Inspection Report Summary
The most recent inspection on June 4, 2025, identified deficiencies related to incomplete discharge documentation for one resident. Earlier inspections showed a mixed pattern, with several citations involving resident care issues such as fall prevention, medication management, infection control, and documentation. Complaint investigations mostly found no deficiencies, though some substantiated complaints involved medication order implementation, abuse allegations, and COVID-19 vaccination compliance. Enforcement actions included termination of an employee related to abuse and no fines or license suspensions were listed in the available reports. The facility’s inspection history shows some ongoing challenges in care and documentation, but recent complaint investigations have generally not resulted in new deficiencies.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
12 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
186% 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
Deficiencies: 1
Date: Dec 30, 2025
Visit Reason
The inspection was conducted to assess compliance with care standards related to urinary tract infection prevention and catheter care following concerns about delayed urine sample collection for a resident.
Findings
The facility failed to timely complete a physician's order to obtain a urine sample for one resident, resulting in a five-day delay with only two documented attempts before notifying the physician and obtaining an order for catheterization. Documentation and policy deficiencies regarding following physician orders and urine sample collection were also noted.
Deficiencies (1)
Failed to complete a physician's order to obtain a urine sample timely for 1 of 3 residents reviewed for urinary tract infections, with a five-day delay and insufficient documentation of attempts.
Report Facts
Days delay in obtaining urine sample: 5
Medication dosage: 250
Medication duration: 7
Residents reviewed for UTI: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Interviewed regarding documentation and notification procedures for urine sample collection | |
| RN 8 | Interviewed regarding facility policy on following physician orders and urine sample collection |
Inspection Report
Deficiencies: 1
Date: Aug 15, 2025
Visit Reason
The inspection was conducted to assess compliance with care plan implementation and resident safety, specifically reviewing a fall incident involving Resident F and evaluating whether the facility followed the resident's plan of care regarding assistance during transfers.
Findings
The facility failed to ensure that Resident F's plan of care was followed, as staff did not provide the required assistance during transfers and toileting, contributing to a fall. The care plan was found to be accurate but not consistently implemented, with minimal harm or potential for actual harm noted.
Deficiencies (1)
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Report Facts
Residents Affected: 1
Medication dosage: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurses Aide 4 | CNA | Indicated Resident F required assistance of one for transfer and toileting |
| Director of Nursing | DON | Indicated Resident F was typically independent but required assistance during UTI |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Aug 15, 2025
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with regulatory requirements related to medication self-administration, care plan implementation, and environmental safety.
Findings
The facility was found deficient in ensuring a resident had proper self-administration medication assessments and orders, failed to follow a resident's care plan for assistance during transfers leading to a fall, and did not maintain a pest-free environment due to observed ants in a resident's bathroom.
Deficiencies (3)
Failed to ensure a resident with medications at bedside had a self-administration assessment, physician orders, and care plan.
Failed to ensure a resident's plan of care was followed by providing assistance during transfers, contributing to a fall.
Failed to provide a safe environment free of pests based on observations of ants in resident bathroom and air conditioner.
Report Facts
Medication dosage: 100
Medication frequency: 2
Medication duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Indicated no medications should be at bedside without order and assessment; commented on resident assistance needs |
| Certified Nurses Aide 4 | Certified Nurses Aide | Indicated resident required assistance of one for transfer and toileting |
| Licensed Practical Nurse 15 | Licensed Practical Nurse | Stated there should be no bugs in resident rooms |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 5, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to the facility's failure to complete required discharge documentation for Resident B.
Complaint Details
This citation relates to Complaint IN00459530.
Findings
The facility failed to complete the required discharge documentation, leaving transfer/discharge forms blank and incomplete. The physician's order for discharge was present, but the reason for transfer or discharge was not properly selected on the form, and the clinical record lacked other physician information related to the discharge.
Deficiencies (1)
Failure to complete required discharge documentation; transfer/discharge documentation left blank and incomplete for Resident B.
Report Facts
Residents Affected: 2
Inspection Report
Complaint Investigation
Census: 97
Capacity: 97
Deficiencies: 1
Date: Jun 4, 2025
Visit Reason
The visit was conducted to investigate two complaints, IN00459077 and IN00459530. Complaint IN00459530 resulted in federal/state deficiencies being cited, while Complaint IN00459077 had no deficiencies related to the allegations.
