Inspection Reports for The Waters of Castleton Skilled Nursing Facility
8400 CLEARVISTA PL, IN, 46256
Back to Facility ProfileDeficiencies per Year
20
15
10
5
0
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Plan of Correction
Deficiencies: 0
May 22, 2025
Visit Reason
Paper compliance review of the Investigation of Complaints IN00450054, IN00451947, and IN00456622 completed on April 2, 2025.
Findings
The Waters of Castleton Skilled Nursing Facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the investigations. All three complaints were corrected.
Complaint Details
Complaints IN00450054, IN00451947, and IN00456622 were investigated and found corrected.
Report Facts
Complaint Investigations: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
May 22, 2025
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00457282 completed on April 16, 2025.
Findings
The Waters of Castleton Skilled Nursing Facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the complaint investigation.
Complaint Details
Complaint IN00457282 was investigated and found to be corrected.
Inspection Report
Complaint Investigation
Census: 52
Capacity: 52
Deficiencies: 3
Apr 16, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00457282 regarding federal and state deficiencies related to the allegations.
Findings
The facility was found deficient in timely implementation of fall interventions for one resident, proper administration and availability of narcotic medications and IV antibiotics for two residents, and failure to conduct gradual dose reduction when discontinuing psychotropic medications for one resident.
Complaint Details
Complaint IN00457282 was investigated with federal and state deficiencies cited at tags F689, F755, and F758 related to fall interventions, medication administration, and psychotropic medication management.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure a fall intervention was implemented timely after a fall event for 1 of 3 residents reviewed for accidents. | SS=D |
| Failed to ensure narcotic medication was administered per physician orders, narcotic medication was readily available, and IV antibiotics were obtained and administered as ordered for 2 of 3 residents reviewed for medication use. | SS=D |
| Failed to ensure a gradual dose reduction was conducted instead of abruptly discontinuing an antidepressant and antianxiety medication for 1 of 3 residents reviewed for unnecessary medications. | SS=D |
Report Facts
Census: 52
Total Capacity: 52
Residents reviewed for accidents: 3
Residents reviewed for medication use: 3
Residents reviewed for unnecessary medications: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sherice Ricks | Laboratory Director or Provider/Supplier Representative | Signed the report |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Present during observation of Resident D and involved in fall intervention corrective actions |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication administration and corrective actions |
| Social Services Director | Social Services Director (SSD) | Interviewed regarding psychotropic medication discontinuation and resident representative communication |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 55
Deficiencies: 6
Apr 2, 2025
Visit Reason
This visit was for the investigation of complaints IN00450054, IN00451947, and IN00456622 regarding resident rights, notification of changes, and wound care.
Findings
The facility was found deficient in timely response to call lights and dignity for residents, failure to notify family and physician timely of significant changes including weight loss and new wounds, failure to develop and implement comprehensive care plans for ADLs, failure to provide bathing and hygiene care per resident preferences, failure to maintain nutrition and hydration status for a resident receiving enteral feedings, and failure to document wound identification and notification properly.
Complaint Details
The investigation was triggered by complaints IN00450054, IN00451947, and IN00456622. Deficiencies related to dignity and call light response, notification of changes, and wound documentation were substantiated.
Severity Breakdown
SS=D: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to honor resident's right for dignity related to timely response to call lights and incontinence care. | SS=D |
| Failed to ensure timely notification of attending physician and family for significant weight loss and new open wound. | SS=D |
| Failed to develop a comprehensive care plan for bathing and hygiene needs. | SS=D |
| Failed to provide bathing and/or showering care per resident preferences. | SS=D |
| Failed to ensure continuous enteral feedings were administered as ordered and timely interventions for significant weight loss. | SS=D |
| Failed to thoroughly document identification of a newly identified open wound and notification of family and physician. | SS=D |
Report Facts
Census: 55
Total Capacity: 55
Weight loss: 30.7
Wound size: 5.1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sherice Ricks | Administrator | Signed the inspection report |
| Director of Nursing | Director of Nursing | Interviewed regarding call light response, notification of changes, and wound care |
| Corporate Nurse | Corporate Nurse | Provided policies and interviewed regarding dignity and notification policies |
Inspection Report
Re-Inspection
Census: 51
Capacity: 114
Deficiencies: 0
Dec 19, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 10/23/24 was performed to verify compliance with fire safety and licensure requirements.
