Inspection Reports for Vermillion Convalescent Center
1705 S Main St, Clinton, IN 47842, IN, 47842
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 30, 2025, found no deficiencies related to complaint investigations. Earlier inspections showed a pattern of deficiencies primarily involving Life Safety Code compliance, such as door closures, fire safety equipment, and electrical protections, as well as issues with resident care documentation and medication management. A substantiated complaint in November 2023 cited improper use of physical restraints, resulting in staff re-education and termination, but no fines or license actions were listed in the available reports. Most complaint investigations were unsubstantiated or found no related deficiencies. The facility’s recent inspections indicate improvement in compliance, particularly with no deficiencies noted in the latest complaint investigations and follow-up surveys confirming correction of prior Life Safety Code issues.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
11.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
169% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Routine
Deficiencies: 11
Date: Aug 19, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, abuse prevention, infection control, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to obtain informed consent for psychotropic medications, improper call light placement, failure to provide showers as preferred, failure to protect residents from abuse, inadequate fingernail care, improper pressure ulcer care, failure to keep urinary catheter bags off the floor, improper medication administration and infection control practices, and failure to follow antibiotic stewardship protocols.
Deficiencies (11)
Failed to ensure informed consent documents for psychotropic medications were obtained for 2 of 5 residents reviewed.
Failed to ensure call light was within reach of residents for 2 of 24 residents reviewed.
Failed to ensure a resident was provided showers as preferred for 1 of 1 residents reviewed.
Failed to protect a resident's right to be free from physical and verbal abuse for 1 of 2 residents reviewed.
Failed to ensure timely report of suspected abuse to the administrator for 1 of 2 residents reviewed.
Failed to ensure fingernail care was provided for 1 of 24 residents reviewed.
Failed to ensure appropriate pressure ulcer care and infection control during dressing changes for 1 of 2 residents reviewed.
Failed to ensure indwelling urinary catheter bag and tubing were kept from touching the floor for 1 of 2 residents reviewed.
Failed to ensure Aplisol solution was disposed of once past the use by date during medication room observations.
Failed to ensure hand hygiene was performed during medication pass and appropriate infection control techniques were utilized for 5 of 5 residents observed; failed to ensure enhanced barrier precautions were followed for 2 of 5 residents observed during medication pass.
Failed to implement a program that monitors antibiotic use, specifically failure to follow antibiotic stewardship protocol for 1 of 24 residents reviewed.
Report Facts
Residents reviewed for unnecessary medications: 5
Residents reviewed for call light placement: 24
Residents reviewed for shower preference: 1
Residents reviewed for abuse: 2
Residents reviewed for fingernail care: 24
Residents reviewed for pressure ulcers: 2
Residents reviewed for urinary catheters: 2
Medication room observations: 1
Residents observed during medication pass: 5
Residents reviewed for antibiotic use: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 11 | Certified Nursing Aide | Named in physical and verbal abuse incident involving Resident 1 |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding informed consent, abuse reporting, infection control, and antibiotic stewardship |
| RN 22 | Registered Nurse | Observed and interviewed regarding medication administration and infection control deficiencies |
| LPN 10 | Licensed Practical Nurse | Observed performing pressure ulcer dressing changes with infection control deficiencies |
| Regional Nurse Consultant | Regional Nurse Consultant (RNC) | Provided policies and interviewed regarding abuse, infection control, and antibiotic stewardship |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 72
Deficiencies: 0
Date: Jun 30, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00458839 and IN00460476.
Complaint Details
Complaint IN00458839 - No deficiencies related to the allegations are cited. Complaint IN00460476 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations in complaints IN00458839 and IN00460476 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 72
Total Capacity: 72
Medicare Census: 6
Medicaid Census: 57
Other Payor Census: 9
Inspection Report
Complaint Investigation
Census: 79
Capacity: 79
Deficiencies: 0
Date: Mar 19, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00453248.
Complaint Details
Complaint IN00453248 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 residents: 9
Medicaid residents: 56
Other residents: 14
Inspection Report
Complaint Investigation
Census: 74
Capacity: 74
Deficiencies: 0
Date: Jan 3, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00446308.
