Inspection Report Summary
The most recent inspection on May 23, 2025, found the facility in compliance with fire safety and licensure requirements and noted no deficiencies. Earlier inspections showed a pattern of some deficiencies related to Life Safety Code issues, such as unsecured sprinkler piping and overdue fire hydrant inspections, as well as resident care concerns including fall prevention, respiratory care, infection control, and documentation accuracy. Complaint investigations were mostly unsubstantiated, with one substantiated complaint that did not result in cited deficiencies. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. The overall trend suggests improvement, with the most recent survey showing no deficiencies after prior mixed results.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
21% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
83% occupied
Based on a May 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Census: 48
Capacity: 58
Deficiencies: 0
Date: May 23, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted to verify compliance with fire safety and licensure requirements.
Findings
The facility was found in compliance with the Requirements for Participation in Medicare, Life Safety from Fire, and applicable state and national fire safety codes. The facility is fully sprinklered with a fire alarm system and had no deficiencies noted at this survey.
Inspection Report
Life Safety
Census: 47
Capacity: 58
Deficiencies: 1
Date: Apr 8, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 04/08/2025.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code due to unsecured sprinkler system piping in the attic area of one smoke compartment, which could affect all residents, staff, and visitors.
Deficiencies (1)
Failed to ensure the sprinkler system piping was properly secured in the attic area of 1 of 6 smoke compartments, with at least 10 sprinkler pipe sprigs not restrained against lateral movement.
Report Facts
Certified beds: 58
Census: 47
Sprinkler pipe sprigs: 10
Audit frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mikayla Watkins | Administrator | Signed the report and participated in exit conference |
| Director of Plant Operations | Acknowledged deficiency and responsible for corrective actions including contacting Firetech Sprinkler and Backflow Service, LLC and auditing the sprinkler system | |
| Regional Maintenance Support | Acknowledged deficiency and participated in exit conference |
Inspection Report
Annual Inspection
Census: 75
Capacity: 75
Deficiencies: 2
Date: Mar 21, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted from March 17 to March 21, 2025.
Findings
The facility was found to have deficiencies related to fall prevention interventions for one resident and missing annual health statements in physician orders for two residents. The facility submitted plans of correction and requested a desk review for substantial compliance.
Deficiencies (2)
Failed to ensure residents received supervision and consistent implementation of interventions to prevent a fall for 1 of 1 residents reviewed for accidents related to falls.
Failed to ensure physician orders contained an annual health statement for 2 of 5 residents reviewed currently residing in the facility.
Report Facts
Census SNF/NF: 48
Census Residential: 27
Total Census: 75
Medicare Census: 13
Medicaid Census: 18
Other Payor Census: 17
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Stallman | Clinical Support | Signed as Laboratory Director's or Provider/Supplier Representative |
| CNA 5 | Certified Nurse Aide | Observed transferring Resident 15 and noted missing Dycem |
| CNA 6 | Certified Nurse Aide | Observed transferring Resident 15 |
| Regional Support Nurse | Provided policy and interview regarding fall interventions and care plan updates | |
| Regional Support 17 | Interviewed regarding missing annual health statements for Residents 2 and 4 |
Inspection Report
Renewal
Deficiencies: 0
Date: Mar 21, 2025
Visit Reason
The inspection was a paper compliance review related to the Recertification and State Licensure Survey ending on March 21, 2025.
Findings
North River Health Campus was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 based on the paper compliance review for the Recertification and State Licensure survey.
Inspection Report
Renewal
Deficiencies: 0
Date: May 21, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey ending on April 19, 2024.
Findings
North River Health Campus 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
Life Safety
Census: 46
Capacity: 58
Deficiencies: 0
Date: May 13, 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 for Medicare and Medicaid Participating Providers and Suppliers, and with Life Safety Code requirements including fire safety and sprinkler systems. The facility is a one-story, fully sprinklered building with a fire alarm system and hard-wired smoke detectors in all required areas.
Report Facts
Certified beds: 58
Census: 46
Inspection Report
Annual Inspection
Census: 29
Capacity: 77
Deficiencies: 4
Date: Apr 19, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted April 15-19, 2024.
Findings
The facility was found to have deficiencies related to accuracy of assessments, respiratory care, resident records, and infection prevention and control. Specific issues included inaccurate MDS assessments regarding restraints, improper labeling and administration of oxygen equipment, inaccurate documentation of pressure ulcers and dental status, and failure to implement enhanced barrier precautions during care of a resident with a permcath dialysis catheter. The facility submitted plans of correction and requested a desk review for substantial compliance.
Deficiencies (4)
Failed to ensure the MDS assessment was completed accurately for 1 of 1 residents reviewed for restraints (Resident 27).
Failed to ensure oxygen equipment was properly labeled and oxygen was administered as ordered for 1 of 2 residents reviewed for respiratory care (Resident 47).
Failed to ensure resident records were accurate for 2 of 2 residents reviewed for pressure ulcers and 1 of 1 residents reviewed for dental (Residents 43, 101, and 47).
Failed to ensure implementation of enhanced barrier precaution during a random observation for 1 of 1 resident with a permcath dialysis catheter while changing linen (Resident 15).
