Inspection Reports for The Waters of Huntington Skilled Nursing Facility
1500 GRANT ST, HUNTINGTON, IN, 46750
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 27, 2025, found the facility in compliance with no deficiencies noted during the post-survey revisit related to a prior complaint. Earlier inspections showed a pattern of deficiencies primarily involving fall prevention and resident assessments, as well as issues with maintaining a clean environment and timely reporting of incidents. Several complaints were substantiated with citations related to supervision, documentation accuracy, and care planning, but enforcement actions such as fines or license suspensions were not listed in the available reports. Most complaint investigations were unsubstantiated or found corrected upon follow-up, and the facility demonstrated correction of previously cited deficiencies. This suggests an overall trend of improvement in addressing identified issues over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
8.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
102% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
56 residents
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Census: 56
Deficiencies: 0
Date: May 27, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00456781 completed on April 11, 2025.
Complaint Details
Complaint IN00456781 - Corrected.
Findings
The Waters of Huntington 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 Investigation of Complaint IN00456781.
Report Facts
Census Bed Type: 56
Census Payor Type: 56
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 0
Date: May 12, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00458556.
Complaint Details
Complaint IN00458556 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 57
Census Bed Type - SNF/NF: 53
Census Bed Type - SNF: 4
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 45
Census Payor Type - Private: 9
Inspection Report
Follow-Up
Deficiencies: 1
Date: Apr 28, 2025
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report confirms that the previously cited deficiency with ID Prefix F0684 related to regulation 483.25 was corrected as of 03/22/2025. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Deficiency with ID Prefix F0684 related to regulation 483.25
Report Facts
Deficiency correction date: Mar 22, 2025
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 2
Date: Apr 10, 2025
Visit Reason
This visit was for the investigation of complaint IN00456781, which involved federal and state deficiencies related to fall prevention and assessment accuracy.
Complaint Details
Complaint IN00456781 involved allegations related to fall prevention and assessment accuracy. Federal and state deficiencies were cited at F689 and F641 respectively.
Findings
The facility failed to provide adequate supervision and fall interventions for residents at risk, resulting in multiple falls and injuries including a left ankle fracture. Additionally, the facility failed to ensure accurate coding of Minimum Data Set (MDS) assessments for residents. Several residents experienced repeated falls without immediate interventions to prevent further incidents.
Deficiencies (2)
Failed to provide supervision and implement fall interventions to prevent repeated falls for residents at risk, resulting in injury.
Failed to ensure Minimum Data Set (MDS) assessments were accurately coded for residents.
Report Facts
Census: 54
Falls reviewed: 90
Safety checks frequency: 30
Completion date for systemic changes: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Interviewed regarding MDS assessment accuracy and care plan updates | |
| Director of Nursing (DON) | Interviewed regarding fall interventions and care plan updates | |
| Assistant Director of Nursing (ADON) | Interviewed regarding fall interventions and staffing | |
| Nurse Practitioner (NP) | Notified of resident falls and involved in care decisions | |
| Regional Nurse Consultant | Provided in-service training on fall interventions and care plan reviews | |
| Licensed Practical Nurses (LPNs) | Interviewed regarding fall assessments and interventions | |
| Certified Nursing Assistants (CNAs) | Interviewed regarding knowledge of fall interventions and resident care |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 1
Date: Mar 4, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00450770, IN00453115, and IN00454234.
Complaint Details
Complaint IN00450770 and Complaint IN00454234 deficiencies related to allegations were cited at F684. Complaint IN00453115 had no deficiencies related to the allegations.
Findings
The facility failed to ensure assessments were completed for 3 of 4 residents reviewed with respiratory illness and falls. Deficiencies related to complaints IN00450770 and IN00454234 were cited at F684, while no deficiencies were related to complaint IN00453115.
Deficiencies (1)
Failure to complete assessments for residents with respiratory illness and falls, including incomplete neurological checks and respiratory assessments for Residents J, C, and D.
