Deficiencies per Year
16
12
8
4
0
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Follow-Up
Census: 59
Capacity: 100
Deficiencies: 2
Jun 30, 2025
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey that exited on 04/29/25 by the Indiana Department of Health.
Findings
At this PSR survey, Willows of Greensburg was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers. However, deficiencies were noted related to corridor areas open to the corridor and HVAC systems, with temporary and continuing annual waivers approved.
Severity Breakdown
SS=E: 1
SS=F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Corridors - Areas Open to Corridor spaces not meeting criteria under 18.3.6.1 and 19.3.6.1 | SS=E |
| HVAC heating, ventilation, and air conditioning not meeting requirements of 9.2 and manufacturer's specifications | SS=F |
Report Facts
Certified beds: 100
Census: 59
Inspection Report
Re-Inspection
Census: 62
Capacity: 62
Deficiencies: 0
May 5, 2025
Visit Reason
This visit was for a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 2025-04-07.
Findings
Willows of Greensburg 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: 2
Census Payor Type - Medicaid: 34
Census Payor Type - Other: 26
Inspection Report
Routine
Census: 57
Capacity: 100
Deficiencies: 15
Apr 29, 2025
Visit Reason
Routine Emergency Preparedness, Life Safety Code, and related regulatory inspections were conducted by the Indiana Department of Health on 04/29/2025.
Findings
The facility was found in substantial compliance with Emergency Preparedness requirements but had multiple deficiencies in Life Safety Code and other regulatory areas including corridor obstructions, exit signage, smoke alarm maintenance, hazardous area door self-closures, kitchen staff training on fire suppression, sprinkler system obstructions, corridor use violations, electrical safety, HVAC system issues, fire evacuation plans, fire drills, and electrical equipment maintenance.
Severity Breakdown
SS=C: 3
SS=E: 8
SS=F: 4
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to provide complete documentation for Emergency Preparedness Plan exercises. | SS=C |
| One corridor means of egress was obstructed by wheeled equipment reducing clear width. | SS=E |
| Two means of egress were obstructed by parked vehicles at exit discharge points. | SS=E |
| Activities area door to outside was not posted with required 'NO EXIT' sign. | SS=E |
| Failed to perform monthly cleaning of battery-operated smoke alarms as per manufacturer instructions. | SS=F |
| Five hazardous area doors lacked properly working self-closing devices. | SS=E |
| Staff not properly instructed on use of UL 300 hood fire suppression system in kitchen. | SS=E |
| Sprinkler heads obstructed or installed less than 4 inches from walls; missing escutcheons. | SS=E |
| One corridor used as treatment room and another corridor used as hazardous area with storage of pallet. | SS=E |
| Two electrical junction boxes not maintained in safe operating condition with exposed wiring. | SS=E |
| Egress corridors used as return air system serving adjoining rooms, requiring waiver. | SS=F |
| Written fire evacuation plan lacked components identifying smoke compartments and evacuation routes. | SS=F |
| Failed to conduct quarterly fire drills on unexpected days and times. | SS=C |
| Power strip used as substitute for fixed wiring to power high current equipment. | SS=E |
| Failed to conduct required maintenance and maintain documentation for Patient Care Related Electrical Equipment (PCREE). | SS=F |
Report Facts
Certified beds: 100
Census: 57
Deficiencies cited: 15
Fire drills reviewed: 12
Fire drills conducted near month end: 9
Residents potentially affected by corridor obstruction: 22
Residents potentially affected by corridor treatment room use: 8
Residents potentially affected by hazardous area corridor: 8
Residents potentially affected by sprinkler obstruction: 4
Residents potentially affected by electrical junction box issues: 15
Residents potentially affected by HVAC corridor return air use: all
Estimated cost to fix HVAC deficiency: 250000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelsey Meal | Event Director | Signed the inspection report |
Inspection Report
Annual Inspection
Census: 60
Capacity: 60
Deficiencies: 10
Apr 7, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted over April 1-4 and 7, 2025.
