Inspection Reports for The Waters of Dunkirk Skilled Nursing Facility
11563 W 300 S, IN, 47336
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 19, 2025, found the facility in compliance with Medicare/Medicaid participation requirements and Life Safety Code standards, with no deficiencies cited. Earlier inspections showed a pattern of deficiencies primarily related to life safety code compliance, emergency preparedness, food service sanitation, medication administration by unqualified personnel, and resident care documentation. Complaint investigations were mostly unsubstantiated, except for a few substantiated cases involving medication administration errors, inadequate resident transfer practices resulting in injury, and insufficient dietary services, but no fines or enforcement actions were listed in the available reports. The facility addressed prior life safety and emergency preparedness issues through follow-up inspections that showed improvement in fire safety and emergency systems. Overall, the inspection history indicates some recurring operational and care-related issues with signs of progress in life safety compliance over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
8.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
110% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
80% occupied
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Census: 37
Capacity: 46
Deficiencies: 0
Jun 19, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 04/21/25 was performed to verify compliance with fire safety and licensure requirements.
Findings
The Waters of Dunkirk Skilled Nursing 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 facility was fully sprinklered with appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 46
Census: 37
Inspection Report
Re-Inspection
Census: 35
Deficiencies: 0
May 6, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on March 21, 2025, conducted in conjunction with the Investigation of Complaint IN00458014.
Findings
No deficiencies related to the complaint 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 PSR to the Recertification and State Licensure Survey.
Complaint Details
Complaint IN00458014 was investigated and no deficiencies related to the allegations were cited.
Report Facts
Census Bed Type: 35
Medicare Census: 5
Medicaid Census: 22
Other Payor Census: 8
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 0
May 6, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00458014 and was conducted in conjunction with the Post Survey Revisit to the Recertification and State Licensure Survey completed on March 21, 2025.
Findings
No deficiencies related to the allegations of Complaint IN00458014 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 IN00458014 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 35
Census Payor Type: 35
Inspection Report
Life Safety
Census: 31
Capacity: 46
Deficiencies: 9
Apr 21, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal and state regulations.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies were identified in emergency lighting documentation, sprinkler system maintenance, corridor door latching, electrical receptacle grounding, fire damper inspection, fire drill documentation, emergency generator testing, automatic transfer switch indicators, and patient care related electrical equipment maintenance.
Severity Breakdown
SS=F: 6
SS=E: 1
SS=D: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to document monthly and annual testing for all battery backup lights as required by Life Safety Code 7.9. | SS=F |
| Failed to maintain automatic sprinkler systems in accordance with NFPA 25, including repair of dry sprinkler system accelerator and removal of combustible storage in sprinkler system water supply tank room. | SS=F |
| Failed to ensure one corridor door to the kitchen had no impediment to closing and latching to resist passage of smoke. | SS=E |
| Failed to ensure electrical receptacles in 2 resident sleeping rooms were properly grounded in accordance with NFPA 70. | SS=D |
| Failed to ensure all fire dampers were inspected and maintained within the most recent four year period as required by NFPA 90A and NFPA 80. | SS=F |
| Failed to document activation of the fire alarm system on fire drills conducted between 6:00 a.m. and 9:00 p.m. on second shift for one quarter. | SS=F |
| Failed to exercise the emergency generator annually to meet NFPA 110 requirements, including monthly load testing at minimum 30% load and 36 month continuous testing for four hours. | SS=F |
| Failed to maintain one of three automatic transfer switches with illuminated position indicators as required by NFPA 110. | — |
| Failed to conduct required maintenance and maintain complete documentation of inspections for all Patient Care Related Electrical Equipment (PCREE). | SS=F |
Report Facts
Facility capacity: 46
Census: 31
Deficiencies cited: 9
Load test percentage: 29
Emergency generator rating: 157
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Max Richardson | Interim Administrator | Named in relation to exit conference and report signature |
Inspection Report
Annual Inspection
Census: 31
Capacity: 31
Deficiencies: 5
Mar 21, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from March 17 to March 21, 2025.
Findings
The facility was cited for deficiencies including failure to post survey results at an accessible height, failure to notify resident representatives in writing of transfer/discharge appeal rights, failure to follow menus and resident preferences, poor palatability of meals, and inadequate sanitation and food storage practices in the kitchen.