Report Facts
Census: 50
Residents reviewed with respiratory illness and falls: 3
Dates of unwitnessed falls for Resident C: 5
Dates of unwitnessed falls for Resident D: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Thompson | Administrator | Signed plan of correction and correspondence |
| Registered Nurse 7 | Interviewed regarding respiratory symptom assessments | |
| Licensed Practical Nurse 2 | Interviewed regarding neurological checks and documentation | |
| Director of Nursing (DON) | Interviewed regarding neurological checks and documentation; acknowledged missing documentation |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 23, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00446015 completed on November 4, 2024.
Complaint Details
Complaint IN00446015 was investigated and found to be corrected.
Findings
The Waters of Huntington 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.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 23, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaints IN00442048 and IN00443645.
Complaint Details
Complaint IN00442048 and Complaint IN00443645 were investigated and found to be corrected.
Findings
The Waters of Huntington 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 complaints. Both complaints were corrected.
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 1
Date: Nov 1, 2024
Visit Reason
This visit was conducted for the investigation of three complaints (IN00446015, IN00446044, and IN00445218) regarding facility conditions and care.
Complaint Details
Complaint IN00446015 was substantiated with a Federal/State deficiency cited at F584. Complaints IN00446044 and IN00445218 were not substantiated with no deficiencies cited.
Findings
The facility failed to maintain a clean, homelike environment as evidenced by stained carpeting, unclean floors, and dirty bathrooms in multiple resident rooms and hallways. The Administrator and Housekeeping Director acknowledged the issues and initiated corrective actions including cleaning and carpet replacement plans.
Deficiencies (1)
Facility was not maintained in a clean, homelike manner with stained carpeting, unclean floors, and dirty bathrooms observed in resident rooms and common areas.
Report Facts
Census: 56
Census Bed Type - SNF: 3
Census Bed Type - SNF/NF: 53
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 42
Census Payor Type - Other: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Thompson | Administrator | Accompanied tours and provided facility policies during inspection |
| Housekeeping Director | Interviewed regarding cleaning plans and acknowledged deficiencies |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 52
Deficiencies: 1
Date: Oct 4, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00443645 and IN00442048 regarding the facility's compliance with care standards.
Complaint Details
The investigation was triggered by complaints IN00443645 and IN00442048. Federal/state deficiencies related to the allegations were cited at F686. The complaint was substantiated by the finding that Resident D had not received a skin assessment since 3/10/24 despite being at risk.
Findings
The facility failed to provide weekly skin assessments for a resident at risk for skin breakdown, contrary to their care plan and facility policy. The deficiency was related to complaints and resulted in a citation.
Deficiencies (1)
Failed to provide weekly skin assessments for a resident identified at risk for skin breakdown according to their plan of care.
Report Facts
Census: 52
Total Capacity: 52
Medicare Residents: 5
Medicaid Residents: 40
Other Payor Residents: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Interviewed and confirmed weekly skin assessments should be performed | |
| MDS Coordinator | Interviewed and confirmed weekly skin assessments should be performed | |
| Director of Nursing (DON)/Designee | Completed audit and in-serviced nursing staff on weekly skin assessments |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 19, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00440436 completed on August 9, 2024.
Complaint Details
Investigation of Complaint IN00440436 was completed with findings of compliance.
Findings
The Waters of Huntington 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.
Inspection Report
Re-Inspection
Census: 50
Capacity: 85
Deficiencies: 0
Date: Aug 9, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 07/01/24 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The Waters of Huntington 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, 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
Complaint Investigation
Census: 48
Capacity: 48
Deficiencies: 2
Date: Aug 8, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00440436 regarding allegations of abuse and inadequate dementia care.
Complaint Details
Complaint IN00440436 was substantiated with federal/state deficiencies cited at F610 and F744 related to allegations of abuse and inadequate dementia care. The facility delayed reporting a resident-to-resident altercation involving Resident B and Resident C. The investigation included interviews with staff and review of clinical records and policies.
