Inspection Reports for University Park Rehabilitation and Healthcare
1400 MEDICAL PARK DR, FORT WAYNE, IN, 46825
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 28, 2025, found University Park Rehabilitation and Healthcare to be in compliance with applicable regulations and without deficiencies. However, prior inspections showed a pattern of deficiencies primarily related to life safety code compliance, resident care including behavioral health and medication management, and environmental cleanliness. Several complaint investigations were substantiated over time, involving issues such as failure to notify physicians of changes in condition, inadequate supervision, and incomplete care plans, but enforcement actions such as fines or license suspensions were not listed in the available reports. Most complaints without deficiencies were clearly noted as unsubstantiated. The facility appears to have made improvements recently, as the latest inspections and complaint follow-ups show compliance after earlier citations.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
23.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
467% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
100% occupied
Based on a May 2025 inspection.
Census over time
Inspection Report
Re-Inspection
Census: 67
Capacity: 67
Deficiencies: 0
Date: May 28, 2025
Visit Reason
This visit was for a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on April 11, 2025.
Findings
University Park Rehabilitation and Healthcare 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: 7
Census Payor Type - Medicaid: 58
Census Payor Type - Other: 2
Inspection Report
Complaint Investigation
Census: 63
Capacity: 63
Deficiencies: 0
Date: May 20, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00459834.
Complaint Details
Complaint IN00459834 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00459834 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 63
Total Capacity: 63
Medicare Residents: 5
Medicaid Residents: 55
Other Payor Residents: 3
Inspection Report
Life Safety
Census: 62
Capacity: 104
Deficiencies: 9
Date: May 15, 2025
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) to assess compliance with fire safety and life safety code requirements.
Findings
The facility was found not in compliance with several life safety code requirements including failure to clean battery-operated smoke alarms monthly, missing grease drip trays in the kitchen, lack of semi-annual visual inspections of the fire alarm system, missing ground fault circuit interrupter (GFCI) protection on a receptacle near a water source, incomplete emergency fire safety plan, improper disposal of cigarette butts in smoking areas, failure to inspect oxygen room fire doors annually, use of extension cords daisy chained with power strips, and improper storage and marking of oxygen cylinders.
Deficiencies (9)
Failed to ensure cleaning of 60 of 60 battery operated smoke alarms in resident rooms according to manufacturer's instructions.
Failed to provide grease drip trays for 1 of 1 kitchens as required by NFPA 96.
Failed to maintain 1 of 1 fire alarm systems with required semi-annual visual inspections.
Failed to ensure 1 of 1 receptacles within 6 feet from a water source had ground fault circuit interrupter (GFCI) protection.
Failed to provide 1 of 1 written emergency fire safety plan that incorporated all required items including use and types of fire extinguishers.
Failed to ensure 1 of 2 smoking areas were maintained with proper metal or noncombustible containers with self-closing covers for cigarette butts.
Failed to ensure annual inspection and testing of 1 of 1 oxygen room fire doors was completed and documented.
Failed to ensure 2 of 2 flexible cords were not used as a substitute for fixed wiring and daisy chained together.
Failed to ensure 20 of 20 full and empty oxygen cylinders were separated and marked to avoid confusion.
Report Facts
Battery operated smoke alarms: 60
Facility capacity: 104
Census: 62
Residents affected: 30
Oxygen cylinders: 20
Residents affected: 25
Residents affected: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brent Swan | Executive Director | Signed report as facility representative |
| Maintenance Director | Interviewed and involved in findings related to smoke alarms, fire alarm system, grease drip trays, GFCI receptacle, fire door inspection, extension cords, oxygen cylinder storage, and smoking area | |
| Administrator | Interviewed and involved in findings related to smoke alarms, fire alarm system, grease drip trays, GFCI receptacle, fire safety plan, smoking area, fire door inspection, extension cords, oxygen cylinder storage | |
| Assistant Director of Nursing | Installed new signage for oxygen cylinder storage and coordinated oxygen company notification | |
| Director of Food Services | Responsible for verifying grease drip tray placement during dietary sanitation audits | |
| Environmental Services Director | Responsible for monitoring and emptying smoking receptacles | |
| Human Resources Director | Tracks and monitors staff education on fire safety plan compliance |
Inspection Report
Annual Inspection
Census: 67
Capacity: 67
Deficiencies: 11
Date: Apr 11, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00456775.
Complaint Details
Complaint IN00456775 was investigated during this visit. Deficiencies related to the allegations were cited at F727, F809, and F921.
Findings
The facility was found deficient in multiple areas including failure to obtain accurate resident weights, ensuring RN coverage for 8 consecutive hours daily, resident-specific behavioral interventions, proper medication storage and labeling, notification of significant lab results, availability of bedtime snacks, food safety and sanitation, garbage disposal, infection control practices, and maintaining a clean environment.
Deficiencies (11)
Failed to ensure accurate weights were obtained for 2 of 16 residents reviewed (Resident 48 and Resident 5).
Failed to ensure a registered nurse was on duty for 8 consecutive hours every day.
Failed to ensure behavioral interventions were resident specific for 1 of 2 residents reviewed (Resident 37).
Failed to ensure medications are stored and labeled properly in 2 of 4 storage areas.
Failed to ensure notification of significant abnormal lab results for 1 of 2 reviewed (Resident 12).
Failed to ensure snacks were available at night for 3 of 24 residents reviewed (Resident B, Resident C, Resident D).