Complaint Details
Complaint IN00446308 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 relevant regulations.
Report Facts
Medicare residents: 9
Medicaid residents: 50
Other residents: 15
Inspection Report
Re-Inspection
Census: 76
Capacity: 119
Deficiencies: 0
Date: Sep 12, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 08/08/24 was performed to verify compliance with previous findings.
Findings
At this PSR survey, Vermillion Convalescent Center was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Report Facts
Facility capacity: 119
Census: 76
Inspection Report
Renewal
Deficiencies: 0
Date: Aug 21, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure survey conducted on July 22, 2024.
Findings
Vermillion Convalescent Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for Recertification and State Licensure.
Inspection Report
Life Safety
Census: 79
Capacity: 100
Deficiencies: 5
Date: Aug 8, 2024
Visit Reason
The survey was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Life Safety Code requirements, including issues with hazardous area door closures, corridor door impediments, smoke barrier door malfunctions, lack of GFCI protection in restrooms, and improper storage of liquid oxygen containers in resident rooms.
Deficiencies (5)
Failed to ensure hazardous area storage room door was self-closing and latched properly.
One corridor door had an impediment to closing and latching, requiring considerable force.
One set of smoke barrier doors failed to close tightly, leaving a 4-inch gap.
Restrooms were not provided with functioning ground fault circuit interrupter (GFCI) protection.
Liquid oxygen containers were stored in resident rooms not separated by fire barriers with required fire resistance rating and self-closing doors.
Report Facts
Certified beds: 100
Census: 79
Residents potentially affected by hazardous area door deficiency: 10
Residents potentially affected by smoke barrier door deficiency: 20
Residents potentially affected by GFCI deficiency: 5
Residents potentially affected by liquid oxygen storage deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Gum | RN, HFA/Administrator | Signed the report |
| Maintenance Director | Interviewed and confirmed deficiencies related to door closures, GFCI receptacle, and liquid oxygen storage | |
| Assistant Administrator | Present at exit conference and reviewed findings |
Inspection Report
Annual Inspection
Census: 76
Capacity: 76
Deficiencies: 5
Date: Jul 22, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from July 16 to July 22, 2024.
Findings
The facility was found deficient in several areas including failure to maintain resident dignity during transport, incomplete documentation of resident hospital transfers, improper catheter bag placement, improper medication labeling and storage, and incomplete medication administration documentation.
Deficiencies (5)
Failure to aid a resident in a manner that maintained or enhanced their dignity during transport in a shower chair.
Failure to ensure documentation of a resident's transfer included physician and family notification.
Failure to ensure a resident's indwelling urinary catheter bag and tubing were kept from making contact with the floor.
Failure to ensure medications were labeled and stored properly in medication and treatment carts.
Failure to ensure medications administered to a resident had been documented.
Report Facts
Survey dates: 5
Census: 76
Total capacity: 76
Medicare residents: 11
Medicaid residents: 52
Other payor residents: 13
Deficiency completion dates: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Gum | RN, HFA/Administrator | Signed the report as provider/supplier representative |
| Licensed Practical Nurse 4 | Licensed Practical Nurse | Interviewed regarding resident dignity and medication labeling |
| Student Nurse Aide 4 | Student Nurse Aide | Interviewed regarding resident dignity during transport |
| Licensed Practical Nurse 13 | Licensed Practical Nurse | Interviewed regarding hospital transfer documentation |
| Regional Nurse Consultant | Regional Nurse Consultant | Provided policies and interviewed regarding multiple deficiencies |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding medication storage and catheter bag placement |
Inspection Report
Routine
Deficiencies: 5
Date: Jul 22, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, transfer documentation, catheter care, medication storage, and medication administration at Vermillion Convalescent Center.
Findings
The facility was found deficient in maintaining resident dignity during transport, documenting hospital transfers, preventing catheter bags from contacting the floor, properly labeling and storing medications, and documenting medication administration for a resident.