Findings
The facility failed to ensure timely reporting of a resident-to-resident altercation to the Administrator, delaying submission to the Indiana Department of Health. Additionally, the facility failed to develop and implement individualized non-pharmacological interventions for behaviors for residents with dementia for 2 residents reviewed.
Deficiencies (2)
Failed to ensure staff reported a resident-to-resident altercation to the Administrator immediately, delaying submission of the incident within the required timeframe.
Failed to develop and implement individualized non-pharmacological interventions for behaviors for residents with dementia.
Report Facts
Census: 48
Total Capacity: 48
Survey Dates: 2
Medicare Residents: 5
Medicaid Residents: 39
Other Payor Residents: 4
Date of Alleged Compliance: Aug 10, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bryce Tomasi | Administrator | Named in relation to the investigation and reporting of resident-to-resident altercation |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 0
Date: Jul 24, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00437360.
Complaint Details
Complaint IN00437360 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 47
Medicare residents: 4
Medicaid residents: 38
Other payor residents: 5
Inspection Report
Life Safety
Census: 46
Capacity: 85
Deficiencies: 7
Date: Jul 1, 2024
Visit Reason
The visit was a Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and an Emergency Preparedness Survey in accordance with 42 CFR 483.73.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies included issues with exterior exit doors not opening easily, hazardous area doors lacking self-closing devices, missing drip trays in the kitchen range hood system, incomplete fire alarm and sprinkler system out-of-service policies, corridor doors not latching properly, and smoke barrier doors not closing and latching completely.
Deficiencies (7)
3 of over 5 exterior exit doors required excessive force to open, affecting all occupants.
2 of over 10 hazardous area doors were not equipped with properly working self-closing devices, affecting more than 5 staff and visitors.
Kitchen range hood system missing 3 of 4 required drip trays, affecting up to 6 staff.
Fire alarm system out of service policy incomplete, lacking specific contact procedures for the Indiana State Department of Health.
Sprinkler system out of service policy incomplete, lacking specific contact procedures for the Indiana State Department of Health.
4 of over 30 corridor doors failed to latch positively into door frames, affecting 6 staff and 6 residents.
1 of 5 sets of smoke barrier doors did not close completely and latch, affecting 17 residents and staff.
Report Facts
Facility capacity: 85
Census: 46
Exterior exit doors deficient: 3
Hazardous area doors deficient: 2
Missing drip trays: 3
Corridor doors deficient: 4
Smoke barrier doors deficient: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bryce Tomasi | Administrator | Named as Administrator involved in the survey and corrective actions. |
| Maintenance Supervisor | Mentioned multiple times as involved in observations, interviews, and corrective actions; no full name provided. |
Inspection Report
Annual Inspection
Census: 40
Capacity: 40
Deficiencies: 4
Date: Jun 7, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including investigation of two complaints (IN00432578 and IN00431396).
Complaint Details
Complaint IN00432578 was substantiated with federal/state deficiencies cited at F0689 related to fall supervision. Complaint IN00431396 was not substantiated with no deficiencies cited.
Findings
The facility was found deficient in ensuring adequate supervision to prevent falls for a cognitively impaired resident, failure to post complete nurse staffing information, failure to remove expired insulin from medication carts, and failure to submit the Alzheimer's/Dementia Special Care Unit form by the due date.
Deficiencies (4)
Failed to ensure adequate supervision to prevent falls for a cognitively impaired resident.
Failed to post complete daily nurse staffing information including hours worked and resident census.
Failed to remove and destroy expired insulin from medication cart affecting one resident.
Failed to ensure the Alzheimer's/Dementia Special Care Unit form was completed and submitted by the due date.
Report Facts
Residents reviewed for accidents: 3
Resident census: 40
Total licensed capacity: 40
Expired insulin doses administered: 6
Residents on memory care unit: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bryce Tomasi | Administrator | Signed the inspection report. |
| DON/Designee | Reviewed and updated fall care plans, educated nurses on fall interventions, and monitored insulin expiration. | |
| CNA 9 | Certified Nursing Assistant | Interviewed regarding resident care and fall awareness. |
| LPN 7 | Licensed Practical Nurse | Interviewed regarding resident care and fall incidents. |
| ADON | Assistant Director of Nursing | Interviewed regarding medication expiration and policy. |
| Business Office Manager | Interviewed regarding nurse staffing posting and resident observation. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 7, 2024
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey, along with an Investigation of Complaint IN00432578.