Failed to ensure open items in kitchen and unit refrigerators were labeled, dated, discarded when appropriate, and hair was covered for all employees present in the kitchen.
Failed to ensure garbage and refuse were contained inside the dumpster.
Failed to ensure a process was in place to correct deficiencies and keep them from re-occurring related to labeling/dating food items and waste management.
Failed to maintain procedures to help prevent development and transmission of communicable diseases and infections.
Failed to ensure a clean and sanitary environment was maintained; vents were covered with excessive dust and debris.
Report Facts
Census: 67
Total Capacity: 67
Deficiencies cited: 11
Survey dates: 5
Blood glucose readings: 527
Blood glucose readings: 560
Weight measurements: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brent Swan | Executive Director | Signed report and mentioned in administrative context |
| RN 4 | Registered Nurse | Named in deficiency for not covering 8 consecutive hours |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding RN coverage, weight accuracy, and infection control |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding RN coverage and infection control |
| Dietary Manager | Dietary Manager (DM) | Interviewed regarding food safety and garbage disposal |
| Licensed Practical Nurse 2 | LPN | Observed and interviewed regarding infection control and medication handling |
| Social Service Director | Social Service Director (SSD) | Interviewed regarding behavioral interventions |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 0
Date: Jan 15, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00449860.
Complaint Details
Complaint IN00449860 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00449860 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type - SNF/NF: 56
Census Bed Type - NCC: 6
Census Total: 62
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 54
Census Payor Type - Other: 6
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 3, 2025
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00449065 completed on December 16, 2024.
Complaint Details
Complaint IN00449065 was corrected and found to be in compliance upon review.
Findings
University Park Rehabilitation and Healthcare 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
Census: 64
Deficiencies: 1
Date: Dec 16, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00448987 and IN00449065. Complaint IN00448987 had no deficiencies cited, while complaint IN00449065 resulted in federal/state deficiencies related to failure to notify the physician of a change in condition following a fall.
Complaint Details
Complaint IN00449065 was substantiated with federal/state deficiencies cited. Complaint IN00448987 had no deficiencies related to the allegation.
Findings
The facility failed to ensure the physician was notified of an acute change in condition for one resident following a fall. The resident experienced an acute change in mental status and unclear speech, but notification to the physician or Nurse Practitioner was not documented until several days later. The facility lacked a policy for notification of changes in resident condition to the physician.
Deficiencies (1)
Failed to ensure the physician was notified of a change in condition following a fall for 1 of 3 residents reviewed (Resident R).
Report Facts
Census: 64
SNF/NF beds: 61
SNF beds: 3
Medicare residents: 3
Medicaid residents: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brent Swan | Executive Director | Signed as Laboratory Director's or Provider/Supplier Representative |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 68
Deficiencies: 2
Date: Nov 25, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00446547 and IN00447233 related to federal/state deficiencies concerning resident care and assessment accuracy.
Complaint Details
Complaint IN00446547 involved failure to monitor and assess a resident with substance use disorder and multiple falls, substantiated by findings of inadequate care and lack of appropriate policies. Complaint IN00447233 involved inaccurate MDS assessments for a resident's skin condition.
Findings
The facility failed to ensure accurate quarterly Minimum Data Set (MDS) assessments for one resident and failed to properly monitor and assess a resident with a history of substance use disorder and multiple falls, resulting in inadequate care and oversight.
Deficiencies (2)
Failure to ensure a quarterly Minimum Data Set (MDS) assessment was coded accurately for 1 of 3 residents reviewed.
Failure to ensure monitoring and assessments were completed for a resident with a history of substance use disorder and multiple falls.
Report Facts
Census: 68
Total Capacity: 68
Number of falls: 9
Audit frequency: 10
Audit duration: 6
Resident drug screen audits: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brent Swan | Executive Director | Signed report and involved in administrative oversight |
| Social Services Director | Responsible for meeting with residents with substance abuse history and auditing care plans | |
| Regional Nurse Consultant | Indicated MDS assessments should be completed according to Resident Assessment Instrument (RAI) guidelines | |
| Medical Nurse Practitioner | NP | Provided medical care and medication adjustments for Resident C |
| Psychiatric Nurse Practitioner | NP | Provided psychiatric assessment and medication management for Resident C |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 25, 2024
Visit Reason
Paper compliance review of the Investigation of Complaints IN00446547 and IN00447233 completed on November 25, 2024.
Complaint Details
Complaints IN00446547 and IN00447233 were investigated and corrected.
Findings
The 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 of the two complaints. Both complaints were corrected.
Inspection Report
Complaint Investigation
Census: 61
Capacity: 61
Deficiencies: 0
Date: Oct 31, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00444119.
Complaint Details
Complaint IN00444119 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations of Complaint IN00444119 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare residents: 5
Medicaid residents: 54
Other residents: 2
Inspection Report
Re-Inspection
Census: 67
Capacity: 104
Deficiencies: 0
Date: Aug 23, 2024
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 07/18/24.
Findings
At this PSR survey, University Park Rehabilitation and Healthcare was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements. The facility was fully sprinklered except for a garage used for facility services which was not sprinklered.
Inspection Report
Complaint Investigation
Census: 66
Capacity: 66
Deficiencies: 0
Date: Aug 6, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00439405.
