Inspection Report Summary
The most recent inspection on May 7, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a pattern of deficiencies primarily involving infection control, supervision and fall prevention, emergency preparedness, and care plan implementation. Complaint investigations were mostly unsubstantiated, though some substantiated complaints involved inadequate supervision leading to resident elopement, failure to prevent falls, and incomplete care according to physician orders. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows some improvement over time, with recent inspections citing fewer issues compared to earlier surveys.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
8.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
110% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
66% occupied
Based on a May 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 54
Capacity: 82
Deficiencies: 0
May 7, 2025
Visit Reason
This visit was for the investigation of Complaint IN00459017.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Complaint IN00459017: No deficiencies related to the allegation(s) are cited.
Report Facts
Census Bed Type: 14
Census Bed Type: 40
Census Bed Type: 28
Total Capacity: 82
Census Payor Type: 14
Census Payor Type: 31
Census Payor Type: 9
Current Census: 54
Inspection Report
Complaint Investigation
Census: 55
Capacity: 82
Deficiencies: 0
Apr 30, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00457314 at Woodmont Health Campus.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00457314 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF: 30
Census Bed Type - SNF/NF: 40
Census Bed Type - Residential: 27
Total Capacity: 82
Census Payor Type - Medicare: 17
Census Payor Type - Medicaid: 27
Census Payor Type - Other: 11
Total Census: 55
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 0
Mar 19, 2025
Visit Reason
This visit was for the investigation of Residential Complaint IN00455380.
Findings
No deficiencies related to the allegation(s) were cited. Woodmont Health Campus was found to be in compliance with 410 IAC 16.2-5.
Complaint Details
Complaint IN00455380: No deficiencies related to the allegation(s) are cited.
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 1
Oct 29, 2024
Visit Reason
This visit was for the investigation of Nursing Home Complaint IN00441635 and the Nursing Home COVID-19 Focused Infection Control Survey, as well as the investigation of Residential Complaint IN00441635 and the Residential COVID-19 Focused Infection Control Survey.
Findings
The facility failed to maintain infection control practices to mitigate the spread of COVID-19, including improper hand hygiene, touching resident furnishings without hand hygiene, and improper disposal of dirty gloves during observed care. Residents C and D suffered no ill effects from these deficient practices. The facility was found to be in compliance regarding the Residential Complaint and Residential COVID-19 Focused Infection Control Survey.
Complaint Details
Complaint IN00441635 was investigated, and federal/state deficiencies were cited at F880 related to infection prevention and control. Residents C and D were monitored with no adverse effects found.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to maintain infection control practices including improper hand hygiene, touching resident furnishings without hand hygiene, and placing a dirty glove on a medication cart during care. | SS=D |
Report Facts
Census Bed Type - SNF: 12
Census Bed Type - SNF/NF: 39
Census Bed Type - Residential: 31
Total Census: 82
Census Payor Type - Medicare: 12
Census Payor Type - Medicaid: 32
Census Payor Type - Other: 7
Total Census Payor: 52
Deficiency Completion Date: Nov 20, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennie Deyne | Executive Director | Signed the report |
| CNA 7 | Named in infection control deficiency related to hand hygiene and care practices | |
| RN 4 | Registered Nurse | Named in infection control deficiency related to hand hygiene and glove disposal |
| Director of Nursing | Director of Nursing | Provided facility policy on hand hygiene |
| Director of Health Services | Director of Health Services (DHS) | Responsible for staff education and audits related to infection control corrective actions |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 29, 2024
Visit Reason
Paper compliance review for the Investigation of Complaint IN00441635 and Focused Infection Control Survey.
Findings
Woodmont 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 Investigation of Complaint IN00441635 and Focused Infection Control Survey.
Complaint Details
Investigation of Complaint IN00441635; facility found in compliance.
Inspection Report
Life Safety
Deficiencies: 0
Oct 8, 2024
Visit Reason
The visit was a Post Survey Revisit (PSR) related to the Life Safety Code Recertification and State Licensure Survey originally conducted on 2024-08-07.
Findings
Woodmont Health Campus was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2000 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: 47
Capacity: 60
Deficiencies: 1
Sep 18, 2024
Visit Reason
This was a Post Survey Revisit (PSR) to the Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey conducted on 08/07/24 to verify compliance and correction of previously cited deficiencies.