Complaint Details
Investigation of Complaint IN00432578 was completed and found the facility in compliance.
Findings
The Waters of Huntington 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 recertification, state licensure survey, and complaint investigation.
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 0
Date: May 20, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00432970.
Complaint Details
Complaint IN00432970 was investigated and found to have no related deficiencies.
Findings
No deficiencies related to the allegations in Complaint IN00432970 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF: 43
Census Payor Type Medicare: 2
Census Payor Type Medicaid: 32
Census Payor Type Other: 9
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 9, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00427231 completed on March 11, 2024.
Complaint Details
Complaint IN00427231 was investigated and the facility was found to be in compliance.
Findings
The Waters of Huntington 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.
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 1
Date: Mar 11, 2024
Visit Reason
This visit was conducted for the investigation of Complaints IN00427231 and IN00429774. Complaint IN00427231 resulted in federal/state deficiencies cited, while Complaint IN00429774 had no deficiencies related to the allegations.
Complaint Details
Complaint IN00427231 was substantiated with federal/state deficiencies cited at F559 related to the allegations. Complaint IN00429774 had no deficiencies related to the allegations.
Findings
The facility failed to involve Resident B prior to a room change, causing the resident to worry about her personal property and experience confusion. The clinical record lacked prior notification to the resident and her representative in writing regarding the room change. Interviews and record reviews confirmed the resident's distress and lack of involvement in the decision.
Deficiencies (1)
Failure to involve the resident prior to a room change, resulting in resident distress and lack of notification to resident and representative.
Report Facts
Census: 49
Survey dates: March 8 and 11, 2024
Deficiency cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bryce Tomasi | Administrator | Signed the report and involved in the plan of correction |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 46
Deficiencies: 0
Date: Dec 28, 2023
Visit Reason
This visit was conducted for the investigation of four complaints: IN00418942, IN00421383, IN00422168, and IN00423467.
Complaint Details
Complaints IN00418942, IN00421383, IN00422168, and IN00423467 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the four complaints were cited. The facility was found to be in compliance with applicable federal and state regulations regarding the investigation of these complaints.
Report Facts
Census: 46
Total Capacity: 46
Medicare Census: 2
Medicaid Census: 35
Other Payor Census: 9
Inspection Report
Re-Inspection
Census: 44
Capacity: 85
Deficiencies: 0
Date: Sep 19, 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 08/03/23.
Findings
At this Post Survey Revisit, The Waters of Huntington 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: 43
Deficiencies: 0
Date: Sep 11, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00416211.
Complaint Details
Complaint IN00416211 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type: 43
Medicare residents: 6
Medicaid residents: 30
Other residents: 7
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 15, 2023
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
The Waters of Huntington 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 for the Recertification and State Licensure survey.
Inspection Report
Routine
Census: 45
Capacity: 85
Deficiencies: 10
Date: Aug 3, 2023
Visit Reason
An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 to assess compliance with emergency preparedness requirements for Medicare and Medicaid participating providers and suppliers.
Findings
The facility was found not in compliance with emergency preparedness requirements, including failure to conduct required emergency plan exercises twice per year. Additional findings included obstructions in corridor egress, incomplete maintenance of battery-operated smoke alarms, incomplete fire alarm system testing, missing sprinkler system quarterly inspection documentation, failure to conduct fire drills on each shift quarterly, incomplete inspection of fire door assemblies, failure to maintain emergency power standby system testing, improper use of power cords, and incomplete inspection of portable fire extinguishers.
Deficiencies (10)
Failed to conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using emergency procedures.
Failed to ensure corridor means of egress were continuously maintained free of obstructions; PPE carts lacked wheels.
Failed to ensure documentation for preventative maintenance of battery-operated smoke alarms in resident rooms was complete.
