Inspection Reports for Community Nursing and Rehabilitation Center
IN, 46218
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 8, 2025, found the facility in compliance based on a paper review of the prior Post Survey Revisit. Earlier inspections showed a pattern of deficiencies primarily related to environmental maintenance, cleanliness, and providing a homelike environment, as well as Life Safety Code issues such as obstructed egress, door latching, and fire safety equipment maintenance. Complaint investigations were mostly unsubstantiated or corrected, with one substantiated complaint in April 2025 involving resident dignity, abuse prevention, medication administration, and infection control deficiencies. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s recent clean inspection suggests some improvement following earlier citations, though Life Safety Code and environmental issues appeared repeatedly over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
31.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
650% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Dec 11, 2025
Visit Reason
The inspection was conducted following complaints and allegations related to resident safety, abuse, neglect, and care concerns at Community Nursing and Rehabilitation Center.
Complaint Details
The investigation involved allegations of staff to resident abuse, failure to report abuse timely, inadequate care including incontinent care delays, unsafe resident transport, and failure to monitor residents leaving the facility without responsible parties. The allegations were substantiated with findings of minimal harm or potential for harm.
Findings
The facility was found deficient in maintaining a safe and clean environment, timely reporting of abuse allegations, providing timely incontinent care, safe resident transport, monitoring residents leaving the facility, and proper respiratory care including oxygen administration and equipment maintenance.
Deficiencies (5)
Failed to maintain a resident's room in good repair contributing to an allegation of abuse.
Failed to timely report an allegation of staff to resident abuse to the Executive Director and Indiana Department of Health.
Failed to provide incontinent care timely for a dependent resident.
Failed to transport a resident in a wheelchair safely and failed to provide adequate monitoring for a resident who exited the facility without a responsible party.
Failed to provide oxygen as ordered and maintain oxygen tubing and humidifier bottle in a sanitary manner.
Report Facts
Residents reviewed: 3
Deficiencies cited: 5
Oxygen liters ordered: 3
Call light wait time: 60
Resident B LOA duration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 2 | Certified Nursing Assistant | Named in allegation of pushing Resident D and involved in abuse investigation |
| Director of Nursing Services | DNS | Provided investigation files and interviews related to abuse and care deficiencies |
| Assistant Director of Nursing Services | ADNS | Provided incontinent care and oxygen equipment maintenance for Resident F |
| Regional Director of Clinical Services | RDCS | Provided interviews and policy information related to abuse reporting and resident transport |
| Housekeeping Supervisor | HS | Observed and reported structural damage in Resident D's room |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 13, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to provide physician-ordered anti-convulsant and anti-anxiety medications to a resident, resulting in increased seizures and hospitalization.
Complaint Details
The complaint investigation found that Resident B did not receive prescribed anti-convulsant and anti-anxiety medications for multiple consecutive doses between 10-17-25 and 10-20-25, resulting in increased seizure activity and hospitalization. The facility lacked documentation of attempts to obtain medications or notify relevant parties. The Director of Nursing acknowledged the issue was discovered late and no formal investigation or additional staff training had been conducted.
Findings
The facility failed to ensure that Resident B received ordered anti-convulsant and anti-anxiety medications for three consecutive days, leading to increased seizures and hospitalization. Documentation and communication failures were noted, including lack of notification to pharmacy, physician, or family, and no formal investigation or staff training had been conducted.
Deficiencies (1)
Failure to provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Report Facts
Consecutive doses not administered: 6
Consecutive doses not administered: 6
Consecutive doses not administered: 7
Consecutive doses not administered: 6
Consecutive doses not administered: 3
Doses not available for administration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration failures and facility expectations |
| Executive Director | Executive Director | Interviewed regarding facility policies and documentation related to medication administration |
| Corporate Nurse | Corporate Nurse | Interviewed regarding facility policies and standards of practice for medication administration |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 14, 2025
Visit Reason
The inspection was conducted in response to complaints regarding resident rights and foot care at the Community Nursing and Rehabilitation Center.
Complaint Details
The inspection relates to Complaint IN00462929 regarding resident rights and Complaint IN00463244 regarding foot care. The resident rights complaint involved a Certified Nurse Aide refusing a resident's request for chocolate milk. The foot care complaint involved failure to order urea 40% cream as recommended by the podiatrist.
Findings
The facility failed to honor a resident's choice regarding food selection for one resident and failed to timely implement a podiatry recommendation for another resident. Both deficiencies were found to have minimal harm or potential for actual harm and affected a few residents.
Deficiencies (2)
Failed to ensure a resident's choice was honored pertaining to selection of food items for 1 of 3 residents reviewed for resident rights (Resident B).
Failed to timely implement a podiatry recommendation for 1 of 3 residents reviewed for foot care (Resident E).
