Inspection Report Summary
The most recent inspection on March 27, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a mix of compliance and cited deficiencies, including issues with Life Safety Code requirements, resident care plans, medication management, and infection control. Complaint investigations were mostly unsubstantiated, though a substantiated complaint in February 2024 cited deficiencies related to fall notification and care plan adherence, and other reports noted medication administration and staff qualification issues. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows some improvement in life safety compliance since mid-2024, but care and medication management issues have appeared intermittently over time.
Deficiencies (last 3 years)
Deficiencies (over 3 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
12
9
6
3
0
Census
Latest occupancy rate
58% occupied
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 58
Capacity: 100
Deficiencies: 0
Mar 27, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00455964.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00455964 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 20
Census Bed Type: 38
Census Bed Type: 42
Census Payor Type: 25
Census Payor Type: 20
Census Payor Type: 13
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 0
Aug 12, 2024
Visit Reason
This visit was conducted for the investigation of complaint IN00439332.
Findings
No deficiencies were cited related to the allegations. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Complaint Details
Complaint IN00439332 was investigated and found to have no deficiencies related to the allegations.
Inspection Report
Re-Inspection
Census: 49
Capacity: 68
Deficiencies: 0
Jul 29, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 06/24/24 was performed to verify compliance with fire safety and licensure requirements.
Findings
At this PSR to the Life Safety Code survey, River Pointe Health Campus 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 functional fire alarm system.
Report Facts
Facility capacity: 68
Census: 49
Inspection Report
Life Safety
Census: 44
Capacity: 68
Deficiencies: 6
Jun 24, 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) and NFPA 101, 2012 edition.
Findings
The facility was found not in compliance with Life Safety Code requirements, with deficiencies including a fire door that did not latch, a stairway door with an impediment preventing latching, lack of documentation for sprinkler system inspections, quarterly rather than monthly firefighter recall elevator testing, an incomplete fire safety plan missing smoke barrier locations, and fire drills not held at varied times across all shifts.
Severity Breakdown
SS=E: 3
SS=C: 2
SS=F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 4 sets of fire doors latched in the 2 hour fire separation wall between Assisted Living and skilled health care sections. | SS=E |
| Failed to ensure 1 of 6 stairway enclosure doors was not provided with an impediment to prevent latching. | SS=E |
| Failed to document sprinkler system inspections for 12 of the past 12 months for the sprinkler system's control valves. | SS=C |
| Failed to ensure documentation was provided for monthly testing of 2 elevators firefighter recall; tests were only performed quarterly. | SS=E |
| Failed to provide a complete facility specific written fire safety plan that accurately addresses all life safety systems including smoke barrier locations. | SS=F |
| Failed to ensure fire drills were held at varied times for 3 of 3 employee shifts during 4 of 4 quarters. | SS=C |
Report Facts
Certified beds: 68
Census: 44
Fire door sets: 4
Stairway enclosure doors: 6
Months missing sprinkler inspection documentation: 12
Elevators: 2
Fire drills: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jordan Shots | Executive Director | Named in relation to review and education on deficiencies and plans of correction. |
| Director of Plant Operations | Involved in observations, interviews, and corrective actions related to fire door, stairway door, sprinkler system, elevator testing, and fire safety plan. | |
| Facility Maintenance Support | Participated in observations and interviews regarding fire door, stairway door, sprinkler system, elevator testing, and fire safety plan. |
Inspection Report
Annual Inspection
Census: 37
Capacity: 78
Deficiencies: 12
Jun 13, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey including a State Residential Licensure Survey conducted on June 7, 10, 11, 12, and 13, 2024.
Findings
The facility was found to have multiple deficiencies including failure to ensure resident dignity, proper medication self-administration orders and care plans, notification of physician for skin conditions, proper use of gait belts, medication storage issues, infection control breaches, incomplete vaccine education documentation, improper medication disposal, and failure to follow enhanced barrier precautions.
