Inspection Reports for Serenity Springs Senior Living at Jasonville
800 E Ohio St, Jasonville, IN 47438, IN, 47438
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Inspection Report
Complaint Investigation
Census: 40
Capacity: 40
Deficiencies: 0
Apr 29, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00457924.
Findings
No deficiencies related to the allegations are cited. Serenity Spring Senior Living at Jasonville 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 IN00457924.
Complaint Details
Complaint IN00457924 - No deficiencies related to the allegations are cited.
Report Facts
Census: 40
Total Capacity: 40
Medicare Census: 5
Medicaid Census: 24
Other Payor Census: 11
Inspection Report
Re-Inspection
Census: 40
Capacity: 60
Deficiencies: 0
Apr 15, 2025
Visit Reason
This was a Post Survey Revisit (PSR) to the Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey conducted on 02/18/25 to verify compliance and corrections.
Findings
At this PSR, Serenity Springs Senior Living At Jasonville was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility was fully sprinklered except for two garages used for storage and maintenance.
Report Facts
Certified beds: 60
Current census: 40
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 4, 2025
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Serenity Springs Senior Living at Jasonville 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.
Inspection Report
Routine
Census: 37
Capacity: 60
Deficiencies: 12
Feb 18, 2025
Visit Reason
Routine Emergency Preparedness and Life Safety Code Recertification 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 review and update the emergency preparedness plan, policies, communication plan, and training/testing program annually. Life Safety Code deficiencies included a hazardous area door without a properly working self-closing device, incomplete fire alarm system sensitivity testing documentation, sprinkler heads with corrosion or paint, lack of GFCI protection at one receptacle, incomplete fire drill documentation, lack of testing and documentation of patient care related electrical equipment, and oxygen storage room ventilation that could be turned off.
Severity Breakdown
SS=F: 7
SS=E: 3
SS=D: 1
SS=C: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to develop and maintain an emergency preparedness plan reviewed and updated at least annually. | SS=F |
| Failed to develop and implement emergency preparedness policies and procedures reviewed and updated at least annually. | SS=F |
| Failed to develop and maintain an emergency preparedness communication plan reviewed and updated at least annually. | SS=F |
| Failed to develop and maintain an emergency preparedness training and testing program reviewed and updated at least annually. | SS=F |
| Failed to ensure 1 of over 10 hazardous area doors had a properly working self-closing device. | SS=E |
| Failed to ensure complete documentation for sensitivity testing of all hard wired smoke detectors. | SS=F |
| Failed to replace sprinkler heads covered with corrosion or paint in 1 of 6 smoke compartments and porch overhangs. | SS=E |
| Failed to ensure 1 of over 10 wet locations was provided with ground fault circuit interrupter (GFCI) protection. | SS=D |
| Failed to provide an accurate written fire safety plan with current inspection company contact information. | SS=C |
| Failed to ensure all 17 fire drill reports included complete documentation of transmission of fire alarm signal to monitoring company/fire department. | SS=F |
| Failed to conduct required maintenance and maintain complete documentation of inspections for Patient Care Related Electrical Equipment (PCREE). | SS=F |
| Failed to ensure oxygen storage room mechanical ventilation operated continuously and was not controlled by a switch that could be turned off. | SS=E |
Report Facts
Certified beds: 60
Current census: 37
Fire drills reviewed: 17
Sprinkler heads with corrosion or paint: 6
Audit frequency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deborah E Davis | LHFA | Laboratory Director or Provider/Supplier Representative who signed the report |
| Maintenance Director | Interviewed and present during inspection, acknowledged deficiencies and corrective actions | |
| Administrator | Interviewed and present during exit conference, involved in corrective action plans |
Inspection Report
Renewal
Census: 36
Capacity: 36
Deficiencies: 3
Feb 10, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from February 4 through February 10, 2025.
Findings
The facility received 3 deficiencies which were low scope and severity in nature, related to accuracy of Minimum Data Set (MDS) assessments, respiratory care for oxygen therapy, and sanitary food storage practices.