Complaint Details
Complaint IN00459530 was substantiated with deficiencies cited related to inappropriate discharge documentation. Complaint IN00459077 was not substantiated with any deficiencies.
Findings
The facility failed to complete the required discharge documentation for Resident B, leaving the Transfer/Discharge documentation blank and incomplete. The discharge form did not have a selected reason from the menu, with 'Resident Request' handwritten instead, and lacked proper physician documentation attached to the discharge notice.
Deficiencies (1)
Failed to complete the required discharge documentation; Transfer/Discharge documentation was left blank and incomplete for Resident B.
Report Facts
Census: 97
Total Capacity: 97
Audit sample size: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maddison Cook | Executive Director | Signed the inspection report |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 96
Deficiencies: 0
Date: May 5, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00457156.
Complaint Details
Complaint IN00457156 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: 21
Census Bed Type: 15
Census Bed Type: 60
Census Total Capacity: 96
Census Payor Type: 9
Census Payor Type: 17
Census Payor Type: 10
Census Total: 36
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 0
Date: Apr 2, 2025
Visit Reason
This visit was for the Investigation of Nursing Home Complaint IN00450258, which included the Investigation of Residential Complaint IN00450258.
Complaint Details
Complaint IN00450258 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations were cited. West River Health Campus was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the Investigation of Nursing Home Complaint IN00450258.
Report Facts
Census Bed Type: 21
Census Bed Type: 20
Census Bed Type: 59
Census Bed Type: 100
Census Payor Type: 15
Census Payor Type: 18
Census Payor Type: 8
Census Payor Type: 41
Inspection Report
Complaint Investigation
Census: 40
Capacity: 93
Deficiencies: 0
Date: Dec 16, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00448811.
Complaint Details
Complaint IN00448811 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
Census Payor Type - Medicare: 17
Census Payor Type - Medicaid: 16
Census Payor Type - Other: 7
Census Bed Type - SNF/NF: 21
Census Bed Type - SNF: 19
Census Bed Type - Residential: 53
Inspection Report
Re-Inspection
Census: 98
Deficiencies: 0
Date: Oct 8, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 2024-08-19, conducted in conjunction with the Investigation of Complaint IN00444082.
Complaint Details
Complaint IN00444082 was investigated and no deficiencies related to the allegations were cited.
Findings
West River Health Campus was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 during the PSR. No deficiencies related to the complaint allegations were cited.
Report Facts
Census Bed Type - SNF: 25
Census Bed Type - SNF/NF: 18
Census Bed Type - Residential: 55
Total Census: 98
Census Payor Type - Medicare: 18
Census Payor Type - Medicaid: 18
Census Payor Type - Other: 7
Total Census Payor: 43
Inspection Report
Life Safety
Census: 38
Capacity: 61
Deficiencies: 0
Date: Aug 27, 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 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
At the Emergency Preparedness survey, West River Health Campus was found in compliance with Emergency Preparedness Requirements. At the Life Safety Code survey, the facility was found in compliance with Requirements for Participation in Medicare/Medicaid and Life Safety from Fire according to NFPA 101 and state regulations.
Report Facts
Facility capacity: 61
Census: 38
Inspection Report
Recertification
Census: 56
Capacity: 91
Deficiencies: 8
Date: Aug 19, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Complaint IN00437352. The complaint was investigated with no deficiencies related to the allegations cited.
Complaint Details
Complaint IN00437352 was investigated with no deficiencies related to the allegations cited.
Findings
The facility was found to have multiple deficiencies including failure to ensure dependent residents received adequate ADL care, failure to prevent accidents and falls, failure to provide proper catheter care resulting in CAUTI and septic shock, failure to address significant weight loss, failure to provide oxygen therapy as ordered, failure to maintain sanitary food service conditions, and failure to ensure proper hand hygiene and infection control practices.
Deficiencies (8)
Failure to ensure dependent residents received bathing as scheduled and per resident preferences.
Failure to ensure residents had supervision and interventions in place to prevent accidents and falls.
Failure to ensure services were provided to prevent catheter-associated urinary tract infection (CAUTI), resulting in septic shock and hospitalization.
Failure to ensure a resident's decline in nutritional status was addressed and recommendations followed for significant weight loss.