Findings
The facility was found deficient in multiple areas including failure to ensure survey results were posted, incomplete documentation of advance directives, failure to follow care plans for fall interventions, medication administration errors, incomplete meal consumption documentation, inadequate RN coverage, medication transcription errors, improper medication storage, delayed laboratory specimen collection, and infection control issues related to PICC lines and urinary catheters.
Severity Breakdown
SS=C: 1
SS=D: 7
SS=E: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to ensure State Survey Results were available to view for 3 of 5 days during the survey. | SS=C |
| Failed to document an appropriate advance directive for 1 of 16 residents reviewed. | SS=D |
| Failed to ensure care planned interventions were followed related to fall interventions and care plans for PTSD were incomplete for 6 of 16 residents. | SS=E |
| Failed to follow MD orders related to cardiac medication administration order parameters for 1 of 16 residents. | SS=D |
| Failed to document meal consumption for 1 of 1 residents reviewed for nutrition. | SS=D |
| Failed to provide required RN coverage for eight consecutive hours a day for 2 of 7 days reviewed. | SS=D |
| Failed to transcribe medications on admission for 1 of 16 residents reviewed for pharmacy services. | SS=D |
| Failed to appropriately store medications in one medication room; opened vials not labeled with opened date. | SS=D |
| Failed to obtain a urinalysis in a timely manner for 1 of 6 residents reviewed for laboratory services. | SS=D |
| Failed to follow infection control guidelines related to PICC lines and indwelling urinary catheters for 3 of 6 residents reviewed. | SS=D |
Report Facts
Survey dates: 5
Census: 60
Total capacity: 60
Residents reviewed for advance directives: 16
Residents reviewed for care plans: 16
Residents reviewed for medication administration: 16
Residents reviewed for nutrition: 1
Days without 8 consecutive RN hours: 2
Residents reviewed for pharmacy services: 16
Residents reviewed for laboratory services: 6
Residents reviewed for infection control: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelsey Meal | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Licensed Practical Nurse 2 | Interviewed regarding advance directives, medication storage, and lab specimen collection | |
| Licensed Practical Nurse 5 | Interviewed regarding fall interventions and medication administration | |
| Licensed Practical Nurse 7 | Interviewed regarding medication administration and lab specimen collection | |
| Certified Nurse Aide 3 | Interviewed regarding fall interventions and catheter care | |
| Certified Nurse Aide 9 | Interviewed regarding catheter care | |
| Director of Nursing | DON | Interviewed regarding medication transcription, lab services, RN coverage, and infection control |
| Social Service Director | SSD | Interviewed regarding care plans for PTSD |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 57
Deficiencies: 0
Jan 28, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00450466.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00450466 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 5
Medicaid census: 31
Other payor census: 21
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 24, 2025
Visit Reason
The inspection was conducted as a paper compliance review of the Investigation of Complaint IN00449496 completed on December 19, 2024.
Findings
Willows of Greensburg was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the complaint investigation.
Complaint Details
Complaint IN00449496 was investigated and found to be corrected.
Inspection Report
Re-Inspection
Census: 57
Capacity: 57
Deficiencies: 1
Dec 19, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to unrelated deficiencies cited from the investigation of Nursing Home Complaints IN00445105 and IN00444920 completed on November 1, 2024, and was conducted in conjunction with investigations of additional complaints IN00447315, IN00447802, IN00447914, and IN00449496.
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 PSR to unrelated deficiencies. No deficiencies were cited related to complaints IN00447315, IN00447802, and IN00447914. One federal/state deficiency related to complaint IN00449496 was cited at F842.
Complaint Details
Complaint IN00447315 - No deficiencies related to the allegations are cited. Complaint IN00447802 - No deficiencies related to the allegations are cited. Complaint IN00447914 - No deficiencies related to the allegations are cited. Complaint IN00449496 - Federal/State deficiency related to the allegation is cited at F842.
