Inspection Reports for Owen Valley Rehabilitation and Healthcare Center
920 W HIGHWAY 46, SPENCER, IN, 47460
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 8, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a pattern of deficiencies primarily involving emergency preparedness and fire safety, including issues with generator maintenance, fire alarm inspections, and sprinkler system upkeep. Prior reports also cited some resident care documentation and care planning concerns, as well as a substantiated complaint related to failure to follow fire safety procedures during a kitchen grease fire in early 2023. Most complaint investigations were unsubstantiated or found no deficiencies, with the exception of the fire safety incident and a prior substantiated issue involving timely family notification and radiology services after a resident accident. The facility’s recent inspections indicate improvement in emergency preparedness and life safety compliance following earlier citations.
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/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
72 residents
Based on a May 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 0
Date: May 8, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00458546 at Owen Valley Rehabilitation and Healthcare Center.
Complaint Details
Complaint IN00458546 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type Total: 72
Census Payor Type Total: 72
SNF/NF Census: 69
SNF Census: 3
Medicare Census: 9
Medicaid Census: 54
Other Payor Census: 9
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 0
Date: Apr 29, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00458305.
Complaint Details
Complaint IN00458305 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations are cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Investigation of Complaint IN00458305.
Report Facts
Census Bed Type - Total: 77
Census Bed Type - SNF/NF: 74
Census Bed Type - SNF: 3
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 52
Census Payor Type - Other: 18
Inspection Report
Re-Inspection
Census: 76
Capacity: 113
Deficiencies: 0
Date: Feb 14, 2025
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 12/16/2024.
Findings
At this PSR, Owen Valley Rehabilitation and Healthcare Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility was fully sprinklered and had a fire alarm system with hard wired smoke detectors in all required areas.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Dec 27, 2024
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey conducted on December 9, 2024.
Findings
Owen Valley Rehabilitation and Healthcare 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
Routine
Census: 76
Capacity: 113
Deficiencies: 16
Date: Dec 16, 2024
Visit Reason
A routine Emergency Preparedness and Life Safety Code survey was conducted by the Indiana Department of Health to assess compliance with Medicare and Medicaid participation requirements and fire safety codes.
Findings
The facility was found not in compliance with emergency preparedness requirements including failure to maintain proper emergency power system inspections, testing, and maintenance, lack of a properly operating emergency generator annunciator panel, incomplete generator load testing records, missing battery backup light for the emergency generator, and deficiencies in fire safety such as lack of self-closing hazardous area doors, incomplete fire alarm system inspections, mixed sprinkler head types, inadequate sprinkler system maintenance, incomplete fire safety plan, and incomplete fire drill scheduling. Additionally, patient care related electrical equipment maintenance documentation was missing.
Deficiencies (16)
Failed to implement emergency power system inspection, testing, and maintenance requirements including a non-operating emergency generator annunciator panel.
Failed to maintain complete written record of monthly generator load testing for 4 of the past 12 months.
Failed to maintain written record of weekly generator inspections for 31 of 52 weeks.
Emergency generator lacked a battery backup light.
Hazardous area door (PPE storage room) lacked a self-closing device.
Failed to maintain fire alarm system in accordance with NFPA 72; semi-annual visual inspections incomplete.
Mixed sprinkler head types (standard and quick response) in one smoke compartment.
Failed to document sprinkler system inspections for dry sprinkler system pressure gauges weekly for 38 of 52 weeks and control valves for 8 of 12 months.
One sprinkler head in laundry room covered with corrosion was not replaced.
Sprinkler system lacked minimum number of spare sprinklers matching type and temperature ratings on premises.
Facility fire safety plan incomplete; did not identify smoke barrier locations or clarify use of K-class extinguisher relative to kitchen overhead extinguishing system.
Fire drills were not held at varied times for 1 of 3 employee shifts during 3 of 4 quarters.
Emergency generator lacked a properly operating alarm annunciator panel at a location readily observed by operating personnel.
Failed to maintain complete written record of monthly generator load testing and weekly inspections; missing battery-operated light inside generator housing.
Failed to maintain weekly inspections of generator batteries for 31 of 52 weeks.
Failed to conduct required maintenance and maintain documentation for Patient Care Related Electrical Equipment (PCREE).
