Deficiencies per Year
12
9
6
3
0
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 96
Capacity: 96
Deficiencies: 1
Mar 21, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00455053 regarding federal and state deficiencies related to admission physician orders for immediate care.
Findings
The facility failed to ensure a newly admitted resident (Resident B) had immediate physician orders for wounds. The investigation revealed documentation and treatment delays for skin integrity issues upon admission, with Resident B discharged prior to correction. The facility has implemented corrective actions including audits, staff in-service, and monitoring to prevent recurrence.
Complaint Details
Complaint IN00455053 was substantiated with federal/state deficiencies cited at F635 related to admission physician orders for immediate care for wounds.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure a newly admitted resident had immediate orders for wounds. | SS=D |
Report Facts
Census: 96
Total Capacity: 96
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Branning | Executive Director | Signed the report |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 21, 2025
Visit Reason
Paper compliance review completed for the Investigation of Complaints IN00455053.
Findings
North Park Nursing Center was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Investigation of Complaints IN00455053.
Complaint Details
Investigation of Complaints IN00455053 was completed and found the facility in compliance.
Inspection Report
Re-Inspection
Census: 91
Capacity: 103
Deficiencies: 0
Nov 25, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 09/10/24 was performed to verify compliance with fire safety and licensure requirements.
Findings
At this PSR to the Life Safety Code survey, North Park Nursing Center was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire regulations, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered except for four detached wood framed sheds used for storage.
Inspection Report
Re-Inspection
Census: 82
Deficiencies: 0
Oct 24, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on August 29, 2024, including a PSR to the Investigation of Complaint IN00435599 completed on August 29, 2024.
Findings
North Park Nursing Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey and the PSR to the Investigation of Complaint IN00435599.
Complaint Details
Complaint IN00435599 was investigated and found to be corrected.
Report Facts
Census Bed Type - SNF: 3
Census Bed Type - NF: 79
Total Census: 82
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 69
Census Payor Type - Other: 12
Inspection Report
Life Safety
Census: 78
Capacity: 103
Deficiencies: 5
Sep 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 but was not in compliance with Life Safety Code requirements. Deficiencies included mixed types of sprinkler heads in multiple areas, obstruction of sprinkler spray patterns due to storage, failure to maintain automatic sprinkler systems including overdue replacement of sprinkler heads, ceiling penetrations near sprinkler heads, and sprinkler piping supporting non-system components.
Severity Breakdown
SS=F: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to ensure only one type of sprinkler head was installed in multiple activity and dining areas. | SS=F |
| Facility failed to ensure spray pattern for sprinkler heads were not obstructed in basement central storage room. | SS=F |
| Facility failed to maintain automatic sprinkler systems per NFPA 25; 8 sprinkler heads needed replacement and had not been replaced. | SS=F |
| Facility failed to maintain ceiling construction around sprinkler heads, with penetrations observed near dryers, washer, and water heater. | SS=F |
| Facility failed to maintain sprinkler piping free from external loads; cables were resting on sprinkler pipe in attic. | SS=F |
Report Facts
Certified beds: 103
Census: 78
Sprinkler heads needing replacement: 8
Sprinkler heads observed in B hall activity room: 6
Sprinkler heads in E hall: 9
Sprinkler heads in D hall dining/activities: 10
Sprinkler heads in C hall dining/activities: 7
Cables resting on sprinkler pipe: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Branning | Executive Director | Named in exit conference and report signature |
| Maintenance Director | Interviewed and involved in observations and corrective actions |
Inspection Report
Annual Inspection
Census: 83
Deficiencies: 11
Aug 29, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00435599 and IN00439126.
Findings
The facility was found deficient in multiple areas including failure to complete care plan conferences, unqualified staff administering insulin, inadequate ADL care, missed medication documentation, improper medication storage and labeling, food served at improper temperatures, inadequate infection control practices, and inaccurate nurse staffing postings.