Failure to ensure oxygen equipment was properly labeled and oxygen services were provided according to physician order.
Failure to ensure food was served in a sanitary manner; food was not labeled, floors and equipment were soiled.
Failure to ensure staff performed proper hand hygiene and sanitation practices while providing care.
Failure to ensure service plans were completed every 6 months and signed by residents.
Report Facts
Survey dates: 2024-08-12 to 2024-08-19
Census Bed Type: 91
Residential Census: 56
Residents reviewed for ADL care: 4
Residents reviewed for accident prevention: 2
Falls documented for Resident 30: 10
Residents reviewed for catheter care: 1
Residents reviewed for nutrition: 1
Residents reviewed for oxygen therapy: 1
Residents reviewed for infection control: 4
Residents reviewed for service plans: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Clinical Support 5 | Provided multiple interviews and policies related to bathing, falls, catheter care, weight tracking, respiratory equipment, and infection control. | |
| Assistant Director of Nursing | ADON | Provided interviews regarding bathing documentation, oxygen therapy, and weight fluctuations. |
| Licensed Practical Nurse 4 | LPN | Observed failing to perform hand hygiene after glove removal and before charting. |
| Certified Nurse Aide 6 | CNA | Observed failing to perform hand hygiene after care and handling soiled linens. |
| Registered Nurse 11 | RN | Observed performing wound care with improper hand hygiene. |
| Dietary Manager | Interviewed regarding food labeling and kitchen cleaning practices. | |
| Administrator | Provided current food labeling and dating policy. |
Inspection Report
Routine
Deficiencies: 7
Date: Aug 12, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulations related to resident care, safety, infection control, nutrition, and facility operations at West River Health Campus.
Findings
The facility was found deficient in multiple areas including failure to provide adequate bathing and ADL care to residents, inadequate supervision and fall prevention interventions, improper catheter care leading to infection, failure to address significant weight loss, improper respiratory care, unsanitary food handling practices, and inadequate infection prevention and control practices including hand hygiene.
Deficiencies (7)
Failure to ensure residents dependent on staff for activities of daily living were bathed as scheduled.
Failure to ensure adequate supervision and interventions to prevent accidents and falls for residents.
Failure to provide appropriate care to prevent catheter-associated urinary tract infection resulting in septic shock and pneumonia.
Failure to address and follow recommendations for significant weight loss in a resident.
Failure to provide safe and appropriate respiratory care including proper labeling and maintenance of oxygen equipment.
Failure to ensure food was served in a sanitary manner; food was unlabeled, floors and equipment were soiled.
Failure to ensure staff performed proper hand hygiene and sanitation practices while providing care.
Report Facts
Deficiencies cited: 7
Resident falls: 10
Resident weight loss: 46.4
Oxygen flow rate: 3
Oxygen flow rate observed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Clinical Support 5 | Provided policies and interviews related to bathing, falls management, catheter care, weight tracking, respiratory equipment, and infection control. | |
| Assistant Director of Nursing | ADON | Provided interviews regarding bathing care, fall interventions, oxygen equipment maintenance, and weight measurement issues. |
| LPN 4 | Licensed Practical Nurse | Observed providing blood glucose level check without hand hygiene. |
| RN 11 | Registered Nurse | Observed performing wound care with partial hand hygiene compliance. |
| Dietary Manager | Interviewed regarding food labeling and kitchen sanitation. | |
| CNA 6 | Certified Nursing Assistant | Observed providing resident care and hand hygiene practices. |
| LPN 12 | Licensed Practical Nurse | Interviewed regarding oxygen tubing and humidification bottle changes. |
| Regional Clinical | Interviewed regarding weight measurement and nursing tasks. |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 93
Deficiencies: 0
Date: Jun 20, 2024
Visit Reason
This visit was for the investigation of complaints IN00436597 and IN00434360.
Complaint Details
Complaint IN00436597 and IN00434360 were investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies related to the allegations were cited for either complaint. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type Total: 93
Census Payor Type Total: 42
SNF Beds: 21
SNF/NF Beds: 21
Residential Beds: 51
Medicare Residents: 17
Medicaid Residents: 18
Other Residents: 7
Inspection Report
Complaint Investigation
Census: 46
Capacity: 97
Deficiencies: 1
Date: May 9, 2024
Visit Reason
The visit was conducted for the investigation of complaints IN00432902, IN00433296, and IN00431331 related to allegations of deficient care.