Report Facts
Certified beds: 113
Current census: 76
Missing monthly generator load test months: 4
Missing monthly sprinkler system control valve inspections: 8
Weekly generator inspections missing weeks: 31
Second shift fire drills performed at similar times: 3
Monthly generator load test reports with load percentage: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Meadows | Executive Director | Named in multiple findings and exit conference |
| Regional Director of Operations | Interviewed regarding generator and fire safety findings | |
| Maintenance Director | Interviewed and involved in corrective actions for generator and fire safety findings |
Inspection Report
Annual Inspection
Census: 75
Capacity: 75
Deficiencies: 2
Date: Dec 9, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaints IN00448613 and IN00446806.
Complaint Details
Complaint IN00448613 and Complaint IN00446806 were investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies were cited related to the complaints investigated. Deficiencies were found related to late completion of admission Minimum Data Set (MDS) assessments for 4 residents and failure to invite a resident to care planning conferences.
Deficiencies (2)
Failed to ensure the admission Minimum Data Set (MDS) assessment was completed within 14 calendar days from the admission date for 4 residents.
Failed to ensure residents were invited to participate in the care planning conference for 1 resident.
Report Facts
Census: 75
Total Capacity: 75
Residents with late MDS assessments: 4
Residents reviewed for care planning invitation: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Patterson | Director of Nursing | Signed the report and provided facility policy regarding care planning |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 76
Deficiencies: 0
Date: Oct 29, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00445209 at Owen Valley Rehabilitation and Healthcare Center.
Complaint Details
Complaint IN00445209 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable federal and state regulations.
Report Facts
Census Bed Type - SNF: 5
Census Bed Type - SNF/NF: 71
Total Census: 76
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 59
Census Payor Type - Other: 14
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 0
Date: Sep 5, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00441941.
Complaint Details
Complaint IN00441941 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type - SNF: 7
Census Bed Type - SNF/NF: 74
Total Census: 81
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 59
Census Payor Type - Other: 18
Inspection Report
Complaint Investigation
Census: 79
Capacity: 79
Deficiencies: 0
Date: Aug 15, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00440520.
Complaint Details
Complaint IN00440520 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations are cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Investigation of Complaint IN00440520.
Report Facts
Census Bed Type: 79
Census Payor Type: 79
Inspection Report
Complaint Investigation
Census: 75
Capacity: 75
Deficiencies: 0
Date: Aug 6, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00440218.
Complaint Details
Complaint IN00440218 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00440218 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 75
Total Capacity: 75
Medicare Residents: 1
Medicaid Residents: 60
Other Payor Residents: 14
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 0
Date: Jul 1, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00436494 at Owen Valley Rehabilitation and Healthcare Center.
Complaint Details
Complaint IN00436494 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 79
Census Bed Type - SNF: 5
Census Bed Type - SNF/NF: 74
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 55
Census Payor Type - Other: 17
Inspection Report
Re-Inspection
Census: 76
Capacity: 113
Deficiencies: 0
Date: Apr 1, 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 02/19/24.
Findings
At this PSR survey, Owen Valley Rehabilitation and Healthcare Center 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: 113
Current census: 76
Inspection Report
Re-Inspection
Census: 73
Deficiencies: 0
Date: Feb 23, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on February 2, 2024.
Findings
Owen Valley Rehabilitation and Healthcare 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 Total: 73
Census Payor Type Total: 73
Medicare Census: 5
Medicaid Census: 57
Other Payor Census: 11
Inspection Report
Life Safety
Census: 74
Capacity: 113
Deficiencies: 12
Date: Feb 19, 2024
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 several Life Safety Code requirements including emergency preparedness, fire alarm system maintenance, emergency power system testing, barrier door functionality, electrical safety, and fire drill documentation.
Deficiencies (12)
Failed to develop and maintain an emergency preparedness plan reviewed and updated at least annually.
Failed to develop and implement emergency preparedness policies and procedures reviewed and updated at least annually.
Failed to develop and maintain an emergency preparedness communication plan reviewed and updated at least annually.
Failed to develop and maintain an emergency preparedness training and testing program reviewed and updated at least annually.
Failed to implement emergency power system inspection, testing, and maintenance requirements in accordance with NFPA 110 and Life Safety Code.
Failed to ensure documentation for emergency generator included a 5 minute cool down period after load test and transfer time to alternate power source on monthly load tests.
