Inspection Report Summary
The most recent inspection on June 25, 2025, found Chesterton Manor in compliance with Life Safety Code and Medicare/Medicaid participation requirements, with no deficiencies noted. Prior inspections showed recurring issues primarily related to Life Safety Code compliance involving kitchen hood fire suppression systems and electrical equipment maintenance, as well as multiple citations for resident care deficiencies such as pressure ulcer treatment, catheter care, medication management, and assistance with activities of daily living. Complaint investigations included some substantiated findings, notably failures in abuse reporting, resident supervision, and staff training, as well as inadequate care for pressure ulcers and catheter maintenance. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s recent clean Life Safety Code inspection and ongoing follow-up visits suggest some improvement in addressing earlier cited deficiencies.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
13.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
217% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
77% 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
Follow-Up
Census: 77
Capacity: 100
Deficiencies: 0
Date: Jun 25, 2025
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on the Life Safety Code Recertification and State Licensure Survey that exited on 04/07/2025 and the PSR survey that exited on 06/02/2025.
Findings
At this Post Survey Revisit, Chesterton Manor 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 was fully sprinklered and had appropriate fire alarm and smoke detection systems.
Inspection Report
Re-Inspection
Census: 78
Capacity: 100
Deficiencies: 2
Date: Jun 2, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey that exited on 04/07/2025 was conducted to verify correction of previously cited deficiencies.
Findings
The facility was found not in compliance with Life Safety Code requirements related to kitchen hood extinguishing system appliance placement and electrical equipment maintenance documentation. Corrective actions were initiated but systemic compliance was still being monitored.
Deficiencies (2)
Failed to provide an approved method for returning cooking appliances to their approved design location under the kitchen hood extinguishing system.
Failed to conduct required maintenance and maintain complete documentation of inspections for Patient Care Related Electrical Equipment (PCREE).
Report Facts
Facility capacity: 100
Census: 78
Deficiency completion date: Jun 11, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sherrie Lamore | Administrator | Named in relation to exit conference and findings review |
| Maintenance Director | Interviewed regarding deficiencies related to kitchen hood extinguishing system and electrical equipment maintenance | |
| Regional Maintenance Director | Educated Maintenance Director on electrical equipment maintenance practice | |
| Dietary Manager | Inserviced on proper placement of stove and fryer |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 71
Deficiencies: 0
Date: May 8, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00459063.
Complaint Details
Complaint IN00459063 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00459063 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 71
Total Capacity: 71
Payor Type Census: 2
Payor Type Census: 50
Payor Type Census: 19
Inspection Report
Renewal
Deficiencies: 0
Date: Apr 24, 2025
Visit Reason
The visit was a paper compliance review related to the Recertification and State Licensure Survey completed on March 6, 2025.
Findings
Chesterton Manor 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: 73
Capacity: 100
Deficiencies: 4
Date: Apr 7, 2025
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101, Life Safety Code.
Findings
Chesterton Manor was found not in compliance with Life Safety Code requirements, with deficiencies related to kitchen hood fire suppression system placement, lack of approved method for returning cooking appliances to approved locations, use of unauthorized power strips in resident rooms, and failure to maintain documentation of Patient Care Related Electrical Equipment (PCREE) inspections.
Deficiencies (4)
Failed to maintain kitchen hood fire extinguishing system pull station at required height between 42 and 48 inches above the floor.
Failed to provide an approved method for returning cooking appliances to approved design location after maintenance or cleaning.
Power strip in resident room 208 did not meet UL 1363 standards and was unauthorized.
Failed to conduct required maintenance and maintain complete documentation of inspections for Patient Care Related Electrical Equipment (PCREE).
