Inspection Reports for Saint Anthony Rehabilitation & Nursing Center
IN, 47904
Back to Facility ProfileInspection Report Summary
The most recent inspection on January 10, 2025, found no deficiencies related to the investigated complaints. Earlier inspections showed a mix of compliance and deficiencies, with issues primarily related to resident supervision and dignity, Life Safety Code compliance, and care plan documentation. Prior citations included failure to prevent unauthorized photographing of a resident, inadequate supervision when a resident eloped, sprinkler system maintenance problems, electrical safety concerns, and incomplete care plan updates. Complaint investigations were mostly unsubstantiated, with one substantiated complaint that did not result in cited deficiencies. The facility’s record shows some recurring Life Safety Code and resident care issues, but recent inspections indicate corrective actions and improvements.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
10% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
100% occupied
Based on a January 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 85
Capacity: 85
Deficiencies: 0
Date: Jan 10, 2025
Visit Reason
This visit was conducted for the investigation of Complaints IN00449717 and IN00447575.
Complaint Details
Complaint IN00449717 and Complaint IN00447575 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations in either complaint were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF beds: 85
Census Medicare residents: 7
Census Medicaid residents: 49
Census Other residents: 29
Inspection Report
Re-Inspection
Census: 80
Capacity: 120
Deficiencies: 0
Date: Nov 15, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 09/16/24 was performed to verify compliance with previous deficiencies.
Findings
The facility 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 building is fully sprinklered except for a detached garage and two woodsheds used for storage.
Report Facts
Facility capacity: 120
Resident census: 80
Inspection Report
Complaint Investigation
Census: 70
Capacity: 70
Deficiencies: 2
Date: Sep 25, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00442388 and IN00441445 related to resident rights and accident hazards.
Complaint Details
Complaint IN00442388 related to accident hazards and supervision; Complaint IN00441445 related to resident rights violations involving unauthorized photographing and videotaping of a resident.
Findings
The facility was found deficient for failing to protect a resident's dignity by allowing a staff member to photograph and post a video of a resident online, and for inadequate supervision when a resident eloped from the facility and was found down the street. Both deficiencies were corrected prior to the survey.
Deficiencies (2)
Failure to ensure a staff member did not photograph or videotape a resident and post the video online on social media.
Failure to ensure a resident received adequate supervision when the resident exited the facility without staff knowledge and was found down the street.
Report Facts
Census: 70
Total Capacity: 70
Resident B elopement duration (minutes): 20
Resident B distance traveled (miles): 0.2
Resident F BIMS score: 3
Resident B BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member 10 | Identified as the staff member who videotaped and photographed Resident F and had the video on her phone; terminated from employment. | |
| Staff Member 3 | Terminated for turning off the secondary alarm and failing to check for missing residents after the alarm sounded. | |
| Executive Director | Executive Director | Interviewed regarding the video of Resident F and the alarm system related to Resident B's elopement. |
| Director of Nursing | Director of Nursing | Interviewed regarding the video incident and Resident B's elopement; notified nursing board about Staff Member 10. |
| Staff Member 2 | Notified facility staff of Resident B's elopement and stayed with resident until nursing staff arrived. | |
| Staff Member 7 | Aware of Resident F's photo posted online and Resident B's elopement; had been in-serviced on abuse and alarm system. | |
| Staff Member 8 | Aware of Resident F's photo posted online and Resident B's elopement; had been in-serviced on abuse and alarm system. | |
| Staff Member 9 | Aware of Resident F's photo posted online and Resident B's elopement; conducted weekly checks on door alarms. |
Inspection Report
Life Safety
Census: 75
Capacity: 120
Deficiencies: 4
Date: Sep 16, 2024
Visit Reason
The Indiana Department of Health conducted an Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey at Saint Anthony Rehab and Nursing Center on 09/16/2024.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements, including deficiencies related to sprinkler system maintenance, electrical junction box covers, electrical receptacle testing documentation, and improper use of power strips.
