Inspection Reports for Ossian Health Care and Rehabilitation Center
215 DAVIS RD, IN, 46777
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 3, 2025, identified several deficiencies related to Life Safety Code requirements, including issues with sprinkler system testing, smoke barrier construction, and fire door inspections. Earlier inspections showed a pattern of Life Safety Code and emergency preparedness deficiencies, as well as some care-related issues such as incomplete care planning and accident risk interventions. Complaint investigations were mostly unsubstantiated, though some substantiated complaints involved medication security, mental abuse, and care planning deficiencies; enforcement actions included staff suspension and termination but no fines or license suspensions were listed in the available reports. The facility has taken corrective actions and implemented monitoring plans following these findings. The inspection history shows ongoing challenges primarily with fire safety compliance and care documentation, with some improvements noted in emergency preparedness and complaint resolution over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
12 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
186% worse than Indiana average
Indiana average: 4.2 deficiencies/year
Deficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
83% occupied
Based on a June 2025 inspection.
Census over time
Inspection Report
Annual Inspection
Census: 83
Capacity: 100
Deficiencies: 6
Jun 3, 2025
Visit Reason
An annual Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) to assess compliance with Medicare/Medicaid participation requirements and Life Safety Code standards.
Findings
The facility was found not in compliance with several Life Safety Code requirements including failure to conduct required testing of dry sprinkler systems, failure to maintain ceiling construction in smoke compartments, failure to ensure smoke barrier walls were constructed to requirements, and failure to complete annual inspection and testing of fire doors in multiple buildings. The facility has taken corrective actions including repairs, education, and implementation of monitoring plans.
Severity Breakdown
SS=F: 4
SS=E: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to conduct required testing for 1 of 1 dry sprinkler systems; 3-year air leakage test was past due. | SS=F |
| Failed to maintain ceiling construction in 1 of 6 smoke compartments; an 8x12 inch hole in ceiling around sprinkler supply line. | SS=F |
| Failed to ensure 2 of 5 smoke barrier walls were constructed to requirements; penetrations sealed with grey caulk without documentation of fire rating. | SS=E |
| Failed to ensure annual inspection and testing of 1 of 1 oxygen room fire doors was completed; door not inspected. | SS=E |
| Failed to conduct required testing for 1 of 1 dry sprinkler systems in Building Two; 3-year air leakage test was past due. | SS=F |
| Failed to ensure annual inspection and testing of 4 of 5 fire doors in separation fire barrier between Building Three and Assisted Living were completed. | SS=F |
Report Facts
Facility capacity: 100
Census: 83
Deficiency count: 6
Fire door inspections missed: 4
Hole size: 96
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tomi Cobb | HFA | Laboratory Director or Provider/Supplier Representative who signed the report |
| Maintenance Director | Interviewed regarding sprinkler system testing, ceiling hole, smoke barrier penetrations, and fire door inspections | |
| Administrator | Interviewed and participated in exit conference regarding deficiencies |
Inspection Report
Annual Inspection
Deficiencies: 0
May 23, 2025
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey was conducted.
Findings
Ossian Health Care and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Annual Inspection
Census: 83
Capacity: 83
Deficiencies: 3
May 9, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted from May 5 to May 9, 2025.
Findings
The facility was found deficient in ensuring accident risks were identified and interventions implemented for one resident, trauma informed care was not adequately provided for one resident, and emergency file books lacked updated hospital preference information for eight residents. The facility submitted plans of correction addressing these issues.