Report Facts
Facility capacity: 100
Census: 73
Resident rooms inspected: 50
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sherrie Lamore | Administrator | Named in relation to findings and exit conference |
| Maintenance Director | Interviewed regarding deficiencies related to kitchen hood system and electrical equipment | |
| Regional Maintenance Director | Educated Maintenance Director on electrical equipment maintenance requirements |
Inspection Report
Annual Inspection
Census: 75
Capacity: 75
Deficiencies: 14
Date: Mar 6, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from March 2 to March 6, 2025.
Findings
The facility was found deficient in multiple areas including misappropriation of property, accuracy of assessments, care plan timing, quality of care, pressure ulcer treatment, range of motion devices, fall prevention, nutrition documentation, oxygen flow rates, pain management, medication storage, infection control, and call light system functionality.
Deficiencies (14)
Failed to protect a resident's right to be free from misappropriation of property related to bank fraud by an agency CNA.
Failed to ensure the Minimum Data Set (MDS) comprehensive assessment was accurately completed related to falls, fractures, and hospice services.
Failed to ensure a care plan meeting was conducted at least quarterly for one resident.
Failed to ensure medications were held per blood sugar parameters, skin conditions assessed and monitored, and constipation treated and monitored.
Failed to ensure pressure ulcer treatments were completed as ordered by the physician.
Failed to ensure an orthotic device was in place for a resident with limited range of motion to the hand.
Failed to ensure fall interventions were in place related to floor mats, bed position, and call lights in reach for residents with a history of falls; also failed to ensure hot water temperatures were below 120 degrees Fahrenheit in multiple areas.
Failed to ensure food consumption logs were completed for residents with a history of weight loss.
Failed to ensure oxygen was at the correct flow rate for residents reviewed for oxygen.
Failed to ensure a resident was free from pain related to pain medications and transportation to the pain clinic not being available.
Failed to ensure proper medication storage related to medicated creams not stored securely.
Failed to ensure infection control practices were in place and implemented related to not donning personal protective equipment for residents in enhanced barrier precautions during wound care.
Failed to ensure the call light system in resident rooms and at the nurses' station was properly functioning.
Failed to ensure employees received the required annual dementia training for 5 of 10 employee records reviewed.
Report Facts
Census: 75
Total Capacity: 75
Insulin administration errors: 15
Pressure ulcer treatment missed dates: 15
Hot water temperature: 142
Weight loss: 6.3
Oxygen flow rate: 3
Dementia training hours missing: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| QMA 1 | Lacked documentation of required annual dementia training | |
| Housekeeper 1 | Lacked documentation of required annual dementia training | |
| Activities Assistant 1 | Lacked documentation of required annual dementia training | |
| Dietary Cook | Lacked documentation of required annual dementia training | |
| CNA 1 | Lacked documentation of required annual dementia training | |
| Sherrie Lamore | Administrator | Signed the report |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 16, 2024
Visit Reason
The visit was a paper compliance review related to the investigation of Complaint IN00445328 completed on November 13, 2024.
Complaint Details
Investigation of Complaint IN00445328 completed on November 13, 2024; facility found in compliance.
Findings
Chesterton Manor was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 76
Capacity: 76
Deficiencies: 2
Date: Nov 13, 2024
Visit Reason
This visit was for the investigation of complaints IN00445328 and IN00446197. Complaint IN00445328 resulted in federal/state deficiencies related to the allegations, while complaint IN00446197 had no deficiencies related to the allegations.
Complaint Details
Complaint IN00445328 was substantiated with federal/state deficiencies cited. Complaint IN00446197 was not substantiated with no deficiencies cited.
Findings
The facility failed to ensure dependent residents received timely assistance with activities of daily living (ADL) related to incontinence care for 2 of 4 residents reviewed (Residents C and F). Additionally, the facility failed to ensure correct Personal Protective Equipment (PPE) use and hand hygiene compliance by staff during care of a resident on Enhanced Barrier Precautions (Resident E).
Deficiencies (2)
Failed to ensure dependent residents received timely assistance with ADL care related to incontinence for 2 of 4 residents reviewed.
