Inspection Report Summary
The most recent inspection on June 20, 2025, was a complaint investigation that found no deficiencies related to the allegations. Earlier inspections showed a pattern of both compliance and some deficiencies, including substantiated complaints involving staff-to-resident abuse, failure to report sexual abuse, and issues with Life Safety Code compliance such as emergency power system maintenance and fire safety measures. The main themes of deficiencies involved resident protection from abuse, care plan adherence, and life safety code violations related to fire safety and emergency preparedness. Several complaint investigations were substantiated with deficiencies cited, but many others were found unsubstantiated or without related deficiencies. The facility appears to have addressed prior abuse-related deficiencies by early 2025, with more recent inspections showing compliance and correction of earlier issues.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
90% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
72% 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
Census: 119
Capacity: 166
Deficiencies: 0
Date: Jun 20, 2025
Visit Reason
This visit was for the investigation of Complaint IN00457667.
Complaint Details
Complaint IN00457667 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations of Complaint IN00457667 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census Bed Type Total: 166
Census Payor Type Total: 119
Census SNF/NF: 114
Census SNF: 5
Census Residential: 47
Census Medicare: 5
Census Medicaid: 81
Census Other: 33
Inspection Report
Complaint Investigation
Census: 120
Capacity: 171
Deficiencies: 0
Date: Mar 6, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00453318.
Complaint Details
Complaint IN00453318 was investigated and found to have no deficiencies related to the allegation.
Findings
No deficiency related to the complaint allegation was cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Report Facts
Census Bed Type Total: 171
Census Payor Type Total: 120
Inspection Report
Re-Inspection
Census: 172
Deficiencies: 0
Date: Feb 7, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00449955, IN00448256, and IN00450213 completed on 2025-01-02.
Complaint Details
This visit was related to complaints IN00449955, IN00448256, and IN00450213. All complaints were corrected.
Findings
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 PSR to the Investigation of Complaints. All three complaints were corrected.
Report Facts
Census Bed Type Total: 172
Census Payor Type Total: 124
SNF Beds: 5
NF Beds: 119
Residential Beds: 48
Medicare Residents: 5
Medicaid Residents: 77
Other Payor Residents: 42
Inspection Report
Complaint Investigation
Census: 125
Capacity: 177
Deficiencies: 0
Date: Jan 22, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00451470, IN00450528, and IN00450648 at Harbour Manor Health & Living Community.
Complaint Details
Investigation of Complaints IN00451470, IN00450528, and IN00450648 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00451470, IN00450528, and IN00450648 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type - SNF/NF: 117
Census Bed Type - SNF: 8
Census Bed Type - Residential: 52
Total Licensed Capacity: 177
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 80
Census Payor Type - Other: 37
Total Census: 125
Inspection Report
Re-Inspection
Census: 113
Capacity: 129
Deficiencies: 0
Date: Jan 9, 2025
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 12/02/24 by the Indiana Department of Health.
Findings
At this PSR survey, Harbour Manor Health & Living Community was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Inspection Report
Complaint Investigation
Census: 117
Capacity: 163
Deficiencies: 3
Date: Jan 2, 2025
Visit Reason
This visit was conducted for the investigation of three complaints (IN00448256, IN00449955, and IN00450213) related to allegations of abuse and failure to follow care plans at Harbour Manor Health & Living Community.
Complaint Details
The investigation was triggered by complaints IN00448256, IN00449955, and IN00450213. Complaint IN00448256 involved abuse allegations substantiated with deficiencies cited at F600 and F607. Complaints IN00449955 and IN00450213 involved failure to follow care plan interventions, with deficiencies cited at F656.
Findings
The facility was found to have failed to protect a resident from staff-to-resident abuse by a nurse, failed to intervene when abuse was witnessed by a CNA, and failed to follow care plan interventions requiring care in pairs for another resident. These deficiencies were substantiated through interviews, record reviews, and policy evaluations.
Deficiencies (3)
Failed to protect a resident's right to be free from staff-to-resident abuse when a nurse physically restrained a cognitively impaired resident and forcibly administered medications while the resident was screaming.
Failed to implement abuse policy when a CNA failed to intervene upon witnessing abuse of a cognitively impaired resident by a nurse.
Failed to follow a care plan intervention requiring care with staff pairs to protect a resident from anxiety related to inappropriate care.
