Inspection Report Summary
The most recent inspection on March 25, 2025, found the facility in compliance based on a paper review of a complaint investigation. Earlier inspections showed a pattern of deficiencies primarily related to medication administration timeliness, urinary incontinence care, and Life Safety Code compliance including fire safety and HVAC issues. Complaint investigations were mostly unsubstantiated, though some were substantiated with deficiencies cited for medication and continence care. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s inspection history shows some improvement in recent months with the latest inspections showing no new deficiencies.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
16.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
288% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
28
21
14
7
0
Census
Latest occupancy rate
100% occupied
Based on a February 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 25, 2025
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00451861 completed on February 19, 2025.
Findings
Shady Nook Care 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.
Complaint Details
Complaint IN00451861 was investigated and found to be corrected.
Inspection Report
Complaint Investigation
Census: 85
Capacity: 85
Deficiencies: 1
Feb 18, 2025
Visit Reason
This visit was conducted for the investigation of four complaints (IN00453427, IN00451861, IN00450888, and IN00450653) regarding the facility's compliance with regulatory requirements.
Findings
The investigation found no deficiencies related to three of the complaints, but cited a federal/state deficiency related to urinary incontinence services for one complaint (IN00451861). The facility failed to ensure timely services to maintain continence for one resident with urinary incontinence.
Complaint Details
Complaint IN00451861 was substantiated with a federal/state deficiency cited at F690 related to failure to provide timely urinary incontinence services. Complaints IN00453427, IN00450888, and IN00450653 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure a resident with urinary incontinence received services to maintain continence in a timely manner. | SS=D |
Report Facts
Census: 85
Total Capacity: 85
Medicare Census: 7
Medicaid Census: 62
Other Payor Census: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lindsey Boltz | Administrator | Named as facility representative and involved in interviews |
| Director of Nursing | Interviewed regarding the deficiency and appointment scheduling for Resident B | |
| LPN 2 | Interviewed about ensuring residents attend scheduled appointments |
Inspection Report
Re-Inspection
Census: 88
Capacity: 94
Deficiencies: 1
Jan 23, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 12/05/24 was performed to verify compliance with fire safety and licensure requirements.
Findings
At this PSR Life Safety Code survey, Shady Nook Care Center was found in compliance with Medicare/Medicaid participation requirements and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinkled and had appropriate fire alarm and smoke detection systems. One deficiency related to HVAC compliance was noted with an annual waiver request.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| HVAC heating, ventilation, and air conditioning shall comply with 9.2 and be installed per manufacturer's specifications. This requirement is not met as evidenced by an annual waiver request. | F |
Report Facts
Facility capacity: 94
Census: 88
Inspection Report
Complaint Investigation
Census: 86
Capacity: 86
Deficiencies: 0
Jan 2, 2025
Visit Reason
This visit was for the Investigation of Complaints IN00449162 and IN00448319 and was conducted in conjunction with a Post Survey Revisit to the Recertification and State Licensure survey completed on November 13, 2024.
Findings
No deficiencies related to the allegations in complaints IN00449162 and IN00448319 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 investigations.
Complaint Details
Complaint IN00449162 and Complaint IN00448319 were investigated with no deficiencies cited related to the allegations.
Report Facts
Census: 86
Total Capacity: 86
Medicare Census: 5
Medicaid Census: 65
Other Payor Census: 16
Inspection Report
Re-Inspection
Census: 86
Capacity: 86
Deficiencies: 0
Jan 2, 2025
Visit Reason
This visit was for the Post Survey Revisit (PSR) to the Recertification and State Licensure survey completed on November 13, 2024, and was conducted in conjunction with the Investigation of Complaints IN00449162 and IN00448319.
Findings
No deficiencies related to the allegations in complaints IN00449162 and IN00448319 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 PSR to Recertification and State Licensure survey.
Complaint Details
Complaint IN00449162 and Complaint IN00448319 were investigated with no deficiencies related to the allegations cited.
Report Facts
Census Bed Type: 86
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 65
Census Payor Type - Other: 16
Inspection Report
Annual Inspection
Census: 85
Capacity: 94
Deficiencies: 7
Dec 5, 2024
Visit Reason
Annual 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 in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies were identified related to means of egress obstructions, sprinkler system maintenance, portable fire extinguisher installation, HVAC return air system use of egress corridors, and improper storage of oxygen cylinders.