Complaint Details
This investigation was triggered by complaints IN00432902, IN00433296, and IN00431331. The deficiencies cited were related to these complaints and substantiated by observations, interviews, and record reviews.
Findings
The facility failed to provide adequate supervision and fall prevention measures for a cognitively impaired resident, resulting in an unwitnessed fall and a left clavicle fracture. The bed was not kept in the low position with a fall mat as required by the care plan.
Deficiencies (1)
Failed to ensure effective supervision and fall prevention for a cognitively impaired resident, resulting in an unwitnessed fall and clavicle fracture.
Report Facts
Census Bed Type - Total: 97
Census Payor Type - Total: 46
Fall Risk Score: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in the fall incident for failing to ensure bed was in low position with fall mat |
| CNA 2 | Certified Nursing Assistant | Named in the fall incident and interview statements regarding bed position |
| Director of Nursing | Director of Nursing | Provided interview and statements regarding the fall and post-fall investigation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 9, 2024
Visit Reason
The inspection was conducted due to complaints related to fall prevention and supervision at the nursing home. The visit aimed to investigate the facility's compliance with ensuring adequate supervision and accident hazard prevention for residents at risk of falls.
Complaint Details
This citation relates to Complaints IN00432902, IN00433296, IN00431331. The investigation found the facility did not ensure fall prevention interventions were implemented, leading to an unwitnessed fall and injury to Resident B.
Findings
The facility failed to provide effective supervision and failed to ensure the resident's bed was in the low position with a fall mat as per the care plan, resulting in an unwitnessed fall and a left clavicle fracture for Resident B. The investigation included observations, interviews, and record reviews confirming the deficient practice and subsequent corrective actions.
Deficiencies (1)
Failed to ensure effective supervision to prevent falls and failed to ensure the bed was in low position with a fall mat as per plan of care for a cognitively impaired resident, resulting in an unwitnessed fall and clavicle fracture.
Report Facts
Fall risk score: 20
Dates of interviews: CNA 1 interviewed on 2/9/24; CNA 2 interviewed on 2/13/24.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Named in the finding for exiting Resident B's room without ensuring bed was in low position with fall mat, contributing to the fall. | |
| CNA 2 | Named in the finding; assisted with Resident B and provided statement regarding bed position knowledge. | |
| Director of Nursing | DON | Observed bed not in low position after fall and provided statements regarding post-fall investigation. |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 0
Date: Jan 8, 2024
Visit Reason
This visit was conducted for the investigation of three complaints: IN00423571, IN00419282, and IN00420899.
Complaint Details
Investigation of Complaint IN00423571, IN00419282, and IN00420899 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census Bed Type: 89
Census Bed Type - SNF: 20
Census Bed Type - SNF/NF: 21
Census Bed Type - Residential: 48
Census Payor Type - Medicare: 13
Census Payor Type - Medicaid: 21
Census Payor Type - Other: 7
Census Payor Type - Total: 41
Inspection Report
Re-Inspection
Census: 38
Capacity: 90
Deficiencies: 0
Date: Oct 25, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the investigation of Nursing Home Complaint IN00416986 and Residential Complaint IN00412478, both completed on September 8, 2023.
Complaint Details
Complaint IN00416986 was corrected as of this visit.
Findings
West River Health Campus 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 Nursing Home Complaint IN00416986.
Report Facts
Census Bed Type - SNF: 20
Census Bed Type - SNF/NF: 18
Census Bed Type - Residential: 52
Total Capacity: 90
Census Payor Type - Medicare: 13
Census Payor Type - Medicaid: 16
Census Payor Type - Other: 9
Current Census: 38
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 2
Date: Sep 8, 2023
Visit Reason
This visit was conducted for the investigation of Nursing Home Complaint IN00416986 and Residential Complaint IN00412478. The investigation focused on allegations related to quality of care and abuse.
Complaint Details
Complaint IN00416986 was substantiated with federal/state deficiencies cited at F684 related to medication order issues. Complaint IN00412478 was investigated with no deficiencies related to the allegations. The abuse allegation involving QMA 1 pulling Resident H's hair was substantiated, resulting in termination of the employee.