Severity Breakdown
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure accident risks were identified and interventions put into place to prevent accidents for Resident 388. | SS=D |
| Failed to ensure trauma informed care was implemented for Resident 53, including lack of identification of trauma triggers and interventions. | SS=D |
| Failed to ensure updated hospital preference information in emergency file book for 8 residents. | — |
Report Facts
Survey dates: 5
Residents affected by emergency file deficiency: 8
Residential Census: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tomi Cobb | HFA | Signed the report as Laboratory Director or Provider/Supplier Representative |
| Licensed Practical Nurse 35 | Licensed Practical Nurse | Interviewed regarding elopement assessments and Resident 388's wandering behavior |
| Director of Nursing | Director of Nursing | Interviewed regarding Resident 388's wandering and care plan updates |
| Certified Nursing Assistant 2 | Certified Nursing Assistant | Interviewed about knowledge of residents with PTSD and trauma triggers |
| Licensed Practical Nurse 3 | Licensed Practical Nurse | Interviewed about knowledge of residents with PTSD and trauma triggers |
| Social Services Director | Social Services Director | Interviewed about Resident 53's care plan and trauma triggers |
| Administrator | Administrator | Interviewed regarding Resident 388's wandering history and emergency file hospital preference issues |
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 0
Apr 11, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00456920.
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 IN00456920 - No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type - SNF/NF: 86
Census Bed Type - Residential: 33
Census Total: 119
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 68
Census Payor Type - Other: 48
Inspection Report
Complaint Investigation
Census: 83
Capacity: 83
Deficiencies: 0
Nov 1, 2024
Visit Reason
This visit was conducted to investigate complaints IN00445606 and IN00445612 at Ossian Health Care and Rehabilitation Center.
Findings
No deficiencies related to the allegations in complaints IN00445606 and IN00445612 were cited. The facility was found to be in compliance with relevant federal and state regulations.
Complaint Details
Investigation of complaints IN00445606 and IN00445612 found no deficiencies related to the allegations.
Report Facts
Census: 83
Total Capacity: 83
Medicare Census: 1
Medicaid Census: 53
Other Payor Census: 29
Inspection Report
Re-Inspection
Census: 83
Capacity: 100
Deficiencies: 0
Aug 21, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey that exited on 07/15/24 was conducted by the Indiana Department of Health in accordance with 42 CFR Subpart 483.90(a).
Findings
At this PSR, Ossian Health Care and Rehabilitation Center 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 (LSC) Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Report Facts
Facility capacity: 100
Census: 83
Inspection Report
Annual Inspection
Census: 84
Capacity: 100
Deficiencies: 5
Jul 17, 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 on 07/17/2024 to assess compliance with federal and state regulations.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies were identified related to cooking facility shutoff access, corridor partitions, ground fault circuit interrupter (GFCI) protection in a shower room, fire drill scheduling, and improper use of extension cords.
Severity Breakdown
SS=E: 4
SS=F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure staff had access to the shutoff switch for 1 of 1 cook tops in the therapy gym; the switch was located outside the cooking facility. | SS=E |
| Failed to ensure 1 of 1 copier rooms was separated from the corridors by a partition capable of resisting the passage of smoke as required in a sprinklered building. | SS=E |
| Failed to ensure 1 of 3 shower rooms were provided with ground fault circuit interrupter (GFCI) protection that functioned properly. | SS=E |
| Failed to vary conditions at unexpected times during fire drills for 4 of 4 quarters and failed to conduct 1 of 3 fire drills for 1 of 4 quarters. | SS=F |
| Failed to ensure 1 of 56 resident rooms did not use flexible cords as a substitute for fixed wiring; an extension cord was used to power a microwave in the staff/resident store. | SS=E |
Report Facts
Facility capacity: 100
Census: 84
Fire drills documented: 11
Fire drills conducted within last week of month: 10
Shower rooms inspected: 3
Resident rooms inspected: 56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tomi Cobb | Administrator | Named in observations and interviews related to deficiencies and exit conference |
| Director of Plant Operations | Named in observations and interviews related to deficiencies and exit conference |
Inspection Report
Annual Inspection
Deficiencies: 0
Jul 11, 2024
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Ossian Health Care and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Annual Inspection
Census: 107
Deficiencies: 1
Jun 28, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Complaints IN00435520 and IN00435805, including a State Residential Licensure Survey.