Severity Breakdown
SS=D: 6
SS=E: 3
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to ensure dignity was respected for residents during care. | SS=D |
| Failure to ensure a resident had an order, evaluation, and care plan for self-administration of medication. | SS=D |
| Failure to notify attending physician of new skin tears and obtain wound care orders. | SS=D |
| Failure to develop and implement care plans for residents regarding gait belt use and self-administration of medications. | SS=D |
| Failure to properly label and store drugs and biologicals, including loose pills in medication cart and incomplete refrigerator temperature logs. | SS=E |
| Failure to follow infection control protocols including glove changes and proper PPE use during Enhanced Barrier Precautions. | SS=D |
| Failure to provide education prior to influenza immunization for residents. | SS=E |
| Failure to maintain oxygen equipment in a safe and operational condition. | SS=D |
| Failure to ensure a resident evaluated as unable to self-administer medications was free of accessible medications in their room. | — |
| Failure to administer the correct dose of medication during medication administration observation. | — |
| Failure to properly dispose of medications after being dropped during administration. | — |
| Failure to isolate a resident to the degree needed to isolate the infecting organism during wound care. | — |
Report Facts
Survey dates: 5
Census Bed Type: 78
Resident census: 37
Deficiency counts: 12
Audit frequencies: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Stallman | RN-BC, Clinical Support | Signed the inspection report |
| QMA 12 | Qualified Medication Aide | Observed administering medications and involved in medication disposal and infection control breaches |
| RN 21 | Registered Nurse | Observed assisting resident and responsible for medication cart cleaning |
| DON | Director of Nursing | Provided multiple interviews, policies, and explanations related to deficiencies |
| HHN 17 | Home Health Nurse | Observed performing wound care without proper PPE |
Inspection Report
Renewal
Deficiencies: 0
Jun 13, 2024
Visit Reason
Paper compliance review for the Recertification and State Licensure survey ending on June 13, 2024.
Findings
River Pointe Health Campus was found to be in compliance with 42 CFR part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 27, 2024
Visit Reason
Paper compliance review for the Investigation of Complaint IN00428144 survey ending on February 27, 2024.
Findings
River Pointe Health Campus 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 for the Investigation of Complaint IN00428144 survey.
Complaint Details
Investigation of Complaint IN00428144; facility found to be in compliance.
Inspection Report
Complaint Investigation
Census: 85
Capacity: 85
Deficiencies: 2
Feb 26, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00428144 regarding allegations related to resident falls and care plan adherence.
Findings
The facility failed to notify a resident's representative of a fall in a timely manner and failed to follow the plan of care for transfers for one resident. Nursing personnel were educated on fall notification protocols and adherence to care plans. No adverse effects were noted for the residents involved.
Complaint Details
Complaint IN00428144 was substantiated with federal/state deficiencies cited at F580 and F656 related to fall notification and care plan adherence.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to notify the resident's representative of a fall until the next day for 1 of 3 residents reviewed (Resident B). | SS=D |
| Failed to follow the plan of care for transfers; a resident was assisted by one staff instead of two (Resident C). | SS=D |
Report Facts
Census: 85
Total Capacity: 85
Residents reviewed for fall notification: 3
Residents reviewed for transfer care plan adherence: 3
Audit sample size for fall notification: 3
Audit sample size for transfer care plan adherence: 5
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 0
Oct 6, 2023
Visit Reason
This visit was conducted to investigate two complaints, IN00415566 and IN00418346, regarding the facility.
Findings
No deficiencies related to the allegations in complaints IN00415566 and IN00418346 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00415566 and IN00418346 were investigated with no deficiencies found related to the allegations.
Report Facts
Census Bed Type - SNF: 28
Census Bed Type - SNF/NF: 20
Census Bed Type - Residential: 39
Total Census: 87
Census Payor Type - Medicare: 14
Census Payor Type - Medicaid: 14
Census Payor Type - Other: 20
Total Census Payor: 48
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 2
Jul 5, 2023
Visit Reason
This visit was conducted for the investigation of Nursing Home Complaint IN00410919, which included the investigation of Residential Complaint IN00410919.
Findings
The facility was found to be in compliance with federal and state requirements regarding the complaint. However, deficiencies were cited related to staff qualifications for insulin administration and lack of physician order for self-administration of medications.