Findings
The facility failed to ensure physician medication orders were properly implemented for one resident, and failed to prevent physical and mental abuse for another resident. Deficiencies related to the nursing home complaint were cited, while no deficiencies were found related to the residential complaint.
Deficiencies (2)
Failed to ensure physician medication orders were put in place for 1 of 3 residents reviewed; a medication dosage increase was not done (Resident E).
Failed to ensure residents were free from physical and mental abuse for 1 of 3 residents reviewed; staff member threatened to pull resident's hair after placing hair in her hand (Resident H).
Report Facts
Census Bed Type - Total: 82
Census Bed Type - SNF/NF: 19
Census Bed Type - SNF: 8
Census Bed Type - Residential: 55
Census Payor Type - Total: 27
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 16
Census Payor Type - Other: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Stallman | RN-BC, Clinical Support | Signed the report |
| QMA 1 | Qualified Medication Aide | Named in abuse finding for pulling resident's hair; employment terminated |
| CNA 1 | Reported abuse allegation against QMA 1 | |
| Executive Director | Administrator | Notified of abuse allegation and oversaw investigation |
| DHS | Director of Health Services | Involved in investigation and reporting of abuse allegation |
| NP | Nurse Practitioner | Provided testimony regarding medication order for Resident E |
| LPN 1 | Licensed Practical Nurse | Described process for receiving physician orders |
| Clinical Support Nurse | Provided policy on medication orders and described order process |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 8, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to the facility's failure to ensure physician medication orders were properly implemented for a resident, specifically regarding a medication dosage increase that was not done.
Complaint Details
This Federal tag relates to Complaint IN00416986.
Findings
The facility failed to ensure physician medication orders were put in place for one resident, resulting in a missed medication dosage increase. The nurse practitioner had ordered an increased dose verbally or in writing, but the order was not documented or implemented in the medication administration record.
Deficiencies (1)
Failure to ensure physician medication orders were put in place for one resident, including a missed medication dosage increase.
Report Facts
Medication administrations: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Indicated process for receiving physician orders and communication with triage |
| Clinical Support Nurse | Provided policy on medication orders and described order communication methods | |
| Nurse Practitioner | NP | Visited Resident E and wrote order to increase medication dose |
Inspection Report
Life Safety
Census: 30
Capacity: 61
Deficiencies: 0
Date: Aug 28, 2023
Visit Reason
A Life Safety Code and Environmental Preoccupancy Survey was conducted by the Indiana Department of Health for the facility renovation in the 300 Hall, including converting resident rooms into common areas and remodeling a courtyard.
Findings
The remodeled portion of the 300 unit at West River Health Campus was found in compliance with Medicare/Medicaid participation requirements, Life Safety Code from Fire, NFPA 101, and Indiana's Health Facilities Rules. The facility is fully sprinklered with a fire alarm system and all resident-accessible areas are sprinklered.
Report Facts
Facility capacity: 61
Census: 30
Inspection Report
Re-Inspection
Census: 35
Capacity: 61
Deficiencies: 0
Date: Jul 19, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 06/07/23 by the Indiana Department of Health.
Findings
West River Health Campus 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.
Inspection Report
Re-Inspection
Census: 84
Deficiencies: 0
Date: Jun 13, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 2023-05-15, including a PSR to the State Residential Licensure Survey completed on the same date.
Findings
West River Health Campus 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 Bed Type - SNF/NF: 17
Census Bed Type - SNF: 15
Census Bed Type - Residential: 52
Census Bed Type - Total: 84
Census Payor Type - Medicare: 10
Census Payor Type - Medicaid: 15
Census Payor Type - Other: 7
Census Payor Type - Total: 32
Inspection Report
Life Safety
Census: 32
Capacity: 61
Deficiencies: 4
Date: Jun 7, 2023
Visit Reason
The visit was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 standards.
Findings
The facility was found not in compliance with Life Safety Code requirements, including issues with fire door closures, delayed egress locking arrangements, and fire drill documentation. Specific deficiencies involved a fire door that did not close and latch properly, delayed egress doors that failed to release upon activation, a locked exit gate that was not readily accessible, and incomplete fire drill documentation.
Deficiencies (4)
Failed to ensure 1 of 2 single fire doors in the 2 hour fire separation wall closed fully and latched when tested.
Failed to ensure 2 of 9 delayed egress locking arrangements released the lock within required time upon application of force to the release device.