Failed to maintain latching hardware on 1 of 5 double door sets; barrier doors failed to fully close and latch.
Failed to maintain fire alarm system in accordance with NFPA 72; semi-annual visual inspections not performed as required.
Failed to ensure 1 of over 20 wet locations had ground fault circuit interrupter (GFCI) protection against electric shock.
Failed to ensure 2 of 12 fire drill reports included complete documentation of transmission of fire alarm signal to monitoring company/fire department.
Failed to ensure documentation for emergency generator included 5 minute cool down period and transfer time to alternate power source on monthly load tests.
Failed to ensure power strips were not used as a substitute for fixed wiring to provide power to equipment with high current draw.
Report Facts
Certified beds: 113
Current census: 74
Fire drill reports missing transmission documentation: 2
Barrier doors inspected: 5
Barrier doors failed to latch: 1
Fire alarm visual inspections missing: 1
Emergency generator monthly load tests missing cool down time: 3
Emergency generator monthly load tests missing transfer time: 3
Wet location outlets missing GFCI protection: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cathy Parker | Executive Director | Signed report and plan of correction |
| Senior Maintenance Director | Interviewed and involved in findings related to emergency preparedness and maintenance | |
| Director of Maintenance | Interviewed and involved in findings related to emergency preparedness, fire alarm, and electrical issues | |
| Administrator in Training | Present at exit conference and involved in review of findings |
Inspection Report
Renewal
Census: 79
Capacity: 79
Deficiencies: 3
Date: Feb 2, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from January 29 to February 2, 2024.
Findings
The facility was found deficient in three main areas: failure to accurately submit Registered Nurse hours in the Payroll Based Journal for quarter 4 of fiscal year 2023; failure to maintain a safe, functional, sanitary, and comfortable environment due to urine odors and unclean air vents in multiple units; and failure to complete criminal background checks for one minor employee.
Deficiencies (3)
Failed to electronically submit complete and accurate Registered Nurse hours based on payroll and other verifiable data for quarter 4 of fiscal year 2023.
Failed to ensure a sanitary and comfortable environment due to urine odor and dirty air vents in 3 of 4 units observed.
Failed to ensure criminal background checks were completed for 1 of 5 new employee files reviewed (minor employee).
Report Facts
Resident census: 79
Total licensed capacity: 79
RN hours missing: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper 1 | Named in deficiency for missing criminal background check | |
| Director of Nursing | Director of Nursing | Interviewed regarding Payroll Based Journal RN hours deficiency |
| Executive Director | Executive Director | Interviewed regarding missing background check for minor employee |
| Director of Health Services | Director of Health Services | Interviewed regarding missing background check for minor employee |
| Maintenance Director | Maintenance Director | Interviewed regarding urine odor and dirty air vents |
| Environmental Services Director | Environmental Services Director | Involved in corrective actions for environmental deficiencies |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 75
Deficiencies: 0
Date: Dec 14, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00422688 and IN00422767.
Complaint Details
Complaint IN00422688 and Complaint IN00422767 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00422688 and IN00422767 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type - SNF/NF: 69
Census Bed Type - SNF: 6
Total Census: 75
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 48
Census Payor Type - Other: 26
Inspection Report
Complaint Investigation
Census: 76
Capacity: 76
Deficiencies: 0
Date: Oct 25, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00419808.
Complaint Details
Investigation of Complaint IN00419808 with no deficiencies related to the allegations cited.
Findings
No deficiencies related to the allegations are cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Investigation of Complaint IN00419808.
Report Facts
Census Bed Type: 6
Census Bed Type: 70
Total Census: 76
Census Payor Type: 6
Census Payor Type: 52
Census Payor Type: 18
Inspection Report
Complaint Investigation
Census: 79
Capacity: 79
Deficiencies: 0
Date: Aug 29, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00415613 at Owen Valley Rehabilitation and Healthcare Center.
Complaint Details
Complaint IN00415613 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 79
Total Capacity: 79
Census Bed Type - SNF: 4
Census Bed Type - SNF/NF: 75
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 60
Census Payor Type - Other: 15
Inspection Report
Complaint Investigation
Census: 78
Capacity: 78
Deficiencies: 0
Date: Jul 17, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00412616.