Findings
The facility was found in compliance with Emergency Preparedness Requirements. However, it was not in compliance with Life Safety Code requirements due to one resident room corridor door (room 210) failing to close completely and latch properly. The door was replaced, and corrective actions including monthly audits were planned to prevent recurrence.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 32 resident room corridor doors would close completely and latch into its door frame, affecting at least 18 residents in the 200 hall. | SS=E |
Report Facts
Certified beds: 60
Census: 47
Resident room corridor doors inspected: 32
Residents potentially affected: 18
Residents potentially affected by deficient practice: 2
Compliance date: Oct 6, 2024
Audit period: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennie Deyne | Executive Director | Signed report and educated Director of Plant Operations on corrective actions |
| Director of Plant Operations | Interviewed regarding door deficiency and responsible for corrective actions |
Inspection Report
Renewal
Deficiencies: 0
Sep 13, 2024
Visit Reason
The visit was conducted as a paper compliance review for the Recertification and State Licensure Survey ending on July 26, 2024.
Findings
Woodmont 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 Recertification and State Licensure Survey.
Inspection Report
Life Safety
Census: 46
Capacity: 60
Deficiencies: 6
Aug 7, 2024
Visit Reason
An Emergency Preparedness and Life Safety Code Recertification Survey was conducted to assess compliance with federal and state regulations including emergency preparedness, sprinkler system maintenance, corridor door functionality, fire drills, and electrical equipment safety.
Findings
The facility was found not in compliance with emergency preparedness requirements due to an incomplete hazard vulnerability assessment and failure to conduct required emergency plan exercises. Life safety deficiencies included sprinkler heads covered with corrosion and paint, a resident room door that would not latch properly, fire drills not held at varied times for all shifts, and improper use of power strips and extension cords in staff offices.
Severity Breakdown
SS=F: 2
SS=E: 3
SS=C: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to maintain a complete emergency preparedness plan including a documented, facility-based and community-based risk assessment utilizing an all-hazards approach. | SS=F |
| Failed to conduct emergency plan exercises at least twice per year including unannounced staff drills. | SS=F |
| Sprinkler heads in 2 of 5 smoke compartments were covered with corrosion, paint, or loaded and were not replaced. | SS=E |
| One of 32 resident room corridor doors would not close completely and latch into its door frame. | SS=E |
| Fire drills were not held at varied times for 1 of 3 employee shifts during 4 of 4 quarters. | SS=C |
| Power strips and multi-plug adapters/extension cords were used as a substitute for fixed wiring in two staff offices. | SS=E |
Report Facts
Certified beds: 60
Census: 46
Sprinkler heads to be replaced: 7
Resident room doors inspected: 32
Fire drills: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennie Deyne | Executive Director | Named in relation to emergency preparedness and life safety findings and plan of correction |
| Director of Plant Operations | Involved in emergency preparedness, sprinkler system, fire drills, and electrical equipment findings and corrective actions | |
| Facility Maintenance Support | Involved in emergency preparedness and sprinkler system findings |
Inspection Report
Annual Inspection
Census: 43
Capacity: 79
Deficiencies: 6
Jul 26, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey including a State Residential Licensure Survey conducted July 21-26, 2024.
Findings
The facility was found deficient in multiple areas including failure to complete quarterly care plan conferences for residents, improper posting of nurse staffing information, unsafe food storage and sanitation practices in the kitchen, inadequate infection prevention practices during incontinence care, unsanitary environmental conditions in resident halls and shower rooms, and failure to involve the local fire department in fire drills. Corrective actions and education plans were implemented for each deficiency.