Complaint Details
Complaint IN00435599 resulted in federal/state deficiencies related to allegations cited at F659 and F760. Complaint IN00439126 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 5
SS=E: 4
SS=C: 1
SS=G: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to ensure care plan conferences were completed for 3 of 3 residents reviewed. | SS=D |
| Staff not qualified to administer insulin; QMAs administered insulin without certification or physician orders. | SS=D |
| Failed to ensure residents dependent on staff for ADL were showered as scheduled. | SS=D |
| Failed to ensure daily weights were obtained as ordered for a resident receiving diuretics. | — |
| Failed to post accurate nurse staffing data for 5 of 7 days during the survey period. | SS=C |
| Resident received significant medication error resulting in insulin overdose and hospitalization. | SS=G |
| Medications were not properly stored and labeled in medication and treatment carts. | SS=E |
| Food was served at temperatures below palatable levels. | SS=E |
| Dishwasher temperatures did not consistently meet required levels; staff failed to wear proper hairnets and gloves when handling food. | SS=E |
| Medication administration documentation was incomplete for 5 of 6 residents reviewed. | SS=E |
| Failed to ensure proper hand hygiene and equipment disinfection during resident care. | SS=D |
Report Facts
Survey dates: August 21, 22, 23, 26, 27, 28, & 29, 2024
Resident census: 83
Medication errors: 1
Missed medication documentation: 5
Dishwasher final rinse temperature: 173
Dishwasher final rinse temperature range: 168-178
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| QMA 8 | Qualified Medication Aide | Named in insulin administration and medication error findings |
| RN 32 | Registered Nurse | Named in insulin medication error finding |
| CNA 18 | Certified Nursing Aide | Named in infection control and hand hygiene deficiency |
| CNA 4 | Certified Nursing Aide | Named in infection control and hand hygiene deficiency |
| LPN 27 | Licensed Practical Nurse | Named in infection control deficiency |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 0
Mar 22, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00429148.
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 investigation.
Complaint Details
Complaint IN00429148 - No deficiencies related to the allegations are cited.
Report Facts
Census: 89
Census Bed Type - SNF/NF: 84
Census Bed Type - SNF: 5
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 72
Census Payor Type - Other: 16
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 1, 2024
Visit Reason
Paper compliance review completed for the Investigation of Complaints IN00426893 completed on January 30, 2024.
Findings
North Park Nursing Center was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Investigation of Complaints IN00426893.
Complaint Details
Investigation of Complaints IN00426893 completed on January 30, 2024; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 1
Jan 29, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00426893 regarding allegations of deficient care related to activities of daily living (ADL) for dependent residents.
Findings
The facility failed to provide adequate ADL care, specifically bathing, for 3 of 3 residents reviewed (Residents B, C, and D). Residents reported missed showers or bed baths, and documentation showed inconsistencies in shower attempts and refusals. The facility lacked a specific bathing policy and had deficiencies in ensuring residents received scheduled showers or baths.
Complaint Details
Complaint IN00426893 was substantiated with federal/state deficiencies cited at F677 related to failure to provide necessary ADL care including bathing for dependent residents.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide ADL care, specifically bathing, to 3 of 3 residents reviewed. | SS=D |
Report Facts
Census: 92
SNF beds: 9
SNF/NF beds: 83
Medicare residents: 3
Medicaid residents: 63
Other payor residents: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brandie Snyder | DNS | Named as Laboratory Director or Provider/Supplier Representative |
| CNA 1 | Interviewed regarding shower refusal and reattempt procedures | |
| DON | Director of Nursing | Interviewed regarding facility policies on bathing and ADLs |
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 0
Dec 12, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00421803 at North Park Nursing Center.
Findings
No deficiencies related to the allegations in Complaint IN00421803 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00421803 - No deficiencies related to the allegations are cited.
Report Facts
Census: 90
Census Bed Type - SNF/NF: 84
Census Bed Type - SNF: 6
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 67
Census Payor Type - Other: 17
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 0
Nov 2, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00420099 and IN00420003 at North Park Nursing Center.
Findings
No deficiencies related to the allegations in complaints IN00420099 and IN00420003 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00420099: No deficiencies related to the allegations were cited. Complaint IN00420003: No deficiencies related to the allegations were cited.
Report Facts
Census Bed Type: 87
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 67
Census Payor Type - Other: 16
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 12, 2023
Visit Reason
Paper compliance review completed for the Investigation of Complaints IN00416094.
Findings
North Park Nursing Center was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Investigation of Complaints IN00416094.
Complaint Details
Investigation of Complaints IN00416094 completed on October 12, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 1
Oct 12, 2023
Visit Reason
This visit was for the investigation of complaints IN00416094, IN00418489, and IN00417966. Deficiencies related to complaint IN00416094 were cited, while no deficiencies were found related to the other complaints.
Findings
The facility failed to ensure accurate and complete documentation on the Electronic Medication Administration Record (EMAR) for 5 of 7 residents reviewed. Several medication doses were not documented as given on multiple dates for residents D, E, F, H, and J.
Complaint Details
Complaint IN00416094 had federal/state deficiencies related to the allegations cited at F842. Complaints IN00418489 and IN00417966 had no deficiencies related to the allegations.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure accurate and complete documentation on the EMAR for medication administration for 5 of 7 residents reviewed. | SS=E |
Report Facts
Residents reviewed for medication documentation: 7
Residents affected: 5
Total census: 88
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Heidorn-kofler | Executive Director | Signed the report |
| Interim Director of Nursing | Interviewed regarding medication documentation issues | |
| LPN 1 | Licensed Practical Nurse | Interviewed regarding medication documentation on EMAR |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 0
Aug 9, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00413554.