Findings
The facility was found deficient for failing to ensure that an intrathecal pump (ITP) for one resident had proper physician orders and monitoring for morphine side effects and infection risks. No deficiencies were cited related to the two complaints investigated. The facility submitted a plan of correction to update orders and educate staff on monitoring requirements.
Complaint Details
Complaint IN00435520 and Complaint IN00435805 were investigated with no deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure an intrathecal pump had physician orders and directions for use, including monitoring for morphine side effects and infection for 1 of 7 residents reviewed (Resident 337). | SS=D |
Report Facts
Census: 107
SNF/NF beds: 81
Residential beds: 26
Medicare residents: 3
Medicaid residents: 68
Other payor residents: 36
Morphine Sulfate concentration: 4
Morphine Sulfate total volume: 40
Continuous Morphine dose: 0.0542
Total Morphine dose per day: 1.3003
Bolus Morphine dose: 0.4504
Maximum bolus activations: 4
Lockout interval: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tomi Cobb | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 84
Deficiencies: 0
Apr 23, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00430702.
Findings
No deficiencies related to the allegations in Complaint IN00430702 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00430702 found no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 84
Census total residents: 84
Census Medicare residents: 5
Census Medicaid residents: 48
Census Other payor residents: 31
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 0
Feb 14, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00450467.
Findings
No deficiencies related to the allegations in Complaint IN00450467 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00450467 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 86
Census Residential: 31
Total Census: 117
Census Payor Medicare: 2
Census Payor Medicaid: 63
Census Payor Other: 52
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 0
Feb 1, 2024
Visit Reason
This visit was conducted for the investigation of three complaints: IN00424448, IN00424996, and IN00427102.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with relevant regulations regarding the complaints investigated.
Complaint Details
Complaints IN00424448, IN00424996, and IN00427102 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 113
Census SNF/NF beds: 85
Census Residential beds: 28
Census Payor Type Medicare: 8
Census Payor Type Medicaid: 60
Census Payor Type Other: 45
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 0
Nov 3, 2023
Visit Reason
This visit was conducted for Investigation of Complaint IN00420877 and included a COVID-19 Focused Infection Control Survey and a Residential COVID-19 Quality Assurance Walk Through.
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 regarding the complaint and the COVID-19 survey.
Complaint Details
Complaint IN00420877 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 87
Census Bed Type - Residential: 32
Census Bed Type - Total: 119
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 56
Census Payor Type - Other: 25
Census Payor Type - Total: 87
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 2
Sep 20, 2023
Visit Reason
This visit was for the investigation of complaints IN00417226, IN00417327, IN00417840 and a COVID-19 Focused Infection Control Survey.
Findings
The facility failed to properly contain the transmission of COVID-19 for 5 of 11 residents reviewed, and failed to ensure families/representatives were notified of COVID-19 exposure for 3 of 10 residents reviewed. Deficiencies related to infection prevention and control and COVID-19 reporting were cited.
Complaint Details
Complaint IN00417226 - Federal/state deficiencies related to the allegations are cited at F880 and F885. Complaint IN00417327 - Federal/state deficiencies related to the allegations are cited at F885. Complaint IN00417840 - No deficiencies related to the allegations are cited.
Severity Breakdown
SS=E: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to properly contain the transmission of COVID-19 for 5 of 11 residents reviewed (Resident E, Resident G, Resident N, Resident O, and Resident Q). | SS=E |
| Failed to ensure families/representatives were notified of COVID-19 exposure for 3 of 10 residents reviewed (Resident B, Resident C, Resident J). | SS=D |
Report Facts
Residents reviewed for infection control: 11
Residents reviewed for notification: 10
COVID positive residents identified: 5
Roommates affected by deficient notification practice: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Activity Assistant 3 | Observed not properly donning and doffing PPE in COVID positive rooms; indicated lack of education on PPE use | |
| Restorative Aide 2 | Observed entering COVID positive rooms without proper PPE (no N95 mask) | |
| Director of Nursing | DON | Interviewed regarding PPE requirements and COVID notification procedures |
| Certified Nurse Aide 5 | CNA | Interviewed regarding PPE donning and doffing practices |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 20, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaints IN00417226 and IN00417327 and the COVID Focused Infection Control Survey.