Failed to ensure correct PPE use and hand hygiene by staff during care of a resident on Enhanced Barrier Precautions.
Report Facts
Census: 76
Total Capacity: 76
Urine volume drained: 900
Residents reviewed for ADL care: 4
Residents affected by ADL deficiency: 2
Residents audited for ADL care monitoring: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in finding related to failure to provide timely ADL care to Resident C |
| CNA 2 | Certified Nursing Assistant | Named in finding related to failure to perform hand hygiene after care for Resident E |
| CNA 3 | Certified Nursing Assistant | Named in finding related to failure to use correct PPE during care for Resident E |
| Administrator | Facility Administrator | Interviewed regarding expectations for ADL care frequency and resident care |
| Director of Nursing | Director of Nursing | Provided current facility policies and involved in corrective action plans |
Inspection Report
Life Safety
Census: 70
Capacity: 100
Deficiencies: 0
Date: Apr 23, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 03/07/24 was performed to verify compliance with Life Safety Code requirements.
Findings
Chesterton Manor was found in compliance with the 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 fully sprinklered and equipped with a fire alarm system and battery-powered smoke detectors in resident rooms.
Report Facts
Facility capacity: 100
Census: 70
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 1, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey and the Investigation of Complaint IN00423048 completed on February 12, 2024.
Findings
Chesterton Manor 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 to the Recertification and State Licensure Survey and complaint investigation.
Inspection Report
Life Safety
Census: 62
Capacity: 100
Deficiencies: 3
Date: Mar 7, 2024
Visit Reason
The Indiana Department of Health conducted a Life Safety Code Recertification and State Licensure Survey on 03/07/2024 to assess compliance with 42 CFR 483.90(a) and the 2012 edition of NFPA 101 Life Safety Code.
Findings
The facility was found not in compliance with Life Safety Code requirements, including incomplete documentation for preventative maintenance of 56 battery-operated smoke alarms, a non-functioning ground fault circuit interrupter (GFCI) receptacle in room 412, and failure to conduct fire drills on each shift for one of four quarters in 2023.
Deficiencies (3)
Failed to ensure documentation for preventative maintenance of 56 battery-operated smoke alarms was complete.
Failed to ensure 1 of 1 ground fault circuit interrupter (GFCI) was properly maintained for protection against electric shock.
Failed to conduct fire drills on each shift for 1 of 4 quarters as required.
Report Facts
Battery operated smoke alarms: 56
GFCI receptacle: 1
Fire drill quarters missed: 1
Facility capacity: 100
Census: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sherrie Lamore | Administrator | Named in relation to findings and exit conference |
| Maintenance Director | Interviewed and involved in findings related to smoke alarms, GFCI receptacle, and fire drills |
Inspection Report
Annual Inspection
Census: 67
Capacity: 67
Deficiencies: 9
Date: Feb 12, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00423048 and IN00424678.
Complaint Details
Complaint IN00423048 resulted in federal/state deficiencies related to the allegations. Complaint IN00424678 had no deficiencies related to the allegations.
Findings
The facility was found deficient in multiple areas including medication self-administration, quality of care related to skin and constipation management, catheter care, PICC line care, oxygen administration, RN staffing, medication storage, resident record documentation, and environmental conditions.
Deficiencies (9)
Failed to ensure residents had Physician's Orders and assessments for self-administration of medications for 3 residents.
Failed to ensure areas of bruising and constipation were assessed and monitored for 4 residents.
Failed to ensure residents with suprapubic catheters received catheter care and urinary drainage bags and tubing were kept off the floor for 2 residents.
Failed to care for a PICC line in accordance with professional standards, including flushing with correct saline amount and documentation for 1 resident.
Failed to ensure oxygen was administered as ordered and set at correct flow rate for 1 resident.
Failed to ensure a Registered Nurse worked 8 consecutive hours in the facility on any given day.
Failed to ensure medications were properly stored; loose pills were found inside medication carts on 2 halls.