Complaint Details
Complaint IN00439405 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00439405 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 5
Medicaid census: 55
Other census: 6
Inspection Report
Life Safety
Census: 64
Capacity: 104
Deficiencies: 2
Date: Jul 18, 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 in accordance with federal regulations.
Findings
The facility was found in substantial compliance with Emergency Preparedness Requirements but had deficiencies related to the emergency preparedness communication plan lacking alternate communication means and smoke barrier walls not constructed to required fire resistance standards. Corrective actions were taken including updating the communication plan and replacing non-compliant fire barrier sealant.
Deficiencies (2)
Emergency preparedness communication plan did not include alternate means for communicating with facility staff and emergency management agencies.
Two of five smoke barrier walls were not constructed to fire resistance requirements; foam used was not verified to meet firestop standards.
Report Facts
Facility capacity: 104
Resident census: 64
Residents potentially affected: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brent Swan | Executive Director | Signed the report |
| Maintenance Director | Interviewed regarding emergency preparedness plan and smoke barrier deficiencies; verified corrective actions | |
| Administrator | Interviewed regarding emergency preparedness plan and smoke barrier deficiencies |
Inspection Report
Re-Inspection
Census: 59
Deficiencies: 0
Date: Jul 16, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Annual Recertification and State Licensure Survey completed on June 6, 2024, conducted in conjunction with the PSR to Complaint IN00436372.
Findings
University Park Rehabilitation and Healthcare was found to be in compliance with 410 IAC 16.2-3.1 related to the PSR to the Annual Recertification and State Licensure Survey.
Report Facts
Census SNF: 2
Census NF: 57
Total Census: 59
Census Medicare: 2
Census Medicaid: 55
Census Other: 2
Inspection Report
Re-Inspection
Census: 59
Deficiencies: 0
Date: Jul 15, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to Complaint IN00436372, conducted in conjunction with the PSR to the Annual Recertification and State Licensure Survey completed on June 6, 2024.
Complaint Details
Complaint IN00436372 was corrected.
Findings
University Park Rehabilitation and Healthcare was found to be in compliance with 410 IAC 16.2-3.1 related to the PSR to the Annual Recertification and State Licensure Survey. Complaint IN00436372 was corrected.
Report Facts
Census Bed Type - SNF: 2
Census Bed Type - NF: 57
Census Total: 59
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 55
Census Payor Type - Other: 2
Inspection Report
Complaint Investigation
Census: 61
Capacity: 61
Deficiencies: 1
Date: Jun 25, 2024
Visit Reason
This visit was for the investigation of Complaint IN00436372 regarding federal/state deficiencies related to allegations of inappropriate staff behavior and failure to ensure effective behavioral health care.
Complaint Details
Complaint IN00436372 was investigated. The allegation of inappropriate touching by a staff member was unsubstantiated. Resident K's behaviors were attributed to a urinary tract infection (UTI).
Findings
The facility failed to ensure an effective behavior care plan, behavioral assessments, behavior monitoring, and documentation for 1 of 3 residents reviewed for behavioral health (Resident K). The resident had multiple mental health diagnoses and a history of UTIs affecting behavior, but the care plan and documentation did not reflect these changes. The allegation of inappropriate touching was unsubstantiated and behaviors were attributed to a UTI. The facility policy on behavioral assessment and monitoring was reviewed and found to require improvements in documentation and monitoring.
Deficiencies (1)
Failure to ensure an effective behavior care plan, behavioral assessments, behavior monitoring, and documentation for Resident K.
Report Facts
Census: 61
Total Capacity: 61
Psychotropic medication dosages: 60
Psychotropic medication dosages: 60
Psychotropic medication dosages: 6
PHQ-9 score: 17
Survey date: Jun 25, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brent Swan | Executive Director | Signed the report |
| Director of Nursing | Interviewed regarding behavior documentation | |
| Licensed Practical Nurse 2 | Interviewed regarding behavior charting | |
| Social Services Director | Responsible for auditing behavior tracking and staff education | |
| Social Services Designee | Interviewed regarding complaint and behavior attribution | |
| Administrator | Interviewed regarding complaint and facility policy |
Inspection Report
Annual Inspection
Census: 59
Capacity: 59
Deficiencies: 9
Date: Jun 6, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of four complaints.
Complaint Details
This visit included the investigation of Complaint IN00435281, Complaint IN00434632, Complaint IN00434654, and Complaint IN00434516. No deficiencies related to the allegations were cited for any of the complaints.
Findings
The facility was found deficient in multiple areas including resident care related to mobility and fall prevention, respiratory equipment maintenance, medication security, kitchen sanitation, garbage containment, environmental cleanliness, and trauma-informed care. Corrective actions and monitoring plans were developed for each deficiency.
Deficiencies (9)
Failed to ensure services and assistance was provided to maintain correct posture for 1 of 1 resident reviewed (Resident 4).
Failed to ensure adequate supervision for prevention of falls for 1 of 1 resident reviewed (Resident 4).
Failed to ensure residents respiratory equipment was maintained to prevent contamination for 1 of 2 residents reviewed (Resident 38).
Failed to ensure triggers were identified, communicated, and interventions in place to avoid or alleviate re-traumatization for 2 of 2 residents reviewed (Resident 2 and Resident 22).
Failed to ensure medications were secured for 2 of 19 residents reviewed (Resident 21 and Resident 35).
Failed to ensure the kitchen was maintained in a sanitary manner to promote food safety.