Deficiencies (1)
| Description |
|---|
| Federal/State deficiency related to complaint IN00449496 cited at F842 |
Report Facts
Census SNF/NF beds: 57
Total licensed capacity: 57
Medicare census: 7
Medicaid census: 28
Inspection Report
Complaint Investigation
Census: 57
Capacity: 57
Deficiencies: 2
Dec 18, 2024
Visit Reason
This visit was for the investigation of complaints IN00447315, IN00447802, IN00447914, and IN00449496, in conjunction with a Post Survey Revisit to unrelated deficiencies cited from previous nursing home complaints completed on November 1, 2024.
Findings
The facility failed to ensure a resident (Resident E) received appropriate care and treatment in a timely manner after an unwitnessed fall, and failed to document and report the fall properly. The resident sustained a fractured right hip after the fall, which was not initially reported or documented by nursing staff. The facility implemented corrective actions including staff in-service training and quality assurance monitoring.
Complaint Details
Complaint IN00449496 was substantiated with federal/state deficiencies cited at F842 and F689 related to failure in timely care and documentation after a resident fall. Complaints IN00447315, IN00447802, and IN00447914 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure a resident received appropriate care and treatment in a timely manner after an unwitnessed fall. | SS=D |
| Failed to document and report forward of a resident's fall to ensure appropriate care and treatment in a timely manner. | SS=D |
Report Facts
Census: 57
Total Capacity: 57
Medicare Census: 7
Medicaid Census: 28
Other Payor Census: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide 2 | CNA | Witnessed resident fall and reported observations to nursing staff |
| Licensed Practical Nurse 3 | LPN | Assessed resident after fall, failed to document or report fall, no longer employed |
| Director of Nursing | DON | Interviewed regarding fall procedures and investigation |
| Nurse Practitioner | NP | Assessed resident post-fall and ordered X-ray |
| Executive Director | Executive Director | Conducted staff in-service training and chart audits as part of corrective action |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 60
Deficiencies: 4
Nov 1, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00445105 and IN00444920. Both complaints were found to have no deficiencies related to the allegations, but unrelated deficiencies were cited during the survey conducted on October 30, 31, and November 1, 2024.
Findings
The facility failed to report an allegation of abuse to the Indiana Department of Health within two hours for 1 of 4 residents reviewed (Resident F). Additionally, the facility failed to accurately complete Minimum Data Set (MDS) assessments, revise behavior care plans, and properly monitor and document behavioral health services for Resident F. Multiple interviews and record reviews documented inappropriate staff-resident interactions and inadequate behavior management and documentation.
Complaint Details
Complaint IN00445105 - No deficiencies related to the allegations are cited. Complaint IN00444920 - No deficiencies related to the allegations are cited.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to report an allegation of abuse to the Indiana Department of Health within two hours for 1 of 4 residents reviewed (Resident F). | SS=D |
| Failed to ensure Minimum Data Set (MDS) assessments were accurately completed for 1 of 4 residents related to behaviors (Resident F). | SS=D |
| Failed to revise a resident's behavior care plan related to interventions for 1 of 4 residents reviewed (Resident F). | SS=D |
| Failed to monitor, completely document, and address a resident's behaviors related to health services for 1 of 4 residents reviewed (Resident F). | SS=D |
Report Facts
Census: 60
Total Capacity: 60
Medicare Census: 8
Medicaid Census: 32
Other Payor Census: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelsey Meal | HFA | Signed as Laboratory Director's or Provider/Supplier Representative |
| Staff Member 11 | Named in abuse allegation involving Resident F | |
| Staff Member 50 | Witnessed inappropriate interactions between Staff Member 11 and Resident F | |
| Staff Member 32 | Witnessed inappropriate interactions between Staff Member 11 and Resident F | |
| Staff Member 9 | Reported Staff Member 11 allowed inappropriate touching by Resident F | |
| Director Of Nursing | DON | Interviewed regarding Resident F's behaviors and care |
| Social Services Director | Responsible for MDS assessment modifications and care plan updates | |
| Administrator | Interviewed about abuse allegation reporting and Social Service Director coverage | |
| CNA 30 | Observed Resident F's behaviors during care | |
| Staff Member 21 | Reported Resident F's aggressive grabbing behaviors | |
| Staff Member 38 | Reported Resident F's aggressive grabbing behaviors | |
| Staff Member 16 | Reported Resident F's inappropriate grabbing and touching behaviors | |
| Staff Member 27 | Reported Resident F's constant grabbing of female staff |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 52
Deficiencies: 0
Aug 5, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00438778.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00438778 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Medicaid residents: 28
Census Other residents: 24
Inspection Report
Annual Inspection
Deficiencies: 0
Jul 23, 2024
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey was conducted.
