Inspection Reports for Clinton House Rehabilitation and Healthcare Center
809 W FREEMAN ST, IN, 46041
Back to Facility ProfileInspection Report Summary
The most recent inspection on February 28, 2025, found the facility in compliance with no deficiencies cited. Prior inspections show a pattern of multiple deficiencies related mainly to resident care, medication administration, and food safety, as well as several life safety code issues involving fire safety equipment and emergency preparedness. Complaint investigations throughout the period were mostly unsubstantiated, with one substantiated complaint in June 2023 related to medication transcription and administration errors. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows some improvement in recent complaint investigations and life safety compliance, although care and medication management issues were noted in earlier inspections.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
12.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
198% 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 February 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 75
Capacity: 75
Deficiencies: 0
Date: Feb 28, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00453619 and IN00451399.
Complaint Details
Investigation of Complaints IN00453619 and IN00451399 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00453619 and IN00451399 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 9
Medicaid census: 57
Other payor census: 9
Inspection Report
Complaint Investigation
Census: 73
Capacity: 73
Deficiencies: 0
Date: Dec 10, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00448748, IN00448443, and IN00447789.
Complaint Details
Complaints IN00448748, IN00448443, and IN00447789 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00448748, IN00448443, and IN00447789 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Medicare census: 2
Medicaid census: 56
Other payor census: 15
Inspection Report
Complaint Investigation
Census: 75
Capacity: 75
Deficiencies: 0
Date: Nov 1, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00446112.
Complaint Details
Complaint IN00446112 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 SNF/NF beds: 75
Census total residents: 75
Census Medicaid residents: 59
Census other payor residents: 16
Inspection Report
Life Safety
Census: 74
Capacity: 88
Deficiencies: 1
Date: Oct 17, 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) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements. However, the Life Safety Code survey identified a deficiency where the housekeeping office door required two operations to open due to an independent dead bolt and locking doorknob, which could affect 2 residents, 2 staff, and 1 visitor.
Deficiencies (1)
Housekeeping office door was provided with door latches that required more than one operation to open, violating LSC 7.2.1.5.10.2.
Report Facts
Certified beds: 88
Census: 74
Residents affected: 2
Staff affected: 2
Visitors affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Goran Prentoski | Executive Director | Signed the report |
| Maintenance Director | Interviewed and confirmed door latch deficiency | |
| Director of Nursing | Participated in exit conference regarding deficiency |
Inspection Report
Life Safety
Deficiencies: 0
Date: Oct 17, 2024
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey was conducted on 10/17/2024.
Findings
Clinton House Rehabilitation and Healthcare Center was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 Edition of the NFPA 101 Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Annual Inspection
Census: 81
Capacity: 81
Deficiencies: 7
Date: Sep 10, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which also included the Investigation of Complaints IN00439641, IN00440622, and IN00441593.
Complaint Details
Complaint IN00439641 - No deficiencies related to the allegations are cited. Complaint IN00440622 - No deficiencies related to the allegations are cited. Complaint IN00441593 - Federal/state deficiencies related to the allegations are cited at F804 (food temperature).
Findings
The facility was found deficient in multiple areas including baseline care plans not completed within 48 hours of admission, failure to administer medications per physician orders, improper respiratory care and equipment storage, lack of assessments and consents for bedrails, psychotropic medication orders without proper stop dates, food served at improper temperatures, and failure to place a resident in contact isolation promptly while awaiting C-Diff test results.
Deficiencies (7)
Failed to ensure baseline care plans were completed within 48 hours after admission for 2 of 2 residents reviewed.
Failed to administer as needed medication for weight gain, notify physician of weight gain, and hold insulin doses per physician's orders for 2 of 2 residents.
Failed to ensure staff stored nebulizer and CPAP/BiPap masks in a sanitary manner and failed to have oxygen orders for 3 of 3 residents reviewed for respiratory care.
Failed to ensure assessments and consents were obtained prior to use of side rails for 2 of 3 residents reviewed.
Failed to ensure PRN psychotropic medication orders were not beyond 14 days without documented rationale for extended use for 2 of 5 residents.
Failed to ensure food was served at proper safe and appetizing temperatures in the kitchen.
Failed to ensure a resident was placed in contact isolation immediately after being tested and while waiting for results for Clostridium Difficile.
