Inspection Report Summary
The most recent inspection on May 23, 2025, found Newburgh Health Care in compliance with Emergency Preparedness and Life Safety Code requirements except for one deficiency related to electrical equipment testing and maintenance, for which a temporary waiver was approved. Earlier inspections showed multiple deficiencies primarily involving emergency preparedness plans, life safety code compliance, and maintenance of electrical and fire safety systems. Complaint investigations mostly found no deficiencies, though substantiated issues included inadequate supervision leading to a resident elopement and failure to maintain a safe and sanitary environment in hallways. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to be making progress in addressing emergency preparedness and life safety concerns, with fewer deficiencies noted in the most recent follow-up inspection.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
18.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
348% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
49% occupied
Based on a May 2025 inspection.
Census over time
Inspection Report
Follow-Up
Census: 56
Capacity: 114
Deficiencies: 1
May 23, 2025
Visit Reason
This was a Post Survey Revisit (PSR) conducted to follow up on previous Emergency Preparedness and Life Safety Code surveys conducted earlier in the year to verify compliance with regulatory requirements.
Findings
At this 2nd PSR, Newburgh Health Care was found in compliance with Emergency Preparedness and Life Safety Code requirements. However, a deficiency was noted related to Electrical Equipment Testing and Maintenance, for which a temporary waiver was approved until 06/30/2025.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Electrical Equipment - Testing and Maintenance requirements not met as evidenced by failure to fully comply with testing intervals and maintenance protocols for patient-care related electrical equipment. | SS=F |
Report Facts
Certified beds: 114
Census: 56
Temporary waiver expiration date: Jun 30, 2025
Inspection Report
Complaint Investigation
Census: 55
Capacity: 55
Deficiencies: 0
May 1, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00455317.
Findings
No deficiencies related to the allegations of the complaint were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00455317; no deficiencies related to the allegations were cited.
Report Facts
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 38
Census Payor Type - Other: 14
Inspection Report
Re-Inspection
Census: 58
Capacity: 114
Deficiencies: 19
Apr 21, 2025
Visit Reason
Post Survey Revisit (PSR) to the Emergency Preparedness Survey conducted on 02/25/25 by the Indiana Department of Health to verify correction of previous deficiencies.
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, training and testing program, and emergency preparedness exercises. Additional deficiencies were found in life safety code compliance including emergency lighting testing, sprinkler system maintenance, fire alarm system policies, fire drills, smoking regulations, electrical equipment maintenance, and use of extension cords.
Severity Breakdown
SS=F: 14
SS=C: 2
SS=E: 1
SS=D: 1
Deficiencies (19)
| Description | Severity |
|---|---|
| Failed to develop and maintain an emergency preparedness plan reviewed and updated at least annually. | SS=F |
| Failed to develop and implement emergency preparedness policies and procedures reviewed and updated annually. | SS=F |
| Failed to ensure emergency preparedness policies include updated arrangements with other LTC facilities. | SS=C |
| Failed to develop and maintain an emergency preparedness communication plan reviewed and updated annually. | SS=F |
| Failed to develop and maintain an emergency preparedness training and testing program reviewed and updated annually. | SS=F |
| Failed to conduct at least two emergency preparedness exercises annually including unannounced drills. | SS=F |
| Failed to maintain written records of routine maintenance and testing for emergency generator. | SS=F |
| Failed to ensure documentation for monthly and annual testing of battery powered emergency lighting. | SS=C |
| Failed to ensure preventative maintenance for battery operated smoke alarms in resident rooms according to manufacturer's instructions. | SS=F |
| Failed to ensure documentation for battery replacement of smoke alarms in resident rooms was complete. | SS=F |
| Failed to provide an approved method to ensure kitchen cooking appliances are returned to approved design location after maintenance. | SS=F |
| Failed to provide a complete written fire watch policy for protection of occupants when fire alarm system is out of service for 4 or more hours. | SS=C |
| Failed to provide a complete facility-specific written fire safety plan addressing all required elements including evacuation of smoke compartments and staff response to battery powered smoke alarms. | SS=F |
| Failed to ensure fire drills included documentation of transmission of fire alarm signal to monitoring company for 4 of 12 drills. | SS=F |
| Failed to ensure fire drills were held at varied times for all three shifts during 4 of 4 quarters. | SS=F |