Findings
Willows of Greensburg was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Capacity: 100
Deficiencies: 0
Jul 10, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 06/12/24 by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
Willows of Greensburg was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility is fully sprinkled with a fire alarm system and smoke detection throughout.
Report Facts
Facility capacity: 100
Inspection Report
Life Safety
Census: 51
Capacity: 100
Deficiencies: 3
Jun 12, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 06/12/2024 to assess compliance with federal and state regulations including 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies included improper maintenance of sprinkler systems, corridor doors failing to latch properly, use of egress corridors as return air systems, and HVAC system issues.
Severity Breakdown
SS=E: 2
SS=F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to maintain sprinkler system in accordance with NFPA 25; wire and conduit draped across sprinkler pipe in attic over Main Electrical Room. | SS=E |
| Corridor doors failed to latch properly, affecting kitchen mop and chemical storage room, kitchen door to dining area, dietary door to service hall, and janitors closet door. | SS=E |
| Egress corridors were used as a return air system serving adjoining rooms, which is not compliant with NFPA 90A. | SS=F |
Report Facts
Certified beds: 100
Census: 51
Residents potentially affected by sprinkler deficiency: 15
Residents and staff potentially affected by door deficiency: 18
Egress corridors affected: 8
Estimated cost to fix HVAC deficiency: 250000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Meadows | Laboratory Director or Provider/Supplier Representative | Signed the report |
| Maintenance Director | Interviewed regarding sprinkler system and door deficiencies; responsible for corrective actions | |
| Interim Administrator | Interviewed and present at exit conference |
Inspection Report
Annual Inspection
Census: 56
Capacity: 56
Deficiencies: 3
May 30, 2024
Visit Reason
This visit was for a Recertification and State licensure survey conducted from May 23 to May 30, 2024.
Findings
The facility was found deficient in quality of care related to insulin pen usage and blood pressure medication administration for 2 residents, urinary catheter care education for 1 resident, and infection control practices related to urinary catheters for another resident. Corrective actions and education plans were implemented for affected residents and staff.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to follow manufacturer's guidelines related to insulin pen usage and physician's orders for blood pressure medication hold parameters for 2 of 7 residents reviewed for quality of care. | SS=D |
| Failed to provide resident education related to urinary catheter care and risk of placement for 1 of 2 residents reviewed for urinary catheters. | SS=D |
| Failed to follow infection control guidelines related to indwelling urinary catheters for 1 of 2 residents reviewed for urinary catheters. | SS=D |
Report Facts
Survey dates: 8
Residents reviewed for quality of care: 7
Days lacking blood pressure documentation: 52
Residents reviewed for urinary catheter care: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Meadows | Laboratory Director or Provider/Supplier Representative | Signed the inspection report |
| RN 3 | Nurse observed administering insulin pens incorrectly | |
| QMA 4 | Qualified Medication Aide | Interviewed regarding medication hold parameters |
| CNA 2 | Certified Nurse Aide | Interviewed regarding urinary catheter care and catheter bag placement |
| DON | Director of Nursing | Provided facility policies and education plans, interviewed about catheter care education and infection control |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 59
Deficiencies: 0
Apr 25, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00430637.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00430637 was investigated and found to have no deficiencies related to the allegation.