Report Facts
Survey dates: 2024-09-03 to 2024-09-10
Census: 81
Total capacity: 81
Medicare census: 8
Medicaid census: 59
Other payor census: 14
Weight gain: 11.1
Weight gain: 6.5
Weight gain: 5.5
Weight gain: 3.5
Food temperature: 106
Food temperature: 51
Food temperature: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Goran Prentoski | Executive Director | Signed the report and plan of correction |
| Brenda Buroker | Director of Division Long Term Care | Recipient of the report letter |
| LPN 7 | Interviewed regarding medication administration | |
| Director of Nursing | DON | Interviewed multiple times regarding deficiencies and policies |
| CNA 5 | Observed handling CPAP/BiPap mask | |
| RN 6 | Interviewed regarding CPAP order | |
| Clinical Support Nurse | Provided policies and interviewed regarding psychotropic medication | |
| Dietary Manager | Interviewed and observed food temperature checks | |
| Interim Executive Director | Interviewed regarding food complaints |
Inspection Report
Deficiencies: 0
Date: Sep 10, 2024
Visit Reason
The inspection was conducted for paper compliance to the Recertification and State Licensure Survey and the Investigation of Complaint IN00441593.
Complaint Details
Investigation of Complaint IN00441593 was completed and found in compliance.
Findings
Clinton House Rehabilitation and Healthcare Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding Recertification and State Licensure and the Investigation of Complaint IN00441593.
Inspection Report
Complaint Investigation
Census: 75
Capacity: 75
Deficiencies: 0
Date: Jun 26, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00436667.
Complaint Details
Investigation of Complaint IN00436667 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00436667 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 3
Medicaid census: 58
Other payor census: 14
Inspection Report
Complaint Investigation
Census: 76
Capacity: 76
Deficiencies: 0
Date: Mar 19, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00426374 and IN00429515.
Complaint Details
Complaint IN00426374 and Complaint IN00429515 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00426374 and IN00429515 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type: 76
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 58
Census Payor Type - Other: 11
Inspection Report
Follow-Up
Census: 68
Capacity: 88
Deficiencies: 0
Date: Dec 21, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 10/11/23 was performed to verify compliance with fire safety and licensure requirements.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 NFPA 101 Life Safety Code. The building was fully sprinklered except for one detached garage used for storage.
Report Facts
Facility capacity: 88
Census: 68
Inspection Report
Complaint Investigation
Census: 76
Capacity: 76
Deficiencies: 0
Date: Dec 11, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00423541, IN00423552, IN00423613, and IN00423616 at Clinton House Rehabilitation and Healthcare Center.
Complaint Details
Complaints IN00423541, IN00423552, IN00423613, and IN00423616 were investigated and no deficiencies related to the allegations were found.
Findings
No deficiencies related to the allegations in any of the 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 in regard to the investigation of these complaints.
Report Facts
Census Bed Type: 76
Total Census: 76
Payor Type Census: 3
Payor Type Census: 63
Payor Type Census: 10
Inspection Report
Annual Inspection
Census: 68
Capacity: 88
Deficiencies: 10
Date: Oct 11, 2023
Visit Reason
Annual Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with several Life Safety Code requirements including missing delayed egress signage on doors, inaccurate fire alarm system time, missing sprinkler escutcheons, sprinkler clearance issues, obstructed fire extinguisher, damaged corridor door, incomplete smoke barrier door closure, incomplete fire drill documentation, combustible decorations not meeting fire safety standards, and improper use of power strips.
Deficiencies (10)
Failed to ensure 5 of 5 egress doors equipped for delayed egress had required signage.
Failed to maintain fire alarm system with accurate time and date information.
Failed to ensure ceiling construction in Garden Lounge met NFPA 13 sprinkler escutcheon requirements.
Failed to maintain clearance of at least 18 inches below sprinkler deflectors in 1 of over 60 rooms.
Failed to ensure 1 of 2 portable fire extinguishers was not obstructed.
Failed to ensure corridor door to clean utility room resisted passage of smoke due to a hole.
Failed to ensure 1 of 4 sets of smoke barrier doors fully closed to restrict smoke movement.
Failed to ensure fire drills included verification of transmission of fire alarm signal for last 4 quarters.
Failed to ensure combustible decorations met flame retardant or fire safety standards in 10 of over 41 rooms.
Failed to ensure Medical Records office did not use flexible cords as substitute for fixed wiring (piggybacked power strips and extension cord).
Report Facts
Certified beds: 88
Census: 68
Deficiencies cited: 10
Fire drills missing verification: 12
Smoke barrier door gap: 4
Smoke barrier door gap: 3
Hole diameter: 0.625
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Wells | Laboratory Director or Provider/Supplier Representative | Signed the report. |
| Maintenance Director | Named in multiple findings related to fire alarm system, sprinkler system, fire extinguisher obstruction, smoke barrier doors, combustible decorations, and electrical equipment. |
Inspection Report
Annual Inspection
Census: 77
Capacity: 77
Deficiencies: 12
Date: Sep 1, 2023
Visit Reason
This visit was for a Recertification and State Licensure Annual Survey conducted by the Indiana State Department of Health from August 27 to September 1, 2023.