Deficiencies (4)
The facility failed to ensure all sprinkler heads that were loaded or damaged were replaced or cleaned in accordance with NFPA 25; sprinklers in the dishwashing area were corroded and bent, and sprinklers near laundry dryers were covered with lint.
The facility failed to ensure one electrical junction box above the drop ceiling near the south nurse's station was maintained in a safe operating condition; the junction box was missing a cover exposing spliced wiring.
The facility failed to ensure documentation of electrical outlet receptacle testing for resident sleeping rooms was available for review as required by NFPA 99.
The facility failed to ensure power strips were not used as a substitute for fixed wiring to provide power to equipment with a high current draw; a power strip was used to power a refrigerator in the Admissions office.
Report Facts
Certified beds: 120
Census: 75
Residents potentially affected by electrical junction box deficiency: 40
Residents potentially affected by electrical receptacle testing deficiency: 70
Staff and visitors potentially affected by power strip deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dylan Johnson | Administrator | Reviewed findings at exit conference |
| Director of Plant Operations | Interviewed and involved in observations and corrective actions related to sprinkler system, electrical junction box, receptacle testing, and power strip use |
Inspection Report
Annual Inspection
Census: 75
Capacity: 75
Deficiencies: 5
Date: Aug 19, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00440491 and IN00438928.
Complaint Details
Complaint IN00440491 and IN00438928 were investigated with no deficiencies related to the allegations cited.
Findings
The facility was found deficient in accommodating a resident's needs related to dining table height, updating comprehensive care plans for functional limitations, documenting and monitoring bruising and reporting out-of-range blood glucose levels, verifying gastrostomy tube placement, and ensuring proper functioning of the resident call light system.
Deficiencies (5)
Failed to ensure a resident was seated at a table with the height adjusted to accommodate the resident's needs.
Failed to ensure a resident's functional limitation in range of motion was included in the comprehensive care plan.
Failed to ensure a resident's bruising was documented as being assessed and monitored and to ensure out of range glucometer readings were reported to the physician as ordered for 3 residents.
Failed to ensure staff followed policy when verifying gastrostomy tube placement prior to medication administration.
Failed to ensure all areas of the wireless call system were functioning properly for 5 halls.
Report Facts
Survey dates: 5
Census: 75
Total capacity: 75
Medicare residents: 5
Medicaid residents: 46
Other payor residents: 24
Blood glucose levels: 9
G-tube flush volume: 60
Bruising size: 3.3
Bruising size: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Hardy | RN | Laboratory Director's or Provider/Supplier Representative's signature on report |
| RN 4 | Registered Nurse | Named in gastrostomy tube placement verification deficiency and interview |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies including blood glucose notification and call light system |
| Assistant Director of Nursing | ADON | Interviewed regarding bruising assessments and blood glucose notifications |
Inspection Report
Renewal
Deficiencies: 0
Date: Aug 19, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure survey completed on August 19, 2024.
Findings
Saint Anthony Rehab and Nursing 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
Complaint Investigation
Census: 80
Capacity: 80
Deficiencies: 0
Date: Nov 2, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00418933 and IN00412484 at Saint Anthony Rehab and Nursing Center.
Complaint Details
Complaint IN00418933 and Complaint IN00412484 were investigated; no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations in complaints IN00418933 and IN00412484 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 11
Medicaid census: 34
Other census: 35
Inspection Report
Life Safety
Census: 69
Capacity: 120
Deficiencies: 1
Date: Jul 27, 2023
Visit Reason
The visit 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).
Findings
The facility was found not in compliance with Life Safety Code requirements due to failure to conduct quarterly fire drills for 2 of 4 quarters, affecting all staff and residents. The facility was otherwise found in compliance with Emergency Preparedness requirements.