| Failed to ensure cigarette butts were properly disposed of in designated staff smoking area. | SS=E |
| Failed to maintain written records of routine maintenance and testing for emergency generator. | SS=F |
| Used extension cords as a substitute for fixed wiring in a resident room. | SS=D |
| Failed to conduct required maintenance and maintain complete documentation of inspections for Patient Care Related Electrical Equipment (PCREE). | SS=F |
Report Facts
Certified beds: 114
Census: 58
Deficiencies cited: 18
Fire drills missing transmission documentation: 4
Fire drills not varied by shift: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ally Lopp | Administrator | Named in relation to findings and exit conference |
| Director of Nursing | Director of Nursing | Interviewed and present during survey and exit conference |
| Maintenance Director | Maintenance Director | Interviewed and present during survey and exit conference |
| Business Office Manager | Business Office Manager | Interviewed and present during survey and exit conference |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 114
Deficiencies: 0
Mar 21, 2025
Visit Reason
This visit was for the investigation of Complaint Number IN00455444.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found in compliance with Medicare/Medicaid participation requirements and Life Safety Code standards.
Complaint Details
Complaint Number IN00455444 - No deficiencies related to the allegation are cited.
Report Facts
Facility capacity: 114
Census: 55
Inspection Report
Life Safety
Census: 55
Capacity: 114
Deficiencies: 19
Feb 25, 2025
Visit Reason
An Emergency Preparedness and Life Safety Code Recertification Survey was conducted by the Indiana Department of Health to assess compliance with federal and state regulations including 42 CFR 483.73 and NFPA 101 standards.
Findings
The facility was found not in compliance with emergency preparedness requirements including failure to annually review and update emergency plans, policies, communication plans, and training. Deficiencies were also found in life safety code compliance such as incomplete fire safety plans, inadequate fire drill documentation, sprinkler system maintenance, emergency power system testing, and improper use of electrical equipment and fire suppression systems.
Severity Breakdown
SS=F: 14
SS=C: 3
SS=E: 1
SS=D: 1
Deficiencies (19)
| Description | Severity |
|---|---|
| Failed to develop and maintain an emergency preparedness plan reviewed and updated annually. | SS=F |
| Failed to develop and implement emergency preparedness policies and procedures reviewed and updated annually. | SS=F |
| Failed to ensure emergency preparedness policies include updated arrangements with other LTC facilities. | SS=C |
| Failed to develop and maintain an emergency preparedness communication plan reviewed and updated annually. | SS=F |
| Failed to develop and maintain an emergency preparedness training and testing program reviewed and updated annually. | SS=F |
| Failed to conduct required emergency preparedness exercises twice per year including unannounced drills. | SS=F |
| Failed to provide complete documentation for emergency power system testing and routine maintenance. | SS=F |
| Failed to ensure monthly and annual testing of battery powered emergency lighting. | SS=C |
| Failed to ensure preventative maintenance and battery replacement for battery operated smoke alarms in resident rooms according to manufacturer's instructions. | SS=F |
| Failed to instruct kitchen staff on proper use of UL 300 hood fire suppression system and provide approved method for returning cooking appliances to approved location. | SS=F |
| Failed to provide complete fire watch policy for sprinkler and fire alarm system impairments including notification procedures. | SS=C |
| Failed to ensure sprinkler system piping was properly secured against lateral movement in attic. | SS=F |
| Failed to inspect sprinkler piping internally every five years as required. | SS=F |
| Failed to provide complete fire safety plan addressing all required elements including smoke compartment evacuation and response to battery powered smoke alarms. | SS=F |
| Failed to document transmission of fire alarm signal to monitoring company for 4 of 12 fire drills and failed to vary fire drill times across shifts. | SS=F |
| Failed to ensure cigarette butts were properly disposed of in designated staff smoking area. | SS=E |
| Failed to provide complete documentation for emergency power system testing and maintenance. | SS=F |
| Used power strips and extension cords as substitute for fixed wiring in resident rooms. | SS=D |
| Failed to conduct required testing and maintain documentation for Patient Care Related Electrical Equipment (PCREE). | SS=F |
Report Facts
Certified beds: 114
Census: 55
Fire drills missing alarm transmission documentation: 4
Fire drills reviewed: 12
Sprinkler pipe sprigs unrestrained: 150
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Emily Diedrich | HFA | Signed report as Laboratory Director or Provider/Supplier Representative |
Inspection Report
Annual Inspection
Census: 59
Capacity: 59
Deficiencies: 12
Feb 13, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from February 9 to 13, 2025.