Severity Breakdown
SS=E: 6
SS=F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 1 corridor means of egress on the Memory Care Hall was continuously maintained free of all obstructions or impediments to full instant use in case of emergency; a large reclining chair obstructed the exit. | SS=E |
| Failed to ensure 1 of over 4 exit discharges had a level walking surface and was free of obstructions; large mats obstructed exit discharge near Hair Care. | SS=E |
| Failed to maintain ceiling construction behind dryers causing potential sprinkler malfunction; hole in ceiling where sprinkler head may have been located. | SS=E |
| Failed to ensure 1 of 1 sprinkler heads in laundry area were not loaded or covered with foreign material; sprinkler head covered in dust. | SS=E |
| Failed to ensure 4 of 4 portable fire extinguishers in Maintenance Office were properly installed; extinguishers were unsecured and sitting on the floor. | SS=E |
| Failed to ensure egress corridors were not used as a portion of a return air system serving adjoining rooms for 47 of 47 resident rooms. | SS=F |
| Failed to ensure 1 of 1 cylinders of nonflammable gases such as oxygen were properly secured from falling; oxygen cylinder was standing upright and not properly chained or supported. | SS=E |
Report Facts
Certified beds: 94
Census: 85
Residents affected by corridor obstruction: 26
Residents affected by exit discharge obstruction: 15
Laundry staff affected: 3
Staff affected: 2
Resident rooms affected: 47
Staff affected: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lindsey Boltz | Maintenance Director | Interviewed regarding multiple deficiencies including corridor obstruction, sprinkler system, fire extinguishers, HVAC, and oxygen cylinder storage. |
Inspection Report
Annual Inspection
Census: 82
Capacity: 82
Deficiencies: 6
Nov 13, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00446976.
Findings
The facility was found deficient in several areas including accuracy of Minimum Data Set assessments, quality of care related to medication administration and vital signs, infection control for urinary catheters, medication storage, and food sanitation. No deficiencies were related to the complaint investigation.
Complaint Details
Complaint IN00446976 was investigated with no deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 5
SS=F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure accuracy of Minimum Data Set assessments for 3 of 21 residents reviewed. | SS=D |
| Failed to obtain physician ordered vital signs prior to medication administration for 1 of 21 residents reviewed. | SS=D |
| Failed to follow appropriate infection control guidelines related to indwelling urinary catheters for 1 of 2 residents reviewed. | SS=D |
| Failed to follow physician's orders related to hold parameters for a medication for 1 of 5 residents reviewed. | SS=D |
| Failed to appropriately store medications for 3 of 4 medication carts reviewed. | SS=D |
| Failed to prepare and store foods in a sanitary manner and maintain resident snack refrigerators in a sanitary manner. | SS=F |
Report Facts
Residents reviewed for MDS accuracy: 21
Residents reviewed for Quality of Care: 21
Residents reviewed for urinary catheters: 2
Residents reviewed for unnecessary drugs: 5
Medication carts reviewed: 4
Residents receiving food: 82
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lindsey Boltz | Administrator | Signed the inspection report |
| RN 4 | Interviewed regarding medication administration and documentation | |
| Director of Nursing | DON | Provided records, interviewed regarding deficiencies, and described corrective actions |
| Therapy Manager | Interviewed regarding resident discharge and ice pack storage | |
| Certified Nurse Aide 2 | CNA | Interviewed regarding catheter care |
| Unit Manager 7 | Observed medication cart deficiencies | |
| Assistant Director of Nursing | ADON | Interviewed regarding snack refrigerator contents and food service |
| Licensed Practical Nurse 6 | LPN | Interviewed regarding snack refrigerator contents |
| Medical Director | Reviewed medical records and vital signs with DON | |
| Dietary Manager | DM | Observed kitchen sanitation and cleaning schedules |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 85
Deficiencies: 0
Sep 11, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00441615 and IN00439979, and included a Covid-19 Infection Control Survey.
Findings
No deficiencies related to the allegations in complaints IN00441615 and IN00439979 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00441615 and Complaint IN00439979 were investigated; no deficiencies related to the allegations were cited.