Severity Breakdown
Level E: 2
Level C: 1
Level F: 1
Level D: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Quarterly care plan conferences were not completed for 4 of 5 residents reviewed for unnecessary medications. | Level E |
| Failed to ensure posted nurse staffing sheets were posted and contained correct information daily for 1 of 6 days reviewed. | Level C |
| Failed to ensure storage of food in a safe and sanitary manner; food items unlabeled and open to air; dishwasher did not reach proper rinse temperature; temperature logs incomplete. | Level F |
| Failed to provide a safe and sanitary environment to help prevent development and transmission of infections; gloves not changed and hands not sanitized between dirty and clean tasks during incontinence care. | Level D |
| Failed to ensure a sanitary and homelike environment; resident toilets visibly soiled, fracture pans and urine hats uncovered and improperly stored, soiled equipment, stained carpet, and damaged shower room tiles. | Level E |
| Failed to attempt to hold fire and disaster drill in conjunction with local fire department at least every six months; no documentation of fire department involvement. | — |
Report Facts
Survey dates: 2024-07-21 to 2024-07-26
Census: 43
Total capacity: 79
Residents affected by care plan deficiency: 4
Days care conferences missing: varies per resident
Dishwasher rinse temperature: 168
Dishwasher rinse temperature: 170
Dishwasher rinse temperature: 172
Dishwasher rinse temperature: 174
Fire drills per year: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennie Deyne | Executive Director | Signed report and involved in corrective action plans |
| CNA 48 | Certified Nurse Aide | Observed providing incontinence care with infection control deficiencies |
| CNA 56 | Certified Nurse Aide | Observed providing incontinence care with infection control deficiencies |
| Cook 17 | Reported dishwasher rinse temperature issues | |
| Dietary Manager | Provided policies and interview regarding food safety and dishwasher maintenance | |
| Social Service Director | SSD | Responsible for care plan conference completion and education |
| Director of Nursing | DON | Provided interview on hand hygiene expectations |
| Maintenance Director | Responsible for fire drill coordination and maintenance issues |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 1
Mar 20, 2024
Visit Reason
This visit was conducted for the investigation of complaint IN00430645 regarding the facility's failure to ensure adequate supervision to prevent a resident with exit-seeking behavior from eloping.
Findings
The facility failed to provide adequate supervision and functioning exit alarms to prevent Resident C, who has a history of exit-seeking behavior and severe cognitive impairment, from exiting the facility unnoticed and being found outside for approximately 45 minutes. The wander guard alarm system was not functioning properly, and the main exit door did not lock as required.
Complaint Details
Complaint IN00430645 was substantiated with federal/state deficiencies cited at F689 related to inadequate supervision and failure of the wander guard alarm system leading to resident elopement.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure adequate supervision and functioning exit alarms to prevent resident elopement. | SS=D |
Report Facts
Residents reviewed for elopement: 3
Resident C elopement duration (minutes): 45
Total census: 80
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 26, 2024
Visit Reason
Paper compliance review related to the Investigation of Complaint IN00418698 and IN00424901 survey ending on January 26, 2024.
Findings
Woodmont 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 Investigation of Complaint IN00418698 and IN00424901 Survey.
Complaint Details
Investigation of Complaint IN00418698 and IN00424901; paper compliance review found in compliance.
Inspection Report
Complaint Investigation
Census: 53
Capacity: 81
Deficiencies: 1
Jan 25, 2024
Visit Reason
This visit was conducted for the investigation of Nursing Home Complaints IN00418698 and IN00424901, including the investigation of Residential Complaint IN00424901.
Findings
The facility failed to provide assistance with bathing for 4 of 5 residents reviewed for activities of daily living (ADLs), specifically Residents B, C, D, and F, who did not receive assistance according to their care plans and bathing schedules. No residential deficiencies were cited related to the residential complaint.
Complaint Details
Complaint IN00418698 and IN00424901 were investigated. Federal/state deficiencies related to the allegations were cited at F677. Residential Complaint IN00424901 had no deficiencies cited and was found to be in compliance.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide assistance with bathing for 4 of 5 residents reviewed for ADLs according to plan of care and bathing schedule. | SS=E |
Report Facts
Census Bed Type - SNF: 13
Census Bed Type - SNF/NF: 40
Census Bed Type - Residential: 28
Total Capacity: 81
Census Payor Type - Medicare: 13
Census Payor Type - Medicaid: 34
Census Payor Type - Other: 6
Total Census: 53
Inspection Report
Re-Inspection
Census: 49
Capacity: 60
Deficiencies: 0
Aug 30, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 07/06/23 was performed by the Indiana Department of Health to verify compliance.
Findings
Woodmont 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. The facility was sprinklered and had a fire alarm system with hard wired smoke detectors in all required areas.
Report Facts
Facility capacity: 60
Census: 49
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 16, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00411865 ending on August 16, 2023.
Findings
Woodmont 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 Investigation of Complaint IN00411865 Survey.