Findings
The facility was found deficient in multiple areas including care plan conferences, care plan development and revision, fall prevention interventions, respiratory care, medication administration, dietary manager qualifications, facility assessment, quality assurance meetings, infection prevention, and intellectual disability program implementation.
Severity Breakdown
SS=D: 5
SS=E: 2
SS=F: 5
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to ensure care plan conferences were completed quarterly for 2 of 2 residents reviewed for ADL assistance. | SS=D |
| Failed to ensure care plans were developed and implemented after new diagnoses and physician orders for 2 residents. | SS=D |
| Failed to revise care plan to reflect changes to a resident's gastrostomy device. | SS=D |
| Failed to ensure residents had interventions in place to prevent accidents for 4 residents reviewed for falls. | SS=E |
| Failed to ensure oxygen equipment was properly labeled and respiratory services were provided according to professional standards for 3 residents. | SS=D |
| Failed to ensure medication error rate was less than 5 percent; observed 2 medication errors during 25 opportunities. | SS=D |
| Failed to ensure the Dietary Manager met required qualifications. | SS=F |
| Failed to comprehensively complete and implement a facility assessment to accurately determine care and resources needed. | SS=F |
| Failed to ensure Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) meetings were held quarterly with required staff present. | SS=F |
| Failed to ensure hand hygiene and Enhanced Barrier Precautions were implemented for 2 residents and waterborne illness testing was not performed for residents consuming water. | SS=F |
| Failed to ensure designation of a certified Infection Preventionist with specialized training and dedicated time. | SS=F |
| Failed to ensure implementation of a program for specialized populations served in the facility (intellectual and/or developmental disability) for 7 residents. | SS=F |
Report Facts
Census: 59
Total Capacity: 59
Medication error rate: 8
Falls: 7
Falls: 11
Falls: 7
Falls: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kitty Cabell | Director Of Nursing | Signed the inspection report |
| Social Services Director | Social Services Director | Mentioned as Qualified Intellectual Disability Professional (QIDP) without certification |
| Assistant Director of Nursing | Assistant Director of Nursing | Infection Preventionist role without certification |
| Dietary Manager | Dietary Manager | Did not have dietary manager certification and was not enrolled in a program |
| RN 5 | Registered Nurse | Medication administration error - failed to prime insulin pen |
| LPN 6 | Licensed Practical Nurse | Medication administration error - failed to prime insulin pen |
Inspection Report
Renewal
Deficiencies: 0
Feb 13, 2025
Visit Reason
Paper compliance review for the Recertification and State Licensure Survey.
Findings
Newburgh Health Care was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 60
Capacity: 114
Deficiencies: 0
Feb 10, 2025
Visit Reason
An investigation of Complaint Number IN00452727 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
No Federal/State deficiencies related to the allegation were cited. The facility was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Complaint Details
Complaint Number IN00452727 was investigated and found to have no deficiencies related to the allegation.
