
Failed to ensure staff were instructed in the use of the UL 300 hood fire suppression system in the kitchen.
Failed to provide an approved method for returning cooking appliances to their designed location under the kitchen hood extinguishing system.
Failed to maintain wet sprinkler system antifreeze solution at the required -10 degrees Fahrenheit, measured at -5 degrees.
Failed to maintain protection of corridor doors on 2 floors; doors failed to close and latch properly.
Report Facts
Certified beds: 225
Census: 155
Deficiency completion date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shanika Willhite | Laboratory Director or Provider/Supplier Representative | Signed the report |
| Cook #1 | Interviewed regarding use of kitchen fire suppression system | |
| Maintenance Director | Interviewed and involved in corrective actions for fire suppression system and sprinkler system | |
| Administrator | Interviewed and involved in corrective actions and staff education | |
| Food Service Manager | Instructed kitchen staff on fire suppression system use and appliance placement | |
| Vice President of Operation | Educated Maintenance on inspection reports and sprinkler system requirements |
Inspection Report
Annual Inspection
Census: 155
Capacity: 155
Deficiencies: 15
Date: Oct 22, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey including the Investigation of Complaints IN00444806, IN00444914, and IN00445179.
Complaint Details
This inspection included investigation of Complaints IN00444806, IN00444914, and IN00445179 with federal/state deficiencies cited related to the allegations.
Findings
The facility was found deficient in multiple areas including resident dignity and privacy, notification of responsible parties for hospital transfers, comprehensive care planning, ADL care, skin condition monitoring, pressure ulcer prevention, mechanical lift safety, water temperature control, tube feeding management, oxygen therapy, food preparation, kitchen sanitation, clinical record accuracy, and environmental cleanliness.
Deficiencies (15)
Failed to ensure resident dignity and privacy related to exposure and wearing hospital gowns during the day for 3 of 6 residents.
Failed to notify resident's responsible party in writing related to hospital transfers for 2 of 3 residents.
Failed to ensure a comprehensive care plan was developed and in place for anti-anxiety medications for 1 of 33 residents.
Failed to invite and hold care planning conferences for residents and/or their family members and update care plans related to preferences for wearing hospital gowns for 6 of 33 residents.
Failed to ensure dependent residents received ADL care related to long and dirty fingernails and facial hair for 4 of 11 residents.
Failed to ensure areas of bruising and scabbing were assessed and monitored, and treatments were in place for non-pressure skin injuries for 3 of 3 residents.
Failed to ensure preventative measures were in place to prevent pressure ulcers related to new pressure area behind a resident's ear for 1 of 2 residents.
Failed to ensure mechanical lift straps were safe for use prior to transfer of a dependent resident, resulting in strap breaking and resident fall with fracture.
Failed to ensure hot water temperatures were below 120 degrees Fahrenheit on 2 of 4 floors throughout the facility.
Failed to ensure enteral tube feedings were infusing at the correct time through a peg tube for 1 resident.
Failed to ensure oxygen was at the correct flow rate for 1 resident.
Failed to correctly prepare pureed diet according to recipe for 10 residents receiving pureed diets.
Failed to keep the kitchen clean and in good repair related to dirty convection ovens, transportation carts, food preparation tables, steam table, reach in coolers, and improper glove usage.
Failed to ensure clinical records were complete and accurately documented related to medication orders for 1 resident and tube feeding orders for another resident.
Failed to keep residents' environment clean and in good repair related to dirty floors, toilets, walls, tube feeding poles, ceiling vents, overflowing garbage cans, debris in light fixtures, and kitchen cleanliness for multiple floors and rooms.
Report Facts
Census: 155
Total Capacity: 155
Medicare Census: 18
Medicaid Census: 114
Other Payor Census: 23
Inspection Dates: 8
Deficiency Count: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shanika Willhite | Administrator | Signed the Statement of Deficiencies report |
| Assistant Director of Nursing | Interviewed regarding resident dignity and oxygen flow rate | |
| Director of Nursing | Interviewed regarding care plans, notification of responsible parties, tube feeding, and oxygen therapy | |
| Social Service Director | Interviewed regarding care planning conferences and care plan updates | |
| Second Floor Unit Manager | Interviewed regarding care planning conferences and resident care | |
| CNA 1 | Interviewed regarding resident care and oxygen therapy | |
| CNA 2 | Interviewed regarding resident care and fingernail trimming | |
| Dietary Cook 1 | Observed and interviewed regarding pureed food preparation and glove use | |
| Food Service Manager | Observed kitchen sanitation and food preparation | |
| Laundry Supervisor | Interviewed regarding mechanical lift sling inspections | |
| Maintenance Supervisor | Interviewed regarding water temperature and maintenance issues | |
| Wound Nurse | Interviewed regarding skin assessments and wound care | |
| Housekeeper 1 | Interviewed regarding cleaning and sanitation |
Inspection Report
Complaint Investigation
Census: 146
Capacity: 146
Deficiencies: 0
Date: Aug 27, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00440143 and IN00441084.