Report Facts
Census SNF/NF: 85
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 63
Census Payor Type - Other: 18
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 31, 2024
Visit Reason
Paper compliance review related to the Investigation of Complaints IN00433817 and IN00435973 completed on June 5, 2024.
Findings
Shady Nook Care 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 investigations.
Complaint Details
The visit was related to complaint investigations IN00433817 and IN00435973, with compliance found upon review.
Inspection Report
Complaint Investigation
Census: 84
Capacity: 84
Deficiencies: 1
Jun 5, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00433817 and IN00435973 regarding pharmacy services and insulin administration.
Findings
The facility failed to administer routine insulin in a timely manner for 1 of 3 residents reviewed (Resident B), with multiple instances of insulin given outside the prescribed time window. The facility policies on insulin and medication administration require timely delivery within one hour of the scheduled time. The facility submitted a plan of correction addressing the issue, including audits, staff education, and ongoing monitoring.
Complaint Details
Complaint IN00433817 and IN00435973 were investigated and substantiated with deficiencies cited at F755 related to pharmacy services and insulin administration.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to provide timely and routinely prescribed insulin administration services for 1 resident reviewed for Medication Administration. | SS=D |
Report Facts
Census: 84
Total Capacity: 84
Medicare Residents: 5
Medicaid Residents: 58
Other Residents: 21
Insulin doses given outside scheduled time: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lindsey M. Boltz | Administrator | Signed report and provided facility policies |
| Licensed Practical Nurse 2 | Interviewed regarding insulin administration timing |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 89
Deficiencies: 0
Apr 30, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00431060, IN00432184, and IN00432361 at Shady Nook Care Center.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaints IN00431060, IN00432184, and IN00432361 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 89
Census Payor Type Medicare: 5
Census Payor Type Medicaid: 57
Census Payor Type Other: 27
Inspection Report
Complaint Investigation
Census: 84
Capacity: 84
Deficiencies: 0
Mar 14, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00429357.
Findings
No deficiencies related to the 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 investigation.
Complaint Details
Complaint IN00429357 - No deficiencies related to the allegations were cited.
Report Facts
Census Bed Type: 84
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 52
Census Payor Type - Other: 26
Inspection Report
Re-Inspection
Census: 75
Capacity: 94
Deficiencies: 0
Nov 30, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 10/11/23 was performed to verify compliance with fire safety and licensure requirements.
Findings
At this PSR survey, Shady Nook Care 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
Re-Inspection
Census: 80
Capacity: 80
Deficiencies: 0
Oct 24, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey and Complaint IN00416797 completed on September 25, 2023.
Findings
Shady Nook Care 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 and Complaint IN00416797.
Complaint Details
Complaint IN00416797 - Corrected
Report Facts
Census SNF/NF beds: 80
Total census: 80
Medicare census: 5
Medicaid census: 60
Other payor census: 15
Inspection Report
Annual Inspection
Census: 83
Capacity: 94
Deficiencies: 12
Oct 11, 2023
Visit Reason
Annual Life Safety Code Recertification and State Licensure Survey 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 fire wall maintenance, egress door accessibility, emergency lighting, hazardous area enclosures, fire alarm system maintenance, sprinkler system installation and maintenance, corridor door smoke resistance, HVAC return air system use, and elevator shunt trip device installation.