Report Facts
Facility capacity: 114
Census: 60
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 19, 2024
Visit Reason
Paper compliance review for the Investigation of Complaint IN00449014.
Findings
Newburgh Health Care was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00449014; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 66
Capacity: 66
Deficiencies: 1
Dec 18, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00449014 regarding federal and state deficiencies related to allegations of unsafe and unsanitary conditions.
Findings
The facility failed to provide a safe and sanitary environment as hallway floors were found sticky and soiled in multiple locations during three random observations. The issue was confirmed through observations, interviews, and record reviews.
Complaint Details
Complaint IN00449014 was investigated and federal/state deficiencies related to the allegations were cited at F921. The citation relates to failure to maintain a safe and sanitary environment.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to provide a safe and sanitary environment; hallway floors were sticky and soiled in multiple areas including outside rooms 21, 43, 44, 48, and the main dining hall. | SS=D |
Report Facts
Census SNF/NF: 66
Total Capacity: 66
Medicare Census: 5
Medicaid Census: 40
Other Payor Census: 21
Survey Dates: 2
Daily floor care schedule: 5
Daily rounding frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kitty Cabell | Director Of Nursing | Signed the report as Laboratory Director or Provider/Supplier Representative |
| Housekeeper 5 | Interviewed regarding floor care responsibilities and schedule | |
| Administrator | Provided Floor Care Procedures policy and was involved in review of findings |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 64
Deficiencies: 0
Nov 14, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00442037.
Findings
No deficiencies related to the allegations in Complaint IN00442037 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00442037 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 64
Total Capacity: 64
Medicare Census: 5
Medicaid Census: 39
Other Payor Census: 20
Inspection Report
Complaint Investigation
Census: 59
Capacity: 59
Deficiencies: 0
Aug 22, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00439733 at Newburgh Health Care.
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.
Complaint Details
Complaint IN00439733 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 59
Total Capacity: 59
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 42
Census Payor Type - Other: 15
Inspection Report
Complaint Investigation
Census: 68
Capacity: 68
Deficiencies: 0
Apr 18, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00432279.
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 in regard to the complaint investigation.
Complaint Details
Complaint IN00432279 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 6
Medicaid census: 44
Other payor census: 18
Inspection Report
Complaint Investigation
Census: 70
Capacity: 70
Deficiencies: 0
Apr 5, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00431839.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00431839 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 7
Medicaid census: 42
Other payor census: 21
Inspection Report
Re-Inspection
Census: 69
Capacity: 114
Deficiencies: 0
Mar 7, 2024
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 01/09/24.
Findings
At this Post Survey Revisit, Newburgh Health Care was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements including fire safety and sprinkler systems.
Report Facts
Certified beds: 114
Census: 69
Inspection Report
Annual Inspection
Census: 64
Capacity: 114
Deficiencies: 11
Jan 9, 2024
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal regulations.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements, Life Safety Code, and other regulatory standards including emergency preparedness policies, emergency power system maintenance, fire safety, electrical safety, and fire drills. Deficiencies included incomplete emergency preparedness policies, missing generator load test documentation, inadequate emergency lighting testing, hazardous area door issues, fire door inspection lapses, incomplete fire drill documentation, and electrical receptacle testing deficiencies.