Failed to ensure garbage and refuse were contained inside the dumpster for 1 of 2 observations.
Failed to ensure a clean environment was maintained in 4 of 5 rooms reviewed affecting 4 residents (Resident 35, Resident 14, Resident 21, Resident 5, and Resident 32).
Failed to ensure a process was in place to identify and correct deficiencies from re-occurring.
Report Facts
Census Bed Type - NF: 56
Census Bed Type - SNF/NF: 3
Total Census: 59
Fall Risk Score: 17
Fall Risk Score: 7
Medication Dosage: 500
Audit Frequency: 3
Audit Frequency: 6
Audit Frequency: 2
Completion Date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brent Swan | Laboratory Director or Provider/Supplier Representative | Signed the inspection report |
| PTA 6 | Physical Therapy Assistant | Provided detailed information about Resident 4's therapy and posture issues |
| Chief Nursing Officer | Provided multiple interviews regarding Resident 4 and Resident 22 care and facility policies | |
| Cook 4 | Provided information about kitchen sanitation and food storage | |
| Dietary Manager | Observed handwashing and kitchen practices | |
| Executive Director | Provided information about QAPI and facility management |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 104
Deficiencies: 0
Date: May 14, 2024
Visit Reason
Investigation of Complaint Number IN00434430 related to a fire at University Park Rehabilitation and Healthcare.
Complaint Details
Complaint Number IN00434430 was substantiated. No deficiencies related to the allegation were cited.
Findings
The complaint was substantiated but no deficiencies related to the allegation were cited. The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire regulations, and the 2012 NFPA 101 Life Safety Code.
Report Facts
Facility capacity: 104
Census: 62
Inspection Report
Complaint Investigation
Census: 69
Capacity: 69
Deficiencies: 1
Date: Mar 26, 2024
Visit Reason
This visit was for the investigation of Complaint IN00430365 regarding federal and state deficiencies related to menu adherence and nutritional adequacy.
Complaint Details
Complaint IN00430365 was substantiated with federal/state deficiencies cited at F803 related to menu adherence and notification of menu changes.
Findings
The facility failed to ensure menus were followed for 5 of 5 residents reviewed, with multiple residents reporting that meals served did not match the posted menu and that they were not informed of menu changes. Observations confirmed discrepancies between meal tickets and actual meals served.
Deficiencies (1)
Menus must meet the nutritional needs of residents and be followed or substitutions provided with notification; facility failed to follow menus for 5 of 5 residents reviewed.
Report Facts
Census SNF/NF: 69
Medicare residents: 6
Medicaid residents: 60
Other residents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Faith Mills | RN-HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 26, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00430365.
Complaint Details
Complaint IN00430365 was investigated and found to be in compliance.
Findings
University Park Rehabilitation and Healthcare 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
Follow-Up
Census: 69
Capacity: 69
Deficiencies: 0
Date: Feb 29, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00427156 completed on February 14, 2024, conducted in conjunction with the Investigation of Complaint IN00428977.
Complaint Details
Complaint IN00427156 was investigated and found to be corrected.
Findings
University Park Rehabilitation and Healthcare 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 Investigation of Complaint IN00427156. Complaint IN00427156 was corrected.
Report Facts
Census SNF/NF: 69
Total Capacity: 69
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 61
Census Payor Type - Other: 1
Inspection Report
Complaint Investigation
Census: 69
Capacity: 69
Deficiencies: 0
Date: Feb 29, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00428977 and was conducted in conjunction with a Post Survey Revisit to the Investigation of Complaint IN00427156 completed on February 14, 2024.
Complaint Details
Complaint IN00428977 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00428977 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.
Report Facts
Census SNF/NF: 69
Total Capacity: 69
Census Payor Type Medicare: 7
Census Payor Type Medicaid: 61
Census Payor Type Other: 1
Inspection Report
Complaint Investigation
Census: 73
Capacity: 73
Deficiencies: 1
Date: Feb 12, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00426575 and IN00427156, resulting in a Partially Extended Survey due to Substandard Quality of Care with Immediate Jeopardy related to complaint IN00427156.
Complaint Details
Complaint IN00426575 had no deficiencies related to the allegations. Complaint IN00427156 resulted in federal/state deficiencies cited at F689 related to unsupervised smoking and hazardous smoking materials accessibility for Resident B.
Findings
The facility failed to ensure adequate supervision to prevent unsupervised smoking and failed to secure hazardous smoking materials for a resident requiring supervised smoking, resulting in Immediate Jeopardy beginning 1/30/24 and removed on 2/14/24 after corrective actions including staff education and policy revision.
Deficiencies (1)
Failure to ensure adequate supervision to prevent unsupervised smoking and failure to secure hazardous smoking materials for Resident B who required supervised smoking.
Report Facts
Census: 73
Total Capacity: 73
Medicare Census: 8
Medicaid Census: 65
Survey Dates: 3
Inspection Report
Complaint Investigation
Census: 74
Capacity: 74
Deficiencies: 0
Date: Jan 18, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00423689.
Complaint Details
Complaint IN00423689 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
Medicare census: 7
Medicaid census: 63
Other payor census: 4
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 6, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00422638.
Complaint Details
The visit was complaint-related for Complaint IN00422638, and the facility was found to be in compliance.