Deficiencies (5)
Failed to aid a resident in a manner that maintained or enhanced their dignity during transport in a shower chair, exposing the resident's buttocks.
Failed to ensure documentation of a resident's transfer included notification of the physician and family representative for hospital transfer.
Failed to ensure a resident's indwelling urinary catheter bag and tubing were kept from making contact with the floor.
Failed to ensure medications were labeled and stored properly for medication carts and treatment carts, including missing dates on insulin pens and loose medications without labels.
Failed to ensure medications administered to a resident were documented on the Medication Administration Record (MAR).
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) 4 | Interviewed regarding resident dignity and medication labeling | |
| Student Nurse Aide 4 | Interviewed regarding resident dignity during transport | |
| Licensed Practical Nurse (LPN) 13 | Interviewed regarding SBAR form completion for hospital transfers | |
| Assistant Director of Nursing (ADON) | Interviewed regarding catheter care and medication storage | |
| Regional Nurse Consultant | Provided facility policies and interviewed regarding deficiencies | |
| Regional Clinical Nurse | Interviewed regarding medication administration documentation expectations |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 71
Deficiencies: 1
Date: Nov 6, 2023
Visit Reason
This visit was conducted for the investigation of complaint IN00420470 regarding allegations of improper use of physical restraints at the facility.
Complaint Details
Complaint IN00420470 was substantiated with federal/state deficiencies cited related to the allegations of improper restraint use involving tape applied to self-releasing seat belts by a CNA. The CNA was suspended, re-educated, and ultimately terminated following investigation.
Findings
The facility failed to ensure that residents' self-releasing seat belts were secured in a manner that allowed residents to freely release them for 2 of 4 residents reviewed. The issue involved a Certified Nursing Aide who used tape to secure the belts, preventing self-release. The facility conducted a full investigation, re-educated staff, terminated the responsible CNA, and corrected the deficient practice prior to the survey.
Deficiencies (1)
Facility failed to ensure residents' self-releasing seat belts were secured to allow free release for 2 of 4 residents reviewed.
Report Facts
Census: 71
Total Capacity: 71
Medicare Census: 6
Medicaid Census: 51
Other Payor Census: 14
PHQ-9 Score Resident B: 6
PHQ-9 Score Resident C: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 8 | Certified Nursing Aide | Named in finding for taping residents' self-releasing seat belts, resulting in termination |
| Assistant Director of Nursing | ADON | Re-educated CNA 8 and involved in investigation |
| Administrator | ADM | Provided internal investigation documentation and oversaw investigation |
| Former Director of Nursing | DON | Provided statements and education related to the incident |
| Laundry Aide 11 | Laundry Aide | Observed tape on seat belts and reported to staff |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 6, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to allegations that a Certified Nursing Aide (CNA) had improperly secured self-releasing seat belts on residents, restricting their ability to release the belts, which is considered a physical restraint.
Complaint Details
This citation relates to complaint IN00420470. The complaint involved allegations that CNA 8 used tape to secure self-releasing seat belts on Residents B and C, removing their ability to self-release. The facility conducted a full investigation, notified families, provided staff education, and terminated the CNA responsible.
Findings
The facility failed to ensure that residents' self-releasing seat belts were secured in a manner allowing free release for 2 of 4 residents reviewed. The incident involved CNA 8 taping the belts, which was confirmed through interviews and investigation. The CNA was re-educated, suspended, and ultimately terminated. The deficient practice was corrected prior to the survey start date, making it past noncompliance.
Deficiencies (1)
Failed to ensure residents' self-releasing seat belts were secured to allow free release, resulting in improper physical restraint for 2 residents.