Severity Breakdown
SS=C: 3
SS=D: 1
SS=E: 2
SS=F: 5
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to ensure emergency preparedness policies include the use of volunteers in an emergency or other emergency staffing strategies. | SS=C |
| Failed to ensure emergency preparedness policies include the role of the LTC facility under a waiver declared by the Secretary. | SS=C |
| Failed to implement emergency power system inspection, testing, and maintenance requirements and maintain complete monthly generator load test documentation. | SS=F |
| Failed to ensure documentation for testing of battery powered emergency lights monthly and annually. | SS=C |
| Failed to ensure hazardous area doors close completely and latch automatically. | SS=E |
| Failed to ensure sprinkler heads were not obstructed by gaps in ceiling allowing full function. | SS=E |
| Failed to ensure resident room corridor doors had no impediment to closing; doors were held open with waste baskets. | SS=F |
| Failed to provide ground fault circuit interrupter (GFCI) protection for an electrical receptacle within three feet of a sink. | SS=D |
| Failed to provide complete fire drill documentation including times for 3 of 12 fire drills performed in the past 12 months. | SS=F |
| Failed to ensure annual inspection and testing of oxygen room fire door assembly was completed and documented. | SS=F |
| Failed to ensure complete documentation was available for all nonhospital-grade electrical receptacles in resident rooms tested at least annually. | SS=F |
Report Facts
Certified beds: 114
Census: 64
Fire drills missing time documentation: 3
Resident room receptacles tested: 26
Generator load test missing months: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ally Lopp | Assistant Administrator | Named in relation to emergency preparedness and generator testing findings |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 63
Deficiencies: 1
Dec 15, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00423804 and was in conjunction with a Recertification and State Licensure Survey.
Findings
The facility failed to promote and facilitate resident self-determination related to bathing for 1 of 3 residents reviewed. Resident F's preference for showers and having her hair washed three times a week was not honored, resulting in deficiencies cited related to resident rights and self-determination.
Complaint Details
Complaint IN00423804 was substantiated with Federal/State deficiencies cited at F561 related to resident self-determination and bathing preferences.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to promote and facilitate resident self-determination related to bathing; Resident F's preference for showers and hair washing three times a week was not honored. | SS=D |
Report Facts
Census: 63
Total Capacity: 63
Medicare Census: 5
Medicaid Census: 40
Other Payor Census: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kitty Cabell | RN/DON | Signed the report as Laboratory Director or Provider/Supplier Representative |
| CNA 27 | Reported on Resident F's hair washing schedule and bathing practices |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 15, 2023
Visit Reason
Paper compliance review for the Investigation of Complaint IN00423804.
Findings
Newburgh Health Care was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00423804; facility found in compliance.
Inspection Report
Annual Inspection
Census: 63
Deficiencies: 8
Dec 15, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted in conjunction with the Investigation of Complaint IN00423804.
Findings
The facility was found deficient in multiple areas including resident dignity and rights, self-determination, notification of changes in condition, psychotropic medication management, medication storage, infection prevention and control, and staff training requirements.
Complaint Details
Complaint IN00423804 was investigated and Federal/State deficiencies related to the allegations were cited at F561.
Severity Breakdown
SS=E: 3
SS=D: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Facility failed to ensure dignity was respected for 1 of 1 residents reviewed and 3 random observations showed staff using cell phones while assisting residents. | SS=E |
| Facility failed to promote and facilitate resident self-determination related to bathing preferences for 1 of 3 residents reviewed. | SS=D |
| Facility failed to ensure timely notification of change in condition to physician for 1 of 1 resident reviewed with elevated blood pressure. | SS=D |
| Facility failed to ensure PRN antianxiety medications were evaluated every 14 days for 2 of 2 residents reviewed for ADL and 1 of 1 resident reviewed for dialysis. | SS=D |
| Facility failed to provide proper storage of medications in medication carts and medication rooms; loose pills and unlabeled medications were observed, and refrigerator temperature logs were incomplete. | SS=E |
| Facility failed to properly prevent and/or contain COVID-19 for 7 of 11 residents reviewed; staff failed to use proper PPE, perform hand hygiene, and clean equipment between residents. | SS=E |
| Facility failed to ensure tuberculin skin tests or risk assessments were completed on 3 of 10 employees selected for review. | — |
| Facility failed to provide documentation of staff completing required dementia-specific training annually and with new hires for 6 of 10 employee records reviewed. | — |
Report Facts
Census: 63
Medicare census: 5
Medicaid census: 40
Other payor census: 18
Survey dates: 5
Deficiency counts: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kitty Cabell | RN/Director of Nursing | Signed the report and responsible for monitoring corrective actions |
| CNA 21 | Observed using cell phone while assisting residents and not wearing proper PPE | |
| LPN 5 | Observed not cleaning blood pressure cuff after use | |
| QMA 3 | Observed not performing hand hygiene and not cleaning blood pressure cuff | |
| LPN 29 | Lacked dementia training and observed unaware of antianxiety medication review requirements |
Inspection Report
Renewal
Deficiencies: 0
Dec 15, 2023
Visit Reason
Paper compliance review for the Recertification and State licensure Survey.