Report Facts
Census Bed Type - SNF/NF: 107
Census Bed Type - SNF: 10
Census Bed Type - Residential: 46
Total Capacity: 163
Census Payor Type - Medicare: 10
Census Payor Type - Medicaid: 80
Census Payor Type - Other: 27
Current Census: 117
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacob Atkinson | Executive Director | Signed the report |
| RN 2 | Registered Nurse | Named in abuse incident involving Resident B |
| CNA 1 | Certified Nursing Assistant | Witnessed abuse incident but failed to intervene |
| Director of Nursing | Director of Nursing | Initiated investigation and provided policy information |
| CNA 3 | Certified Nursing Assistant | Alleged to have touched Resident C inappropriately and failed to follow care plan intervention |
| CNA 4 | Certified Nursing Assistant | Reported care provided to Resident C in pairs |
| CNA 5 | Certified Nursing Assistant | Reported care provided to Resident C in pairs |
| Administrator | Facility Administrator | Reported abuse incident and described quality assurance monitoring |
Inspection Report
Life Safety
Census: 121
Capacity: 129
Deficiencies: 7
Date: Dec 2, 2024
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on December 2, 2024, to assess compliance with emergency preparedness and life safety requirements.
Findings
The facility was found in substantial compliance with Emergency Preparedness Requirements but not in compliance with several Life Safety Code requirements including emergency power system inspection and maintenance, exit signage, sprinkler system maintenance, electrical wiring protection, fire drills, combustible decorations, and documentation of emergency generator inspections.
Deficiencies (7)
Failed to implement emergency power system inspection, testing, and maintenance requirements; missing documentation for weekly emergency generator inspections for 12 weeks of the past 52 weeks.
Exit signage was conflicting with arrows pointing to resident rooms instead of exits, potentially causing confusion during emergency evacuation.
Failed to document sprinkler system inspections fully in accordance with NFPA 25 for 3 weeks of the past 52 weeks for the sprinkler system's pressure gauges.
Electrical wiring was not protected in 1 of 10 smoke compartments; missing cover plate on electrical junction box with exposed wires in the kitchen.
Failed to conduct quarterly fire drills for 1 of 4 quarters and incomplete documentation for 1 of 12 fire drills performed during the past 12 months.
Combustible decorations covered over 90% of two resident room doors without fire retardant treatment or compliance with NFPA standards.
Failed to maintain a written record of weekly inspections for the emergency generator set for all 52 weeks from October 2023 through October 2024.
Report Facts
Certified beds: 129
Census: 121
Missing weekly emergency generator inspections: 12
Missing sprinkler gauge inspections: 3
Fire drills missing: 1
Fire drills incomplete documentation: 1
Resident rooms with combustible decorations: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacob Atkinson | Executive Director | Signed plan of correction letter |
| Brenda Buroker | Director, Long-Term Care Division, Indiana State Department of Health | Recipient of plan of correction letter |
| Maintenance Director | Interviewed and involved in review of deficiencies and corrective actions | |
| Maintenance Supervisor | Provided education and involved in corrective actions |
Inspection Report
Renewal
Census: 114
Capacity: 165
Deficiencies: 1
Date: Oct 21, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted from October 15 to 21, 2024.
Findings
The facility failed to ensure shift-to-shift narcotic count reconciliation was completed for 1 of 3 medication carts reviewed, specifically the Rehab 1 cart, missing counts on October 17, 18, 19, and 20, 2024. The facility was found in compliance with the State Residential Licensure Survey requirements.
Deficiencies (1)
Failure to ensure shift to shift narcotic count reconciliation was completed for 1 of 3 medication carts reviewed (Rehab 1 cart).
Report Facts
Census Bed Type Total: 165
Census Payor Type Total: 114
Deficiency duration: 4
Audit frequency: 30
Audit frequency weekly: 12
Audit frequency monthly: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 2 | Interviewed regarding narcotic count reconciliation and missing counts | |
| LPN 3 | Interviewed regarding narcotic sign in sheets and incomplete reconciliation | |
| Rehab Unit Manager | Interviewed regarding shift to shift reconciliation process and missing narcotic card counts | |
| DON | Director of Nursing interviewed regarding missing narcotic count numbers and facility policy |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Oct 21, 2024
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure Survey completed on October 21, 2024.
Findings
Harbour Manor Health & Living Community was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 112
Capacity: 112
Deficiencies: 0
Date: Sep 24, 2024
Visit Reason
This visit was conducted for the investigation of Nursing Home Complaint IN00442162.
Complaint Details
Complaint IN00442162 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 Bed Type Total: 112
Census Payor Type Total: 112
SNF/NF Census: 9
SNF Census: 103
Medicare Census: 9
Medicaid Census: 79
Other Payor Census: 24
Inspection Report
Life Safety
Census: 118
Capacity: 129
Deficiencies: 0
Date: Jul 26, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Pre-Occupancy Survey conducted on 06/19/24 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
Harbour Manor Health & Living Community was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), 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 with a fire alarm system and smoke detection throughout. Remodeling included removal of locking hardware on cross-corridor doors, creation of new resident rooms with private toilets, and alterations to smoke barriers.
Report Facts
Facility capacity: 129
Census: 118
Inspection Report
Complaint Investigation
Census: 123
Capacity: 174
Deficiencies: 0
Date: Jul 17, 2024
Visit Reason
This visit was conducted for the investigation of Nursing Home Complaints IN00437008 and IN00437071.