Findings
The facility was found deficient in multiple areas including resident rights and dignity, care plan revisions, ADL care, quality of care including skin and weight monitoring, tube feeding management, respiratory care, staffing levels, dementia care programming, pharmacy services, food preparation, and sanitary food handling.
Deficiencies (12)
Failed to ensure residents were treated with dignity including proper clothing, bed positioning, and staff sitting while feeding.
Failed to update care plan for a resident after acquiring a pressure ulcer on his heel.
Failed to ensure a resident received teeth brushing twice daily as ordered by the dentist.
Failed to ensure assessments and documentation of care were completed for residents with sutures, head injury after a fall, and notification of weight changes for congestive heart failure.
Failed to notify physician, implement timely interventions, and document re-weights for significant weight changes.
Failed to ensure enteral feeding tube was unclamped and connected properly during feeding.
Failed to ensure physician's order for oxygen administration and oxygen saturation monitoring prior to setting oxygen flow rate.
Failed to have Certified Nursing Assistant coverage for evening shift on Memory Care Unit to ensure residents received scheduled showers.
Failed to provide a consistent program of cognitively stimulating activities for a resident with dementia.
Failed to ensure reconciliation of controlled drugs in medication carts and maintain insulin medication integrity.
Failed to prepare pureed foods according to recipes in the kitchen.
Failed to ensure refrigerator did not contain employee drinks, dishwasher was washing at recommended temperature, and sanitizing solution bucket levels were in range.
Report Facts
Residents on pureed diet: 5
Residents on Memory Care Unit: 18
Shower counts: 8
Weight loss: 6.74
Weight gain: 12.59
Dishwasher rinse temperature: 116
Dishwasher rinse temperature: 117
Missing narcotic count entries: 48
Missing narcotic count entries: 13
Missing narcotic count entries: 37
RN coverage missing days: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tracey Wells | Executive Director | Named in Plan of Correction and interview regarding staffing and facility operations. |
| Brenda Buroker | Director of Division Long Term Care | Recipient of survey report letter. |
| LPN 14 | Interviewed regarding bed positioning and resident care. | |
| RN 12 | Interviewed regarding resident care and dental recommendations. | |
| Clinical Support Nurse | Interviewed regarding care plan updates and dental recommendations. | |
| Director of Nursing | Interviewed regarding care plan updates, staffing, and medication management. | |
| CNA 13 | Interviewed regarding Memory Care Unit shower staffing and narcotic counts. | |
| Dietary Manager | Interviewed regarding food preparation and kitchen sanitation. |
Inspection Report
Renewal
Deficiencies: 0
Date: Sep 1, 2023
Visit Reason
Paper compliance to the Recertification and State Licensure survey completed on September 1, 2023.
Findings
Clinton House Rehabilitation and Healthcare Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to Recertification and State Licensure.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 12, 2023
Visit Reason
Investigation of Complaint IN00404299 completed on June 6, 2023.
Complaint Details
Investigation of Complaint IN00404299 completed and found the facility in compliance.
Findings
Clinton House Rehabilitation and Healthcare Center 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 Complaint IN00404299.
Inspection Report
Complaint Investigation
Census: 81
Capacity: 81
Deficiencies: 1
Date: Jun 6, 2023
Visit Reason
This visit was for the investigation of complaints IN00404299, IN00409207, and IN00409597 at Clinton House Rehabilitation and Healthcare Center.
Complaint Details
Complaint IN00404299 was substantiated with federal/state deficiencies cited. Complaints IN00409207 and IN00409597 had no deficiencies related to the allegations.
Findings
The facility was found deficient related to complaint IN00404299 for failure to ensure a resident's medications were transcribed and administered as ordered on the hospital discharge record for 1 of 3 residents reviewed (Resident H). No deficiencies were cited for the other two complaints.
Deficiencies (1)
Failure to ensure a resident's medications were transcribed and administered as ordered on the hospital discharge record for 1 of 3 residents reviewed (Resident H).
Report Facts
Census: 81
Total Capacity: 81
Medicaid Census: 65
Other Payor Census: 16
Units of Insulin Ordered: 35
Medication Dosage: 80
Medication Dosage: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tracey Wells | Executive Director | Signed the Plan of Correction |
| Brenda Buroker | Director of Division Long Term Care | Recipient of the Plan of Correction letter |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 76
Deficiencies: 0
Date: Feb 17, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00392111.
Complaint Details
Complaint IN00392111 was investigated and found unsubstantiated due to lack of evidence.
Findings
The complaint IN00392111 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare residents: 3
Medicaid residents: 50
Other residents: 23
Inspection Report
Re-Inspection
Census: 78
Capacity: 88
Deficiencies: 0
Date: Nov 4, 2022
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 09/26/22.