Findings
Newburgh Health Care 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 for the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 52
Capacity: 52
Deficiencies: 0
Sep 25, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00417494.
Findings
No deficiencies were cited related to the allegations. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00417494 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 3
Medicaid census: 36
Other payer census: 13
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 23, 2023
Visit Reason
Paper compliance review for the Investigation of Complaint IN00415380.
Findings
Newburgh Health Care was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00415380; survey completed on August 23, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 54
Capacity: 54
Deficiencies: 1
Aug 21, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00415380 regarding federal and state deficiencies related to allegations of inadequate supervision leading to a resident elopement.
Findings
The facility failed to ensure adequate supervision to prevent a resident with dementia from exiting the facility and returning home unsupervised. The front door was found unlocked with no staff present, and the resident was discovered outside the facility after an elopement incident. The facility implemented corrective actions including updated care plans, increased supervision, and policy revisions.
Complaint Details
Complaint IN00415380 was substantiated with federal and state deficiencies cited related to allegations of inadequate supervision resulting in resident elopement.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure adequate supervision to prevent a resident with dementia from eloping. | SS=D |
Report Facts
Census: 54
Total Capacity: 54
Medicare Census: 3
Medicaid Census: 38
Other Payor Census: 13
Date of Deficiency Correction: Sep 28, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ally Lopp | Assistant Administrator | Signed report and involved in administrative oversight |
| LPN 5 | Licensed Practical Nurse | Resident's nurse on the morning of the elopement, observed resident and participated in search |
| RN 7 | Registered Nurse | Provided information on facility policy regarding wanderguard bracelet checks |
| Director of Nursing | Director of Nursing | Involved in notification and investigation of the elopement incident |
| Facility Administrator | Facility Administrator | Involved in investigation and oversight of the elopement incident |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 60
Deficiencies: 0
Apr 27, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00402295.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00402295 found no deficiencies related to the allegation.
Report Facts
Medicare census: 8
Medicaid census: 37
Other payor census: 15
Inspection Report
Follow-Up
Census: 59
Capacity: 114
Deficiencies: 0
Sep 7, 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 07/07/22.
Findings
At this Post Survey Revisit, Newburgh Health Care 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: 114
Census: 59
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 4, 2022
Visit Reason
Paper compliance review for the Investigation of Complaint IN00385996.
Findings
Newburgh Health Care was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00385996; survey completed on August 4, 2022; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 55
Capacity: 55
Deficiencies: 2
Aug 3, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00385996, which was substantiated with federal/state deficiencies cited related to the allegations.
Findings
The facility failed to ensure that written notice of transfer/discharge was provided to residents or their representatives for 2 of 3 residents reviewed for hospitalizations, and failed to notify the area ombudsman of transfer/discharges for all 3 residents reviewed. The Social Service Director indicated a misunderstanding about notification requirements, which was corrected with a revised process.
Complaint Details
Complaint IN00385996 was substantiated. The deficiencies related to failure to provide written notice of transfer/discharge to residents or representatives and failure to notify the area ombudsman of transfers/discharges.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure a notice of transfer/discharge was supplied in writing to a resident and/or a resident representative for 2 of 3 residents reviewed for hospitalizations. | SS=D |
| Failed to ensure the area ombudsman was notified of transfer/discharges for 3 of 3 residents reviewed for hospitalizations. | SS=D |
Report Facts
Census: 55
Total Capacity: 55
Medicare Census: 6
Medicaid Census: 27
Other Census: 22
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