Severity Breakdown
SS=E: 5
SS=F: 4
SS=D: 3
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to maintain building construction type for Type V(111) construction in 4 of 6 fire walls due to missing firestop foam with UL listing/documentation. | — |
| Failed to ensure means of egress doors were readily accessible; exit door keypad code not posted. | — |
| One battery powered emergency light failed to illuminate during testing. | SS=D |
| Failed to separate hazardous areas (mechanical room) by smoke resistant partitions due to unsealed pipe penetration. | SS=D |
| Fire alarm system did not display accurate time and date; missing inspection/testing documentation for elevator machine room initiating devices. | SS=F |
| Sprinkler system had two sprinklers spaced less than 6 feet apart in oxygen storage room. | SS=E |
| One sprinkler deflector not installed parallel to ceiling in oxygen storage room. | SS=E |
| Missing escutcheon on ceiling mounted sprinkler in D Street shower room closet. | SS=E |
| Corridor doors to resident rooms 24, 26, and 33 had gaps preventing resistance to smoke passage. | SS=E |
| Egress corridors used as return air system for 47 resident rooms, not permitted by NFPA 90A. | SS=F |
| Elevator machine room sprinkler system lacked shunt trip device to disconnect power upon sprinkler activation. | SS=D |
| Failed to maintain automatic sprinkler system inspection/testing records; missing documentation for dry pendent sprinklers tested/replaced in 2019. | SS=F |
Report Facts
Certified beds: 94
Census: 83
Oxygen cylinders: 108
Sprinkler spacing: 4.5
Sprinkler spacing: 1.5
Sprinkler spacing: 1
Cost estimate: 29782
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lindsey Boltz | Administrator | Named in relation to findings and exit conference |
| Maintenance Director | Named in relation to multiple findings and interviews |
Inspection Report
Annual Inspection
Census: 81
Capacity: 81
Deficiencies: 6
Sep 25, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00416797.
Findings
The facility was found deficient in multiple areas including failure to follow physician orders for insulin administration, inadequate fall interventions, lack of catheter care education and transmission-based precautions, failure to follow weight monitoring orders, lack of trauma-informed care interventions, and a significant medication error related to insulin administration.
Complaint Details
Complaint IN00416797 was investigated during this visit. A Federal/State deficiency related to the allegation was cited at F689.
Severity Breakdown
SS=D: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to follow physician orders related to insulin administration, notification, and hold parameters for 1 of 21 residents reviewed for quality of care (Resident 48). | SS=D |
| Failure to ensure appropriate fall interventions were implemented for 1 of 4 residents reviewed for falls (Resident C). | SS=D |
| Failure to ensure a resident who provided self-care with an indwelling urinary catheter was educated on catheter care and infection control guidelines related to transmission-based precautions for a urinary tract infection (Resident 77). | SS=D |
| Failure to follow a physician's order related to weight monitoring for 2 of 21 residents reviewed for hydration status (Residents 29 and 71). | SS=D |
| Failure to ensure resident specific interventions to provide trauma informed care were in place for 1 of 1 resident with a diagnosis of Post Traumatic Stress Disorder (Resident 11). | SS=D |
| Failure to prevent a significant medication error related to insulin administration for 1 of 4 residents reviewed for medication administration (Resident 48). | SS=D |
Report Facts
Census: 81
Total Capacity: 81
Insulin administration errors: 9
Weight gain notifications missing: 11
Weight gain notifications missing: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lindsey Boltz | Administrator | Signed the inspection report |
| LPN 3 | Licensed Practical Nurse | Named in insulin administration deficiency and medication error |
| RN 6 | Registered Nurse | Interviewed regarding medication administration documentation |
| CNA 2 | Certified Nurse Aide | Interviewed regarding fall incident and gait belt use |
| CNA 5 | Certified Nurse Aide | Interviewed regarding catheter care and gait belt use |
| QMA 4 | Qualified Medication Aide | Observed obtaining blood glucose level for Resident 48 |
| DON | Director of Nursing | Interviewed regarding insulin administration, catheter care, fall prevention, and weight monitoring |
| Social Services Director | Interviewed regarding trauma informed care for Resident 11 |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 80
Deficiencies: 0
Aug 25, 2023
Visit Reason
This visit was conducted for the Investigation of Complaint IN00415405 and included a COVID-19 Focused Infection Control Survey.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable federal and state regulations regarding the complaint.
Complaint Details
Complaint IN00415405 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 80
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 52
Census Payor Type - Other: 23
Inspection Report
Complaint Investigation
Census: 80
Capacity: 80
Deficiencies: 0
Jul 17, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00412277 and IN00413012.
Findings
No deficiencies related to the allegations in complaints IN00412277 and IN00413012 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00412277 and IN00413012 were investigated with no deficiencies cited related to the allegations.
Report Facts
Census Bed Type: 80
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 50
Census Payor Type - Other: 24
Inspection Report
Complaint Investigation
Census: 81
Capacity: 81
Deficiencies: 0
Jun 28, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00410964.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00410964 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 5
Medicaid census: 58
Other payor census: 18
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 23, 2023
Visit Reason
The visit was conducted as a paper compliance review related to the investigation of Complaint IN00406692.