Report Facts
Residents reviewed for resident rights: 3
Residents reviewed for foot care: 3
Date of podiatry order: Sep 25, 2024
Date of podiatry note: Jun 14, 2025
Duration for urea cream application: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide 2 | Certified Nurse Aide | Named in resident rights deficiency for refusing resident's request for chocolate milk |
| Licensed Practical Nurse 3 | Licensed Practical Nurse | Witnessed interaction between CNA 2 and Resident B |
| Executive Director | Executive Director | Interviewed regarding staff education on resident choice and preferences |
| Director of Nursing | Director of Nursing | Interviewed regarding podiatry recommendation processing and Resident E's foot care |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 8, 2025
Visit Reason
Paper compliance review to the Post Survey Revisit (PSR) completed on June 10, 2025, related to the Annual Recertification and State Licensure survey completed on April 25, 2025.
Findings
Community Nursing and Rehabilitation Center 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 of the PSR to the Recertification and State Licensure survey.
Inspection Report
Re-Inspection
Census: 55
Capacity: 55
Deficiencies: 2
Date: Jun 10, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on April 25, 2025, including a PSR to the Investigation of Complaint IN00456672 completed on April 25, 2025.
Complaint Details
Complaint IN00456672 was investigated and corrected.
Findings
The facility failed to ensure cleanliness of the kitchen and failed to provide a homelike environment for 3 of 5 residents reviewed. Deficiencies included dirty kitchen floors, food debris in the dishwasher drain, dust on walls, ceiling, and shelves, missing paint and holes in call light box coverings in resident rooms, and dust on a resident's fan. The facility had not implemented systemic plans of correction to prevent recurrence.
Deficiencies (2)
Failed to ensure cleanliness of the kitchen, including dirty floors, food debris in dishwasher drain, and dust on walls and shelves.
Failed to provide a homelike environment for 3 of 5 residents, including missing paint, holes in call light box coverings, and dust on resident's fan.
Report Facts
Residents affected by kitchen cleanliness deficiency: 55
Residents reviewed for physical environment: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paige Metzler | Executive Director | Interviewed regarding kitchen cleanliness and homelike environment policies; named in findings and corrective action plans. |
| Culinary Manager | Culinary Manager | Conducted kitchen tour and observations related to cleanliness deficiencies. |
Inspection Report
Life Safety
Census: 55
Capacity: 115
Deficiencies: 15
Date: May 20, 2025
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 05/20/2025.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Multiple deficiencies were identified including obstructed means of egress, improperly secured stairwell exit doors, storage in stairwells, emergency lighting documentation issues, lack of preventative maintenance on battery-operated smoke alarms, sprinkler system obstructions and maintenance issues, smoke barrier door malfunctions, fire drills not conducted at varying times, malfunctioning rolling fire door, incomplete emergency generator battery testing records, and improper use of extension cords.
Deficiencies (15)
Means of egress were obstructed by stored items in corridors.
Stairwell exit door on second floor had incorrect keypad code posted.
Items stored in first floor exit stairwell interfered with egress.
Failed to document monthly testing for 1 of 4 battery backup emergency lights.
Failed to ensure preventative maintenance for all battery operated smoke alarms in resident rooms.
Stairwell door on second floor did not latch properly, compromising smoke barrier.
Curtain obstructed sprinkler spray pattern in second floor Activities Office.
Rusted sprinkler head in visitor's restroom behind reception desk not replaced.
Therapy room door lacked positive latching mechanism to secure door closed.
Corridor walls near mechanical room did not resist transfer of smoke due to HVAC return not flush with grill.
One set of smoke barrier doors failed to fully self-close due to malfunctioning door coordinator.
Failed to conduct quarterly fire drills at unexpected times on third shift for four calendar quarters.
Rolling steel fire door in kitchen did not operate automatically and was awaiting repair/replacement.
Incomplete written record of monthly testing of emergency generator starting batteries for 11 of 12 months.
Extension cord used as substitute for fixed wiring in first floor dining room.
Report Facts
Certified beds: 115
Census: 55
Third shift fire drills: 10
Third shift fire drills: 12
Battery backup lights: 4
Battery backup lights: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and involved in findings and corrective actions throughout the report | |
| Executive Director | Interviewed and involved in exit conferences and corrective action plans |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 25, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of disrespectful and rough care, failure to maintain residents' dignity, and inadequate assistance with activities of daily living.
Complaint Details
This citation relates to Complaint IN00456672 involving allegations of rough and disrespectful care, failure to maintain dignity, and inadequate ADL assistance.
Findings
The facility failed to ensure residents' dignity and respectful treatment for multiple residents, including rough handling by staff and improper use of tablecloths as clothing protectors. Additionally, the facility failed to timely assist a resident in bed and provide consistent showers as scheduled for another resident.
Deficiencies (2)
Failed to honor residents' right to a dignified existence, self-determination, communication, and to exercise rights, including rough and disrespectful care by staff.
Failed to provide care and assistance to perform activities of daily living, including timely repositioning in bed and consistent showers.