Complaint Details
Complaint IN00410919 was investigated and related state deficiencies were cited at R0117. The facility was found in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure residents received care by qualified staff; QMAs administered insulin without certification for 3 diabetic residents (Residents F, G, H). |
| Facility failed to ensure a physician order to self-administer medications was obtained for 1 resident (Resident C) with medications left at bedside. |
Report Facts
Census: 96
Residents with insulin administration deficiency: 3
Residents observed for medication self-administration: 5
Survey dates: July 5 and 6, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jordan Shots | Executive Director | Signed the report |
| LPN 22 | Licensed Practical Nurse | Observed leaving medications with Resident C without physician order for self-administration |
| QMA 2 | Uncertified for insulin administration; documented insulin administration | |
| QMA 3 | Uncertified for insulin administration; documented insulin administration | |
| QMA 4 | Uncertified for insulin administration; documented insulin administration | |
| QMA 5 | Interviewed regarding QMA insulin administration certification requirements | |
| DON | Director of Nursing | Interviewed regarding insulin administration policy and self-administration medication orders |
| Regional Consultant | Provided facility policies and participated in interviews |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 27, 2023
Visit Reason
Paper compliance review for the Investigation of Complaints IN00408526 and IN00408532 survey resulting in an unrelated deficiency ending on May 18, 2023.
Findings
River Pointe Health Campus 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 Complaint IN00408526 and IN00408532 survey and the unrelated deficiency.
Complaint Details
Investigation of Complaints IN00408526 and IN00408532; facility found in compliance with no deficiencies related to these complaints.
Inspection Report
Re-Inspection
Census: 50
Capacity: 68
Deficiencies: 0
May 18, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 04/04/23 was performed to verify compliance with previous findings.
Findings
The facility was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code. The facility is fully sprinklered with a fire alarm system and had no deficiencies at the time of this survey.
Report Facts
Facility capacity: 68
Census: 50
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 1
May 17, 2023
Visit Reason
This visit was for the investigation of Nursing Home Complaint IN00408526 and Residential Complaint IN00408532 at River Pointe Health Campus.
Findings
No deficiencies were cited related to the allegations in both complaints. However, an unrelated deficiency was cited regarding misappropriation of narcotic medication for one resident (Resident B).
Complaint Details
Complaint IN00408526 and Complaint IN00408532 were investigated. No deficiencies related to the allegations were cited in either complaint. The narcotic misappropriation issue was unrelated to the complaints.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure a resident was free from misappropriation of their property; narcotics (Norco 7.5/325 mg) were unaccounted for. | SS=D |
Report Facts
Census Bed Type - SNF/NF: 50
Census Bed Type - Residential: 42
Total Census: 92
Census Payor Type - Medicare: 15
Census Payor Type - Medicaid: 13
Census Payor Type - Other: 22
Medication quantity lost: 30
Dates narcotic counts not completed: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jordan Shots | Executive Director | Signed the report |
| RN 7 | Registered Nurse | Signed for the medication delivery on 4/23/23 and was interviewed regarding missing medication |
| QMA 5 | Qualified Medication Aide | Provided information about narcotic medication administration and documentation practices |
| Director of Nursing | Director of Nursing | Interviewed regarding the missing narcotic medication and investigation |
| Lead Pharmacist | Lead Pharmacist | Interviewed about medication delivery and signing procedures |
Inspection Report
Life Safety
Census: 53
Capacity: 68
Deficiencies: 8
Apr 4, 2023
Visit Reason
The inspection was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 standards.
Findings
The facility was found not in compliance with several Life Safety Code requirements including exit discharge walking surfaces, self-closing hazardous area doors, fire alarm system testing and maintenance, sprinkler system maintenance, corridor door smoke resistance, smoke barrier integrity, and smoke barrier door latching. Corrective actions and ongoing compliance measures were planned for each deficiency.