Complaint Details
Complaint IN00440143 and IN00441084 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00440143 and IN00441084 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: 146
Medicare Census: 11
Medicaid Census: 115
Other Payor Census: 20
Inspection Report
Life Safety
Census: 155
Capacity: 225
Deficiencies: 0
Date: Jul 25, 2024
Visit Reason
A Life Safety Code Preoccupancy Survey was conducted by the Indiana Department of Health to assess compliance with fire safety and life safety code requirements following removal of basement employee break room and storage room to create a dialysis unit.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements, the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code, and state regulations. The building is fully sprinklered, has a fire alarm system with smoke detection, and is protected by a diesel-powered generator.
Report Facts
Facility capacity: 225
Census: 155
Generator power: 200
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 18, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of complaints IN00436912 and IN00437044 completed on July 3, 2024.
Complaint Details
The visit was related to complaint investigations IN00436912 and IN00437044. The facility was found to be in compliance based on the paper review.
Findings
Munster Med-Inn 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: 159
Capacity: 159
Deficiencies: 2
Date: Jul 2, 2024
Visit Reason
This visit was conducted for the investigation of four complaints (IN00436138, IN00436912, IN00437044, and IN00437634) regarding care and treatment at Munster Med-Inn.
Complaint Details
Complaint IN00436138 and IN00437634 had no deficiencies related to the allegations. Complaint IN00436912 and IN00437044 had federal/state deficiencies cited related to pressure ulcer treatment and tube feeding management respectively.
Findings
The facility was found deficient in two complaints related to pressure ulcer treatment and tube feeding management, with failures to update and implement wound care orders and dietary recommendations for residents. Two complaints had no deficiencies cited.
Deficiencies (2)
Failed to ensure each resident received necessary treatment and services to promote healing for pressure ulcers, related to ensuring wound care orders were updated and implemented for 1 of 3 residents reviewed (Resident D).
Failed to ensure gastrostomy tube dietary recommendations were followed for 1 of 3 residents reviewed for peg tubes (Resident H).
Report Facts
Census: 159
Total Capacity: 159
Medicare Census: 15
Medicaid Census: 121
Other Payor Census: 12
Weight Loss Percentage: 8.2
Tube Feeding Rate: 55
Tube Feeding Rate: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shanika Willhite | Laboratory Director's or Provider/Supplier Representative | Signed the report |
| Director of Nursing | Interviewed regarding lack of documentation for updated treatment orders and implementation of dietary recommendations |
Inspection Report
Complaint Investigation
Census: 153
Capacity: 153
Deficiencies: 0
Date: May 23, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00431631 and IN00433446.
Complaint Details
Complaint IN00431631 and Complaint IN00433446 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00431631 and IN00433446 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF beds: 153
Census Medicare residents: 16
Census Medicaid residents: 117
Census Other residents: 20
Inspection Report
Complaint Investigation
Census: 149
Capacity: 149
Deficiencies: 1
Date: Feb 29, 2024
Visit Reason
This visit was conducted for the investigation of Complaints IN00428029 and IN00428477 and included a COVID-19 Focused Infection Control Survey.
Complaint Details
Complaint IN00428029 - No deficiencies related to the allegations are cited. Complaint IN00428477 - Federal/State deficiencies related to the allegations are cited at F880.
Findings
The facility failed to properly prevent and/or contain COVID-19 due to lack of assessment and monitoring of COVID-19 positive residents for 3 residents reviewed. Deficiencies related to Complaint IN00428477 were cited, while no deficiencies were found related to Complaint IN00428029.
Deficiencies (1)
Failure to properly prevent and/or contain COVID-19 related to lack of assessment and monitoring of COVID-19 positive residents (Residents B, D, and E).