Complaint Details
Complaint IN00412616 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00412616 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 78
Total Capacity: 78
Census Bed Type - SNF/NF: 74
Census Bed Type - SNF: 4
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 53
Census Payor Type - Other: 20
Inspection Report
Complaint Investigation
Census: 74
Capacity: 74
Deficiencies: 2
Date: Jun 29, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00411250, which involved federal and state deficiencies related to allegations cited at F580 and F776.
Complaint Details
Complaint IN00411250 was substantiated with federal/state deficiencies cited at F580 and F776 related to failure to notify family of an accident and untimely completion of radiology services for Resident B.
Findings
The facility failed to notify the family of a resident's accident in a timely manner and failed to ensure that an ordered x-ray was completed promptly for the resident. Corrective actions and monitoring plans were implemented to address these issues.
Deficiencies (2)
Failed to notify the resident's family of an accident in a timely manner.
Failed to ensure an x-ray was completed in a timely manner for a resident after an accident.
Report Facts
Census: 74
Total Capacity: 74
Residents with Medicare: 2
Residents with Medicaid: 56
Residents with Other payor: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Patterson | Director of Nursing | Named in relation to findings and plan of correction |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 29, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00411250 completed on June 29, 2023.
Complaint Details
Investigation of Complaint IN00411250 was completed with findings of compliance.
Findings
Owen Valley Rehabilitation and Healthcare 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 of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 74
Capacity: 74
Deficiencies: 0
Date: Jun 16, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00410331.
Complaint Details
Investigation of Complaint IN00410331 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00410331 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 74
Medicare Census: 3
Medicaid Census: 58
Other Payor Census: 13
Inspection Report
Re-Inspection
Census: 71
Capacity: 113
Deficiencies: 0
Date: May 25, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 03/27/23 was performed by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR survey, Owen Valley Rehabilitation Healthcare 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. The facility was fully sprinklered with a fire alarm system and hard wired smoke detectors in all required areas.
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 0
Date: May 24, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00408424.
Complaint Details
Complaint IN00408424 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type: 70
Medicare Census: 6
Medicaid Census: 54
Other Payor Census: 10
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 0
Date: Apr 25, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00403687, IN00404930, IN00406457, and IN00407089 at Owen Valley Rehabilitation and Healthcare Center.
Complaint Details
Complaints IN00403687, IN00404930, IN00406457, and IN00407089 were investigated and no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations in any of the four complaints 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 investigation of complaints.
Report Facts
Census Bed Type: 77
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 59
Census Payor Type - Other: 13
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 12, 2023
Visit Reason
The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure survey completed on March 9, 2023.
Findings
Owen Valley Rehabilitation and Healthcare 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
Life Safety
Census: 77
Capacity: 113
Deficiencies: 6
Date: Mar 27, 2023
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 Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. Deficiencies included issues with egress door signage and codes, illumination of exit means, self-closing hazardous area doors, cooking equipment safety, sprinkler system maintenance, and electrical receptacle GFCI protection.
Deficiencies (6)
Failed to ensure the means of egress through 1 of 8 delayed egress locks were readily accessible; missing required signage and keypad code.
Failed to ensure lighting for 2 of 7 exit means of egress was properly maintained and would not leave the area in darkness.
Failed to ensure corridor door to 1 of over 10 hazardous area doors (Activity Storage room) was provided with a properly operating self closing device.
Failed to ensure the cook top in 1 of 1 Garden Unit kitchenette was shut off at the switch when not in use.
Failed to ensure sprinkler heads in 2 of 6 smoke compartments covered with corrosion or loaded were replaced.
Failed to ensure 2 of over 20 wet locations were provided with ground fault circuit interrupter (GFCI) protection against electric shock.
Report Facts
Certified beds: 113
Current census: 77
Delayed egress locks: 1
Exit means lighting: 2
Hazardous area doors: 1
Sprinkler heads: 4
Wet locations without GFCI: 2
Inspection Report
Annual Inspection
Census: 75
Capacity: 75
Deficiencies: 6
Date: Mar 9, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from March 5 to March 9, 2023.
Findings
The facility was found deficient in several areas including accuracy of Minimum Data Set assessments, development and implementation of comprehensive care plans, provision of activities of daily living care, documentation of skin tears, nutrition and hydration maintenance, and respiratory care including oxygen therapy.