Failed to maintain complete and accurate clinical records related to clarification of PRN pain medication orders and meal consumption documentation for 2 residents.
Failed to keep the resident environment in good repair, including marred walls, doors, door frames, missing baseboards, and peeling non-skid strips in 2 units.
Report Facts
Census: 67
Total Capacity: 67
Medication cart loose pills: 9
Medication cart loose pills: 15
RN coverage missing days: 6
PICC flush saline ordered: 10
PICC flush saline administered: 4
PICC flush heparin ordered: 5
PICC flush heparin administered: 5
Oxygen liter flow ordered: 4
Oxygen liter flow observed: 3.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sherrie Lamore | Administrator | Signed report and provided facility responses |
| RN 1 | Observed administering PICC line medication and flushing; interviewed about medication cart cleaning | |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple findings including medication self-administration, catheter care, PICC line care, oxygen administration, and staffing |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding skin bruise assessments |
| Maintenance Director | Maintenance Director | Interviewed regarding environmental repairs and ongoing maintenance |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 62
Deficiencies: 0
Date: Aug 30, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00412963.
Complaint Details
Investigation of Complaint IN00412963 found no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 4
Medicaid census: 49
Other payor census: 9
Inspection Report
Complaint Investigation
Census: 61
Capacity: 61
Deficiencies: 0
Date: Jun 5, 2023
Visit Reason
This visit was for the investigation of complaints IN00408370 and IN00409935.
Complaint Details
Investigation of complaints IN00408370 and IN00409935 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00408370 and IN00409935 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 61
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 49
Census Payor Type - Other: 9
Inspection Report
Life Safety
Census: 61
Capacity: 100
Deficiencies: 0
Date: Jun 2, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 04/20/23 by the Indiana Department of Health in accordance with 42 CFR Subpart 483.90(a).
Findings
Chesterton Manor was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility is fully sprinklered, has a fire alarm system with hard wired smoke detection in corridors, battery powered smoke detectors in resident rooms, and is protected by a Natural Gas powered generator.
Report Facts
Facility capacity: 100
Census: 61
Inspection Report
Annual Inspection
Census: 65
Capacity: 100
Deficiencies: 2
Date: Apr 20, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on April 20, 2023, as part of the annual survey process.
Findings
Chesterton Manor was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements due to deficiencies in emergency lighting testing and annual fire door inspections.
Deficiencies (2)
Failed to ensure 1 of 1 battery backup emergency lights were tested monthly as required.
Failed to ensure annual inspection and testing of 1 of 1 fire door assemblies in the facility were completed in accordance with Life Safety Code requirements.
Report Facts
Facility capacity: 100
Census: 65
Deficiencies cited: 2
Residents potentially affected: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sherrie Lamore | Administrator | Signed the report and participated in exit conference |
| Maintenance Director | Interviewed regarding emergency lighting testing and fire door inspection deficiencies | |
| Executive Director | Participated in exit conference and interview regarding deficiencies |
Inspection Report
Annual Inspection
Census: 64
Capacity: 64
Deficiencies: 10
Date: Mar 24, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from March 20 to 24, 2023.
Findings
The facility was found deficient in multiple areas including resident self-administration of medications without proper orders or assessments, inadequate ADL care for dependent residents, failure to assess and treat skin excoriations and bruising, inadequate hearing care, failure to document food consumption for a resident with weight loss, incorrect oxygen flow rates, improper medication management, failure to follow food preparation recipes, lack of antibiotic stewardship, and environmental maintenance issues.
Deficiencies (10)
Failed to ensure residents had Physician's Orders and assessments to self-administer medications for 3 residents.
Failed to provide ADL assistance related to showers and shaving for 3 of 7 residents reviewed.
Failed to ensure skin excoriation and bruising was assessed, monitored, and treated for 2 of 7 residents.