Findings
Ossian Healthcare and Rehabilitation Center 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.
Complaint Details
Investigation of Complaints IN00417226 and IN00417327; facility found in compliance.
Inspection Report
Follow-Up
Census: 86
Capacity: 100
Deficiencies: 0
Aug 28, 2023
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 07/10/23, including a Life Safety Code Complaint Investigation of Complaint IN00412273.
Findings
At this Post Survey Revisit, Ossian Health Care and Rehabilitation Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Complaint Details
This visit was conducted in conjunction with the PSR for Life Safety Code Complaint Investigation of Complaint IN00412273.
Report Facts
Certified beds: 100
Census: 86
Inspection Report
Complaint Investigation
Census: 86
Capacity: 100
Deficiencies: 0
Aug 28, 2023
Visit Reason
This was a Post Survey Revisit (PSR) to investigate Complaint Number IN00412273 that exited on 07/10/23, conducted in conjunction with the PSR for the Life Safety Code Recertification and Emergency Preparedness Survey.
Findings
At this Complaint PSR survey, Ossian Health Care and Rehabilitation Center was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered with a fire alarm system and smoke detection in required areas.
Complaint Details
Complaint IN00412273 was corrected as of the date of this survey.
Report Facts
Facility capacity: 100
Census: 86
Inspection Report
Complaint Investigation
Census: 83
Capacity: 100
Deficiencies: 1
Jul 10, 2023
Visit Reason
The inspection was conducted as an investigation of Complaint Number IN00412273 by the Indiana Department of Health, in conjunction with the Life Safety Code Recertification and Emergency Preparedness Survey on 07/10/2023.
Findings
The facility was found not in compliance with fire safety requirements due to failure to minimize the possibility of a fire emergency, specifically related to damaged electrical wiring in resident room 308 that caused burning smells and heat, requiring fire department intervention and electrical repairs.
Complaint Details
Complaint IN00412273 was substantiated with a federal/state deficiency cited at K911 related to electrical fire safety hazards in resident room 308.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to minimize the possibility of a fire emergency due to damaged electrical wiring in resident room 308. | SS=E |
Report Facts
Facility capacity: 100
Census: 83
Residents affected: 10
Complaint number: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tomi Cobb | HFA | Signed the report |
| Regional Director of Property Management | Interviewed regarding electrical repairs in room 308 |
Inspection Report
Routine
Census: 83
Capacity: 100
Deficiencies: 18
Jul 10, 2023
Visit Reason
Routine Emergency Preparedness and Life Safety Code inspection survey 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 not in compliance with Emergency Preparedness requirements including failure to annually review and update the Emergency Preparedness Plan, Policies and Procedures, Communication Plan, and Training and Testing Plan. Life Safety Code deficiencies included a smoke barrier door failing latch test, obstructions in means of egress, improper exit signage, lack of staff training on kitchen fire suppression system, fire alarm system issues including wrong date/time and incomplete maintenance, incomplete fire drills, and incomplete fire door inspections.