Severity Breakdown
SS=D: 2
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for 2 of 13 residents reviewed, including lack of documentation of antibiotic use and UTI diagnosis in assessments. | SS=D |
| Failed to provide respiratory care for 1 of 1 residents reviewed for oxygen therapy; oxygen tubing was not labeled with a date or documented as changed. | SS=D |
| Failed to ensure food was stored in a sanitary manner; expired foods were not discarded and food was not labeled. | SS=E |
Report Facts
Deficiencies cited: 3
Residents reviewed for MDS accuracy: 13
Oxygen therapy residents reviewed: 1
Census: 36
Total licensed capacity: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deborah E Davis | Health Facility Administrator | Named in relation to findings and plan of correction. |
| Brenda Buroker | Long Term Care Director | Recipient of the plan of correction letter. |
| LPN 1 | Interviewed regarding oxygen tubing labeling deficiency. |
Inspection Report
Deficiencies: 0
Feb 20, 2024
Visit Reason
The visit was conducted to complete paper compliance for the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey.
Findings
The Good Samaritan Society Shakamak Retirement Community was found in compliance with Medicare/Medicaid Emergency Preparedness Requirements and Life Safety Code requirements as per the 2012 Edition of the NFPA 101, Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Annual Inspection
Deficiencies: 0
Feb 9, 2024
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure Survey conducted on January 16, 2024.
Findings
Good Samaritan Society Shakamak Retirement Community 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.
Inspection Report
Life Safety
Census: 38
Capacity: 60
Deficiencies: 5
Jan 31, 2024
Visit Reason
Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and Emergency Preparedness Survey in accordance with 42 CFR 483.73.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code requirements, receiving 6 deficiencies which were low scope and severity. Deficiencies included failure to maintain means of egress free of obstructions, failure to ensure hazardous areas had self-closing doors, failure to inspect kitchen fire suppression system semiannually, failure to provide quarterly sprinkler system inspection documentation for one quarter, and failure to document 36-month emergency generator testing.
Severity Breakdown
SS=E: 2
SS=D: 1
SS=F: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to maintain means of egress free from obstructions in 1 of 4 corridors; a plastic storage bin without wheels was stored in the corridor. | SS=E |
| Failed to ensure hazardous areas (storage room #403) had properly working self-closing door and latch. | SS=E |
| Failed to ensure kitchen fire suppression system was inspected semiannually; missing inspection documentation. | SS=D |
| Failed to provide written documentation for sprinkler system inspection for 1 of 4 quarters in 2023. | SS=F |
| Failed to document 36-month emergency generator testing for 1 of 1 emergency generators. | SS=F |
Report Facts
Deficiencies cited: 6
Certified beds: 60
Current census: 38
Emergency generator test duration: 4
Emergency generator test date: Jul 21, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deborah E Davis | Health Facility Administrator | Named in relation to plan of correction and correspondence. |
| Maintenance Supervisor | Interviewed regarding deficiencies and missing documentation. |
Inspection Report
Annual Inspection
Census: 37
Capacity: 37
Deficiencies: 3
Jan 16, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from January 9 through January 16, 2024.
Findings
The facility received 3 deficiencies which were low scope and severity in nature related to notice requirements before transfer/discharge, notice of bed hold policy before/after transfer, and food procurement and sanitary preparation. The facility submitted plans of correction addressing these issues.
Severity Breakdown
SS=D: 2
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure written notification of transfer/discharge was given to resident and representative for 1 of 1 resident reviewed for hospitalization. | SS=D |
| Failed to ensure notification of bed-hold policy was provided in writing to resident or representative for 1 of 1 resident reviewed for hospitalization. | SS=D |
| Failed to ensure food was stored and prepared in a sanitary manner; uncovered, unlabeled, undated foods and beverages and staff hair not fully covered. | SS=E |
Report Facts
Deficiencies cited: 3
Census: 37
Total Capacity: 37
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deborah E Davis | Health Facility Administrator | Signed the report and plan of correction letter. |
| Brenda Buroker | Long Term Care Director | Addressee of the plan of correction letter. |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 36
Deficiencies: 0
Sep 6, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00414902.