Deficiencies (1)
Failed to conduct quarterly fire drills for 2 of 4 quarters as required by LSC 19.7.1.6, affecting all staff and residents.
Report Facts
Certified beds: 120
Census: 69
Fire drill quarters missed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dylan Johnson | Administrator | Signed report and participated in exit conference |
| Director of Plant Operations | Interviewed regarding fire drill deficiencies and responsible for corrective actions |
Inspection Report
Life Safety
Deficiencies: 0
Date: Jul 27, 2023
Visit Reason
The Life Safety Code Recertification and State Licensure Survey was conducted to assess compliance with fire safety and state licensure requirements.
Findings
Saint Anthony Rehab and Nursing Center was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101 Life Safety Code.
Inspection Report
Renewal
Census: 70
Capacity: 70
Deficiencies: 0
Date: Jun 20, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted over multiple days in June 2023.
Findings
Saint Anthony Rehab and Nursing Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 during the Recertification and State Licensure Survey.
Report Facts
Census Payor Type - Medicare: 24
Census Payor Type - Medicaid: 37
Census Payor Type - Other: 9
Inspection Report
Complaint Investigation
Census: 81
Capacity: 81
Deficiencies: 0
Date: Nov 3, 2022
Visit Reason
This visit was for the investigation of Complaint IN00392009.
Complaint Details
Complaint IN00392009 was investigated and found to be unsubstantiated due to lack of evidence.
Findings
The complaint IN00392009 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
Total Capacity: 81
Medicare Census: 15
Medicaid Census: 41
Other Payor Census: 25
Inspection Report
Complaint Investigation
Census: 72
Capacity: 72
Deficiencies: 0
Date: Aug 30, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00388372.
Complaint Details
Complaint IN00388372 was substantiated, but no deficiencies related to the allegations were cited.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 11
Medicaid census: 35
Other payor census: 26
Inspection Report
Life Safety
Census: 75
Capacity: 120
Deficiencies: 3
Date: Aug 11, 2022
Visit Reason
The survey 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 related regulations.
Findings
The facility was found not in compliance with Life Safety Code requirements, including failure to maintain means of egress free of obstructions, failure to maintain fire alarm system testing and maintenance documentation, and failure to secure electrical panels from unauthorized access.
Deficiencies (3)
Facility failed to maintain the means of egress free from obstructions in 1 of 8 corridors due to a 3-drawer plastic chest of drawers containing PPE stored in the corridor outside resident room #C124.
Facility failed to maintain 1 of 1 fire alarm systems in accordance with NFPA 72; no documentation of visual semi-annual fire alarm system inspection was available.
Facility failed to ensure all electrical panels in the corridors were secured from non-authorized personnel; electric panel outside resident's room F147 was unlocked.
Report Facts
Deficiencies cited: 3
Facility capacity: 120
Census: 75
Residents potentially affected: 16
Staff potentially affected: 4
Visitors potentially affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Plant Operations | Director of Plant Operations (D.P.O.) | Interviewed and acknowledged deficiencies related to means of egress obstruction, fire alarm system inspection, and electrical panel security. |
| Executive Director | Executive Director | Provided information regarding fire panel access requirements during electrical panel deficiency observation. |
Inspection Report
Life Safety
Deficiencies: 0
Date: Aug 11, 2022
Visit Reason
The visit was conducted as a Life Safety Code Recertification and State Licensure Survey.
Findings
Saint Anthony Rehab and Nursing Center was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Renewal
Census: 71
Capacity: 71
Deficiencies: 0
Date: Jul 27, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey and included the Investigation of Complaint IN00384802.
Complaint Details
Complaint IN00384802 was investigated and found to be unsubstantiated due to lack of evidence.
Findings
Saint Anthony Rehab and Nursing Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1. The complaint investigation was unsubstantiated due to lack of evidence.
Report Facts
Census SNF/NF: 71
Census Medicare: 8
Census Medicaid: 37
Census Other: 26
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