Deficiencies (6)
Failed to ensure accuracy of Minimum Data Set (MDS) assessment for a resident with falls.
Failed to ensure an activities of daily living (ADL) care plan was developed for 2 of 6 residents reviewed.
Failed to provide necessary services to maintain good grooming and personal hygiene for 4 of 6 residents reviewed.
Failed to document a skin tear in the clinical record for 1 of 3 residents reviewed for skin conditions.
Failed to ensure staff assessed and addressed the needs of residents with significant weight loss for 2 of 5 residents reviewed for nutrition.
Failed to provide respiratory care consistent with professional standards; no physician order for oxygen and equipment not dated.
Report Facts
Deficiency count: 6
Census: 75
Total Capacity: 75
Weight loss percentage: 14.34
Weight loss percentage: 12.25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Patterson | Director of Nursing | Named in relation to findings and corrective actions |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 28, 2023
Visit Reason
Paper compliance to the investigation of Complaint Number IN00400965 conducted on 02/08/23 was completed on 02/28/23.
Complaint Details
Investigation of Complaint Number IN00400965 conducted on 02/08/23 was completed with compliance found.
Findings
Owen Valley Rehabilitation and Healthcare 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.
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 0
Date: Feb 14, 2023
Visit Reason
This visit was conducted for the investigation of three complaints: IN00398632, IN00401055, and IN00401561.
Complaint Details
Complaint IN00398632 - Substantiated with no deficiencies cited. Complaint IN00401055 - Unsubstantiated due to lack of evidence. Complaint IN00401561 - Unsubstantiated due to lack of evidence.
Findings
Complaint IN00398632 was substantiated but no deficiencies related to the allegations were cited. Complaints IN00401055 and IN00401561 were unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant federal and state regulations regarding these complaints.
Report Facts
Census: 76
Census Bed Type - SNF/NF: 74
Census Bed Type - SNF: 2
Census Payor Type - Medicare: 9
Census Payor Type - Medicaid: 62
Census Payor Type - Other: 5
Inspection Report
Complaint Investigation
Census: 77
Capacity: 113
Deficiencies: 1
Date: Feb 8, 2023
Visit Reason
An investigation of Complaint Number IN00400965 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a). The complaint was substantiated and related to fire safety compliance.
Complaint Details
Complaint Number IN00400965 was substantiated. The complaint related to failure to follow fire safety procedures during a grease fire in the kitchen.
Findings
The facility failed to fully follow its fire safety plan during a grease fire incident in the kitchen on 02/04/23, including improper use of fire extinguishers and failure to activate the kitchen hood fire suppression system. The fire alarm activated after the fire extinguisher was discharged, and the local fire department responded. The facility was found not in compliance with NFPA 101, 2012 edition, Section 19.7.2.2 requirements for fire safety plans.
Deficiencies (1)
Failed to follow the facility's fire safety plan completely for the protection of 77 residents, including improper use of fire extinguishers and failure to activate fire suppression system as required by NFPA 101, 2012 edition, Section 19.7.2.2.
Report Facts
Facility capacity: 113
Census: 77
Deficiency completion date: Feb 24, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Russell | Executive Director | Named as participant in exit conference and report signature |
| Director of Plant Operations | Interviewed regarding fire incident and fire safety plan | |
| Director of Food Services | Interviewed regarding fire incident and fire safety plan | |
| Dietary Aide | Interviewed regarding fire incident and fire extinguisher use |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 0
Date: Oct 31, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00392721.
Complaint Details
Complaint IN00392721 - Unsubstantiated due to lack of evidence.
Findings
Complaint IN00392721 was found to be unsubstantiated due to lack of evidence. 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.
Report Facts
Census: 81
Census Bed Type: 81
Census Payor Type: 81
Inspection Report
Complaint Investigation
Census: 76
Capacity: 76
Deficiencies: 0
Date: Aug 31, 2022
Visit Reason
This visit was for the investigation of Complaint IN00387610.
Complaint Details
Complaint IN00387610 was investigated and found to be unsubstantiated due to lack of evidence.
Findings
The complaint IN00387610 was found to be unsubstantiated due to lack of evidence. 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.
Report Facts
Census: 76
Total Capacity: 76
Medicare Census: 1
Medicaid Census: 66
Other Payor Census: 9
Viewing
Loading inspection reports...