Report Facts
Residents affected: 3
Residents affected: 7
Shower days missed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 2 | Certified Nurse Aide | Named in multiple findings related to rough care and poor attitude towards residents |
| QMA 10 | Qualified Medication Aide | Observed during medication administration and noted failure to ensure resident was pulled up in bed |
| CNA 22 | Certified Nurse Aide | Responsible for pulling resident up in bed but failed to do so timely |
| CNA 23 | Certified Nurse Aide | Mentioned as potential assistance for repositioning resident in bed |
| Director of Nursing | Director of Nursing | Interviewed regarding ADL care policies and shower scheduling |
| Executive Director | Executive Director | Provided shower sheets indicating missed showers for Resident B |
Inspection Report
Complaint Investigation
Deficiencies: 16
Date: Apr 25, 2025
Visit Reason
The inspection was conducted based on complaints regarding residents' dignity, abuse investigations, grievances follow-up, medication administration, infection control, and other care concerns at Community Nursing and Rehabilitation Center.
Complaint Details
The inspection was complaint-related, addressing multiple complaints including dignity violations, abuse allegations, grievance follow-up failures, medication errors, infection control lapses, and environmental concerns.
Findings
The facility failed to ensure residents' dignity and respect, timely follow-up on grievances, protection from abuse, appropriate medication administration, infection control, food safety, and a homelike environment. Multiple residents reported rough or disrespectful care, delayed pain medication, improper handling of grievances, and issues with food temperature and quality. Infection control lapses and environmental concerns were also noted.
Deficiencies (16)
Failed to honor residents' right to a dignified existence and respect during care, including rough handling and disrespectful behavior by staff.
Failed to follow up on grievances for residents, resulting in unresolved complaints and missing grievance documentation.
Failed to protect residents from abuse, including sexual abuse and inappropriate behaviors between residents.
Failed to maintain evidence of thorough investigation of abuse allegations.
Failed to timely refer residents with new psychiatric diagnoses for required Level 2 assessments.
Failed to provide timely assistance with activities of daily living, including repositioning in bed and consistent showers.
Failed to administer medications and treatments as ordered, including insulin, pain medication, and topical treatments.
Failed to provide safe and appropriate respiratory care by not ensuring oxygen was delivered as ordered.
Failed to provide adequate pain management with delays in administration of pain medications.
Failed to timely document behaviors and initiate new interventions for a resident with dementia exhibiting wandering and inappropriate urination.
Failed to timely follow-up on pharmacy recommendations for discontinuation of unnecessary medications.
Failed to ensure drugs and biologicals were labeled with open or expiration dates and stored properly.
Failed to ensure food was served at palatable temperatures and consistent quality as reported by residents and observed during resident council meetings.
Failed to ensure kitchen cleanliness, proper food storage, staff hygiene including beard nets, and covered trash cans.
Failed to maintain infection control practices including hand hygiene prior to eye drop administration, timely removal of bodily fluids, and use of gowns during high contact care.
Failed to promote a homelike environment with broken blinds, urine odor, and damaged walls in residents' rooms.
Report Facts
Missed doses of mycophenolate mofetil: 10
Missed insulin administrations: 6
Residents attending resident council: 54
Residents reviewed for food: 4
Residents reviewed for dignity: 3
Residents reviewed for abuse: 3
Residents reviewed for unnecessary medications: 5
Residents reviewed for activities of daily living: 4
Residents observed during medication administration: 7
Residents reviewed for infection control: 7
Residents reviewed for environment: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 2 | Certified Nurse Aide | Named in findings related to rough care and resident complaints. |
| LPN 25 | Licensed Practical Nurse | Administered medications and was involved in pain medication delay findings. |
| QMA 10 | Qualified Medication Aide | Observed during medication administration with infection control lapses and oxygen care. |
| RN 24 | Registered Nurse | Interviewed regarding medication labeling and expiration dates. |
| DA 15 | Dietary Aide | Observed in kitchen with food storage and hygiene violations. |
| DA 17 | Dietary Aide | Observed serving food with beard net improperly worn. |
| DM | Dietary Manager | Interviewed regarding food storage and kitchen cleanliness. |
| WS 8 | Weekend Supervisor | Involved in abuse investigation and reporting. |
| NC 12 | Nurse Consultant | Observed oxygen care and assisted with resident repositioning. |
| NC 13 | Nurse Consultant | Observed medication administration and interviewed about pain medication delays. |
| MD | Doctor of Medicine | Interviewed regarding medication administration and pharmacy recommendations. |
| ED | Executive Director | Provided policies and interviewed regarding multiple findings. |
| DON | Director of Nursing | Interviewed regarding medication administration, grievances, and infection control. |
| SSD | Social Services Director | Interviewed regarding grievance follow-up and PASRR screenings. |
| MS | Maintenance Supervisor | Interviewed regarding environmental repairs. |
| HS | Housekeeping Supervisor | Interviewed regarding room odor and cleaning. |
Inspection Report
Annual Inspection
Census: 54
Capacity: 54
Deficiencies: 15
Date: Apr 25, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00456672.
Complaint Details
Complaint IN00456672 was investigated with federal/state deficiencies cited related to allegations of dignity, abuse, grievance follow-up, ADL care, medication administration, and infection control.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, grievance follow-up, abuse prevention and investigation, timely PASARR assessments, ADL care, medication administration, food temperature and storage, infection control, and environmental maintenance.
Deficiencies (15)
Failed to ensure residents' respect and dignity were maintained for multiple residents during care and dining.
Failed to follow up on grievances for 2 residents reviewed.