Severity Breakdown
SS=B: 1
SS=D: 1
SS=E: 1
SS=F: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure the results from the last annual Indiana Department of Health survey report were posted at an accessible height for residents. | SS=B |
| Failed to ensure resident's representatives were notified in writing of transfer/discharge appeal rights for hospitalizations. | SS=D |
| Failed to ensure menus and resident preferences were followed for dining services. | SS=F |
| Failed to ensure palatability of meals served to residents. | SS=E |
| Failed to ensure high-temperature dishwasher functioned properly and failed to maintain sanitary food storage and equipment cleanliness. | SS=F |
Report Facts
Census: 31
Total Capacity: 31
Dishwasher temperature: 113
Survey dates: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tyisha Archer | HFA | Signed laboratory director/provider representative on report |
| QMA 10 | Interviewed regarding accessibility of survey binder and meal complaints | |
| LPN 6 | Interviewed regarding transfer/discharge process and meal quality | |
| Dietary Manager 2 | Interviewed regarding food supply, meal quality, and kitchen sanitation | |
| Administrator | Interviewed regarding survey binder accessibility, transfer/discharge policies, and kitchen performance improvement plan | |
| SSD/Designee | Social Services Director or Designee | Interviewed regarding transfer/discharge appeal rights notification |
| Maintenance Director | Interviewed regarding dishwasher malfunction and repair |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 10, 2025
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00448842 completed on December 31, 2024.
Findings
The Waters of Dunkirk 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
Investigation of Complaint IN00448842 was completed with the facility found in compliance.
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 1
Dec 31, 2024
Visit Reason
This visit was for the investigation of Complaint IN00448842 regarding allegations of deficiencies related to physical transfers and supervision.
Findings
The facility failed to identify the number of staff needed for physical transfers and to ensure transfers were provided consistently for a resident requiring extensive assistance, resulting in a fracture to the resident's right ankle. The investigation included review of clinical records, interviews, and observations confirming inconsistent transfer practices and lack of staff awareness.
Complaint Details
Complaint IN00448842 was substantiated with federal/state deficiencies cited at F689 related to the allegations of improper physical transfers causing injury.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to identify the number of staff needed for physical transfers and to ensure physical transfers were provided in a consistent manner for a resident requiring extensive assistance for mobility. | SS=D |
Report Facts
Census: 30
Residents reviewed for accidents: 3
Pain rating: 7
Date of fracture incident: Dec 7, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tyisha Archer | HFA | Laboratory Director or Provider/Supplier Representative signature on report |
| CNA 3 | Certified Nursing Assistant involved in transferring Resident B when injury occurred; unaware of two-person assist requirement | |
| ADON | Assistant Director of Nursing | Provided education to staff regarding two-person transfers and transfer policies |
| CNA 2 | Certified Nursing Assistant who previously transferred Resident B with another staff member and reviewed assignment sheets | |
| CNA 6 | Certified Nursing Assistant who frequently assisted Resident B and noted no major change post-injury |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 46
Deficiencies: 0
Nov 12, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00446041.
Findings
No deficiencies related to the allegations in Complaint IN00446041 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00446041 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type Total: 46
Census Payor Type Total: 34
Census SNF/NF Beds: 42
Census SNF Beds: 4
Census Medicare Residents: 2
Census Medicaid Residents: 26
Census Other Residents: 6
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 0
Sep 19, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00441816.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00441816 found no deficiencies related to the allegations.
Report Facts
Census: 31
Census Bed Type: 31
Medicare Census: 2
Medicaid Census: 20
Other Payor Census: 9
Inspection Report
Re-Inspection
Census: 36
Capacity: 46
Deficiencies: 0
Aug 19, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey that exited on 06/10/24 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The Waters of Dunkirk Skilled Nursing Facility was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinklered with a fire alarm system and smoke detection throughout.
Inspection Report
Annual Inspection
Census: 35
Capacity: 46
Deficiencies: 5
Jun 10, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 06/10/2024.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements. Deficiencies included issues with exit door locking, hazardous area enclosure, unsecured electrical panels, improper use of power strips, and lack of mechanical ventilation in the oxygen storage room.
Severity Breakdown
SS=E: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Exit door #6 was magnetically locked and the code to open it was not posted at the exit, affecting egress accessibility. | SS=E |
| Failed to maintain protection of hot oil in popcorn popper in the activities area; door with self-closing device did not latch. | SS=E |
| Electrical panels in corridors were not secured from non-authorized personnel; electrical panel near 200 hall nurses station was unlocked. | SS=E |
| Flexible cord power strip powering medical equipment in resident room 215 did not meet required UL rating and was used improperly with non-medical devices. | SS=E |
| Oxygen storage/transfer room lacked properly working mechanical ventilation; exhaust fan was disconnected. | SS=E |
Report Facts
Facility capacity: 46
Census: 35
Residents potentially affected by exit door locking deficiency: 8
Residents potentially affected by popcorn popper deficiency: 15
Staff and residents potentially affected by electrical panel deficiency: 12
Residents potentially affected by oxygen storage ventilation deficiency: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tyisha Wheeler | Administrator | Named as the Administrator who verified corrective actions and participated in exit conferences. |
| Maintenance Director | Interviewed regarding deficiencies and corrective actions related to maintenance issues. | |
| Maintenance Supervisor | Responsible for implementing corrective actions and preventive maintenance related to deficiencies. |
Inspection Report
Renewal
Census: 34
Capacity: 34
Deficiencies: 0
May 28, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted over May 21, 22, 23, 24, and 28, 2024.