Report Facts
Census: 149
Total Capacity: 149
Medicare Census: 11
Medicaid Census: 119
Other Payor Census: 19
Isolation Duration: 10
Audit Frequency: 2
Audit Duration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shanika Willhite | Administrator | Signed the report |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 29, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00428477 and a COVID-19 Focused Infection Control Survey.
Complaint Details
Investigation of Complaint IN00428477 was reviewed and found to be in compliance.
Findings
Munster Med-Inn 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 COVID-19 Focused Infection Control Survey.
Inspection Report
Follow-Up
Census: 149
Capacity: 225
Deficiencies: 0
Date: Feb 2, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 12/07/23 and 12/08/23 by the Indiana Department of Health.
Findings
At this Life Safety Code PSR, Munster Med-Inn 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.
Report Facts
Facility capacity: 225
Census: 149
Inspection Report
Complaint Investigation
Census: 156
Capacity: 156
Deficiencies: 0
Date: Dec 11, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00422879.
Complaint Details
Complaint IN00422879 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations are cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the complaint.
Report Facts
Census SNF/NF: 156
Total Capacity: 156
Census Payor Type Medicare: 17
Census Payor Type Medicaid: 124
Census Payor Type Other: 15
Inspection Report
Life Safety
Census: 155
Capacity: 225
Deficiencies: 6
Date: Dec 8, 2023
Visit Reason
The survey 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).
Findings
The facility was found not in compliance with Life Safety Code requirements, with deficiencies noted in battery-operated smoke alarms, hazardous area door latching, fire pump maintenance, electrical panel security, emergency generator annunciator visibility, and emergency generator maintenance.
Deficiencies (6)
Failed to ensure 1 of over 60 battery operated smoke alarms in resident sleeping rooms were not over ten years old as required by NFPA 72.
Failed to ensure 1 of 1 100-hall soiled utility rooms had a self-closing door that would automatically latch into the frame.
Failed to maintain 1 of 1 fire pump system in accordance with NFPA 25; issues with breaker and required churn test.
Failed to ensure 1 of 1 electrical panel in the 300 hall was secured from non-authorized personnel.
Failed to ensure 1 of 1 emergency generator annunciator panel was readily observed by operating personnel.
Failed to ensure continuing reliability and integrity of 1 of 1 emergency generators; fuel system additives for cold weather protection were recommended but not completed.
Report Facts
Certified beds: 225
Census: 155
Battery operated smoke alarms: 60
Residents potentially affected: 20
Fire pump recommendation date: Nov 17, 2020
Audit duration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosa McGowen | VP of Operations | Signed report as provider/supplier representative |
| Maintenance Director | Interviewed and involved in observations and corrective actions for multiple deficiencies | |
| Maintenance Technician #1 | Observed during survey and involved in smoke alarm replacement and door testing | |
| Administrator | Participated in exit conferences and interviews regarding deficiencies | |
| Maintenance Assistant #1 | Participated in generator annunciator panel observation |
Inspection Report
Annual Inspection
Census: 157
Capacity: 157
Deficiencies: 14
Date: Nov 20, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey including the Investigation of Complaints IN00418486, IN00419836, IN00420482, and IN00420643.
Complaint Details
Complaints IN00418486, IN00419836, IN00420482, and IN00420643 were investigated. Deficiencies were cited related to complaints IN00418486, IN00419836, and IN00420643. Complaint IN00420482 had no deficiencies cited.
Findings
The facility was cited for multiple deficiencies including failure to ensure proper medication self-administration orders, incomplete care plans, inadequate assistance with activities of daily living, insufficient skin and pressure ulcer care, improper foot care, failure to follow medication administration parameters, unsanitary food handling and storage, and environmental maintenance issues.
Deficiencies (14)
Resident self-administration of medications lacked physician orders and assessments.
Failure to develop and implement comprehensive care plans related to pressure ulcers and medication use.
Dependent residents did not consistently receive assistance with nail care and shaving.
Failure to assess and monitor bruising, dry skin, scabbed areas, and constipation in residents.
Failure to ensure timely completion of optometrist recommendations for eye drops.
Pressure ulcers were not covered securely and treatment orders were not obtained timely for new pressure sores.
Dependent residents did not receive proper foot care and routine podiatry visits were not ensured.
Suprapubic catheter bag was resting on the floor and catheter care was not consistently provided as ordered.
Oxygen was not administered at the correct flow rate as ordered.