Findings
The Waters of Castleton Skilled Nursing Facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 NFPA 101 Life Safety Code. The facility is fully sprinklered except for one detached storage building.
Report Facts
Facility capacity: 114
Census: 51
Inspection Report
Life Safety
Census: 45
Capacity: 114
Deficiencies: 6
Oct 23, 2024
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 related regulations.
Findings
The facility was found not in compliance with several Life Safety Code requirements including failure to replace battery-operated smoke alarms in resident rooms, failure to maintain sprinkler systems, incomplete fire drill documentation, malfunctioning rolling steel fire doors, failure to properly exercise the emergency generator, and improper use of extension cords as substitutes for fixed wiring.
Severity Breakdown
SS=E: 3
SS=F: 3
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to replace battery-operated smoke alarms installed in resident sleeping rooms in accordance with NFPA 72. | SS=E |
| Failed to maintain automatic sprinkler systems in accordance with NFPA 25. | SS=F |
| Failed to document quarterly fire drills on the second shift for 1 of 4 quarters and failed to conduct fire drills at unexpected times under varying conditions. | SS=F |
| Failed to ensure proper operation of rolling steel fire doors in accordance with NFPA 80; door failed to reset mechanically after test. | SS=E |
| Failed to exercise the emergency generator annually and monthly load tests did not meet minimum load requirements per NFPA 110. | SS=F |
| Failed to ensure extension cords including power strips were not used as a substitute for fixed wiring. | SS=E |
Report Facts
Certified beds: 114
Census: 45
Residents potentially affected: 20
Residents potentially affected: 20
Generator rating: 80
Load test duration: 4
Load test maximum load: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sherice Ricks | Administrator | Named in exit conference and verification of corrective actions |
| Maintenance Director | Interviewed regarding deficiencies and corrective actions | |
| Maintenance Supervisor | Responsible for corrective actions and monitoring | |
| Director of Operations | Interviewed regarding deficiencies and corrective actions |
Inspection Report
Annual Inspection
Census: 49
Capacity: 49
Deficiencies: 8
Oct 8, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00428580, IN00433065, IN00435133, and IN00442971.
Findings
The facility was found deficient in multiple areas including resident dignity during feeding, grievance handling, MDS assessment accuracy, medication administration, RN coverage, food temperature safety, payroll staffing data accuracy, and COVID-19 immunization documentation.
Complaint Details
This citation relates to Complaints IN00433065 and IN00428580. Deficiencies were cited related to these complaints, including failure to maintain resident dignity and failure to have RN coverage.
Severity Breakdown
SS=D: 2
SS=B: 1
SS=E: 2
SS=F: 2
SS=C: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure a resident's dignity was maintained by not sitting down while assisting a resident with eating. | SS=D |
| Failed to timely address a resident's grievance for choices. | SS=D |
| Failed to accurately code the Minimum Data Set (MDS) assessment for 4 of 7 residents reviewed for MDS accuracy. | SS=B |
| Failed to administer medications and collect urine samples as ordered, timely schedule follow-up appointments, and implement dietary recommendations. | SS=E |
| Failed to have a Registered Nurse (RN) on duty for at least eight consecutive hours a day, seven days a week. | SS=F |
| Failed to hold food on a steam table at safe temperatures. | SS=F |
| Failed to submit accurate direct care staffing information to CMS regarding RN work category. | SS=C |
| Failed to ensure residents or representatives were provided education regarding the 2023-2024 COVID-19 vaccine and proper documentation. | SS=E |
Report Facts
Residents present: 49
Total licensed capacity: 49
RN coverage missing days: 12
Temperature of mixed vegetables: 121.8
Temperature of bourbon fish fillets: 107
Temperature of French fries: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN 9 | Registered Nurse | Weekend option nurse whose licensure status was not updated in PBJ system |
| CNA 1 | Certified Nursing Assistant | Observed standing while assisting resident with eating |
| Nurse Consultant | Provided multiple interviews and policy clarifications | |
| Director of Nursing | DON | Provided interviews and corrective action plans |
| Staffing Coordinator | Provided interview regarding staffing and RN coverage | |
| Facility Cook 1 | Observed food temperatures during lunch service | |
| Facility Cook 2 | Observed food temperatures during lunch service | |
| Administrator | Provided schedules and corrective action information |
Inspection Report
Annual Inspection
Deficiencies: 0
Oct 8, 2024
Visit Reason
The inspection was conducted as part of the Annual Recertification and State Licensure survey, including investigation of two complaints (IN00428580 and IN00433065).