Complaint Details
Investigation of Complaint IN00411865; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 50
Capacity: 81
Deficiencies: 1
Aug 15, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00411865 regarding allegations of inadequate supervision and fall prevention at Woodmont Health Campus.
Findings
The facility failed to provide adequate supervision and fall prevention interventions for Resident B, who had multiple falls and inconsistent care plans and physician orders. Observations and interviews confirmed missing fall interventions such as non-skid strips and lack of gait belt use during ambulation.
Complaint Details
Complaint IN00411865 was substantiated with a Federal/State deficiency cited at F0689 related to failure to prevent accidents and provide adequate supervision/devices.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide adequate supervision and prevent falls for Resident B with multiple falls and inconsistent care plans. | D |
Report Facts
Census total residents: 50
Total licensed capacity: 81
Number of falls for Resident B in last 90 days: 6
Audit frequency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica West | Executive Director | Signed report as facility representative |
| LPN 7 | Licensed Practical Nurse | Provided CNA Assignment Form and interview regarding Resident B |
| QMA 3 | Qualified Medication Aide | Observed failing to assist Resident B with walker and gait belt |
| CNA 9 | Certified Nurse Aide | Interviewed regarding Resident B's assistance level |
| QMA 5 | Qualified Medication Aide | Interviewed about fall interventions for Resident B |
| CNA 11 | Certified Nurse Aide | Interviewed about Resident B's transfer assistance and fall interventions |
Inspection Report
Life Safety
Census: 54
Capacity: 60
Deficiencies: 7
Jul 6, 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 related NFPA codes.
Findings
The facility was found not in compliance with Life Safety Code requirements, including issues with fire door closures, egress door accessibility, smoke detector placement, sprinkler system inspection documentation, boiler inspection certificates, GFCI protection in wet locations, and incomplete fire drill documentation.
Severity Breakdown
SS=F: 2
SS=E: 2
SS=C: 2
SS=D: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 1 single fire door in the 2 hour fire separation wall was not held open by an object and would close fully and latch. | SS=F |
| Failed to ensure means of egress through 2 of 8 locked exit doors was readily and easily accessible; doors required heavy force to open. | SS=E |
| Failed to ensure 2 of over 100 hard wired smoke detectors were not installed where air flow would adversely affect operation. | SS=E |
| Failed to document sprinkler system inspections in accordance with NFPA 25 for 1 of 1 sprinkler system. | SS=C |
| Failed to ensure 2 of 2 fuel-fired boilers had current inspection certificates to ensure safe operating condition. | SS=C |
| Failed to ensure 1 of over 10 wet locations was provided with ground fault circuit interrupter (GFCI) protection against electric shock. | SS=D |
| Failed to provide quarterly fire drill documentation for 2 of 3 shifts during 3 of 4 quarters. | SS=F |
Report Facts
Certified beds: 60
Census: 54
Fire drills performed: 12
Locked exit doors requiring heavy force: 2
Hard wired smoke detectors: 100
Smoke detectors improperly located: 2
Fuel-fired boilers: 2
Wet locations: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica West | Executive Director | Named in exit conference and education related to deficiencies |
| Director of Plant Operations | Named in multiple findings including fire door issues, egress door issues, smoke detector placement, sprinkler system inspection, boiler inspection, GFCI receptacle, and fire drill documentation |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 76
Deficiencies: 9
Jun 9, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Complaint IN00404924, including a State Residential Licensure Survey.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, advance directives compliance, care plan implementation, respiratory care, nurse staffing posting accuracy, behavioral health services, psychotropic medication management, infection control practices, and QMA authorization for PRN medications.
Complaint Details
Complaint IN00404924 was investigated with federal/state deficiencies cited related to allegations at F740.