Failed to ensure residents with impaired hearing received necessary services related to ear wax removal for 1 of 2 residents.
Failed to ensure acceptable parameters of nutrition were maintained related to documenting food consumption for a resident with weight loss.
Failed to ensure oxygen was set at the correct flow rate and functioning for 3 of 3 residents reviewed for oxygen.
Failed to manage medications appropriately related to not monitoring side effects of opioid medication and administering blood pressure medication outside parameters for 2 of 5 residents.
Failed to ensure food was prepared in a form to meet individual needs related to not following a recipe for pureed food.
Failed to promote antibiotic stewardship related to unnecessary antibiotic use for 1 of 1 resident reviewed.
Failed to ensure the residents' environment was clean and in good repair related to marred doors and door frames, chipped floor tile, and broken shower heads on 2 of 4 units and 1 of 2 shower rooms.
Report Facts
Census: 64
Total Capacity: 64
Survey Dates: 5
Residents affected by self-administration deficiency: 3
Residents affected by ADL care deficiency: 3
Residents affected by skin care deficiency: 2
Residents affected by hearing care deficiency: 1
Residents affected by nutrition documentation deficiency: 1
Residents affected by oxygen care deficiency: 3
Residents affected by medication management deficiency: 2
Residents affected by antibiotic stewardship deficiency: 1
Rooms with environmental deficiencies: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sherrie Lamore | Administrator | Signed the report and involved in interview |
Inspection Report
Renewal
Deficiencies: 0
Date: Mar 24, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on March 24, 2023.
Findings
Chesterton Manor was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 60
Capacity: 60
Deficiencies: 0
Date: Feb 2, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00399577.
Complaint Details
Complaint IN00399577 was investigated and found unsubstantiated due to lack of evidence.
Findings
The complaint IN00399577 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Report Facts
Medicare residents: 2
Medicaid residents: 42
Other residents: 16
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 15, 2022
Visit Reason
Paper compliance review to the Post Survey Revisit (PSR) completed on November 15, 2022, related to the Investigation of Complaint IN00390759 completed on September 30, 2022.
Complaint Details
Investigation of Complaint IN00390759 completed on September 30, 2022; paper compliance review conducted on November 15, 2022.
Findings
Chesterton Manor 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 to the PSR to the complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 15, 2022
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00393843 completed on November 15, 2022.
Complaint Details
Investigation of Complaint IN00393843 completed on November 15, 2022; facility found in compliance.
Findings
Chesterton Manor was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Re-Inspection
Census: 62
Capacity: 62
Deficiencies: 2
Date: Nov 14, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00390759 completed on 9/30/22 and was in conjunction with the Investigation of Complaint IN00393843.
Complaint Details
Complaint IN00390759 was not corrected. Complaint IN00393843 was substantiated with federal/state deficiencies cited at F609 and F943.
Findings
The facility was found deficient in providing necessary treatment and services for residents with pressure ulcers and urinary catheters, including failure to document turning and repositioning, administer nutritional supplements as ordered, and provide catheter care every shift. The facility failed to implement a systemic plan of correction to prevent recurrence of these deficiencies.
Deficiencies (2)
Failed to ensure residents with pressure ulcers received necessary treatment and services to prevent further skin breakdown and promote healing, including lack of documentation of turning and repositioning and providing nutritional supplements as ordered for 2 of 3 residents reviewed.
Failed to ensure residents with urinary catheters and history of urinary tract infections received proper care and services related to improper catheter tubing positioning, care plan interventions not followed for catheter usage, and catheter care not provided every shift for 2 of 3 residents reviewed.