Failed to protect residents' right to be free from abuse for 2 residents reviewed.
Failed to maintain evidence that an allegation of abuse was thoroughly investigated for 2 residents reviewed.
Failed to timely refer a resident with a new psychiatric diagnosis for a Level 2 PASARR assessment.
Failed to timely pull a resident up in bed as requested and provide consistent showers per resident preference.
Failed to ensure resident's oxygen was provided as ordered.
Failed to provide adequate pain control for 2 residents reviewed for pain medication.
Failed to timely document behaviors and initiate new interventions for a resident with dementia exhibiting wandering and inappropriate urination.
Failed to timely follow-up on pharmacy recommendations for a resident reviewed for unnecessary medications.
Failed to ensure insulin medications had open and/or expiration dates on medication carts.
Failed to ensure food was served at palatable temperatures for multiple residents and resident council attendees.
Failed to ensure kitchen was clean and in good repair, staff contained hair, food was properly covered, labeled, dated, and trash cans were covered when not in use.
Failed to ensure infection control was maintained by utilizing hand hygiene prior to administering eye drops, timely removing feces and urine from bedside table, and wearing gown while disposing bodily fluids for residents on Enhanced Barrier Precautions.
Failed to promote a homelike environment by not repairing broken blinds, addressing urine odor, and repairing scraped paint in resident rooms.
Report Facts
Survey dates: 5
Residents present: 54
Residents Medicare: 1
Residents Medicaid: 44
Residents Other: 9
Deficiency counts: 14
Missed medication doses: 10
Insulin doses missed: 6
Food temperature: 126.3
Food temperature: 153
Food temperature: 50.7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Keshia Polston | Regional Vice President of Operations | Signed report cover page |
| CNA 2 | Named in abuse and dignity findings related to resident care and attitude | |
| LPN 5 | Licensed Practical Nurse | Named in delayed pain medication administration |
| LPN 25 | Licensed Practical Nurse | Named in delayed pain medication administration |
| QMA 10 | Qualified Medication Aide | Named in infection control and oxygen administration findings |
| RN 24 | Registered Nurse | Named in insulin medication labeling deficiency |
| DA 15 | Dietary Aide | Named in food storage and hygiene deficiencies |
| DA 17 | Dietary Aide | Named in food service temperature and hygiene deficiencies |
| DM | Dietary Manager | Named in food storage and hygiene deficiencies |
| WS 8 | Weekend Supervisor | Named in abuse and resident wandering incident |
| SSD | Social Service Director | Named in grievance and behavior management findings |
| DON | Director of Nursing | Named in multiple findings including abuse, medication, and infection control |
| NC 13 | Nurse Consultant | Named in abuse and infection control findings |
| DNS | Director of Nursing Services | Named in medication and infection control corrective actions |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 55
Deficiencies: 0
Date: Jan 16, 2025
Visit Reason
This visit was for the investigation of complaints IN00436227 and IN00451332.
Complaint Details
Complaint IN00436227 - No deficiencies related to the allegations are cited. Complaint IN00451332 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations in complaints IN00436227 and IN00451332 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 these complaints.
Report Facts
Census SNF/NF beds: 55
Total census: 55
Medicare census: 1
Medicaid census: 47
Other payor census: 7
Inspection Report
Life Safety
Census: 51
Capacity: 115
Deficiencies: 0
Date: Jul 11, 2024
Visit Reason
A second Post Survey Revisit (PSR) to the Post Survey Revisit conducted on 06/10/24 to the Life Safety Code Recertification and State Licensure Survey conducted on 05/14/24 was conducted by the Indiana Department of Health.
Findings
At this PSR survey, Community Nursing and Rehabilitation Center 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 was fully sprinklered except for two detached buildings used for storage which were not sprinklered.
Report Facts
Facility capacity: 115
Census: 51
Inspection Report
Re-Inspection
Census: 55
Capacity: 115
Deficiencies: 2
Date: Jun 10, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 05/14/24 was performed to verify correction of previously cited deficiencies.
Findings
The facility was found not in compliance with Life Safety Code requirements, specifically regarding corridor door latching and ground fault circuit interrupter (GFCI) maintenance. Deficiencies from the prior survey were not fully corrected, indicating failure to implement systemic corrective actions.
Deficiencies (2)
Failed to ensure 1 of over 40 corridor doors had no impediment to closing and latching into the door frame, affecting 4 residents.
Failed to ensure all ground fault circuit interrupters (GFCI) were properly maintained for protection against electric shock, specifically in resident room 139.
Report Facts
Facility capacity: 115
Census: 55
Corridor doors inspected: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paige Metzler | Executive Director | Interviewed regarding door latching and GFCI deficiencies; also contact for desk review |
Inspection Report
Renewal
Deficiencies: 0
Date: May 22, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the Recertification and State Licensure of the facility.
Findings
Community Nursing and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 during the paper compliance review for Recertification and State Licensure.
Inspection Report
Life Safety
Census: 50
Capacity: 115
Deficiencies: 3
Date: May 14, 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 but was not in compliance with Life Safety Code requirements. Deficiencies included corridor doors that failed to latch properly, smoke barrier doors that did not close to form a smoke resistant barrier, and a ground fault circuit interrupter (GFCI) receptacle that did not trip when tested.