Failed to ensure the means of egress through 1 of 1 locked exit courtyard gate was readily accessible for residents, staff, and visitors.
Failed to ensure 1 of 12 fire drill reports included complete documentation of the transmission of a fire alarm signal to the monitoring company/fire department during the past twelve months.
Report Facts
Facility capacity: 61
Census: 32
Delayed egress doors: 2
Fire drill reports: 1
Fire drills frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maddison Cook | Laboratory Director or Provider/Supplier Representative | Signed the report |
| Director of Plant Operations | Named in multiple findings related to fire door and egress door deficiencies and corrective actions | |
| Executive Director | Involved in review of findings and corrective action plans |
Inspection Report
Annual Inspection
Census: 52
Capacity: 85
Deficiencies: 9
Date: May 15, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey including a State Residential Licensure Survey conducted May 9-15, 2023.
Findings
The facility was found to have multiple deficiencies including failure to provide necessary documentation for Medicaid/Medicare coverage notices, improper use of psychotropic medications, medication errors, improper medication storage, food safety violations including improper labeling and dishwasher temperature monitoring, failure to invite fire department to fire drills, and incomplete resident evaluations and service plans.
Deficiencies (9)
Failed to provide Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) before proposed end of services for 2 of 3 beneficiary notices reviewed.
Failed to ensure residents were free from unnecessary psychotropic medications; one resident had PRN anti-anxiety medication ordered for greater than 14 days without proper evaluation.
Medication error rate of 8% observed with 2 errors during 25 medication administration opportunities.
Failed to ensure proper storage of medications; loose pills found in medication carts and storage rooms, incomplete refrigerator temperature logs.
Failed to ensure food was stored appropriately; food not labeled correctly, left open to air, expired food not discarded, and dishwasher temperatures not consistently documented or at appropriate levels.
Failed to invite fire department to attend fire drills at least every 6 months.
Failed to ensure semi-annual resident evaluations were completed or signed for 2 of 5 residents reviewed.
Failed to assess resident capability for self-administration of medications for 1 of 3 residents observed self-administering medications.
Failed to ensure service plans were completed or signed by resident or responsible party for 2 of 5 residents reviewed.
Report Facts
Census SNF/NF: 19
Census SNF: 14
Census Residential: 52
Total Capacity: 85
Census Payor Medicare: 8
Census Payor Medicaid: 19
Census Payor Other: 6
Medication Administration Opportunities: 25
Medication Errors: 2
Medication Error Rate: 8
Dishwasher Temperature Logs Missing Dates: 9
Fire Drills per Year: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Stallman | RN-BC Clinical Support | Signed report |
Inspection Report
Deficiencies: 4
Date: May 15, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulations related to medication management, medication storage, food safety, and overall facility regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to ensure residents were free from unnecessary medications, medication error rates exceeding 5%, improper medication storage with loose pills and incomplete temperature logs, and food safety violations including improper food labeling, expired food not discarded, and inadequate dishwasher temperature monitoring.
Deficiencies (4)
Failure to ensure residents were free from unnecessary medications; a resident's as needed anti-anxiety medication was ordered for greater than 14 days without physician reassessment.
Medication error rate exceeded 5% with 2 errors observed during 25 medication administration opportunities, including a resident choking on partially crushed medication and incorrect dose administration.
Improper storage of medications with loose pills found in medication carts and incomplete refrigerator temperature logs in medication storage rooms.
Food safety violations including unlabeled and open food items, expired food not discarded, and dishwasher final wash temperatures not consistently documented or at appropriate levels.
Report Facts
Medication error rate: 8
Medication administration opportunities: 25
Medication errors observed: 2
Medication doses administered: 10
Medication doses ordered: 2
Dishwasher final rinse temperature: 170
Dishwasher final rinse temperature: 180
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 3 | Licensed Practical Nurse | Observed administering medications and involved in medication error findings |
| RN 7 | Registered Nurse | Provided information about medication cart cleaning responsibilities and medication storage |
| Kitchen Manager | Provided information about dishwasher temperature monitoring and food labeling practices | |
| Kitchen Staff 2 | Provided information about dishwasher temperature gauge readings | |
| Regional Consultant | Provided interviews and policies related to medication administration and storage, and food safety |
Inspection Report
Complaint Investigation
Census: 31
Capacity: 85
Deficiencies: 1
Date: Apr 21, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00405930 regarding federal and state deficiencies related to the allegations.