Findings
The Waters of Dunkirk 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 Recertification and State Licensure Survey.
Report Facts
Census Bed Type: 34
Census Payor Type: 34
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 0
Feb 14, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00428133 at the Waters of Dunkirk Skilled Nursing Facility.
Findings
No deficiencies related to the allegations in Complaint IN00428133 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00428133 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 33
Census Bed Type: 33
Census Payor Type: 33
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 0
Nov 30, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00418870 and IN00421701.
Findings
No deficiencies related to the allegations in complaints IN00418870 and IN00421701 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00418870 - No deficiencies related to the allegations are cited. Complaint IN00421701 - No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type - SNF: 3
Census Bed Type - SNF/NF: 39
Total Census: 42
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 25
Census Payor Type - Other: 12
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 14, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00409625 completed on June 15, 2023.
Findings
The Waters of Dunkirk 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 the paper review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00409625 completed on June 15, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 41
Capacity: 41
Deficiencies: 2
Jun 14, 2023
Visit Reason
This visit was for Investigation of Complaint IN00409625 and included a COVID-19 Focused Infection Control Survey.
Findings
The facility failed to ensure residents received medications, including insulin injections, from qualified nursing personnel. An unlicensed nursing student administered medications to five residents during a job shadowing activity without proper authorization or facility policy, potentially affecting all 41 residents.
Complaint Details
Complaint IN00409625 was substantiated with federal and state deficiencies cited at F726 and F835 related to medication administration by unqualified personnel.
Severity Breakdown
SS=F: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure residents received medications, including insulin injections, from qualified nursing personnel for 5 of 5 residents reviewed. | SS=F |
| Facility management allowed an unqualified individual to provide care and access resident information, failing to prevent medication administration by an unlicensed person. | SS=F |
Report Facts
Residents reviewed for medication administration: 5
Total residents in facility: 41
Date of occurrence: May 25, 2023
Date of survey: Jun 14, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tyisha Wheeler | Administrator | Named as Administrator during interviews regarding complaint and findings |
| LPN 1 | Licensed Practical Nurse who allowed her daughter, a nursing student, to administer medications | |
| QMA 4 | Qualified Medication Aide | Witnessed medication administration by nursing student and described facility medication administration policies |
| DON | Director of Nursing | Gave permission for job shadowing but did not authorize medication administration; was out of facility during survey |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 25, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00406798 completed on April 24, 2023.
Findings
The Waters of Dunkirk 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 of the complaint investigation.
Complaint Details
Investigation of Complaint IN00406798 completed on April 24, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 1
Apr 24, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00406798 regarding allegations related to quality of care at the facility.
Findings
The facility failed to assess and document bruising of unknown origin on a resident's hand (Resident B) during a respite stay. The bruising was noted but not properly documented or investigated, and the resident was discharged with a significant bruise and fracture. The facility implemented corrective actions including staff education and increased skin assessments.
Complaint Details
Complaint IN00406798 was substantiated with federal/state deficiencies cited at F684 related to quality of care and failure to properly assess and document bruising on Resident B.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to assess and document bruising of unknown origin on Resident B's hand. | SS=D |
Report Facts
Census: 37
SNF/NF beds: 35
SNF beds: 2
Medicare residents: 3
Medicaid residents: 31
Other payor residents: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tyisha Wheeler | Administrator | Signed report and involved in facility administration |
| LPN 23 | Interviewed regarding bruising on Resident B's hand | |
| LPN 15 | Interviewed regarding bruising on Resident B's hand | |
| ADON | Assistant Director of Nursing | Interviewed regarding bruising on Resident B's hand |
| LPN 27 | Interviewed regarding skin checks on Resident B | |
| CNA 17 | Certified Nursing Assistant | Noticed bruising on Resident B's hand and reported it |
| DON | Director of Nursing | Interviewed regarding bruising and documentation practices |
Inspection Report
Re-Inspection
Census: 37
Capacity: 46
Deficiencies: 0
Apr 13, 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 02/27/23.
Findings
At this Post Survey Revisit, The Waters of Dunkirk Skilled Nursing Facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 0
Mar 8, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00402574 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 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation and the COVID-19 survey.