Deficiencies (3)
Failed to ensure 2 of over 40 corridor doors had no impediment to closing and latching into the door frame and would resist the passage of smoke, potentially affecting 4 residents.
Failed to ensure 1 of 6 sets of smoke barrier doors would close to form a smoke resistant barrier, potentially affecting 40 residents, staff, and visitors.
Failed to ensure all ground fault circuit interrupter (GFCI) receptacles were properly maintained; one GFCI receptacle in resident room 139 did not trip when tested, potentially affecting one resident and staff.
Report Facts
Certified beds: 115
Census: 50
Corridor doors with deficiency: 2
Smoke barrier door sets with deficiency: 1
GFCI receptacle with deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paige Metzler | Executive Director | Named as Executive Director and contact for desk review |
| Maintenance Director | Interviewed and confirmed deficiencies related to door latching and smoke barrier door coordination | |
| Field Maintenance Supervisor | Participated in observations and interviews regarding deficiencies | |
| Director of Property Management | Present at exit conference reviewing findings |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Apr 22, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for Community Nursing and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to timely provide assistance with activities of daily living, medication administration errors, inadequate behavioral health care and monitoring, failure to maintain safe food temperatures, failure to maintain a clean and safe environment, and failure to provide appropriate care for residents with feeding tubes.
Deficiencies (7)
Failed to timely provide assistance with dressing for 1 of 1 resident reviewed for ADL care (Resident 6).
Failed to assess a resident's skin condition; clarify antipsychotic medication dosage and administration time; administer insulin as ordered; and monitor bowel movements for residents (Residents B and 27).
Failed to provide oral care as ordered and timely obtain physician's order for gastrostomy tube site care for 1 resident (Resident 23).
Failed to adequately monitor and document behaviors and provide necessary behavioral health care for residents (Residents 38 and 45).
Failed to ensure medication error rate less than 5 percent; 2 errors in 34 opportunities observed for 1 resident (Resident 43).
Failed to serve breakfast at safe and palatable temperatures potentially affecting 54 of 55 residents.
Failed to maintain first-floor shower room in good condition and timely repair leaking pipe in kitchen, potentially affecting all residents.
Report Facts
Medication error rate: 5.88
Residents affected by cold breakfast: 54
Residents affected by environmental deficiencies: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 3 | Licensed Practical Nurse | Observed administering insulin and obtaining blood sugars; involved in medication error finding |
| Director of Nursing Services | DNS | Interviewed regarding medication errors, behavioral health care, and other deficiencies |
| Executive Director | ED | Provided investigative files and interviewed regarding behavioral incidents and environmental issues |
| Social Services Director | SSD | Interviewed regarding behavioral health care and resident incidents |
| Facility Cook 5 | FC | Observed during breakfast service related to food temperature deficiencies |
| Dietary Manager | DM | Observed and interviewed regarding food temperature and kitchen pipe leak |
| Infection Preventionist Float | IPF | Provided policies and interviewed regarding bowel elimination and behavior management |
| Licensed Practical Nurse 3 | LPN | Observed providing oral care and gastrostomy tube care |
Inspection Report
Annual Inspection
Census: 55
Capacity: 55
Deficiencies: 7
Date: Apr 22, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00432069, IN00431934, and IN00432753.
Complaint Details
Complaints IN00432069, IN00431934, and IN00432753 were investigated with no deficiencies related to the allegations cited.
Findings
The facility was found deficient in multiple areas including timely assistance with dressing, medication administration errors, inadequate skin assessments, failure to monitor bowel movements, improper oral and gastrostomy tube care, behavioral health monitoring deficiencies, medication error rate exceeding 5%, serving food at safe temperatures, and environmental maintenance issues such as a leaking pipe and unclean shower room.
Deficiencies (7)
Failed to timely provide assistance with dressing for 1 of 1 resident reviewed for ADL care (Resident 6).
Failed to assess a resident's skin condition; clarify medication dosage and administration time; administer insulin as ordered; and monitor bowel movements for residents (Residents B and 27).
Failed to provide oral care as ordered and timely obtain physician's order for gastrostomy tube site care for 1 resident (Resident 23).
Failed to adequately monitor and document behaviors for 1 resident reviewed for mood and behaviors and 2 residents reviewed for unnecessary medications (Residents 38 and 45).
Medication error rate exceeded 5 percent with 2 errors in 34 opportunities involving 1 resident (Resident 43).
Failed to serve breakfast at safe and palatable temperatures affecting 54 of 55 residents.
Failed to maintain the first-floor shower room in good condition and timely repair a leaking pipe in the kitchen affecting all residents.