Severity Breakdown
E: 9
F: 7
C: 2
Deficiencies (18)
| Description | Severity |
|---|---|
| Failed to review and update Emergency Preparedness Plan annually. | F |
| Failed to review and update Emergency Preparedness Policies and Procedures annually. | F |
| Failed to review and update Emergency Preparedness Communication Plan annually. | F |
| Failed to review and update Emergency Preparedness Training and Testing Plan annually. | F |
| Failed to conduct emergency preparedness exercises twice annually including unannounced staff drills. | C |
| Smoke barrier door on 300 hall failed latch test. | E |
| Means of egress obstructed by clean linen cart and service hall table. | E |
| PPE cart in corridor lacked wheels to allow removal during emergency. | E |
| Failed to maintain itemized records of emergency lighting battery tests. | E |
| Courtyard doors incorrectly marked as exits or lacked NO EXIT signage. | E |
| Kitchen staff not instructed on proper use of UL 300 hood fire suppression system. | E |
| Fire alarm control panel displayed incorrect date and time. | C |
| Fire alarm system had unresolved defects including batteries needing replacement and smoke detector sensitivity failure. | F |
| Corridor door to training room had a pencil size hole compromising smoke resistance. | E |
| Fire safety plan lacked complete instructions for evacuation of Dementia Unit smoke compartment. | E |
| Fire drills failed to include verification of fire alarm signal transmission to monitoring station for drills between 9pm and 6am. | F |
| Failed to complete annual inspection and testing of fire door assemblies. | F |
| Failed to maintain complete written records of monthly generator load testing and weekly inspections. | F |
Report Facts
Deficiencies cited: 18
Facility capacity: 100
Census: 83
Fire drills missing staff roster: 3
Fire drills missing transmission test: 1
Generator weekly inspections missed: 7
Generator monthly tests missed: 2
Inspection Report
Renewal
Census: 78
Capacity: 78
Deficiencies: 0
Jun 30, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted from June 26 to June 30, 2023.
Findings
Ossian Health Care and Rehabilitation was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Recertification and State Licensure Survey.
Report Facts
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 48
Census Payor Type - Other: 26
Inspection Report
Renewal
Deficiencies: 1
Jun 7, 2023
Visit Reason
This was an offsite licensure investigation survey conducted to review the facility's compliance with timely renewal of its license to operate as a health care and residential care facility.
Findings
The facility failed to submit a renewal application and payment at least 45 days prior to the expiration of its license, resulting in a late renewal submission postmarked June 1, 2023, after the license expired on May 31, 2023.
Deficiencies (1)
| Description |
|---|
| Failure to submit a renewal application at least 45 days prior to license expiration. |
Report Facts
Days prior to license expiration for renewal submission: 45
License expiration date: May 31, 2023
Renewal application submission date: Jun 1, 2023
Corrective action completion date: Jun 16, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rose Smalley | Regulatory Compliance Director | Signed as Laboratory Director's or Provider/Supplier Representative |
Inspection Report
Complaint Investigation
Census: 123
Deficiencies: 0
May 25, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00408954.
Findings
No deficiencies related to the allegations are cited. Ossian Health Care and Rehabilitation 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 Investigation of Nursing Home Complaint IN00408954.
Complaint Details
Complaint IN00408954 - No deficiencies related to the allegations are cited.
Report Facts
Census SNF/NF: 85
Census Residential: 38
Total Census: 123
Medicare Census: 4
Medicaid Census: 48
Other Payor Census: 71
Inspection Report
Complaint Investigation
Census: 83
Capacity: 83
Deficiencies: 0
Apr 11, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00404799.
Findings
No deficiencies related to the allegations in Complaint IN00404799 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00404799 found no deficiencies related to the allegations.
Report Facts
Census Bed Type: 83
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 47
Census Payor Type - Other: 29
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 0
Mar 23, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00402311.
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
Investigation of Complaint IN00402311 found no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 83
Census Residential: 36
Total Census: 119
Census Medicare: 6
Census Medicaid: 44
Census Other: 69
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 19, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00398123 completed on January 5, 2023.
Findings
Ossian Healthcare and Rehabilitation Center 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.
Complaint Details
Investigation of Complaint IN00398123 completed on January 5, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 117
Capacity: 117
Deficiencies: 1
Jan 5, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00398123, which was substantiated with federal and state deficiencies cited related to the allegations.
Findings
The facility failed to ensure one of five residents was free from mental abuse by staff, specifically involving a video posted on social media of a resident dancing with staff. The investigation concluded only one resident was affected, and corrective actions including staff suspension and termination were taken.