Findings
The Waters of Castleton Skilled Nursing Facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on paper review. Both complaints investigated were corrected.
Complaint Details
Complaints IN00428580 and IN00433065 were investigated and found to be corrected.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 5, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00419427 completed on January 25, 2024.
Findings
Waters of Castleton Skilled Nursing Facility 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 to the Complaint Investigation.
Complaint Details
Investigation of Complaint IN00419427 completed on January 25, 2024; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 1
Jan 25, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN0041942 and IN00426071 at Waters of Castleton Skilled Nursing Facility.
Findings
The facility failed to ensure a Minimum Data Set (MDS) assessment was accurately completed related to falls for 1 of 3 residents reviewed (Resident B). The admission MDS assessment did not reflect two falls sustained by Resident B prior to the assessment reference date.
Complaint Details
Complaint IN00419427 was substantiated with a federal/state deficiency cited at F641. Complaint IN00426071 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a Minimum Data Set (MDS) assessment was correctly completed related to falls for Resident B. | SS=D |
Report Facts
Census: 46
Falls: 2
Audit timeframe: 90
Monitoring duration: 6
Compliance threshold: 95
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James Thompson | Administrator | Signed the report |
| Corporate Nurse | Interviewed regarding MDS assessment staffing and process | |
| Executive Director | Interviewed regarding facility policy on MDS assessments | |
| MDS Coordinator | Responsible for corrective actions and audits related to MDS accuracy | |
| MDS Consultant | Provided education to MDS Coordinator on accuracy of MDS assessments |
Inspection Report
Re-Inspection
Census: 46
Capacity: 114
Deficiencies: 0
Oct 27, 2023
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 08/29/23.
Findings
The Waters of Castleton Skilled Nursing Facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements. The facility is fully sprinklered except for one detached storage building and has appropriate fire alarm and smoke detection systems.
Report Facts
Certified beds: 114
Census: 46
Inspection Report
Re-Inspection
Census: 46
Deficiencies: 0
Oct 3, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 2023-08-11, including a PSR to the Investigation of Complaint IN00411900 completed on 2023-08-11.
Findings
The Waters of Castleton Skilled Nursing 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 the Recertification and State Licensure Survey and the PSR to the Investigation of Complaint IN00411900.
Complaint Details
Complaint IN00411900 was investigated and found to be corrected.
Report Facts
Census: 46
SNF/NF beds: 32
SNF beds: 14
Medicare residents: 2
Medicaid residents: 31
Other residents: 13
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 0
Sep 1, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00415795.
Findings
No deficiencies related to the allegations in Complaint IN00415795 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00415795; no deficiencies related to the allegations were cited.
Report Facts
Census: 46
Census Bed Type - SNF/NF: 32
Census Bed Type - SNF: 14
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 35
Census Payor Type - Other: 10
Inspection Report
Routine
Census: 47
Capacity: 114
Deficiencies: 18
Aug 29, 2023
Visit Reason
Routine Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health.
Findings
The facility was found not in compliance with multiple Life Safety Code and regulatory requirements including emergency preparedness, fire safety, fire alarm system maintenance, sprinkler system maintenance, fire drills, and door egress requirements.