Dialysis resident received incorrect nutritional supplement not ordered by physician.
Blood pressure medications were administered on dialysis days contrary to physician orders and without checking vital signs as ordered.
Psychotropic medication was administered without documented indication or behavioral service evaluation.
Food and beverages were transported uncovered and kitchen sanitation was inadequate with grease buildup, spills, and undated food.
Resident environment was unclean and in disrepair with dirty floors, marred walls, loose baseboards, missing tiles, and improperly stored personal items.
Report Facts
Census: 157
Total Capacity: 157
Deficiencies cited: 14
Survey dates: 2023-11-14 to 2023-11-20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| shanika willhite | Administrator | Signed the inspection report |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 20, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey and the investigation of Complaints IN00418486, IN00419836, and IN00420643.
Findings
Munster Med-Inn 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 and complaint investigation.
Inspection Report
Complaint Investigation
Census: 163
Capacity: 163
Deficiencies: 0
Date: Sep 6, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00413434 and IN00416475.
Complaint Details
Complaint IN00413434 and Complaint IN00416475 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00413434 and IN00416475 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census SNF/NF beds: 163
Total Census: 163
Medicare Census: 11
Medicaid Census: 126
Other Payor Census: 26
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 27, 2023
Visit Reason
Paper compliance review to the Investigation of Complaints IN00404797 and IN00407209 completed on June 28, 2023.
Complaint Details
The visit was related to complaint investigations IN00404797 and IN00407209, with compliance found upon paper review.
Findings
Munster Med-Inn 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: 161
Capacity: 161
Deficiencies: 3
Date: Jun 28, 2023
Visit Reason
This visit was for the investigation of multiple complaints (IN00399417, IN00399633, IN00404797, IN00407209, and IN00410183) at Munster Med-Inn.
Complaint Details
The investigation was triggered by complaints IN00399417, IN00399633, IN00404797, IN00407209, and IN00410183. Deficiencies related to complaints IN00404797 and IN00407209 were substantiated with federal/state deficiencies cited. Complaints IN00399417, IN00399633, and IN00410183 had no deficiencies related to the allegations.
Findings
The facility was found deficient in several areas related to pressure ulcer treatment, catheter care, and respiratory care. Specific deficiencies included failure to update and complete treatments for pressure ulcers, inadequate catheter care documentation and provision, and lack of physician orders and proper oxygen flow rate for oxygen therapy.
Deficiencies (3)
Failed to ensure residents with pressure ulcers received necessary treatment and services to promote healing, related to treatments not updated and completed as ordered for 1 of 3 residents reviewed for pressure ulcers (Resident C).
Failed to ensure nursing staff provided foley catheter care every shift for 4 of 4 residents reviewed for catheters (Residents F, J, K, and D).
Failed to ensure orders were obtained for oxygen use and the oxygen was infusing at the correct flow rate for 1 of 1 residents reviewed for oxygen (Resident F).
Report Facts
Census: 161
Total Capacity: 161
Oxygen flow rates observed: 1
Oxygen flow rates observed: 1.5
Oxygen flow rates observed: 3
Foley catheter size: 16
Foley catheter size: 22
Deficiency completion date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosa McGowen | VPO | Signed the inspection report |
Inspection Report
Life Safety
Census: 177
Capacity: 225
Deficiencies: 7
Date: Dec 6, 2022
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 standards.
Findings
The facility was found not in compliance with Life Safety Code requirements, including failure to replace outdated battery-operated smoke alarms, maintain accurate fire alarm system time and date, inspect portable fire extinguishers monthly, ensure corridor doors latch properly, maintain smoke barrier doors, enforce smoking regulations, and improper use of extension cords and power strips.
Deficiencies (7)
Failed to replace 2 battery operated smoke alarms in resident rooms 108 and 216 that were over 10 years old.
Failed to maintain fire alarm system with accurate time and date information.
Failed to inspect 1 portable fire extinguisher in the generator room monthly; missing documented inspections for October and November 2022.
Failed to ensure corridor door to resident room 210 latched properly.
Failed to ensure smoke barrier doors near Administration Office fully closed due to malfunctioning coordinator.
Failed to enforce smoking policy; employee observed smoking outside near 200 kW generator with improper disposal of cigarette butts.
Failed to ensure extension cords and power strips were not used as substitutes for fixed wiring in laundry room and Business Office.