Complaint Details
Complaint IN00437008 and Complaint IN00437071 were investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies related to the allegations in complaints IN00437008 and IN00437071 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type Total: 174
Census Payor Type Total: 123
SNF/NF Beds: 110
SNF Beds: 13
Residential Beds: 51
Medicare Residents: 10
Medicaid Residents: 83
Other Payor Residents: 30
Inspection Report
Life Safety
Census: 118
Capacity: 129
Deficiencies: 3
Date: Jun 19, 2024
Visit Reason
A Pre-Occupancy 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 the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC). The survey included review of fire safety, smoke barriers, hazardous areas, and electrical panel security following facility renovations.
Findings
The facility was found not in compliance with Life Safety Code requirements due to deficiencies including a storage room on the 200 hall not protected as a hazardous area, incomplete smoke barrier walls in resident rooms 210 and 212, and unsecured electrical panels in the 200 hall. These deficiencies could affect residents and staff in the 200 hall area. Corrective actions and education were planned with ongoing audits.
Deficiencies (3)
Storage room on the 200 hall greater than 50 square feet was not protected as a hazardous area because the corridor door was not self-closing or automatic closing and contained combustible storage.
Smoke barrier walls in resident rooms 210 and 212 were not fully constructed to maintain smoke resistance, missing completely sealed walls to resist passage of smoke.
Electrical panel in the 200 hall near resident rooms 210, 211, and 212 was unlocked and unsecured from non-authorized personnel.
Report Facts
Certified beds: 129
Census: 118
Residents potentially affected: 2
Residents potentially affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacob Atkinson | Executive Director | Signed the report |
| Assistant Administrator | Interviewed and acknowledged deficiencies during the survey |
Inspection Report
Complaint Investigation
Census: 121
Capacity: 165
Deficiencies: 0
Date: Jun 12, 2024
Visit Reason
This visit was conducted for the investigation of Nursing Home Complaints IN00434835 and IN00436172, as well as the investigation of Residential Complaint IN00434789.
Complaint Details
Complaint IN00434835 and Complaint IN00436172 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations were cited for complaints IN00434835 and IN00436172. The facility was found to be in compliance with relevant regulations regarding these complaints.
Report Facts
Census Bed Type - SNF/NF: 107
Census Bed Type - SNF: 14
Census Bed Type - Residential: 44
Census Bed Type - Total: 165
Census Payor Type - Medicare: 14
Census Payor Type - Medicaid: 84
Census Payor Type - Other: 23
Census Payor Type - Total: 121
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 31, 2024
Visit Reason
The visit was a paper compliance review related to the investigation of Complaint IN00431938 completed on April 24, 2024.
Complaint Details
Investigation of Complaint IN00431938 completed on April 24, 2024; facility found in compliance.
Findings
Harbour Manor Health & Living Community 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: 116
Capacity: 168
Deficiencies: 1
Date: Apr 23, 2024
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00430518, IN00431838, IN00431938, IN00432126, and IN00432885) regarding the facility.
Complaint Details
Complaint IN00431938 was substantiated with federal/state deficiencies cited at F610 related to failure to investigate verbal abuse allegations. Other complaints (IN00430518, IN00431838, IN00432126, IN00432885) had no deficiencies related to the allegations.
Findings
The facility was found deficient for failing to complete an investigation of an allegation of verbal abuse for one resident (Resident D). Other complaints were found to have no deficiencies related to the allegations.
Deficiencies (1)
Failed to complete an investigation of an allegation of verbal abuse for 1 of 3 residents reviewed for abuse (Resident D).
Report Facts
Census: 116
Total Capacity: 168
Deficiency Completion Date: May 17, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident D | Resident | Subject of verbal abuse allegation |
| Activities Director | Activities Director | Alleged perpetrator of verbal abuse |
| PT 2 | Physical Therapy Staff | Reported incident to supervisor |
| PT 3 | Physical Therapy Staff | Informed Director of Nursing about allegation |
| DON | Director of Nursing | Unaware of verbal abuse allegation at time of interview |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 11, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00428301 completed on February 16, 2024.
Complaint Details
Investigation of Complaint IN00428301 completed on February 16, 2024; facility found in compliance.
Findings
Harbour Manor Health & Living Community 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 complaint investigation.
Inspection Report
Complaint Investigation
Census: 126
Capacity: 173
Deficiencies: 1
Date: Feb 16, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00428301 regarding allegations of sexual abuse at the facility.
Complaint Details
Complaint IN00428301 was substantiated with federal/state deficiencies cited related to failure to report sexual abuse allegations involving Resident B. The facility did not notify law enforcement despite the resident's report and investigation findings.