Findings
Shady Nook Care 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
Complaint IN00406692 was investigated with a paper compliance review completed on May 11, 2023, and found to be in compliance.
Inspection Report
Complaint Investigation
Census: 78
Capacity: 78
Deficiencies: 1
May 10, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00407790 and IN00406692. Complaint IN00407790 had no deficiencies related to the allegations, while Complaint IN00406692 resulted in federal/state deficiencies cited related to medication administration timeliness.
Findings
The facility failed to administer medications in a timely manner for 5 of 5 residents reviewed (Residents B, C, D, E, and F). Multiple instances of late medication administration were documented, with delays ranging from minutes to several hours beyond scheduled times. The facility policy requires medications to be administered within one hour of the prescribed time.
Complaint Details
Complaint IN00406692 was substantiated with federal/state deficiencies cited at F755 related to medication administration timeliness. Complaint IN00407790 had no deficiencies related to the allegations.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to administer medications in a timely manner for 5 of 5 residents reviewed. | SS=E |
Report Facts
Residents reviewed for medication timeliness: 5
Facility census: 78
Facility total capacity: 78
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lindsey Boltz | Director of Nursing | Provided Medication Administration Audit Reports and participated in interviews regarding medication administration findings. |
| RN 3 | Registered Nurse | Interviewed regarding medication administration documentation and timing. |
| Qualified Medication Aide 2 | QMA | Interviewed regarding medication administration documentation and timing. |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 81
Deficiencies: 0
Jan 23, 2023
Visit Reason
This visit was conducted for the Investigation of Complaint IN00399064 and included a COVID-19 Focused Infection Control Survey.
Findings
The complaint IN00399064 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 IN00399064 was unsubstantiated due to lack of evidence.
Report Facts
Census SNF/NF: 81
Total Capacity: 81
Census Payor Type Medicare: 8
Census Payor Type Medicaid: 58
Census Payor Type Other: 15
Inspection Report
Complaint Investigation
Census: 81
Capacity: 81
Deficiencies: 0
Dec 5, 2022
Visit Reason
This visit was for the investigation of complaints IN00389547 and IN00391378.
Findings
Both complaints IN00389547 and IN00391378 were 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 investigation of these complaints.
Complaint Details
Complaint IN00389547 - Unsubstantiated due to lack of evidence. Complaint IN00391378 - Unsubstantiated due to lack of evidence.
Report Facts
Census: 81
Total Capacity: 81
Medicare Census: 10
Medicaid Census: 58
Other Payor Census: 13
Inspection Report
Re-Inspection
Census: 78
Capacity: 94
Deficiencies: 0
Nov 9, 2022
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey originally conducted on 09/14/22.
Findings
At this Life Safety Code survey, Shady Nook Care Center was found in compliance with Emergency Preparedness Requirements and Life Safety from Fire requirements. The facility was fully sprinkled with a fire alarm system and smoke detection in all resident areas.
Report Facts
Certified beds: 94
Census: 78
Inspection Report
Life Safety
Census: 80
Capacity: 94
Deficiencies: 25
Sep 14, 2022
Visit Reason
Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health.
Findings
The facility was found not in compliance with several Life Safety Code requirements including emergency preparedness, means of egress, fire alarm system, sprinkler system, hazardous areas, and fire safety plan deficiencies.