Complaint Details
Complaint IN00398123 was substantiated. The complaint involved mental abuse of Resident B by staff members who posted a video of the resident on social media without consent.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a resident was free from mental abuse by staff involving posting a video on social media. | SS=D |
Report Facts
Residents present: 117
Total licensed capacity: 117
Residents affected: 1
Staff members video sent to: 7
Staff inservice monitoring duration: 6
Staff post quiz participants: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tomi Cobb | HFA | Facility representative signing the report |
| CNA 2 | Certified Nursing Assistant | Staff involved in video with Resident B |
| CNA 3 | Certified Nursing Assistant | Staff who posted video of Resident B on social media |
| Scheduler 7 | Staff who received and reported the video to the Director of Nursing | |
| Director of Nursing | DON | Provided investigation file and conducted interviews |
Inspection Report
Follow-Up
Census: 85
Capacity: 100
Deficiencies: 0
Dec 16, 2022
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 10/17/22 by the Indiana Department of Health in accordance with 42 CFR Subpart 483.90(a).
Findings
At this PSR survey, Ossian Health Care and Rehabilitation Center 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 (LSC). All resident-accessible areas and facility services were sprinklered except for two sheds used for maintenance storage.
Report Facts
Facility capacity: 100
Census: 85
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 0
Dec 7, 2022
Visit Reason
This visit was conducted for the investigation of two complaints, IN00393525 and IN00395432.
Findings
Complaint IN00393525 was unsubstantiated due to lack of evidence. Complaint IN00395432 was substantiated but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00393525 was unsubstantiated due to lack of evidence. Complaint IN00395432 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Census Bed Type - SNF/NF: 57
Census Bed Type - Residential: 23
Census Total: 80
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 53
Census Payor Type - Total: 57
Inspection Report
Complaint Investigation
Census: 87
Capacity: 87
Deficiencies: 2
Oct 27, 2022
Visit Reason
This visit was for the investigation of Complaint IN00392398, which was substantiated. The complaint involved allegations related to medication misappropriation and medication storage and destruction practices.
Findings
The facility failed to ensure the security of medications from misuse for one resident, where staff gave discontinued antibiotics to a CNA for personal use. Additionally, the facility failed to ensure timely destruction of discontinued medications. The facility provided corrective actions including staff education and auditing medication carts to prevent recurrence.
Complaint Details
Complaint IN00392398 was substantiated. The complaint involved misappropriation of medications by staff, specifically CNA 5 receiving discontinued antibiotics from LPN 2 and QMA 6. The facility paid for the medications due to a pharmacy selection error and the resident was not charged. The facility implemented corrective actions including education and audits.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure security of medications from misuse for 1 of 1 residents reviewed. | SS=D |
| Failed to ensure medication was destroyed in a timely manner for 1 of 1 residents reviewed. | SS=D |
Report Facts
Census: 87
Total Capacity: 87
Medications destroyed: 17
Medications given: 2
Medications discontinued: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Brummett | MedScript pharmacy consultant | Provided education to nurses and QMAs on medication policies and procedures |
| LPN 2 | Licensed Practical Nurse | Gave discontinued antibiotics to CNA 5 and destroyed 17 pills |
| QMA 6 | Qualified Medication Assistant | Involved in giving discontinued antibiotics to CNA 5 |
| CNA 5 | Certified Nursing Assistant | Received discontinued antibiotics from staff for personal use |
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 27, 2022
Visit Reason
Paper compliance review to the Investigation of Complaint IN0392398 completed on October 27, 2022.
Findings
Ossian Healthcare and Rehabilitation Center 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 complaint investigation.
Complaint Details
Investigation of Complaint IN0392398; paper compliance review found the facility in compliance.
Inspection Report
Life Safety
Census: 85
Capacity: 100
Deficiencies: 5
Oct 17, 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).
Findings
The facility was found not in compliance with Life Safety Code requirements, including failure to inspect a portable fire extinguisher monthly, resident room corridor doors not latching properly, occupancy separation fire barrier door not latching, lack of shutoff access for cooktop in therapy gym, and use of a non-UL rated power strip in a patient care area.