Findings
University Park Rehabilitation and Healthcare 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: 69
Capacity: 69
Deficiencies: 2
Date: Dec 5, 2023
Visit Reason
This visit was conducted for the investigation of Complaints IN00421973 and IN00422638.
Complaint Details
Complaint IN00421973 was not substantiated with deficiencies. Complaint IN00422638 was substantiated with deficiencies cited at F684 and F761.
Findings
Complaint IN00421973 had no deficiencies related to the allegations. Complaint IN00422638 resulted in federal/state deficiencies cited at F684 for failure to follow physician orders regarding weekly weights for one resident, and F761 for failure to ensure medication and treatment carts were secured/locked during observations.
Deficiencies (2)
Failure to follow physician orders for weekly weights for 1 of 3 residents reviewed (Resident G).
Failure to ensure medication and treatment carts were secured/locked for 2 of 3 observations.
Report Facts
Census: 69
Total Capacity: 69
Residents on 100 hall: 17
Residents on 200 hall: 28
Residents on 300 hall: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Faith Mills | RN-HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Qualified Medication Aide 2 | Qualified Medication Aide | Interviewed regarding documentation of refusals and medication cart locking |
| Licensed Practical Nurse 3 | Licensed Practical Nurse | Interviewed regarding medication and treatment cart locking |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 2, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00417648 completed on October 12, 2023.
Complaint Details
Complaint IN00417648 was investigated and found to be in compliance as of the review date November 2, 2023.
Findings
University Park Rehabilitation and Healthcare 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: 65
Capacity: 65
Deficiencies: 1
Date: Oct 12, 2023
Visit Reason
This visit was conducted for the investigation of two complaints, IN00417648 and IN00419499. Deficiencies related to complaint IN00417648 were cited, while no deficiencies were found related to complaint IN00419499.
Complaint Details
Complaint IN00417648 was substantiated with federal/state deficiencies cited at F689. Complaint IN00419499 was not substantiated with no deficiencies found.
Findings
The facility failed to ensure elopement prevention interventions were in place for one of three residents reviewed. Specifically, the facility entrance door code was accessible to a resident who used it to exit the building without staff supervision, posing a safety risk. The facility has since changed the door code, educated staff on code security, and implemented monitoring and assessment procedures to prevent recurrence.
Deficiencies (1)
Failure to ensure elopement prevention interventions were in place for one resident, allowing unauthorized access to the facility via the entrance door code.
Report Facts
Census: 65
Total Capacity: 65
Medicare Residents: 4
Medicaid Residents: 60
Other Payor Residents: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Faith Mills | RN-DON | Named as Laboratory Director or Provider/Supplier Representative signing the report |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 67
Deficiencies: 0
Date: Sep 14, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00416870.
Complaint Details
Complaint IN00416870 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00416870 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 67
Total Capacity: 67
Medicare Census: 3
Medicaid Census: 52
Other Payor Census: 12
Inspection Report
Re-Inspection
Census: 60
Capacity: 104
Deficiencies: 0
Date: Sep 6, 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 07/06/23.
Findings
At this PSR survey, University Park Rehabilitation and Healthcare was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility was fully sprinklered except for a garage used for facility services which was not sprinklered.
Report Facts
Facility capacity: 104
Census: 60
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 10, 2023
Visit Reason
The visit was a paper compliance review related to the Investigation of Complaint IN00408505 completed on March 25, 2023.
Complaint Details
Investigation of Complaint IN00408505 completed on March 25, 2023; facility found in compliance.
Findings
University Park Rehabilitation and Health Care 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
Annual Inspection
Deficiencies: 0
Date: Jul 10, 2023
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey, as well as the investigation of Complaint IN00409749 completed on June 16, 2023.
Complaint Details
Investigation of Complaint IN00409749 was completed and found to be in compliance.
Findings
University Park Rehabilitation and Health Care 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
Life Safety
Census: 64
Capacity: 104
Deficiencies: 11
Date: Jul 6, 2023
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was 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 emergency power system testing, smoke barrier penetrations, hazardous area protections, fire alarm system issues, sprinkler system policies, electrical outlet safety, and oxygen cylinder storage and signage.
Deficiencies (11)
The generator lacked monthly load testing required by LSC and NFPA 110.
Documentation for preventative maintenance of 55 battery operated smoke alarms in resident rooms was incomplete.
Room 103 with large combustible storage was not protected as a hazardous area due to non-self-closing corridor door.
Fire alarm control panel time and date were incorrect.
Facility failed to provide a complete written policy for fire alarm system out of service procedures.
Facility failed to provide correct written policies for sprinkler system out of service procedures.
Penetrations through smoke barrier walls were not sealed to maintain smoke resistance.
Electrical outlet by 200-hall mop sink lacked a faceplate.
Facility failed to maintain complete written record of monthly generator load testing for 2 of last 12 months.
Oxygen cylinders were not separated or marked as full or empty; O2 storage room door lacked required caution signage.
Oxygen transfilling room door lacked signage indicating transfilling in progress.
Report Facts
Facility capacity: 104
Census: 64
Battery operated smoke alarms: 55
Combustible storage room size: 50
Unsealed smoke barrier penetrations: 3
Oxygen cylinders: 18
Missing generator load test months: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Goran Prentoski | Administrator | Named in relation to review and exit conference of findings |
Inspection Report
Annual Inspection
Census: 62
Capacity: 62
Deficiencies: 3
Date: Jun 16, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the investigation of Complaint IN00409749.