Report Facts
Census: 55
Total Capacity: 55
Medication error rate: 5.88
Insulin dosage: 22
Insulin dosage: 12
Food temperature: 86
Food temperature: 100
Food temperature: 109
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paige Metzler | Executive Director | Signed report and contact for desk review |
| LPN 3 | Observed administering insulin and blood sugar checks with errors | |
| DNS | Director of Nursing Services | Interviewed regarding medication errors, skin assessments, and behavioral health |
| CNA 2 | Certified Nursing Assistant | Interviewed regarding Resident 6's dressing assistance |
| FC 5 | Facility Cook | Observed serving cold food |
| DM | Dietary Manager | Observed food temperatures and kitchen pipe leak |
| IPF | Infection Preventionist Float | Provided policies and observations on bowel management and food temperatures |
| ED | Executive Director | Provided investigative files and interviewed about behavioral incidents and environmental issues |
| SSD | Social Services Director | Interviewed regarding behavioral incidents and resident interviews |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 55
Deficiencies: 0
Date: Apr 22, 2024
Visit Reason
The visit was conducted for the investigation of Complaint IN00432753 and included the investigation of Complaints IN00432069 and IN00431934, in conjunction with the Recertification and State Licensure Survey.
Complaint Details
Complaint IN00432069 - No deficiencies related to the allegations are cited. Complaint IN00431934 - No deficiencies related to the allegations are cited. Complaint IN00432753 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations of any of the complaints were cited. The facility was found to be in substantial compliance with 42 CFR Part 483, Subpart B regarding the investigation of Complaint IN00432753.
Report Facts
Census SNF/NF beds: 55
Total census: 55
Medicare census: 1
Medicaid census: 47
Other payor census: 7
Inspection Report
Complaint Investigation
Census: 44
Capacity: 44
Deficiencies: 0
Date: Sep 7, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00413637 and IN00416066.
Complaint Details
Investigation of Complaints IN00413637 and IN00416066 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00413637 and IN00416066 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 44
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 39
Census Payor Type - Other: 4
Total Census: 44
Inspection Report
Re-Inspection
Census: 44
Capacity: 115
Deficiencies: 0
Date: Jul 6, 2023
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 05/16/23.
Findings
The facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements, including fire safety and sprinkler systems. The facility is fully sprinklered except for two detached storage buildings.
Report Facts
Certified beds: 115
Census: 44
Inspection Report
Follow-Up
Census: 42
Capacity: 42
Deficiencies: 0
Date: Jun 21, 2023
Visit Reason
This visit was for the Post Survey Revisit (PSR) to the Recertification and State Licensure Survey and the investigation of Complaints IN00402254, IN00400685, and IN00399680.
Complaint Details
Complaints IN00400685, IN00399680, and IN00402254 were investigated and found to be corrected.
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 the Recertification and State Licensure Survey and the PSR to the Investigation of the three complaints, all of which were corrected.
Report Facts
Census SNF/NF: 42
Total Capacity: 42
Census Medicaid: 33
Census Other: 9
Inspection Report
Annual Inspection
Census: 46
Capacity: 115
Deficiencies: 5
Date: May 16, 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 in accordance with federal regulations and state codes.
Findings
The facility was found in substantial compliance with Emergency Preparedness Requirements but had multiple deficiencies related to Life Safety Code including missing generator testing documentation, lack of self-closing device on a medical records office door, smoke barrier doors not closing completely, improper use of power strips, and missing fire rating identification on an oxygen storage room door.
Deficiencies (5)
Failed to maintain complete weekly generator inspection documentation for a five-week period.
Corridor door to Medical Records office lacked a self-closing device.
Smoke barrier doors in Administration Hall did not close completely, leaving a one-inch gap.
Power strip used as an extension cord in the Executive Director's office.
Door to oxygen transfilling room had fire rating sticker painted over and illegible.
Report Facts
Certified beds: 115
Census: 46
Missing generator testing documentation weeks: 5
Residents potentially affected by smoke barrier door deficiency: 16
Staff potentially affected by smoke barrier door deficiency: 4
Visitors potentially affected by smoke barrier door deficiency: 2
Residents potentially affected by power strip deficiency: 10
Staff potentially affected by power strip deficiency: 6
Visitors potentially affected by power strip deficiency: 1
Residents potentially affected by oxygen room door deficiency: 16
Staff potentially affected by oxygen room door deficiency: 4
Visitors potentially affected by oxygen room door deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Keith Davis | Senior Executive Director | Signed the report and educated Maintenance Director on generator testing and other deficiencies |
| Maintenance Director | Acknowledged deficiencies and was educated on corrective actions including generator testing, self-closing doors, power strip usage, and fire rating door identification |
Inspection Report
Complaint Investigation
Deficiencies: 10
Date: May 11, 2023
Visit Reason
The inspection was conducted based on complaints related to resident care, grievances, abuse, care planning, medication administration, infection control, and facility environment.
Complaint Details
The inspection was conducted in response to Complaint IN00402254 and related complaints IN00400685 and IN00399680.
Findings
The facility failed to promote resident self-determination, address grievances, prevent verbal abuse, develop comprehensive care plans, ensure proper discharge summaries, provide appropriate pain management, maintain food safety standards, ensure proper medication administration and infection control, monitor antibiotic use, and maintain a safe and clean environment.
Deficiencies (10)
Failed to promote and facilitate resident self-determination through support of resident choice regarding bathing and morning routines.
Failed to address grievances for a resident and did not follow grievance policy properly.