Severity Breakdown
SS=E: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to inspect 1 of 1 portable fire extinguishers in the laundry each month. | SS=E |
| Resident corridor doors to rooms 219 and 116 did not latch closed. | SS=E |
| Assisted Living/Skilled Nursing Facility door did not latch into frame. | SS=E |
| Failed to show shut off location to stove in therapy gym. | SS=E |
| Power strip in therapy gym was not the required UL rating for patient care areas. | SS=E |
Report Facts
Facility capacity: 100
Census: 85
Deficiencies cited: 5
Residents potentially affected: 4
Residents potentially affected: 15
Residents potentially affected: 5
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 0
Oct 6, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00389855.
Findings
The complaint IN00389855 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00389855 was investigated and found unsubstantiated due to lack of evidence.
Report Facts
Census Bed Type - SNF/NF: 83
Census Bed Type - Residential: 36
Census Total: 119
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 45
Census Payor Type - Other: 35
Census Payor Type - Total: 83
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 2, 2022
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Ossian Health Care and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Renewal
Census: 82
Capacity: 82
Deficiencies: 2
Aug 22, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted on August 17, 18, 19, and 22, 2022.
Findings
The facility was found deficient in completing accurate Minimum Data Set (MDS) assessments for hospice care and developing comprehensive care plans for hospice services for one of five residents reviewed (Resident 56). The facility failed to complete the MDS reflecting hospice care and did not have a care plan for hospice services. Corrective actions and audits were planned to ensure compliance.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure the MDS for hospice care was completed for 1 of 5 residents reviewed (Resident 56). | SS=D |
| Failed to ensure a care plan for hospice care was completed for 1 of 5 residents reviewed (Resident 56). | SS=D |
Report Facts
Census: 82
Total Capacity: 82
Survey Dates: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding MDS and care plan deficiencies for hospice care | |
| Administrator | Interviewed regarding MDS and care plan deficiencies for hospice care | |
| MDS Coordinator | Reviewed and modified MDS and care plan for Resident 56 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 15, 2022
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00385715 completed on July 27, 2022.
Findings
Ossian Health Care and Rehabilitation Center 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.
Complaint Details
Paper compliance to the Investigation of Complaint IN00385715 completed on July 27, 2022. Facility found in compliance.
Inspection Report
Complaint Investigation
Census: 89
Capacity: 89
Deficiencies: 1
Jul 27, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00385715. The complaint was substantiated and federal/state deficiencies related to the allegations were cited at F690.
Findings
The facility failed to ensure assessment and care plan development for urinary incontinence for 1 of 3 residents reviewed (Resident J). Resident J had overactive bladder and required assistance with personal care. The care plans lacked interventions to prevent urinary tract infections and did not address refusals of care or behaviors related to incontinence. The resident had multiple refusals of incontinence care and showers, developed a urinary tract infection and a severe yeast infection, and family concerns about care were documented.
Complaint Details
Complaint IN00385715 was substantiated. The complaint involved inadequate assessment and care planning for urinary incontinence, refusals of care, urinary tract infection, and hygiene concerns for Resident J.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure assessment and care plan development for urinary incontinence for Resident J. | SS=D |
Report Facts
Census: 89
Total Capacity: 89
Medicare Census: 5
Medicaid Census: 46
Other Payor Census: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 5 | Certified Nurse Assistant | Reported on Resident J's resistance to incontinence care and showers |
| Social Services Director | Social Services Director | Discussed Resident J's care plan and resistance to care |
| Director of Nurses | Director of Nurses | Discussed facility efforts to assist Resident J and care planning |
| Certified Occupational Therapy Assistant | Certified Occupational Therapy Assistant | Provided information on Resident J's contributing issues to incontinence |
| Administrator | Administrator | Interviewed regarding Resident J's care and toileting plan |
| MDS Nurse | MDS Nurse | Interviewed regarding Resident J's care and history |
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