Complaint Details
Complaint IN00409749 was investigated and a deficiency related to the allegations was cited at F0694 regarding the port dressing change.
Findings
The facility was found deficient in ensuring a resident's port dressing was changed per physician orders, failure to post daily nurse staffing information, and failure to maintain cleanliness and proper food safety in the kitchen and dumpsters.
Deficiencies (3)
Failed to ensure a resident's port dressing was changed per physician orders for 1 of 2 residents reviewed (Resident 165).
Failed to ensure the daily report of nursing staff directly responsible for resident care was posted daily, potentially affecting all 62 residents.
Failed to maintain cleanliness of the kitchen and dumpsters, including uncovered trash cans, outdated food items, and improper storage of food items.
Report Facts
Residents present: 62
Medicare residents: 3
Medicaid residents: 55
Other residents: 4
Dates dressing changed: 3
Survey dates: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Grabbe | RN Regional Nurse Consultant | Signed the report |
| Goran Prentoski | Executive Director | Named in Plan of Correction submission |
| Brenda Buroker | Director of Division Long Term Care | Recipient of survey letter |
Inspection Report
Follow-Up
Census: 70
Capacity: 104
Deficiencies: 0
Date: Jun 14, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to investigate Complaint Number IN00407356 from 04/28/2023.
Complaint Details
Complaint IN00407356 was corrected as of the survey date.
Findings
At this PSR survey, University Park Rehabilitation and Healthcare 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.
Report Facts
Facility capacity: 104
Census: 70
Inspection Report
Complaint Investigation
Census: 63
Capacity: 63
Deficiencies: 3
Date: May 24, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00408505 regarding federal and state deficiencies related to allegations cited at F689, F740, and F921.
Complaint Details
Complaint IN00408505 was investigated by the Indiana State Department of Health on May 24 and 25, 2023. The complaint involved allegations related to accident hazards, behavioral health services, and environmental conditions. Deficiencies were substantiated as cited at F689, F740, and F921.
Findings
The facility was found deficient in maintaining a safe environment to prevent accidents for residents, failed to develop and implement a comprehensive behavioral health care plan for substance use disorder, and failed to maintain a clean, functional, and sanitary environment affecting multiple residents.
Deficiencies (3)
Failed to initiate practices to prevent avoidable accidents due to environmental issues for 2 of 3 residents reviewed (loose sink causing fall, unsecured closet door falling on resident).
Failed to develop and implement a comprehensive behavioral care plan for substance use disorder for 1 of 1 residents reviewed.
Failed to maintain a clean and functional environment for 19 rooms affecting 36 residents, including issues such as brown debris on floors, broken closet doors, missing blinds, strong ammonia odors, soiled briefs on floors, and cluttered rooms.
Report Facts
Census: 63
Total Capacity: 63
Residents affected by environmental deficiencies: 36
Rooms affected by environmental deficiencies: 19
Medicare census: 4
Medicaid census: 55
Other payor census: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Goran Prentoski | Administrator | Named in relation to plan of correction and interview regarding environmental and safety deficiencies |
| Pamela Grabbe | RN Regional Nurse Consultant | Signed the report as Laboratory Director's or Provider/Supplier Representative |
| Brenda Buroker | Director of Division Long Term Care | Recipient of complaint letter and plan of correction |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 104
Deficiencies: 3
Date: Apr 28, 2023
Visit Reason
An investigation of Complaint Number IN00407356 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a). The survey was complaint-related to assess compliance with Medicare/Medicaid participation requirements and Life Safety Code standards.
Complaint Details
The survey was conducted in response to Complaint Number IN00407356. Federal/State deficiencies related to the allegation were cited at K100 and K914, and a deficiency unrelated to the allegation was cited at K920.
Findings
The facility was found not in compliance with requirements related to Life Safety from Fire and electrical safety. Deficiencies included failure to maintain 55 PTAC units in safe operational condition, failure to test non-hospital grade electrical receptacles annually, and improper use of power strips in patient care areas. These deficiencies could affect all residents.
Deficiencies (3)
Failed to ensure 55 of 55 Packaged Terminal Air Conditioner (PTAC) units were maintained in a safe operational condition, including clogged air filters and a burnt receptacle in room 314.
Failed to ensure non-hospital grade electrical receptacles in 55 resident sleeping rooms were tested at least annually and new receptacles tested upon installation.
Failed to ensure 1 of 1 flexible cord power strips in patient care locations met required UL rating and were not used as a substitute for fixed wiring to power high current draw equipment.
Report Facts
Facility capacity: 104
Census: 70
PTAC units: 55
Resident sleeping rooms: 55
Non-hospital grade electrical receptacles: 5
Residents affected by power strip deficiency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Goran Prentoski | Administrator | Signed the report |
| Maintenance Director | Interviewed and acknowledged deficiencies related to PTAC maintenance, electrical receptacle testing, and power strip use | |
| Director of Nursing | Participated in exit conference reviewing findings |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 0
Date: Apr 14, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00406238.
Complaint Details
Complaint IN00406238 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 - NF: 59
Census Bed Type - NCC: 7
Total Census: 66
Census Payor Type - Medicaid: 59
Census Payor Type - Other: 7
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 0
Date: Mar 9, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00402280 and IN00402835.
Complaint Details
Complaint IN00402280 - No deficiencies related to the allegation are cited. Complaint IN00402835 - No deficiencies related to the allegation are cited.