Severity Breakdown
SS=E: 7
SS=F: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to maintain the walking surface for 1 of 7 exit discharge areas with level changes creating a tripping hazard. | SS=E |
| Failed to ensure corridor door to hazardous area (storage room 606) was provided with a self-closing device. | SS=E |
| Failed to ensure documentation for sensitivity testing of all smoke detectors was complete; some detectors were not tested or documented properly. | SS=F |
| Failed to maintain fire alarm system in accordance with NFPA 72; smoke detectors hanging from ceiling and some detectors not tested. | SS=F |
| Failed to ensure sprinkler head escutcheon ring was in place, leaving a gap around sprinkler pipe. | SS=E |
| Failed to ensure 1 of over 100 corridor doors resisted passage of smoke due to holes in door. | SS=E |
| Failed to maintain smoke barrier wall integrity; a two inch hole with wires was not properly fire stopped. | SS=E |
| Failed to ensure 1 of 5 sets of smoke barrier doors closed and latched properly to form a smoke resistant barrier. | SS=E |
Report Facts
Certified beds: 68
Census: 53
Exit discharge areas: 7
Hazardous area doors: 10
Smoke detectors not tested: 11
Sprinkler compartments: 5
Smoke barrier doors: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jordan Shots | Executive Director | Signed report and participated in exit conference |
| Director of Plant Operations | Named in multiple findings related to exit discharge, hazardous area doors, fire alarm system, sprinkler system, corridor doors, smoke barrier walls and doors |
Inspection Report
Recertification
Census: 43
Capacity: 103
Deficiencies: 5
Mar 20, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Complaint IN00403738. The visit included a State Residential Licensure Survey.
Findings
The facility was found to have deficiencies related to resident self-administration of medications, reasonable accommodations for call light accessibility, resident privacy during care, comprehensive care planning for residents with respiratory and antibiotic needs, and water temperatures exceeding safe limits in resident rooms. No deficiencies were related to the complaint investigation.
Complaint Details
Complaint IN00403738 was investigated and no deficiencies related to the allegations were cited.
Severity Breakdown
SS=D: 4
SS=E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure residents self-administering medications were assessed for capability and had appropriate orders, care plans, and assessments. | SS=D |
| Failed to ensure residents received services with reasonable accommodation of needs, specifically call lights were out of reach for residents. | SS=E |
| Failed to maintain resident privacy during medication administration and care; privacy curtains and doors were left open and computer screens with resident information were left visible. | SS=D |
| Failed to develop and implement comprehensive person-centered care plans for residents with respiratory care and antibiotic use needs; care plans and interventions were lacking or not followed. | SS=D |
| Failed to provide a safe, functional, and comfortable environment by maintaining water temperatures within safe limits; water temperatures in resident rooms exceeded 120 degrees Fahrenheit. | SS=D |
Report Facts
Survey dates: March 13, 14, 15, 16, 17, 20, 2023
Census Bed Type: 103
Resident census: 43
Residents observed for self-administration: 3
Residents reviewed for activities of daily living: 5
Residents observed for medication privacy: 4
Resident rooms observed for water temperature: 16
Water temperature: 122.3
Water temperature: 123.1
Water temperature: 123.2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jordan Shots | Executive Director | Signed report |
| QMA 9 | Qualified Medication Aide | Observed administering medications and noted lack of order for self-administration |
| QMA 21 | Qualified Medication Aide | Observed medication storage and administration practices |
| Clinical Support 43 | Interviewed regarding lack of self-administration assessments | |
| RN 23 | Registered Nurse | Interviewed regarding self-administration policies and oxygen flow rate adjustment |
| LPN 25 | Licensed Practical Nurse | Interviewed regarding medication administration and privacy practices |
| CNA 14 | Certified Nurse Aide | Interviewed regarding call light use and resident accommodations |
| Clinical Support 29 | Provided policies and interviewed regarding care plan and environmental compliance | |
| DHS and/or designee | Responsible for audits and ongoing compliance monitoring |
Inspection Report
Renewal
Deficiencies: 0
Mar 20, 2023
Visit Reason
Paper compliance review for the Recertification and State Licensure survey ending on March 20, 2023.
Findings
River Pointe Health Campus was found to be in compliance with 42 CFR part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Recertification and State Licensure Survey.
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