Report Facts
Residents affected: 2
PHQ-9 depression score: 6
PHQ-9 depression score: 11
Dates of relevant physician orders: Oct 9, 2023
Dates of relevant physician orders: Oct 6, 2023
Dates of physical restraint assessments: Oct 2, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 8 | Certified Nursing Aide | Named as the staff who taped the self-releasing seat belts, leading to improper restraint and termination. |
| Assistant Director of Nursing | ADON | Provided re-education to CNA 8 and involved in the investigation. |
| Former Director of Nursing | DON | Provided statements during investigation and conducted staff education. |
| Administrator | ADM | Oversaw the investigation, reviewed documentation, and signed termination paperwork. |
| Laundry Aide 11 | Laundry Aide | Observed tape on seat belt and reported to staff during investigation. |
Inspection Report
Re-Inspection
Census: 71
Capacity: 119
Deficiencies: 0
Date: Aug 15, 2023
Visit Reason
A Post-Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 07/11/23 was performed to verify compliance with previous deficiencies.
Findings
At this PSR survey, Vermillion Convalescent Center 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: 119
Census: 71
Inspection Report
Renewal
Deficiencies: 0
Date: Aug 1, 2023
Visit Reason
The inspection was a paper compliance review related to the Recertification and State Licensure survey completed on June 15, 2023.
Findings
Vermillion Convalescent Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for Recertification and State Licensure.
Inspection Report
Life Safety
Census: 72
Capacity: 119
Deficiencies: 4
Date: Jul 11, 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 on 07/11/2023.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies included failure to test battery backup emergency lights monthly, corroded and dirty sprinkler heads in the kitchen, a corridor door that was difficult to close and latch, and failure to test non-hospital grade electrical receptacles in resident sleeping rooms annually.
Deficiencies (4)
Failed to ensure 1 of 1 battery backup lights were tested monthly as required.
Failed to ensure all sprinkler heads in the kitchen were free of corrosion, dirt, grease, and foreign material.
One corridor door to Resident Room 251 had an impediment to closing and latching, requiring considerable force to operate.
Failed to ensure non-hospital grade electrical receptacles at 55 resident sleeping rooms were tested at least annually.
Report Facts
Certified beds: 119
Census: 72
Non-hospital grade electrical receptacles: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Gum | Administrator | Named during exit conference and signature on report |
| Maintenance Director | Interviewed regarding deficiencies and testing records | |
| Maintenance Supervisor | Responsible for corrective actions and testing |
Inspection Report
Annual Inspection
Census: 68
Capacity: 68
Deficiencies: 4
Date: Jun 15, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00405579.
Complaint Details
Complaint IN00405579 was investigated and no deficiencies related to the allegations were cited.
Findings
The facility was found deficient in several areas including failure to ensure code status/advance directive documents matched physician orders, food temperature and palatability issues, unsanitary kitchen conditions, improper food handling by staff, and employment of a licensed nurse with an expired license. Corrective actions and monitoring plans were implemented for each deficiency.
Deficiencies (4)
Failed to ensure the Code Status/Advanced Directive document matched the physician's order for code status for 1 of 24 residents reviewed.
Failed to ensure the temperature and palatability of food served for 1 of 1 test tray and 2 of 26 residents reviewed for food palatability.
Failed to ensure cleanliness and sanitation of the kitchen and food preparation/storage areas and sanitary food handling when assisting residents with eating.
Failed to ensure that all licensed employees had an active Indiana license for 1 of 69 licensed employees.
Report Facts
Census: 68
Total Capacity: 68
Medicare Census: 7
Medicaid Census: 52
Other Payor Census: 9
Expired License Date: Oct 31, 2022
Food Temperature: 100
Food Temperature: 135
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Gum | Administrator | Signed the report and plan of correction |
| LPN 15 | Licensed Practical Nurse | Had an expired Indiana nursing license and was removed from schedule |
| Licensed Practical Nurse 10 | Licensed Practical Nurse | Interviewed regarding code status document at nurse's station |
| Director of Nursing | Director of Nursing | Interviewed regarding code status document and facility policies |
| Dietary Manager | Dietary Manager | Interviewed regarding food temperature and kitchen sanitation |
| Dietary Aide 17 | Dietary Aide | Observed entering kitchen without hairnet and placing personal items on kitchen cart |
| Certified Nursing Aide 7 | Certified Nursing Aide | Observed handling resident food without hand sanitation |
| Regional Nurse Consultant | Regional Nurse Consultant | Interviewed regarding expired license and facility policies |
| Regional Manager | Regional Manager | Provided job description policy |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jun 15, 2023
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements related to resident rights, food safety, sanitation, and employee licensing at Vermillion Convalescent Center.