Findings
No deficiencies related to the allegations in complaints IN00402280 and IN00402835 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type - SNF: 7
Census Bed Type - NF: 53
Census Total: 60
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 49
Census Payor Type - Other: 6
Inspection Report
Complaint Investigation
Census: 62
Capacity: 62
Deficiencies: 0
Date: Jan 24, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00399139 and included a COVID-19 Focused Infection Control Survey.
Complaint Details
Complaint IN00399139 was unsubstantiated due to lack of evidence.
Findings
The complaint IN00399139 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 the COVID-19 Focused Infection Control Survey.
Report Facts
Census SNF/NF beds: 62
Total census: 62
Medicare census: 5
Medicaid census: 44
Other payor census: 13
Inspection Report
Follow-Up
Census: 59
Capacity: 104
Deficiencies: 0
Date: Jan 3, 2023
Visit Reason
A 2nd Post Survey Revisit (PSR) was conducted to follow up on the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey previously conducted on 10/04/22.
Findings
At this PSR survey, University Park Rehabilitation and Healthcare was found in compliance with Emergency Preparedness Requirements and Life Safety Code Recertification requirements. The facility was fully sprinklered except for a garage used for facility services and maintenance supplies storage.
Report Facts
Facility capacity: 104
Census: 59
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 16, 2022
Visit Reason
Paper compliance review related to the Investigation of Complaint IN00392439 completed on December 1, 2022.
Complaint Details
Investigation of Complaint IN00392439; paper compliance review completed with findings of compliance.
Findings
University Park Rehabilitation and Healthcare 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: 63
Capacity: 63
Deficiencies: 0
Date: Dec 12, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00396028.
Complaint Details
Complaint IN00396028 was investigated and found unsubstantiated due to lack of evidence.
Findings
The complaint IN00396028 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 in regard to the complaint investigation.
Report Facts
Census SNF/NF beds: 63
Total census: 63
Medicare census: 4
Medicaid census: 48
Other payor census: 11
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Dec 1, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to activities of daily living (ADL) care for dependent residents.
Findings
The facility failed to ensure that one of four residents (Resident C) received bathing at least twice weekly as required. Documentation and interviews revealed inconsistent bathing and shampooing, with some missed baths and incomplete records.
Deficiencies (2)
Failed to ensure Resident C received bathing at least twice weekly as required.
A policy was requested but not provided by the exit of the survey.
Report Facts
Deficiencies cited: 1
Date of Compliance: Dec 15, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Grabbe | RN Regional Nurse Consultant | Signed the inspection report |
| Director of Nursing | Provided point of care history report and interviews related to bathing documentation | |
| Certified Nursing Assistant 2 | Interviewed regarding bathing frequency and procedures |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Nov 16, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with emergency preparedness training, emergency power system maintenance, hazardous area protections, and fire safety plans.
Findings
The facility failed to demonstrate staff knowledge of emergency preparedness despite annual training, lacked monthly load testing and weekly inspections of the emergency generator, had a hazardous area (bathing room) not properly protected due to a door not self-closing, and had an incomplete written fire safety plan missing response procedures to battery-operated smoke alarms.
Deficiencies (5)
Failed to demonstrate staff knowledge of emergency preparedness despite annual training.
Failed to implement emergency power system inspection, testing, and maintenance requirements including missing monthly load testing and weekly inspections.
Failed to ensure a bathing room with combustible storage and greater than 50 square feet was protected as a hazardous area due to a door not self-closing.
Failed to provide a written emergency fire safety plan that included response to battery-operated smoke alarms.
Failed to maintain complete written records of monthly generator load testing and weekly inspections.
Report Facts
Deficiencies cited: 5
Staff tested weekly: 5
Staff tested monthly: 5
Residents potentially affected: 20
Generator load testing months missing: 1
Generator weekly inspections missing: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Goran Prentoski | RDO | Signed the report as Laboratory Director or Provider/Supplier Representative. |
Inspection Report
Routine
Census: 58
Capacity: 104
Deficiencies: 18
Date: Oct 4, 2022
Visit Reason
Routine Life Safety Code and Emergency Preparedness Survey conducted by the Indiana Department of Health.
Findings
The facility was found not in compliance with multiple Emergency Preparedness and Life Safety Code requirements including failure to update emergency preparedness plans annually, incomplete emergency communication plans, lack of annual emergency preparedness training, missing emergency power system testing and maintenance, deficient fire safety plans, incomplete fire drills, and various Life Safety Code violations such as inadequate illumination of means of egress, hazardous area protections, sprinkler system maintenance, fire alarm system maintenance, and electrical safety issues.
Deficiencies (18)
Failed to review and update the Emergency Preparedness Plan annually.
Failed to ensure emergency preparedness communication plan includes required contact information.
Failed to conduct annual emergency preparedness training and demonstrate staff knowledge.
Failed to conduct required emergency preparedness exercises annually and additional exercises every two years.
Failed to implement emergency power system inspection, testing, and maintenance per NFPA 110 and Life Safety Code.
Egress lighting for one exit discharge was not continuously operational or capable of automatic operation.
Failed to maintain documentation for preventative maintenance of battery operated smoke alarms in resident rooms.
One bathing room with combustible storage over 50 square feet was not protected as a hazardous area with self-closing door.
Failed to ensure semiannual inspection of kitchen fire suppression system.