Failed to ensure all smoke detectors for fire alarm system were inspected, tested, and maintained; one smoke detector was not tested.
Failed to provide written documentation or evidence that sprinkler system components had been inspected and tested for one quarter.
Failed to inspect 2 of 2 portable fire extinguishers in the laundry each month; missing documentation for July 2023.
Failed to conduct fire drills on each shift for one of four quarters; failed to verify transmission of fire alarm signal during some third shift drills.
Failed to ensure annual inspection and testing of fire door assemblies were completed as required.
Failed to maintain emergency power standby system testing including a required four-hour run test within the last 36 months and annual fuel quality test.
Failed to ensure power cord daisy chains were not used as a substitute for fixed wiring and flexible cords were installed properly and used safely.
Report Facts
Facility capacity: 85
Census: 45
Deficiency count: 10
Fire drills missing transmission verification: 3
Fire drills missing documentation: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bryce Tomasi | Administrator | Named as Administrator who reviewed findings and plans of correction |
| Maintenance Director | Interviewed regarding deficiencies and maintenance issues | |
| Maintenance Supervisor | Responsible for corrective actions and inspections |
Inspection Report
Renewal
Census: 41
Capacity: 41
Deficiencies: 4
Date: Jul 14, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from July 10 to July 14, 2023.
Findings
The facility was found deficient in several areas including failure to provide resident information during emergency hospital transfers, failure to complete significant change Minimum Data Set (MDS) assessments after hospice initiation, failure to assure collaborative communication with hospice providers, and failure to implement Enhanced Barrier Precautions for residents requiring transmission-based precautions.
Deficiencies (4)
Failed to provide resident information to assure continuity of care for a resident's emergency transfer to an acute care hospital.
Failed to ensure a significant change Minimum Data Set (MDS) assessment was completed when hospice services were initiated.
Failed to assure collaborative communication with the hospice provider for residents receiving hospice services.
Failed to implement Enhanced Barrier Precautions for a resident reviewed for Transmission Based Precautions.
Report Facts
Survey dates: 5
Census: 41
Total capacity: 41
Residents reviewed for hospitalization: 5
Residents reviewed for hospice services: 4
Residents reviewed for transmission based precautions: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anna Foster | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| RN 2 | Interviewed regarding emergency transfer procedures and missing documentation for Resident 6 | |
| Director of Nursing | DON | Interviewed regarding emergency transfer documentation and hospice communication |
| MDS Nurse | Interviewed regarding missed significant change MDS assessment for hospice initiation | |
| LPN 4 | Interviewed regarding lack of hospice documentation for Resident 15 | |
| Corporate Nurse Consultant | Provided facility policies and interviewed regarding hospice communication and documentation | |
| LPN 3 | Interviewed regarding PPE use and Enhanced Barrier Precautions for Resident 19 |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 0
Date: Apr 18, 2023
Visit Reason
This visit was for the investigation of complaints IN00404781 and IN00402503 and included a COVID-19 Focused Infection Control Survey.
Complaint Details
Complaint IN00404781 and Complaint IN00402503 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00404781 and IN00402503 were cited. The facility was found to be in compliance with relevant regulations including 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census Bed Type: 41
Census Payor Type - Medicare: 9
Census Payor Type - Medicaid: 28
Census Payor Type - Other: 4
Inspection Report
Re-Inspection
Census: 48
Capacity: 85
Deficiencies: 0
Date: Aug 22, 2022
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 06/21/22 was performed to verify compliance with previous deficiencies.
Findings
At this PSR survey, Miller's Merry Manor 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. The facility was fully sprinklered with appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 85
Resident census: 48
Inspection Report
Complaint Investigation
Census: 47
Capacity: 47
Deficiencies: 0
Date: Aug 4, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00386712.
Complaint Details
Complaint IN00386712 was substantiated; however, no deficiencies related to the allegations were cited.
Findings
The complaint was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF: 47
Medicare residents: 6
Medicaid residents: 34
Other payor residents: 7
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