Complaint Details
Complaint IN00402574 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 39
Census SNF/NF beds: 35
Census SNF beds: 4
Census Payor Medicare: 6
Census Payor Medicaid: 27
Census Payor Other: 6
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 28, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00397976 completed on February 2, 2023.
Findings
The Waters of Dunkirk 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 IN00397976 completed with paper compliance found.
Inspection Report
Routine
Census: 37
Capacity: 46
Deficiencies: 8
Feb 27, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health to assess compliance with emergency preparedness and life safety requirements.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements, Life Safety Code requirements including exit door accessibility, fire alarm system maintenance, fuel-fired water heater inspections, ground fault circuit interrupter functionality, smoking policy enforcement, fire door inspections, kitchen serving door operation, and power strip usage.
Severity Breakdown
SS=F: 5
SS=E: 2
SS=D: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills. | SS=F |
| Means of egress through 2 exit doors were not readily accessible due to locked doors without posted access codes. | SS=E |
| Fire alarm panel was in trouble mode and not fully operational until repaired. | SS=F |
| Two fuel fired water heaters lacked current inspection certificates. | SS=F |
| Ground fault circuit interrupter (GFCI) in 200 hall shower room failed to trip and did not break electrical circuit. | SS=D |
| Smoking was observed outside a non-designated smoking exit door area. | SS=D |
| Failed to ensure annual inspection and testing of fire door assemblies and proper operation of kitchen serving doors. | SS=F |
| Power strip in Activity room did not meet UL 1363 standards. | SS=E |
Report Facts
Facility capacity: 46
Census: 37
Deficiency count: 9
Date of survey: Feb 27, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tyisha Wheeler | Administrator | Named in relation to findings and plan of correction |
Inspection Report
Renewal
Census: 40
Capacity: 40
Deficiencies: 1
Feb 20, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted over February 14, 15, 16, 17, and 20, 2023.
Findings
The facility was found deficient for failing to develop and implement interventions to reduce the risk of falls for one resident, resulting in a fall with fracture requiring hospitalization. The facility requested a desk review due to the low scope and severity and only one deficiency cited.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to develop and implement interventions to reduce the risk of falls for 1 of 3 residents reviewed, resulting in a fall with fracture requiring hospitalization. | SS=D |
Report Facts
Census: 40
Total Capacity: 40
Medicare Census: 5
Medicaid Census: 30
Other Payor Census: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tyisha Wheeler | Administrator | Signed the report |
| CNA 5 | Interviewed regarding resident's use of alarms and falls | |
| LPN 7 | Interviewed regarding resident's frequent falls and care needs |
Inspection Report
Annual Inspection
Deficiencies: 0
Feb 20, 2023
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey was completed.
Findings
The Waters of Dunkirk 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 for Recertification and State Licensure.
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 3
Feb 2, 2023
Visit Reason
This visit was for the investigation of Complaint IN00397976, which was substantiated with federal/state deficiencies cited.
Findings
The facility failed to ensure dietary employees were competently trained in food storage, safe food temperatures, and completion of dietary duties; menus were not approved by a Registered Dietitian and lacked proper guidance for diet types; and food was not prepared, stored, and served under safe and sanitary conditions, potentially impacting all 40 residents.
Complaint Details
Complaint IN00397976 was substantiated with federal/state deficiencies cited at F802, F803, and F812.
Severity Breakdown
SS=F: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to employ sufficient dietary staff with appropriate competencies and skills to ensure proper food storage, safe food temperatures, and completion of assigned dietary duties. | SS=F |
| Failed to ensure menus were approved by a Registered Dietitian with guidance for diet types. | SS=F |
| Failed to ensure food was prepared, stored, and served under safe and sanitary conditions. | SS=F |
Report Facts
Residents present: 40
Dietary employees: 5
Dietary employees less than 5 months: 3
Opened cans stored without proper containers: 5
Temperature readings above 41 F: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tyisha Wheeler | Administrator | Named in relation to dietary leadership and corrective actions |
| Cook 1 | Named in relation to dietary deficiencies and observations | |
| Cook 2 | Named in relation to dietary deficiencies and observations |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 0
Dec 13, 2022
Visit Reason
This visit was conducted for the investigation of three complaints: IN00396883, IN00395387, and IN00394457.
Findings
All three complaints were substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00396883 - Substantiated with no deficiencies cited. Complaint IN00395387 - Substantiated with no deficiencies cited. Complaint IN00394457 - Substantiated with no deficiencies cited.
Report Facts
Census SNF/NF beds: 38
Census SNF beds: 4
Total census: 42
Census Medicare residents: 5
Census Medicaid residents: 33
Census Other payor residents: 4
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