Report Facts
Census Bed Type: 62
Census Payor Type: 62
Medicare census: 10
Medicaid census: 48
Other census: 4
Pressure ulcer wound size: 1.5
Pressure ulcer wound size: 4
Pressure ulcer wound size: 0.6
Pressure ulcer wound size: 0.3
Pressure ulcer wound size: 5
Pressure ulcer wound size: 6
Pressure ulcer wound size: 1.5
Pressure ulcer wound size: 1.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paula Winebrenner | RN | Laboratory Director's or Provider/Supplier Representative's signature on report |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 62
Deficiencies: 3
Date: Nov 14, 2022
Visit Reason
This visit was for the investigation of Complaint IN00393843 and was conducted in conjunction with a Post Survey Revisit to Complaint IN00390759. The complaint IN00393843 was substantiated and related federal/state deficiencies were cited.
Complaint Details
Complaint IN00393843 was substantiated. Complaint IN00390759 was not corrected. The investigation found failures in abuse reporting, supervision of residents smoking, and staff training on abuse policies.
Findings
The facility failed to immediately report an allegation of abuse to the Administrator for one resident, failed to ensure adequate supervision of residents who smoked, and failed to train agency staff on the facility's abuse policy and procedures. These deficiencies had the potential to affect all residents in the facility.
Deficiencies (3)
Failed to ensure an allegation of abuse was immediately reported to the Administrator for 1 of 4 residents reviewed for allegations of abuse (Resident K).
Failed to ensure residents received adequate supervision related to residents assessed for supervised smoking observed smoking without supervision for 2 of 4 residents observed (Residents G and L).
Failed to ensure staff at the facility were trained on the facility's abuse policy and procedure, related to 3 of 4 Agency CNAs not educated on the facility's abuse policy and procedures prior to working with residents.
Report Facts
Census: 62
Total Capacity: 62
Medicare Census: 10
Medicaid Census: 48
Other Payor Census: 4
Survey Dates: 2
Agency CNAs not trained: 3
Staff queried weekly: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paula Winebrenner | RN | Laboratory Director or Provider/Supplier Representative who signed the report |
| Nurse 1 | Nurse interviewed who indicated no allegation of abuse was reported to her | |
| CNA 2 | Agency CNA | Agency CNA who had not been educated on the facility's abuse policy prior to working |
| CNA 3 | CNA who reported resident concerns about rough care but did not notify Administrator | |
| CNA 4 | Agency CNA | Agency CNA who had not been educated on the facility's abuse policy prior to working |
| CNA 5 | Agency CNA | Agency CNA who had not been educated on the facility's abuse policy prior to working |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 65
Deficiencies: 2
Date: Sep 29, 2022
Visit Reason
This visit was conducted for the investigation of three complaints (IN00382961, IN00383520, and IN00390759). Two complaints were substantiated with deficiencies cited related to complaint IN00390759.
Complaint Details
Complaint IN00382961 was unsubstantiated due to lack of evidence. Complaint IN00383520 was substantiated but no deficiencies related to the allegations were cited. Complaint IN00390759 was substantiated with federal/state deficiencies cited at F686 and F690.
Findings
The facility was found deficient in providing necessary treatment and services to prevent further pressure ulcer breakdown for one resident, and failed to ensure proper catheter care documentation for another resident. Preventative measures and documentation were lacking, particularly related to turning, repositioning, and catheter care.
Deficiencies (2)
Failed to ensure a resident admitted with a pressure ulcer received necessary treatment and services to prevent further breakdown, including lack of documentation of turning, repositioning, and transferring the resident out of bed, resulting in an unstageable necrotic pressure ulcer.
Failed to ensure catheter care was documented for a resident with an indwelling catheter, despite physician orders for catheter care every shift.
Report Facts
Census: 65
Total Capacity: 65
Medicare Census: 5
Medicaid Census: 53
Other Payor Census: 7
Pressure Ulcer Size: 5
Pressure Ulcer Size: 4
Pressure Ulcer Size: 7
Pressure Ulcer Size: 5
Pressure Ulcer Size: 5
Pressure Ulcer Size: 2.5
Foley Catheter Balloon Size: 10
Antibiotic Dosage: 400
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Mar 6, 2025
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