Failed to protect a resident from verbal abuse by a staff member.
Failed to develop a comprehensive person-centered care plan for residents on hospice and with skin conditions.
Failed to ensure discharge summaries included a recap of the resident's stay.
Failed to provide appropriate pain management including timely addressing pain, assessing pain intensity, and providing nonpharmacological interventions.
Failed to store, prepare, distribute, and serve food in accordance with professional standards including dishwasher not reaching adequate temperature, improper hair restraints, personal items in food areas, and improper food storage.
Failed to ensure medication was not administered after being dropped, hand hygiene was done prior to donning gloves, and gloves were donned prior to administering insulin.
Failed to ensure a resident had an infection that met criteria for antibiotic usage prior to providing an antibiotic.
Failed to provide a clean, sanitary, and homelike environment including broken window, black substance on vents, peeling paint, loose toilet, missing light covers, and other environmental deficiencies.
Report Facts
Bed baths and showers: 83
Residents on Night Shift Get Up's list: 5
Use by dates: 4
Missed morphine doses: 5
Antibiotic doses: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 3 | Licensed Practical Nurse | Witnessed verbal abuse incident between CNA 4 and Resident 17 and reported it to DNS and ED. |
| CNA 4 | Certified Nursing Assistant | Involved in verbal abuse incident with Resident 17. |
| CNA 21 | Certified Nursing Assistant | Left Resident 35 on edge of bed leading to fall. |
| QMA 22 | Qualified Medication Assistant | Unaware of hospice services schedule for Resident 1 and involved in medication administration. |
| RNC | Regional Nurse Consultant | Provided multiple policy interviews and indicated failures in pain management and medication administration. |
| DNS | Director of Nursing Services | Interviewed regarding grievance process and pain management. |
| ED | Executive Director | Interviewed regarding grievances, environmental issues, and verbal abuse incident. |
| TD | Therapy Director | Reviewed therapy notes and pain management for Resident F. |
| RN 31 | Registered Nurse | Observed not performing hand hygiene properly during medication administration. |
| FDNS | Float Director of Nursing Services | Observed fall incident and interviewed about antibiotic stewardship. |
Inspection Report
Complaint Investigation
Deficiencies: 16
Date: May 11, 2023
Visit Reason
The inspection was conducted based on complaints alleging multiple deficiencies including medication self-administration, resident grievances, abuse allegations, care planning, pain management, food safety, and environmental concerns at the Community Nursing and Rehabilitation Center.
Complaint Details
The investigation was complaint-driven, addressing multiple allegations including medication self-administration without proper evaluation, verbal abuse by staff, failure to notify physicians of falls, inadequate grievance handling, pain management deficiencies, and environmental safety concerns. Some abuse allegations were substantiated with findings of verbal abuse and failure to properly investigate and report incidents.
Findings
The facility was found deficient in multiple areas including failure to properly evaluate residents for self-administration of medications, failure to notify physicians of resident falls, inadequate grievance handling, verbal abuse incidents not properly investigated or reported, incomplete care plans especially for hospice and skin care, inadequate pain management, unsafe food handling practices, and environmental maintenance issues compromising resident safety and comfort.
Deficiencies (16)
Failed to have interdisciplinary team determine and document clinical appropriateness for self-administration of medications for residents.
Failed to ensure reasonable accommodations for resident by preventing roommate's personal items from blocking sink access.
Failed to notify physician of resident's fall and conduct post-fall assessment.
Failed to address resident grievances and follow up on complaints.
Failed to protect resident from verbal abuse by staff and failed to timely report and investigate abuse allegations.
Failed to develop comprehensive person-centered care plans for hospice and skin care needs.
Failed to ensure discharge summaries included recaps of resident stays.
Failed to provide adequate materials for written communication for resident with aphasia.
Failed to timely address dietary recommendations for resident with weight loss.
Failed to timely address residents' pain and assess effectiveness of pain management interventions.
Failed to provide trauma-informed care and coordinate psychiatric services for resident with PTSD.
Failed to ensure a Registered Nurse worked 8 hours per day on multiple days.
Failed to store, prepare, distribute, and serve food in accordance with professional standards including dishwasher malfunction and improper food storage.
Failed to accurately submit licensed personnel staffing data to CMS for Payroll Based Journal reporting.
Failed to ensure antibiotic use met criteria for infection prior to administration.
Failed to maintain a clean, safe, and homelike environment including broken windows, peeling paint, unsecured toilets, and missing bathroom light covers.