Severity Breakdown
SS=F: 14
SS=D: 3
SS=E: 1
Deficiencies (18)
| Description | Severity |
|---|---|
| Failed to maintain an emergency preparedness plan based on a documented facility-based and community-based risk assessment reviewed within the most recent twelve month period and include strategies for addressing emergency events. | SS=F |
| Failed to develop and implement emergency preparedness policies and procedures based on the emergency plan and risk assessment, reviewed and updated at least annually. | SS=F |
| Failed to ensure emergency preparedness training program includes initial and annual training, documentation, and demonstration of staff knowledge. | SS=F |
| Failed to conduct exercises to test the emergency plan at least twice per year including unannounced staff drills. | SS=F |
| Failed to implement emergency power system inspection, testing, and maintenance requirements including weekly inspections, monthly load testing, 36 month load bank testing, and annual fuel quality testing. | SS=F |
| Failed to ensure means of egress doors were readily accessible without requiring a key or tool to open from the egress side, including keypad codes not posted and keypad locked in a box without key access. | SS=F |
| Failed to provide corridor doors with not more than one releasing operation. | SS=F |
| Failed to ensure kitchen exit door was not equipped with locks which cannot be opened from the egress side. | SS=F |
| Failed to ensure stairway enclosure door latching mechanism was operational and door had a method to release from stairwell side. | SS=E |
| Failed to document monthly and annual testing for all battery backup emergency lights. | SS=F |
| Failed to ensure hazardous areas such as laundry and combustible storage rooms were separated from other spaces by smoke resistant partitions and doors with self-closing devices. | SS=D |
| Failed to ensure kitchen fire suppression system and kitchen exhaust system were inspected semi-annually and grease filter baffles were installed correctly without gaps. | SS=D |
| Failed to ensure portable fire extinguisher in laundry was properly mounted. | SS=D |
| Failed to maintain fire alarm system including smoke detector sensitivity testing, semi-annual inspections, and accurate time and date on fire alarm control panel. | SS=F |
| Failed to maintain automatic sprinkler systems including quarterly inspections, five year internal pipe inspections, and correction of deficiencies. | SS=F |
| Failed to ensure openings through ceiling smoke barriers were protected to maintain fire resistance rating. | SS=D |
| Failed to conduct fire drills on all shifts for all quarters and document activation of fire alarm system on drills conducted between 6:00 a.m. and 9:00 p.m. | SS=F |
| Failed to conduct annual inspection and testing of all fire door assemblies including stairwell exits and oxygen room doors. | SS=F |
Report Facts
Certified beds: 114
Current census: 47
Deficiency count: 18
Emergency generator rating: 80
Fire drills missing: 2
Smoke detectors failed sensitivity: 19
Fire alarm system smoke detectors tested: 117
Fire damper inspection interval: 4
Fire door assemblies inspected: 2
Fire door assemblies missing: 2
Fire resistance rating: 90
Fire damper inspection date: Jun 1, 2020
Fire suppression system inspection date: Sep 12, 2022
Fire alarm system inspection date: May 15, 2023
Kitchen fire suppression system inspection missing: 1
Kitchen exhaust system inspection missing: 1
Battery operated smoke detectors manufacture date: Sep 30, 2011
Battery operated smoke detectors age: 10
Fire drills missing documentation: 1
Fire drills missing alarm activation documentation: 2
Portable fire extinguisher weight limit: 40
Fire door inspection frequency: 1
Fire door inspection missing doors: 2
Fire damper inspection frequency: 4
Emergency generator weekly inspection missing: 8
Emergency generator monthly load testing missing: 8
Emergency generator load rating: 80
Emergency generator 36 month testing missing: 1
Annual fuel quality test fail: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brittany McKinney | Executive Director | Named in relation to multiple findings and exit conference. |
| Maintenance Director | Named in relation to multiple findings, interviews, and exit conference. | |
| Administrator | Named in relation to corrective actions and training. | |
| Maintenance Supervisor | Named in relation to corrective actions, inspections, and training. | |
| DON | Director of Nursing | Named in relation to corrective actions and training. |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 14
Aug 11, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey including the Investigation of Complaint IN00411900.
Findings
The facility was found deficient in multiple areas including failure to address resident grievances, failure to issue Notices of Medicare Non Coverage, failure to allow anonymous grievance filing, verbal and sexual abuse incidents, failure to timely create baseline care plans, failure to develop discharge plans, failure to update care plans for refusals and dehydration risk, medication administration errors, failure to store controlled medications properly, failure to monitor and address resident behaviors, and deficiencies in staff training and personnel records.
Complaint Details
Complaint IN00411900 - Federal/State deficiencies related to allegations of abuse, grievance handling, medication errors, and care planning.