Findings
No deficiencies related to the allegations in Complaint IN00414902 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00414902 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 36
Total Capacity: 36
Payor Type Census: 1
Payor Type Census: 25
Payor Type Census: 10
Inspection Report
Complaint Investigation
Census: 33
Capacity: 33
Deficiencies: 0
Feb 21, 2023
Visit Reason
This visit was conducted for the Investigation of Complaint IN00395484 and included a COVID-19 Focused Infection Control Survey.
Findings
The complaint IN00395484 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 regarding the complaint investigation and COVID-19 survey.
Complaint Details
Complaint IN00395484 was unsubstantiated due to lack of evidence.
Report Facts
Census SNF/NF: 33
Total Capacity: 33
Census Payor Type Medicare: 3
Census Payor Type Medicaid: 24
Census Payor Type Other: 6
Inspection Report
Annual Inspection
Deficiencies: 0
Dec 20, 2022
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey conducted on November 18, 2022.
Findings
Good Samaritan Society Shakamak Retirement Community 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.
Inspection Report
Life Safety
Census: 32
Capacity: 60
Deficiencies: 2
Dec 19, 2022
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) and NFPA 101 standards.
Findings
The facility was found not in compliance with Life Safety Code requirements due to failure to ensure annual testing of all fire alarm system devices and lack of proper signage for the fire department connection. The facility was otherwise sprinklered and had a fire alarm system with smoke detection. Corrective actions and plans of correction were documented.
Severity Breakdown
SS=F: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure the annual testing of all devices connected to the fire alarm system was performed as required by NFPA 72. | SS=F |
| Failed to ensure the fire department connection (FDC) had proper signage to be visible and accessible to responding fire departments as required by NFPA 25. | SS=F |
Report Facts
Certified beds: 60
Census: 32
Deficiencies cited: 2
Inspection Report
Life Safety
Deficiencies: 0
Dec 19, 2022
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey conducted on 12/19/22.
Findings
Good Samaritan Society Shakamak Retirement Community was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 Edition of the NFPA 101 Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Renewal
Deficiencies: 1
Dec 13, 2022
Visit Reason
The inspection was conducted as an offsite Licensure Investigation Survey to assess the facility's compliance with license renewal requirements.
Findings
The facility failed to submit their license renewal application at least 45 days prior to the expiration of their current license, which expired on 10/31/22. The renewal application and payment were received by the state agency on 11/1/22, after the deadline.
Deficiencies (1)
| Description |
|---|
| Failure to submit a renewal application to the director at least forty-five (45) days prior to the expiration of the license. |
Report Facts
License expiration date: 1031
Days late for renewal application: 1
Days required for renewal submission: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Davis | HFA | Signed as Laboratory Director or Provider/Supplier Representative |
Inspection Report
Renewal
Census: 32
Capacity: 32
Deficiencies: 2
Nov 18, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from November 14 through November 18, 2022.
Findings
The facility received two deficiencies which were low scope and severity in nature. Deficiencies included failure to implement a fall care plan intervention for a resident with a history of falls and failure to provide respiratory care in accordance with professional standards for five residents, including unlabeled and undated oxygen tubing and oxygen not administered as ordered.
Severity Breakdown
Level D: 1
Level E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure staff implemented a fall care plan intervention for a resident with a history of falls (Resident 15). | Level D |
| Failure to provide respiratory care consistent with professional standards and plan of care for 5 residents; oxygen tubing was not labeled and dated, and oxygen was not administered as ordered. | Level E |
Report Facts
Deficiencies cited: 2
Census: 32
Total Capacity: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deborah E Davis | Health Facility Administrator | Named in relation to plan of correction and facility response. |
| Director of Nursing | Provided facility policies and indicated deficiencies related to oxygen tubing labeling and fall care plan. | |
| Nurse Educator | Created resource binder and educated nursing staff on fall prevention policy and procedures. | |
| LPN 1 | Licensed Practical Nurse | Observed and responded to Resident 2 not wearing oxygen. |
| RN 2 | Registered Nurse | Observed and responded to Resident 2 not wearing oxygen. |
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