Findings
The facility was found to have multiple deficiencies including failure to ensure accurate code status documentation for residents, inadequate food temperature and palatability, unsanitary kitchen and food handling practices, and employing a licensed nurse with an expired license.
Deficiencies (4)
Failed to ensure the Code Status/Advanced Directive document matched the physician's order for code status for 1 of 24 residents reviewed.
Failed to ensure the temperature and palatability of food served for 1 of 1 test tray and 2 of 26 residents reviewed.
Failed to ensure cleanliness and sanitation of kitchen and food preparation/storage areas and sanitary food handling when assisting residents with eating.
Failed to ensure that all licensed employees had an active Indiana license for 1 of 69 licensed employees.
Report Facts
Residents reviewed for advanced directives: 24
Test trays reviewed for temperature and palatability: 1
Residents reviewed for food palatability: 26
Residents affected by kitchen sanitation issues: 67
Licensed employees: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 15 | Licensed Practical Nurse | Named in finding for having an expired Indiana nursing license since 10/31/22 |
| Licensed Practical Nurse 10 | Licensed Practical Nurse | Interviewed regarding code status documentation discrepancies |
| Director of Nursing | Director of Nursing | Interviewed regarding code status documentation and facility policies |
| Dietary Manager | Dietary Manager | Interviewed and observed regarding food temperature, kitchen sanitation, and policies |
| Certified Nursing Aide 7 | Certified Nursing Aide | Observed assisting residents with meals without proper hand sanitation |
| Regional Nurse Consultant | Regional Nurse Consultant | Interviewed regarding expired license and facility policies |
| Regional Manager | Regional Manager | Provided job description policy related to licensed staff requirements |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 72
Deficiencies: 0
Date: Nov 18, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00388531.
Complaint Details
Complaint IN00388531 was investigated and determined to be unsubstantiated due to lack of evidence.
Findings
The complaint IN00388531 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 72
Total Capacity: 72
Medicare Residents: 9
Medicaid Residents: 54
Other Payor Residents: 9
Inspection Report
Renewal
Deficiencies: 0
Date: Sep 30, 2022
Visit Reason
The inspection was conducted as a paper compliance review related to the Recertification and State Licensure survey.
Findings
The Vermillion Convalescent Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for Recertification and State Licensure.
Inspection Report
Life Safety
Census: 63
Capacity: 119
Deficiencies: 5
Date: Jul 27, 2022
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) and NFPA 101 standards.
Findings
The facility was found not in compliance with Life Safety Code requirements, including failure to maintain spare sprinklers, inadequate inspection of portable fire extinguishers, malfunctioning smoke barrier doors, and insufficient intake combustion air in the boiler room. Corrective actions were planned and documented.
Deficiencies (5)
Failed to ensure spare sprinklers, a sprinkler cabinet, and a sprinkler wrench were maintained on the premises as required by NFPA 25.
Failed to ensure all loaded sprinklers were replaced or cleaned in accordance with NFPA 25.
Failed to ensure 1 of 23 portable fire extinguishers was inspected at least monthly and documented accordingly.
Failed to ensure 1 of 6 sets of smoke barrier doors would restrict the movement of smoke for at least 20 minutes due to malfunctioning door closing coordinator.
Failed to ensure 1 of 1 boiler rooms were provided with intake combustion air from the outside for rooms containing fuel fired equipment.
Report Facts
Certified beds: 119
Census: 63
Portable fire extinguishers: 23
Sets of smoke barrier doors: 6
Boiler rooms: 1
Inspection Report
Life Safety
Deficiencies: 0
Date: Jul 27, 2022
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey conducted on 07/27/22 was completed on 08/18/22.
Findings
Vermillion Convalescent Center 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.
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