Report Facts
Dates without RN working 8 hours: 8
Missed morphine doses: 5
Antibiotic treatment days: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 15 | Licensed Practical Nurse | Observed Resident 20 holding medication cup and involved in medication administration observation. |
| QMA 22 | Qualified Medication Aide | Involved in medication administration and resident care observations. |
| Float DNS | Director of Nursing Services | Provided policy information and interviews regarding medication self-administration and abuse investigations. |
| CNA 21 | Certified Nursing Assistant | Named in verbal abuse allegation investigation and fall incident. |
| LPN 3 | Licensed Practical Nurse | Witnessed verbal abuse incident and reported it to administration. |
| CNA 4 | Certified Nursing Assistant | Involved in verbal abuse incident with Resident 17. |
| CNA 5 | Certified Nursing Assistant | Involved in verbal altercation with staff and resident. |
| LPN 24 | Licensed Practical Nurse | Staff member with same first name as CNA 21, involved in verbal abuse allegation investigation. |
| ED | Executive Director | Interviewed regarding multiple incidents including abuse investigations and environmental concerns. |
| RNC | Regional Nurse Consultant | Provided interviews and policy information related to abuse investigations and pain management. |
| MDSC | Minimum Data Set Coordinator | Interviewed regarding care planning for skin care. |
| TD | Therapy Director | Interviewed regarding pain management and therapy notes for Resident F. |
| PNP | Psychiatric Nurse Practitioner | Interviewed regarding psychiatric care and triggers for Resident 43. |
| FSS | Float Social Services | Interviewed regarding communication barriers and resident grievances. |
Inspection Report
Recertification
Census: 46
Deficiencies: 18
Date: May 11, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00402254, IN00400685, and IN00399680.
Complaint Details
This inspection included investigations of Complaints IN00402254, IN00400685, and IN00399680. Deficiencies related to these complaints were cited throughout the report including medication self-administration, grievance handling, abuse, notification of changes, and quality of care.
Findings
The facility was found deficient in multiple areas including medication self-administration evaluations, reasonable accommodations, resident self-determination, notification of changes, grievance handling, abuse prevention and investigation, care planning, discharge summaries, activities of daily living, nutrition, pain management, infection control, environmental safety, and staffing requirements.
Deficiencies (18)
Failed to have interdisciplinary team determine and document clinical appropriateness of self-administration of medications for 2 residents.
Failed to ensure reasonable accommodations for a resident whose roommate blocked sink access.
Failed to promote and facilitate resident self-determination including shower preferences, nail care, and timely assistance to wheelchair for breakfast.
Failed to notify physician of a resident's fall and complete post-fall assessment.
Failed to address resident grievances promptly and document resolutions.
Failed to protect resident from verbal abuse by staff and failed to timely report and investigate abuse allegations.
Failed to develop comprehensive person-centered care plans for hospice and skin care needs.
Failed to provide 8 consecutive hours of RN coverage daily on multiple days.
Failed to store, prepare, distribute, and serve food in accordance with food safety standards including dishwasher not reaching adequate temperature, improper food storage, and poor personal hygiene of kitchen staff.
Failed to accurately submit payroll based journal staffing data for licensed personnel to CMS.
Failed to ensure medication administration infection control practices including hand hygiene and disposal of dropped medication.
Failed to ensure antibiotic stewardship by providing antibiotic without infection criteria and without proper follow-up.
Failed to maintain a safe, sanitary, and homelike environment including broken window, black substance on vents, peeling paint, loose toilet, missing light covers, dirty equipment, and missing handrail.
Failed to provide pain management including timely pain assessments, documentation of pain intensity, effectiveness of medications, and nonpharmacological interventions.
Failed to provide trauma-informed care for a resident with PTSD including care planning and staff education.
Failed to provide communication materials in reach and in good condition for a resident with aphasia.
Failed to develop comprehensive discharge summaries including recap of resident's stay for discharged residents.
Failed to follow physician order to hold medication when pulse below 65 and to perform pulse assessments prior to medication administration.
Report Facts
Residents present: 46
Deficiency counts: 19
Days without 8 hour RN coverage: 8
Weight loss: 11
Medication doses held: 7
Antibiotic days: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Keith Davis | Senior Executive Director | Signed report and involved in corrective actions and interviews |
| LPN 3 | Licensed Practical Nurse | Witnessed verbal abuse incident and reported it |
| CNA 4 | Certified Nursing Assistant | Involved in verbal abuse incident with Resident 17 |
| CNA 21 | Certified Nursing Assistant | Alleged verbal abuse by Resident 35, suspended pending investigation |
| RNC | Regional Nurse Consultant | Provided policies, interviewed staff, and reviewed investigations |
| DNS | Director of Nursing Services | Interviewed regarding multiple findings including abuse, falls, and pain management |
| FDNS | Float Director of Nursing Services | Interviewed regarding falls and staffing |
| QMA 22 | Qualified Medication Aide | Observed medication administration with dropped pill |
| RN 31 | Registered Nurse | Observed medication administration and hand hygiene deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 17, 2022
Visit Reason
The inspection was a paper compliance review related to the investigation of multiple complaints (IN00383511, IN00375446, IN00372383, and IN00382973) completed on June 30, 2022.
Complaint Details
The visit was related to complaint investigations IN00383511, IN00375446, IN00372383, and IN00382973. The facility was found to be in compliance based on the paper review.
Findings
Community Nursing and Rehabilitation Center 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
Deficiencies: 0
Date: Jul 26, 2022
Visit Reason
The visit was a paper compliance review related to the investigation of Complaint IN00382284 completed on June 10, 2022.
Complaint Details
The complaint investigation IN00382284 was completed on June 10, 2022, and the facility was found in compliance during the paper review.
Findings
Community Nursing and Rehabilitation Center 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.
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