Findings
At this PSR survey, Clinton House Rehabilitation and Healthcare Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility was fully sprinklered except for one detached garage and had a fire alarm system with smoke detection in required areas.
Report Facts
Certified beds: 88
Census: 78
Inspection Report
Re-Inspection
Census: 75
Capacity: 75
Deficiencies: 0
Date: Oct 17, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on August 31, 2022.
Findings
Clinton House Rehabilitation and Healthcare Center 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: 10
Census Payor Type - Medicaid: 47
Census Payor Type - Other: 18
Inspection Report
Complaint Investigation
Census: 76
Capacity: 76
Deficiencies: 0
Date: Sep 30, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00390923 and included a COVID-19 Focused Infection Control Survey.
Complaint Details
Complaint IN00390923 was substantiated; however, no deficiencies related to the allegations were cited.
Findings
Complaint IN00390923 was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census SNF/NF beds: 76
Census total residents: 76
Census Medicare residents: 10
Census Medicaid residents: 48
Census other payor residents: 18
Inspection Report
Routine
Census: 77
Capacity: 88
Deficiencies: 9
Date: Sep 26, 2022
Visit Reason
Routine Emergency Preparedness and Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health.
Findings
The facility was found in substantial compliance with Emergency Preparedness requirements but had deficiencies in emergency power system maintenance, life safety code compliance including egress door locking, emergency lighting testing, sprinkler system maintenance, fire drills, fire door inspections, electrical system maintenance, generator testing, and gas cylinder storage.
Deficiencies (9)
Failed to provide weekly or monthly generator testing documentation for October, November, or December 2021.
Failed to ensure means of egress door was readily accessible; front door was magnetically locked with a code not common knowledge.
Failed to ensure monthly testing of battery backup emergency lights for three of the last twelve months and maintain written records.
Failed to document sprinkler system inspections weekly and monthly for several months.
Failed to conduct quarterly fire drills for one of four quarters and failed to verify transmission of fire alarm signal in 8 of 9 drills.
Failed to ensure annual inspection and testing of two fire door assemblies.
Failed to ensure approximately 270 nonhospital-grade electrical receptacles at resident rooms were tested annually.
Failed to maintain written records of weekly generator inspections for 14 weeks and monthly load testing for 3 months.
Failed to ensure 8 oxygen cylinders were properly secured from falling in the oxygen storage and transfilling room.
Report Facts
Certified beds: 88
Census: 77
Deficiency weeks missing: 14
Deficiency months missing: 3
Number of oxygen cylinders unsecured: 8
Number of nonhospital-grade receptacles: 270
Inspection Report
Annual Inspection
Census: 81
Capacity: 81
Deficiencies: 10
Date: Aug 31, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted by the Indiana State Department of Health from August 25 to 31, 2022.
Findings
The facility was found deficient in multiple areas including failure to obtain physician orders for hospice care upon admission, incomplete significant change assessments, failure to identify skin conditions during weekly assessments, unsafe transportation practices, improper medication storage and labeling, inappropriate use of psychotropic medications, lack of dental service consents, non-compliance with dietary menu preparation, and unsafe water temperatures and damaged bathroom doors.
Deficiencies (10)
Failed to ensure a physician's order was obtained for a resident receiving hospice services upon admission.
Failed to complete a significant change assessment for a resident with a major decline in condition.
Failed to assess and identify skin conditions of excoriation and bruising during weekly skin assessments for residents.
Failed to ensure emergency brake was engaged before assisting a resident off the facility bus and to ensure resident was secured during transport.
Failed to ensure expired controlled medications were disposed of and controlled medication packaging was intact.
Failed to ensure residents with dementia had appropriate diagnoses for prescribed psychotropic medications.
Failed to ensure oral, topical and inhaled medications were stored separately in medication carts.
Failed to ensure residents and representatives were aware of available dental services and obtained consent or declination for dental services.
Failed to ensure menus were followed when staff prepared food, resulting in non-compliance with established menu or dietician-approved recipe.
Failed to ensure water temperatures were at a comfortable and safe level and bathroom doors were in good condition.
Report Facts
Census: 81
Total Capacity: 81
Survey Dates: 5
Expired Morphine Volume: 30
Water Temperature: 98
Water Temperature: 133
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tracey Wells | Executive Director | Named in relation to Plan of Correction submission |
| Brenda Buroker | Director of Division Long Term Care | Recipient of survey report letter |
Report
Aug 15, 2025
Report
Aug 15, 2025
Report
Sep 10, 2024
Report
Sep 10, 2024
Report
Dec 11, 2023
Report
Sep 1, 2023
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Jun 6, 2023
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