Complaint Details
Complaint IN00405930 was substantiated with federal/state deficiencies cited at F656 related to failure to follow the plan of care for fall interventions for Resident D.
Findings
The facility failed to ensure the plan of care was followed for 1 of 3 residents reviewed (Resident D), specifically a fall intervention involving placement of dycem on the air mattress was not implemented as ordered.
Deficiencies (1)
Failure to develop and implement a comprehensive person-centered care plan including fall interventions for Resident D.
Report Facts
Census SNF beds: 14
Census SNF/NF beds: 17
Census Residential beds: 54
Total licensed capacity: 85
Census Medicare residents: 8
Census Medicaid residents: 16
Census Other payor residents: 7
Total census: 31
Fall intervention frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Stallman | RN-BC, Clinical Support | Signed the report and provided policy information |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 21, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00405930.
Complaint Details
Investigation of Complaint IN00405930; the facility was found to be in compliance.
Findings
West River Health Campus 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 the complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 21, 2023
Visit Reason
The inspection was conducted in response to a complaint (IN00405930) regarding the facility's failure to follow the plan of care for a resident, specifically related to fall interventions.
Complaint Details
This Federal tag relates to Complaint IN00405930.
Findings
The facility failed to ensure the plan of care was followed for Resident D, who was at risk for falls. The required fall intervention, placement of dycem on the mattress, was not implemented as observed during the visit.
Deficiencies (1)
Failure to develop and implement a complete care plan that meets all the resident's needs, including fall interventions.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Clinical Support Nurse | Provided the current Fall Management Program Guidelines policy. | |
| CNA 1 | Observed making Resident D's bed and described fall interventions in place. | |
| CNA 2 | Indicated linens applied when making Resident D's bed and fall interventions in place. |
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 0
Date: Dec 21, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00391979.
Complaint Details
Complaint IN00391979 was substantiated but no deficiencies were cited related to the allegation.
Findings
The complaint was substantiated; however, no deficiencies were cited related to the allegation. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type - SNF: 17
Census Bed Type - SNF/NF: 22
Census Bed Type - Residential: 45
Census Total: 84
Census Payor Type - Medicare: 10
Census Payor Type - Medicaid: 18
Census Payor Type - Other: 11
Census Payor Type - Total: 39
Inspection Report
Complaint Investigation
Census: 50
Capacity: 88
Deficiencies: 2
Date: Sep 12, 2022
Visit Reason
This visit was for Investigation of Nursing Home Complaint IN00388820 and IN00389251, including a COVID-19 Focused Infection Control Survey and a Residential COVID-19 Quality Assurance Walk Through.
Complaint Details
Complaint IN00388820 was substantiated with deficiencies cited at F888. Complaint IN00389251 was unsubstantiated due to lack of evidence.
Findings
Complaint IN00388820 was substantiated with federal/state deficiencies cited at F888 related to staff COVID-19 vaccination and care plan compliance. Complaint IN00389251 was unsubstantiated due to lack of evidence. The facility failed to ensure physician orders were followed for one resident transfer and failed to comply with staff COVID-19 vaccination requirements for some employees.
Deficiencies (2)
Failure to ensure physician orders were followed for resident transfer (Resident B).
Failure to comply with COVID-19 vaccination requirements for facility staff, including partially vaccinated staff without exemption and medical exemptions not meeting clinical contraindications.
Report Facts
Survey dates: September 8, 9, 12, 2022
Census Bed Type - Total Capacity: 88
Census - Residents present: 50
Census Payor Type - Total: 38
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee 1 | Partially vaccinated staff without exemption; involved in COVID-19 vaccination deficiency | |
| Employee 2 | Staff with medical exemption not meeting clinical contraindications; involved in COVID-19 vaccination deficiency | |
| Employee 3 | Staff with medical exemption not meeting clinical contraindications; involved in COVID-19 vaccination deficiency |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 12, 2022
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00388820 and the Nursing Home Covid 19 Focused Infection Control Survey.
Complaint Details
Investigation of Complaint IN00388820 was reviewed and found to be in compliance.
Findings
West River Health Campus 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 the complaint investigation and the Covid 19 focused infection control survey.
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