Report Facts
Survey dates: 5
Census SNF/NF beds: 18
Census SNF beds: 30
Census Residential beds: 29
Total licensed capacity: 77
Census Medicare residents: 11
Census Medicaid residents: 18
Census Other payor residents: 19
Total residents with payor type: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Stallman | RN-BC, Clinical Support | Signed the report as Laboratory Director or Provider/Supplier Representative |
| RN 9 | Registered Nurse | Interviewed regarding oxygen tubing change and policy |
| CNA 11 | Certified Nurse Aide | Interviewed regarding wound dressing and care |
| LPN 17 | Licensed Practical Nurse | Interviewed regarding wound care and documentation |
| RN 3 | Registered Nurse | Interviewed regarding enhanced barrier precautions |
| MDS Coordinator | Interviewed regarding MDS assessment accuracy and care plan errors | |
| Clinical Support Nurse | Interviewed regarding wound documentation and policy | |
| Regional Support Nurse | Interviewed regarding wound assessment and documentation |
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 0
Date: Jun 1, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00406991.
Complaint Details
Complaint IN00406991 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00406991 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF: 45
Census Residential: 37
Total Census: 82
Census Payor Medicare: 12
Census Payor Medicaid: 16
Census Payor Other: 17
Total Census Payor: 45
Inspection Report
Re-Inspection
Census: 47
Capacity: 58
Deficiencies: 0
Date: Mar 30, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 02/02/23 was performed by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR survey, North River Health Campus was found in compliance with Requirements for Participation in Medicare, 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. The facility was fully sprinklered with a fire alarm system and hard wired smoke detectors in all required areas.
Report Facts
Facility capacity: 58
Census: 47
Inspection Report
Renewal
Deficiencies: 0
Date: Feb 28, 2023
Visit Reason
The visit was a paper compliance review related to the Recertification and State Licensure Survey ending on January 23, 2023.
Findings
North River Health Campus 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
Life Safety
Census: 43
Capacity: 58
Deficiencies: 1
Date: Feb 2, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements due to failure to ensure two private fire hydrants were inspected and tested annually as required by NFPA 25. The last inspection was over a year and a half overdue.
Deficiencies (1)
Failed to ensure 2 of 2 private fire hydrants were continuously maintained in reliable operating condition and inspected and tested periodically as required by NFPA 25.
Report Facts
Certified beds: 58
Census: 43
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shelly Miller | Executive Director | Signed the report and mentioned in plan of correction |
| Director of Plant Operations | Interviewed regarding fire hydrant inspection deficiency |
Inspection Report
Renewal
Census: 30
Capacity: 75
Deficiencies: 5
Date: Jan 23, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including State Residential Licensure Survey conducted on January 17, 18, 19, 20, and 23, 2023.
Findings
The facility was found to have multiple deficiencies including failure to assess residents for self-administration of medications, lack of physician orders and care plans for respiratory care and medication administration, improper food handling and hygiene practices, inadequate infection control practices including catheter care and hand hygiene, and incomplete COVID-19 vaccination policies and exemptions for staff.
Deficiencies (5)
Failure to ensure residents self-administering medications were assessed for capability and had appropriate physician orders and care plans.
Failure to ensure necessary respiratory care and services were provided according to professional standards for a resident with CPAP machine.
Failure to ensure food was prepared in a sanitary manner; staff observed with hair not fully covered, feeding residents with bare hands, and reaching over resident's plates.
Failure to maintain infection control practices including improper glove use during incontinence care and catheter bag dragging on floor.
Failure to ensure staff COVID-19 vaccination medical exemptions specified recognized contraindications and policy lacked additional precautions for unvaccinated staff.
Report Facts
Survey dates: 5
Census Bed Type - SNF/NF: 20
Census Bed Type - SNF: 25
Census Bed Type - Residential: 30
Total Capacity: 75
Census Payor Type - Medicare: 12
Census Payor Type - Medicaid: 18
Census Payor Type - Other: 15
Total Census: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Stallman | RN-BC, Clinical Support | Signed the report and involved in clinical support |
| Staff 10 | Had a medical exemption for COVID-19 vaccination; exemption reviewed and discussed in findings | |
| Qualified Medication Aide 22 | QMA | Provided information about Resident 24's medication administration |
| Licensed Practical Nurse 23 | LPN | Interviewed regarding Resident 24's medication administration |
| Nurse 6 | Interviewed regarding Resident 37's glucose pills | |
| CNA 3 | Certified Nurse Aide | Observed during infection control and food handling deficiencies |
| CNA 5 | Certified Nurse Aide | Observed during infection control deficiencies |
| CNA 1 | Certified Nurse Aide | Interviewed and observed regarding food handling and feeding practices |
| Dietary Manager | Interviewed regarding hairnet policy and food handling | |
| Clinical Support 32 | Interviewed regarding policies and practices for CPAP use and food handling | |
| RN 21 | Registered Nurse | Observed providing catheter care |
| PT 7 | Physical Therapist | Observed pushing wheelchair with catheter bag dragging floor |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 0
Date: Dec 6, 2022
Visit Reason
This visit was for the Investigation of Nursing Home Complaint IN00389579, which included the Investigation of Residential Complaint IN00389579 and a COVID-19 Focused Infection Control Survey.
Complaint Details
Complaint IN00389579 was substantiated but no deficiencies related to the allegations were cited.
Findings
Complaint IN00389579 was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation and the COVID-19 survey.
Report Facts
Census SNF/NF: 49
Census Residential: 36
Total Census: 85
Census Payor Medicare: 15
Census Payor Medicaid: 19
Census Payor Other: 15
Total Census Payor: 49
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