Severity Breakdown
Level G: 1
Level E: 1
Level A: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| Failure to ensure grievances reported were addressed with resolutions and failure to allow anonymous grievance filing. | Level E |
| Failure to issue Notices of Medicare Non Coverage to residents discharged with benefit days remaining. | Level A |
| Failure to ensure residents were free from verbal, mental, and sexual abuse. | Level G |
| Failure to timely create baseline care plans within 48 hours of admission. | — |
| Failure to develop discharge planning care plans and provide discharge summaries. | — |
| Failure to update care plans for refusals of bathing and shampooing and for residents at high risk for dehydration. | — |
| Failure to implement fall prevention interventions including use of scoop mattress and call light modifications. | — |
| Failure to clarify oxygen therapy orders and ensure oxygen was administered as ordered. | — |
| Failure to administer psychoactive and narcotic medications as ordered, failure to implement individualized mental health safety plan, and failure to adequately monitor behaviors. | — |
| Medication administration errors with unavailable medications and administration of discontinued medications. | — |
| Failure to store controlled medications under double lock in medication room. | — |
| Failure to implement a corrective plan of action with monitoring and evaluation for abuse concerns. | — |
| Failure to provide staff with required tuberculin skin testing, dementia, and resident rights training. | — |
| Failure to provide bathing and hair shampooing as per resident preferences and failure to provide toileting sling as recommended. | — |
Report Facts
Residents present: 48
Medication error rate: 8
Residents affected by grievance issue: 6
Residents reviewed for medication errors: 5
Residents reviewed for abuse: 5
Residents reviewed for bathing/shampooing refusals: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brittany McKinney | Executive Director | Provided investigative file and interviewed regarding abuse and QAPI |
| QMA 4 | Qualified Medication Aide | Observed medication administration and resident behavior |
| CNA 30 | Certified Nursing Assistant | Observed resident care and behaviors |
| Social Service Director | Social Service Director | Interviewed regarding grievances, abuse, and mental health safety plans |
| Director of Nursing | Director of Nursing | Interviewed regarding care plans, medication errors, and abuse |
| Activities Director | Activities Director | Interviewed regarding grievance process |
| Laundry Aide 5 | Laundry Aide | Witnessed verbal abuse incident |
| QMA 7 | Qualified Medication Aide | Involved in resident transfer and abuse investigation |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 1, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00410707 completed on June 20, 2023.
Findings
Miller's Senior Living Community 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 to the Complaint Investigation.
Complaint Details
Investigation of Complaint IN00410707 completed on June 20, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 2
Jun 19, 2023
Visit Reason
This visit was conducted for the investigation of three complaints (IN00406374, IN00407853, and IN00410707). Two complaints had no deficiencies related to the allegations, while the third complaint (IN00410707) resulted in federal/state deficiencies cited.
Findings
The facility was found deficient in providing timely and continued treatment for pressure ulcers for 2 of 3 residents reviewed, and failed to implement follow-up instructions for tracheostomy care for 1 of 2 residents reviewed. Deficiencies were cited related to pressure ulcer treatment and respiratory/tracheostomy care.
Complaint Details
Complaint IN00406374 and IN00407853 had no deficiencies related to the allegations. Complaint IN00410707 had federal/state deficiencies cited at F686 (pressure ulcer treatment) and F695 (respiratory/tracheostomy care).
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure a resident with pressure ulcers received timely and continued treatment for 2 of 3 residents reviewed (Resident B and Resident G). | SS=D |
| Failed to implement follow-up instructions to change a tracheostomy every 2 weeks for 1 of 2 residents reviewed (Resident B). | SS=D |
Report Facts
Census: 57
Pressure ulcer residents reviewed: 3
Residents with pressure ulcer deficiencies: 2
Residents reviewed for tracheostomy care: 2
Residents with tracheostomy care deficiency: 1
Inspection Report
Plan of Correction
Deficiencies: 0
May 10, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00404639 completed on April 12, 2023.
Findings
Miller's Senior Living Community 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 to the Complaint Investigation.
Complaint Details
Investigation of Complaint IN00404639 completed on April 12, 2023; paper compliance review found the facility in compliance.
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 2
Apr 10, 2023
Visit Reason
This visit was conducted for the investigation of three complaints (IN00404639, IN00398885, IN00392443). Deficiencies related to complaint IN00404639 were cited, while no deficiencies were found related to the other two complaints.
Findings
The facility was found deficient in maintaining complete and accurate resident records for personal property and in ensuring residents' rooms were maintained in a clean manner regarding floor care for two residents. Specifically, Resident L's personal property inventory was incomplete, and rooms of Residents B and K were not cleaned adequately.
Complaint Details
Complaint IN00404639 was substantiated with federal/state deficiencies cited at F921 and F842. Complaints IN00398885 and IN00392443 were not substantiated with no deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure complete and accurate documentation of a resident's clinical record for personal property (Resident L). | SS=D |
| Failure to ensure residents' rooms were maintained in a cleanly manner regarding floor care for 2 of 5 residents reviewed (Residents B and K). | SS=D |
Report Facts
Census: 60
Census bed type: 14
Census bed type: 46
Census payor type: 6
Census payor type: 48
Census payor type: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chris Peter | Administrator | Signed the report |
Loading inspection reports...