Severity Breakdown
SS=C: 6
SS=D: 1
SS=E: 9
SS=F: 7
SS=B: 2
Deficiencies (25)
| Description | Severity |
|---|---|
| Emergency preparedness policies lacked a system to track location of on-duty staff and sheltered residents during and after an emergency. | SS=C |
| Emergency preparedness policies lacked procedures for use of volunteers and emergency staffing strategies. | SS=C |
| Emergency preparedness communication plan lacked a method for sharing information with residents and families. | SS=C |
| Three basement storage room egress doors, one resident room door, and one activities storage room door were not equipped with latches or locks that allow instant use from inside. | SS=D |
| Basement/lower level egress corridor was obstructed by five chairs. | SS=B |
| Facility emergency preparedness policies and procedures lacked complete compliance with tracking, volunteers, communication, and emergency staffing requirements. | — |
| Fire alarm delayed egress locking arrangements did not release locks within 15 seconds as required. | SS=F |
| Dining room exit means of egress was not properly illuminated beyond porch overhang. | SS=E |
| Exit signage was missing in courtyard to direct residents and staff to exit gate. | SS=E |
| Facility failed to ensure combustible storage in basement/lower level was separated from egress corridor by smoke resisting partitions. | SS=E |
| Activity room and maintenance room doors were not provided with self-closing devices. | SS=E |
| Cooktop stove in Physical Therapy room was not shut off at switch when not in use and was functional. | SS=E |
| Interior wall and ceiling finishes in basement/lower level storage room corridor wall were painted plywood without proper flame spread rating. | SS=E |
| One of two fire alarm control annunciator panels was not protected by automatic smoke detection. | SS=F |
| Documentation for sensitivity testing of smoke detectors was incomplete and inconsistent with inspection reports. | SS=F |
| Facility fire watch policy was incomplete lacking IDOH contact web link, training documentation, and sole responsibility of fire watch personnel. | SS=F |
| Two areas open to corridor in basement/lower level were not protected by electrically supervised automatic smoke detection system. | SS=E |
| Sprinkler escutcheons in staff breakroom and resident room 20 were missing or hanging leaving gaps. | SS=B |
| Facility failed to provide a complete written policy for sprinkler system impairment procedures and fire watch requirements. | SS=F |
| Laundry chute door was not fully self-closing and positive latching; soiled linen chute lacked automatic sprinkler protection. | SS=E |
| Wet locations including activity office, C Hall bathroom, and beauty salon lacked ground fault circuit interrupter (GFCI) protection. | SS=E |
| Egress corridors were used as return air system for all resident rooms and corridors without proper waiver. | SS=C |
| Fire safety plan was incomplete and did not address backup 9-1-1 call, staff response to battery smoke alarms, K-class extinguisher use, removal of wheeled equipment, and evacuation procedures. | SS=F |
| Laundry chute door was not self-closing, positive latching, and gasketed; sprinkler not installed in soiled linen chute. | SS=E |
| Facility failed to ensure fire drills were held at varied times for second shift during 3 of 4 quarters. | SS=C |
Report Facts
Certified beds: 94
Census: 80
Deficiency count: 36
Smoke detectors: 49
Smoke detectors tested: 36
Fire drills: 4
Fire drills second shift: 3
Sprinkler escutcheons inspected: 6
Sprinkler escutcheons deficient: 2
Wet locations without GFCI: 3
Inspection Report
Re-Inspection
Census: 77
Capacity: 77
Deficiencies: 0
Sep 8, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on August 4, 2022.
Findings
Shady Nook Care 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 Payor Type - Medicare: 10
Census Payor Type - Medicaid: 52
Census Payor Type - Other: 15
Inspection Report
Annual Inspection
Census: 79
Capacity: 79
Deficiencies: 5
Aug 4, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from July 31 to August 4, 2022.
Findings
The facility was found deficient in multiple areas including nutrition and hydration status maintenance, psychotropic medication monitoring, medication storage and labeling, food safety and storage, and infection control related to indwelling urinary catheters.
Severity Breakdown
SS=D: 4
SS=E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide nutritional supplements for a resident with poor meal intake (Resident 61). | SS=D |
| Failed to monitor residents who received psychotropic medications for adverse side effects (Residents 48, 15, and 46). | SS=D |
| Failed to store medications appropriately related to labeling medications in medication carts (B Hall, C Hall, D Hall medication carts). | SS=D |
| Failed to store foods in a sanitary manner related to unlabeled and outdated foods in the kitchen. | SS=E |
| Failed to follow appropriate infection control guidelines related to indwelling urinary catheters for 2 residents (Residents 70 and 175). | SS=D |
Report Facts
Census: 79
Total Capacity: 79
Survey Dates: 5
Residents reviewed for nutrition: 2
Residents reviewed for psychotropic medication monitoring: 5
Medication carts reviewed: 6
Residents reviewed for infection control: 3
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