Report Facts
Certified beds: 225
Census: 177
Battery operated smoke alarms: 2
Fire extinguishers: 1
Missing inspection months: 2
Smoke barrier doors: 1
Resident rooms affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Petty | Administrator | Signed report |
| Maintenance Director | Interviewed and involved in observations and corrective actions | |
| Corporate Facilities Engineer | Interviewed and involved in observations and corrective actions | |
| Unnamed female facility employee | Observed smoking outside near generator |
Inspection Report
Life Safety
Deficiencies: 0
Date: Dec 6, 2022
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey conducted on 12/6/22.
Findings
Munster Med-Inn 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: 174
Deficiencies: 15
Date: Nov 9, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey including the Investigation of Complaints IN00392363 and IN00393937.
Complaint Details
Complaint IN00392363 - Substantiated. No deficiencies related to the allegations are cited. Complaint IN00393937 - Substantiated. No deficiencies related to the allegations are cited.
Findings
The facility was found deficient in multiple areas including medication self-administration orders, call light accessibility, personal privacy, comprehensive care plans, ADL assistance, activity programming, quality of care including skin and mobility management, nutrition and hydration documentation, infection control, and psychotropic medication use. Several residents were affected by these deficiencies.
Deficiencies (15)
Failed to ensure residents had Physician's Orders and assessments for self-administration of medications for 2 residents.
Failed to accommodate the needs of a dependent resident related to call light being out of reach.
Failed to ensure residents had their personal privacy respected related to posting of medical and personal information for 2 residents.
Failed to develop and implement a comprehensive care plan for a diuretic medication for 1 resident.
Failed to ensure residents were involved in care planning decisions related to new medications and treatments for 1 resident.
Failed to provide assistance with activities of daily living related to nail care for 2 residents.
Failed to ensure ongoing activity program for cognitively impaired and dependent residents for 2 residents.
Failed to ensure geri sleeves were applied as ordered and bruises assessed and monitored for 2 residents.
Failed to ensure splints were applied as ordered for 2 residents with limited range of motion.
Failed to document meal consumption and ensure supplements were monitored for 3 residents with weight loss or nutritional risk.
Failed to ensure peripherally inserted central catheter (PICC) dressings were completed as ordered for 1 resident.
Failed to ensure fluid restriction was monitored for 1 resident on dialysis.
Failed to ensure a resident with dementia received appropriate individualized interventions for behaviors and activities.
Failed to ensure a resident was free from unnecessary psychotropic medications related to adequate indications for use.
Failed to ensure infection control guidelines were implemented related to COVID-19 monitoring and testing for 2 residents.
Report Facts
Survey dates: 2022-10-31 to 2022-11-09
Census SNF: 14
Census SNF/NF: 160
Total Census: 174
Medicare Census: 40
Medicaid Census: 111
Other Census: 23
Deficiencies cited: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert A Petty | Administrator | Named in report signature |
Inspection Report
Renewal
Deficiencies: 0
Date: Nov 9, 2022
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on November 9, 2022.
Findings
Munster Med-Inn 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.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 13, 2022
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of complaints IN00383028 completed on August 24, 2022.
Complaint Details
Complaint investigation IN00383028 was reviewed and found to be in compliance.
Findings
Munster Med-Inn 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: 164
Capacity: 164
Deficiencies: 1
Date: Aug 24, 2022
Visit Reason
This visit was for the investigation of multiple complaints (IN00379357, IN00382050, IN00383028, IN00383595, IN00386583, and IN00387312) at Munster Med-Inn.
Complaint Details
Complaint IN00379357 was unsubstantiated due to lack of evidence. Complaints IN00382050, IN00383595, IN00386583, and IN00387312 were substantiated but no deficiencies related to the allegations were cited. Complaint IN00383028 was substantiated with federal/state deficiencies cited at F684.
Findings
The facility was found to have failed to ensure follow-up documentation and assessment after a resident had a significant change in condition related to increased and excessive secretions. Several complaints were substantiated, with federal/state deficiencies cited related to Complaint IN00383028 at tag F684.
Deficiencies (1)
Failed to ensure follow-up documentation and assessment after a resident had a significant change in condition related to increased and excessive secretions.
Report Facts
Census Bed Type - SNF/NF: 149
Census Bed Type - SNF: 15
Total Census: 164
Census Payor Type - Medicare: 34
Census Payor Type - Medicaid: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for nursing staff documentation and follow-up after increased secretions |
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