Severity Breakdown
SS=D: 8
SS=C: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Resident 199 was observed uncovered and unattended, violating dignity and respect requirements. | SS=D |
| Resident 24's advanced directive and DNR form lacked physician signature and proper documentation. | SS=D |
| Resident 24's care plan lacked implementation of fall interventions; non-skid strips were not placed as ordered. | SS=D |
| Resident 8's respiratory care equipment was not properly maintained; CPAP filter was dirty and tubing undated. | SS=D |
| Nurse staffing records posted were inaccurate for 1 of 6 days observed. | SS=C |
| Resident G was not provided adequate behavioral health monitoring despite repeated bathroom requests and cognitive impairment. | SS=D |
| Resident 13 had a PRN anti-anxiety medication order exceeding 14 days without documented physician review. | SS=D |
| Residents G and 15 were observed with poor infection control practices; hand hygiene and glove changes were not performed between dirty and clean tasks. | SS=D |
| Resident 8's PRN medications administered by QMAs lacked required nurse authorization documentation. | SS=D |
Report Facts
Census Bed Type - SNF/NF: 43
Census Bed Type - SNF: 6
Census Bed Type - Residential: 27
Total Capacity: 76
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 37
Census Payor Type - Other: 4
PRN hydrocodone-acetaminophen doses: 17
PRN benzonatate doses: 5
Incorrect Bactrim doses: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica West | Executive Director | Signed report and involved in administrative oversight |
| LPN 25 | Licensed Practical Nurse | Interviewed regarding Resident 199 dignity and discharge plans |
| LPN 23 | Licensed Practical Nurse | Interviewed regarding DNR orders and code status |
| QMA 15 | Qualified Medication Aide | Interviewed regarding DNR orders and respiratory equipment |
| RN 21 | Registered Nurse | Interviewed regarding QMA authorization for PRN medications |
| Administrator | Provided multiple interviews regarding policies, staffing, and deficiencies | |
| Regional Consultant | Provided interviews regarding policies and findings | |
| Infection Preventionist | Interviewed regarding hand hygiene and infection control practices | |
| CNA 3 | Certified Nurse Aide | Observed during care of Resident 15 and Resident G |
| CNA 6 | Certified Nurse Aide | Observed during care of Resident 15 and Resident G |
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 9, 2023
Visit Reason
Paper compliance review for the Recertification and State licensure and the Investigation of Complaint IN00404924 survey ending on June 9, 2023.
Findings
Woodmont 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 Recertification and State licensure and the Investigation of Complaint IN00404924 Survey.
Complaint Details
Investigation of Complaint IN00404924 was included in the survey.
Inspection Report
Complaint Investigation
Census: 49
Capacity: 77
Deficiencies: 1
Mar 9, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00403391 related to allegations of staff qualifications and medication administration.
Findings
The facility was found to be in compliance overall, but failed to ensure that Qualified Medication Aides (QMAs) administering insulin were properly certified, affecting 3 diabetic residents. The facility submitted a plan of correction addressing staff training, certification, and ongoing compliance monitoring.
Complaint Details
Complaint IN00403391 was investigated with state deficiencies cited at R117 related to staff qualifications and insulin administration. The complaint was substantiated with findings that QMAs administered insulin without certification.
Deficiencies (1)
| Description |
|---|
| QMAs documented administration of routine insulin injections without certification to administer insulin for 3 diabetic residents. |
Report Facts
Residents affected: 3
Total census: 49
Total capacity: 77
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 9, 2022
Visit Reason
Investigation of Complaint IN00374679 and Covid 19 Focused Infection Control Survey.
Findings
Woodmont 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 Investigation of Complaint IN00374679 and the Covid 19 Focused Infection Control Survey.
Complaint Details
Investigation of Complaint IN00374679; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 54
Capacity: 77
Deficiencies: 1
Sep 8, 2022
Visit Reason
This visit was conducted for the investigation of four complaints (IN00378797, IN00376110, IN00374679, and IN00374838) and included a COVID-19 Focused Infection Control Survey.
Findings
The facility was found to have a substantiated deficiency related to failure to follow a physician's plan of care for treatment of skin tears for one resident (Resident B). Treatment and dressing changes were not completed as prescribed, with dressings not changed timely and drainage observed. Other complaints were unsubstantiated due to lack of evidence.
Complaint Details
Complaint IN00374679 was substantiated with related deficiencies cited at F656. Complaints IN00378797, IN00376110, and IN00374838 were unsubstantiated due to lack of evidence.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to follow a physician plan of care for treatment of skin tears for 1 of 3 residents reviewed; treatment and dressing changes were not completed as prescribed. | SS=D |
Report Facts
Census total: 54
Total licensed capacity: 77
Number of complaints investigated: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) 3 | Indicated dressings on Resident B's right forearm should have been changed on 9/6/22 but had not been changed since 9/3. |
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