Failed to ensure fire alarm control panel was protected against unauthorized use.
Failed to maintain fire alarm system with required semi-annual visual inspections.
Failed to maintain sprinkler system with required internal pipe inspection and quarterly inspection/testing documentation.
Penetrations through smoke barrier walls were not properly sealed to maintain smoke resistance.
Failed to maintain current inspection certificates for fuel fired water heaters.
Electrical junction box in south hall was missing cover and had exposed wiring.
Power strip in resident room did not meet required UL rating for patient care vicinity.
Failed to conduct fire drills on each shift for 2 of 4 quarters.
Emergency task generator lacked battery powered emergency lighting and incomplete weekly and monthly testing documentation.
Report Facts
Facility capacity: 104
Census: 58
Deficiency count: 17
Fire drills missing: 3
Sprinkler system internal pipe inspection last done: 2015
Inspection Report
Complaint Investigation
Census: 55
Capacity: 55
Deficiencies: 3
Date: Sep 28, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00390877, which was substantiated with federal and state deficiencies cited related to the allegations.
Complaint Details
Complaint IN00390877 was substantiated. The complaint involved failure to provide proper discharge notice and paperwork, failure to permit resident return after hospitalization, and failure to provide pain medication.
Findings
The facility failed to provide a 30-day notice of discharge for one resident, failed to permit a resident to return after hospitalization based on behavior concerns, and failed to ensure pain medications were available for administration to a resident requiring pain management.
Deficiencies (3)
Failed to provide a 30 day Notice of Discharge for 1 of 3 residents reviewed for discharge (Resident C).
Failed to allow a resident to return to the facility after hospitalization using the resident's behaviors prior to transfer as a basis for the decision (Resident C).
Failed to ensure pain medications were available for administration for 1 of 1 residents reviewed for pain (Resident M).
Report Facts
Census: 55
Total Capacity: 55
Medicare residents: 2
Medicaid residents: 45
Other residents: 8
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 28, 2022
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00390594.
Complaint Details
Complaint IN00390594 was investigated and found to be in compliance as of September 28, 2022.
Findings
University Park Rehabilitation and Health Care was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Inspection Report
Re-Inspection
Census: 55
Deficiencies: 0
Date: Sep 22, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey and Complaint Investigation IN00387630 completed on August 23, 2022.
Complaint Details
Complaint IN00387630 was corrected.
Findings
University Park Rehabilitation and Healthcare 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 Investigation.
Report Facts
Census Bed Type: 55
Census Payor Type: 55
SNF/NF beds: 8
SNF beds: 2
NF beds: 45
Medicare residents: 3
Medicaid residents: 45
Other payor residents: 8
Inspection Report
Complaint Investigation
Census: 58
Capacity: 58
Deficiencies: 0
Date: Sep 1, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00388580.
Complaint Details
Complaint IN00388580 was substantiated, but no deficiencies related to the allegations were cited.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 58
Total Capacity: 58
Medicare Census: 1
Medicaid Census: 51
Other Payor Census: 6
Inspection Report
Complaint Investigation
Census: 54
Capacity: 54
Deficiencies: 7
Date: Aug 23, 2022
Visit Reason
This visit was for a Recertification and State Licensure and Investigation of Complaints IN00385705 and IN00387630. Complaint IN00385705 was unsubstantiated due to lack of evidence. Complaint IN00387630 was substantiated with related Federal/State deficiencies cited.
Complaint Details
Complaint IN00385705 was unsubstantiated due to lack of evidence. Complaint IN00387630 was substantiated with related deficiencies cited at F677.
Findings
The facility was found deficient in multiple areas including failure to ensure quarterly care plan meetings, failure to provide scheduled ADL care such as showers or bed baths, failure to implement a comprehensive interdisciplinary plan of care for hospice services, failure to maintain a safe environment free of accident hazards, failure to provide catheter care per physician orders, failure to provide trauma informed care for a resident with PTSD, and failure to complete required employee pre-hire screenings and documentation.
Deficiencies (7)
Failure to ensure quarterly care plan meetings were completed for 1 of 1 residents reviewed (Resident 44).
Failure to ensure residents received showers or bed baths as scheduled for 3 of 3 residents reviewed (Residents B, C, D).
Failure to ensure a comprehensive interdisciplinary plan of care was implemented to provide hospice services for 1 of 1 resident reviewed (Resident 14).
Failure to ensure the environment remained free of potential accident hazards in 1 of 1 observation (Resident 3).
Failure to ensure catheter care was provided per physician orders for 2 of 2 residents reviewed (Residents 6 and 46).
Failure to ensure trauma informed care in accordance with professional standards of practice for 1 of 1 resident reviewed (Resident 11 with PTSD).
Failure to ensure prospective employees' reference checks were completed and documented in 4 of 5 employee records. Failure to ensure physical exam and Mantoux PPD screening were completed and documented within one month prior to employment in 5 of 5 employee records. Failure to ensure job descriptions and orientation of specific job skills documentation were completed in 2 of 5 employee records.
Report Facts
Census: 54
Total Capacity: 54
Residents reviewed for care plan meetings: 1
Residents reviewed for ADL care: 3
Residents reviewed for catheter care: 2
Employee files reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda Buroker | Director of Division Long Term Care | Recipient of report letter |
| Tammy Denlinger | Executive Director | Signed Plan of Correction and contact for questions |
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