Findings
No deficiencies related to the allegations in Complaint IN00413554 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaint IN00413554 found no deficiencies related to the allegations.
Report Facts
Census Bed Type Total: 93
Census Payor Type Medicaid: 73
Census Payor Type Other: 20
Census Payor Type Medicare: 0
Inspection Report
Re-Inspection
Census: 88
Deficiencies: 0
Jul 6, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 2023-05-25.
Findings
North Park Nursing Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey.
Report Facts
Census Bed Type - SNF/NF: 5
Census Bed Type - SNF: 83
Census Bed Type - Total: 88
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 70
Census Payor Type - Other: 17
Census Payor Type - Total: 88
Inspection Report
Life Safety
Census: 87
Capacity: 103
Deficiencies: 0
Jun 21, 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).
Findings
The facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility is fully sprinklered except for four detached wood framed sheds used for storage, and has a fire alarm system with hard wired smoke detectors and battery operated smoke alarms in resident sleeping rooms.
Report Facts
Certified beds: 103
Census: 87
Inspection Report
Annual Inspection
Census: 88
Deficiencies: 8
May 25, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including investigation of Complaints IN00403761 and IN00404545.
Findings
The facility was found deficient in multiple areas including failure to assess residents for medication self-administration, failure to maintain resident dignity during care and dining, failure to notify representatives timely of changes or incidents, failure to maintain resident privacy, inadequate supervision to prevent falls resulting in injury, improper medication storage, improper food storage and labeling, and lapses in infection control practices including glove use and glucometer cleaning.
Complaint Details
Complaint IN00403761 and IN00404545 were investigated with no deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 4
SS=E: 3
SS=G: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure residents self-administering medications were assessed and had orders for self-administration. | SS=D |
| Failed to maintain resident dignity during incontinence care and meal service. | SS=E |
| Failed to notify resident representatives timely of accidents and changes in physician. | SS=D |
| Failed to maintain resident privacy during medication administration, incontinence care, and with computer screens displaying resident information. | SS=D |
| Failed to ensure adequate supervision and consistent implementation of fall prevention interventions, resulting in a fall with fracture. | SS=G |
| Failed to ensure proper storage of medications; loose pills found in medication carts. | SS=E |
| Failed to ensure food was stored appropriately; unlabeled and undated food items found in kitchen storage and freezer. | SS=D |
| Failed to ensure infection control practices; improper glove use during incontinence care and wound care, and improper cleaning of glucometers. | SS=E |
Report Facts
Census: 88
Survey dates: 5
Deficiencies cited: 8
Residents observed for medication self-administration: 2
Residents observed for dignity: 4
Residents reviewed for notification: 5
Residents observed for privacy: 4
Residents reviewed for falls: 3
Medication carts observed: 3
Food storage observations: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 25 | Certified Nurse Aide | Named in dignity, privacy, and infection control findings |
| QMA 54 | Qualified Medication Aide | Named in dignity, privacy, and infection control findings |
| DON | Director of Nursing | Interviewed regarding multiple findings including medication self-administration, dignity, notification, privacy, and infection control |
| LPN 3 | Licensed Practical Nurse | Observed and interviewed regarding medication storage and glucometer cleaning |
| RN 7 | Registered Nurse | Observed and interviewed regarding glucometer cleaning and privacy |
| RN 23 | Registered Nurse | Interviewed regarding notification and fall prevention |
| LPN 5 | Licensed Practical Nurse | Observed and interviewed regarding wound care and glove use |
| Dietary Manager | Interviewed regarding food storage and labeling | |
| Administrator | Interviewed regarding privacy and notification policies | |
| Social Services Director | Interviewed regarding notification of resident representative |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 0
Feb 1, 2023
Visit Reason
This visit was conducted for the investigation of complaint IN00399823.
Findings
The complaint IN00399823 was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00399823 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Census: 92
Medicare residents: 5
Medicaid residents: 73
Other payor residents: 14
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 0
Jan 20, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00398749 and IN00396715.
Findings
Complaint IN00398749 was substantiated but no deficiencies related to the allegations were cited. Complaint IN00396715 was unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00398749 - Substantiated with no deficiencies cited. Complaint IN00396715 - Unsubstantiated due to lack of evidence.
Report Facts
Census: 94
SNF beds: 12
SNF/NF beds: 82
Medicare residents: 8
Medicaid residents: 73
Other payor residents: 13
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 0
Aug 18, 2022
Visit Reason
This visit was conducted for the investigation of two complaints, IN00369712 and IN00385991.
Findings
Both complaints were substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00369712 - Substantiated with no deficiencies cited. Complaint IN00385991 - Substantiated with no deficiencies cited.
Report Facts
Census Bed Type: 91
Census Payor Type - Medicare: 68
Census Payor Type - Medicaid: 4
Census Payor Type - Other: 19
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