Report Facts
Medicare residents: 2
Medicaid residents: 31
Other payor residents: 26
Inspection Report
Complaint Investigation
Census: 55
Capacity: 55
Deficiencies: 1
Feb 2, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00425267 regarding pharmacy services and medication administration.
Findings
The facility failed to ensure that a resident received the correct prescribed medications, resulting in one resident receiving another resident's medications. The incident involved a Qualified Medication Aide (QMA) who did not supervise medication administration properly. The facility implemented corrective actions including staff education and monitoring.
Complaint Details
Complaint IN00425267 was substantiated with a Federal/State deficiency cited at F755 related to medication administration errors.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to assure the appropriate resident received prescribed medications for 1 of 4 residents reviewed for pharmacy services (Resident B). | SS=D |
Report Facts
Census: 55
Total Capacity: 55
Residents reviewed for pharmacy services: 4
Medicare residents: 1
Medicaid residents: 29
Other payor residents: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Qualified Medication Aide (QMA) | Involved in medication administration error | |
| Director of Nursing (DON) | Provided information about medication administration procedures and incident |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 57
Deficiencies: 0
Dec 21, 2023
Visit Reason
This visit was conducted for the investigation of two complaints, IN00423012 and IN00421016, regarding the facility.
Findings
No deficiencies related to the allegations in either complaint were cited. The facility was found to be in compliance with relevant federal and state regulations.
Complaint Details
Complaint IN00423012 and Complaint IN00421016 were investigated; no deficiencies related to the allegations were cited.
Report Facts
Census Bed Type: 57
Medicare Census: 5
Medicaid Census: 34
Other Payor Census: 18
Inspection Report
Complaint Investigation
Census: 58
Capacity: 58
Deficiencies: 0
Oct 4, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00416772.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00416772 found no deficiencies related to the allegations.
Report Facts
Census: 58
Total Capacity: 58
Medicare Census: 4
Medicaid Census: 27
Other Payor Census: 27
Inspection Report
Complaint Investigation
Census: 52
Capacity: 52
Deficiencies: 0
Aug 17, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00411977.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00411977; no deficiencies related to the allegations were cited.
Report Facts
Medicare residents: 2
Medicaid residents: 23
Other residents: 27
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 1, 2023
Visit Reason
This document is a Plan of Correction following a Paper Compliance Post Survey Revisit (PSR) that exited on 05/23/23 and a Life Safety Code Recertification and State Licensure Survey that exited on 04/12/23.
Findings
Heritage House of Greensburg 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, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Re-Inspection
Census: 50
Capacity: 100
Deficiencies: 1
May 23, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 04/12/23 was conducted by the Indiana Department of Health to verify compliance with fire safety regulations.
Findings
The facility was found not in compliance with Life Safety Code requirements related to HVAC systems using egress corridors as return air systems. A waiver request was submitted due to the high cost of correction and prior waiver granted in 2017. Smoke and duct detectors and smoke dampers were installed to mitigate risk.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure egress corridors were not used as a portion of a return air system serving adjoining rooms in 8 of 8 egress corridors. | SS=F |
Report Facts
Facility capacity: 100
Census: 50
Estimated cost to fix deficiency: 250000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vicki Mcguire | Administrator | Administrator acknowledged the finding and was present at exit conference |
Inspection Report
Annual Inspection
Deficiencies: 0
May 15, 2023
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure survey conducted on March 27, 2023.
Findings
Heritage House of Greensburg was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Annual Inspection
Census: 49
Capacity: 100
Deficiencies: 7
Apr 12, 2023
Visit Reason
An annual Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health to assess compliance with Medicare/Medicaid participation requirements and life safety codes.
Findings
The facility was found not in compliance with several Life Safety Code requirements including missing signage on delayed egress doors, uneven exit discharge surfaces, inaccurate fire alarm system time and date, hazardous storage in corridor alcoves, corridor doors not properly closing or latching, improper smoking area maintenance, and lack of documentation for electrical receptacle testing.
Deficiencies (7)
| Description |
|---|
| Delayed egress exit door lacked proper signage indicating doors can be opened in 15 seconds by pushing. |
| Exit discharge from Station 3 Exit corridor had large cracks and uneven concrete, not providing a level walking surface free of obstructions. |
| Fire alarm control panel displayed incorrect time and date, not maintained accurately. |
| Alcove open to corridor used as hazardous storage with combustible materials. |
| Corridor doors failed to close properly or latch, including kitchen storage door propped open and resident room #88 door not latching. |
| One of three smoking areas was not maintained properly; cigarette butts were found disposed on the ground instead of in a metal container with self-closing cover. |
| Facility failed to provide documentation of electrical outlet receptacle testing for the past 12 months as required. |
Report Facts
Certified beds: 100
Census: 49
Residents potentially affected by delayed egress signage deficiency: 8
Residents potentially affected by exit discharge deficiency: 8
Residents potentially affected by hazardous storage: 13
Residents potentially affected by corridor door deficiencies: 8
Residents potentially affected by smoking area deficiency: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vicki Mcguire | Administrator | Named as facility administrator signing the report |
| Maintenance Director | Interviewed regarding multiple deficiencies including door signage, exit discharge, fire alarm system, hazardous storage, corridor doors, and smoking area |
Inspection Report
Annual Inspection
Census: 53
Capacity: 53
Deficiencies: 9
Mar 27, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from March 21 to March 27, 2023.
Findings
The facility was found deficient in multiple areas including wound care assessment and treatment, pressure ulcer assessment, nurse staffing posting, medication administration, behavioral health services, food safety, and immunization protocols.
Severity Breakdown
SS=D: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to appropriately assess and administer treatments for wounds for 1 of 2 residents reviewed. | SS=D |
| Failed to assess a resident admitted with a pressure ulcer for 1 of 1 resident reviewed for pressure ulcers. | SS=D |
| Failed to post nurse staffing daily for the survey period. | SS=D |
| Failed to address psychological evaluation recommendations for 1 of 5 residents reviewed for unnecessary medications. | SS=D |
| Failed to ensure medications were available and administered as ordered by the physician for 3 of 6 residents reviewed for medications. | SS=D |
| Failed to administer medications related to hold parameters for 3 of 6 residents reviewed for unnecessary medications. | SS=D |
| Failed to store foods appropriately related to thawing meat and labeling foods for 1 of 3 kitchen observations and labeling residents' food from outside sources for 1 of 2 snack refrigerators observed. | SS=D |
| Failed to offer a resident the pneumococcal vaccine for 1 of 5 residents reviewed for immunizations. | SS=D |
| Failed to offer a resident the COVID-19 vaccine or booster for 1 of 5 residents reviewed for immunizations. | SS=D |
Report Facts
Survey dates: 5
Census: 53
Total capacity: 53
Residents reviewed for medications: 6
Residents reviewed for immunizations: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Charlson DePrez | Regional Manager | Signed the report |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 46
Deficiencies: 0
Jan 24, 2023
Visit Reason
This visit was conducted for the investigation of two complaints, IN00395801 and IN00394542.
Findings
Both complaints were substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00395801 - Substantiated with no deficiencies cited. Complaint IN00394542 - Substantiated with no deficiencies cited.
Report Facts
Census: 46
Total Capacity: 46
Medicare Census: 5
Medicaid Census: 20
Other Payor Census: 21
Inspection Report
Complaint Investigation
Census: 44
Capacity: 44
Deficiencies: 0
Oct 6, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00384675 and IN00384427.
Findings
Both complaints IN00384675 and IN00384427 were found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00384675 - Unsubstantiated due to lack of evidence. Complaint IN00384427 - Unsubstantiated due to lack of evidence.
Report Facts
Census: 44
Total Capacity: 44
Payor Type Census: 1
Payor Type Census: 23
Payor Type Census: 20
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