Findings
The facility failed to report allegations of sexual abuse to law enforcement and adult protective services for one resident. Interviews and record reviews confirmed the lack of timely reporting despite the resident's allegation and facility policy requirements.
Deficiencies (1)
Failure to report allegations of sexual abuse to law enforcement and adult protective services for one resident.
Report Facts
Census: 126
Total Capacity: 173
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacob Atkinson | Executive Director | Signed the report |
Inspection Report
Follow-Up
Census: 120
Capacity: 129
Deficiencies: 0
Date: Jan 2, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 11/13/23 was performed to verify compliance with Life Safety Code requirements.
Findings
The facility was found in compliance with the Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. All resident-accessible areas and facility service areas were sprinklered, and the fire alarm system was operational.
Report Facts
Facility capacity: 129
Census: 120
Inspection Report
Complaint Investigation
Census: 124
Deficiencies: 0
Date: Dec 28, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00423304 and IN00422250 and included a COVID-19 Focused Infection Control Survey.
Complaint Details
Investigation of Complaints IN00423304 and IN00422250 found no deficiencies related to the allegations; both complaints were not substantiated.
Findings
No deficiencies related to the allegations in complaints IN00423304 and IN00422250 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaints and the COVID-19 Focused Infection Control Survey.
Report Facts
Census: 124
Census Bed Type - SNF/NF: 112
Census Bed Type - SNF: 12
Census Payor Type - Medicare: 12
Census Payor Type - Medicaid: 87
Census Payor Type - Other: 25
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Nov 17, 2023
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey was completed.
Findings
Harbour Manor Health & Living Community was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 120
Capacity: 129
Deficiencies: 4
Date: Nov 13, 2023
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) to assess compliance with Life Safety from Fire and related regulations.
Findings
The facility was found not in compliance with Life Safety Code requirements, with deficiencies noted in means of egress accessibility, delayed egress door signage, corridor door latching, and improper use of multi-plug adapters in mechanical rooms.
Deficiencies (4)
Failed to ensure the means of egress through 2 of over 8 exits was readily accessible; exit doors were magnetically locked with incorrect posted code.
Failed to ensure the means of egress through 1 of over 8 delayed egress locks was readily accessible; lacked proper signage indicating door can be opened in 15 seconds.
Failed to ensure 1 of over 30 corridor doors had no impediment to closing and latching into the door frame and would resist the passage of smoke; corridor door to Resident Room #39 failed to close and latch positively.
Failed to ensure 1 of 1 mechanical rooms did not use multi-plug adaptors as a substitute for fixed wiring; multi-plug adaptor powering water heater control modules was in use.
Report Facts
Certified beds: 129
Census: 120
Number of exits with egress issues: 2
Number of delayed egress locks with signage issues: 1
Number of corridor doors with latching issues: 1
Number of mechanical rooms with improper wiring: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacob Atkinson | Executive Director | Acknowledged findings during observations and exit conference |
| Brenda Buroker | Director, Long-Term Care Division, Indiana State Department of Health | Recipient of Plan of Correction letter |
Inspection Report
Recertification
Census: 49
Capacity: 163
Deficiencies: 3
Date: Oct 30, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Complaint IN00420307. The visit included a State Residential Licensure Survey.
Complaint Details
Complaint IN00420307 was investigated and no deficiencies related to the allegations were cited.
Findings
The facility was found to have deficiencies related to urinary catheter care, narcotic reconciliation, and hospice services communication. Complaint allegations were not substantiated. The facility was found in substantial compliance with state licensure requirements.
Deficiencies (3)
Facility failed to ensure a resident was scheduled with urology as ordered by the primary care provider for urinary tract infections/catheter care (Resident 98).
Facility failed to ensure narcotics were reconciled per facility policy for 2 of 4 medication carts reviewed for medication storage (East 1 cart and East 2 cart).
Facility failed to ensure timely communication was maintained between the facility and the hospice provider for 1 of 2 residents reviewed for hospice services (Resident 31).
Report Facts
Survey dates: 6
Census Bed Type Total Capacity: 163
Residential Census: 49
Residents with medications on East 1 cart: 24
Residents with medications on East 2 cart: 23
Urine drained during catheterization: 800
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacob Atkinson | Executive Director | Signed the report. |
| LPN 3 | Accompanied medication storage observation of East 1 cart. | |
| QMA 4 | Accompanied medication storage observation of East 2 cart. | |
| LPN 5 | Provided information about hospice communication binder and resident visits. | |
| ADON | Assistant Director of Nursing | Provided information about referral procedures and hospice communication. |
| Unit Manager | Responsible for initiating physician or nurse practitioner orders for appointments. |
Inspection Report
Complaint Investigation
Census: 118
Deficiencies: 0
Date: Sep 29, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00417264.
Complaint Details
Complaint IN00417264 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00417264 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type: 118
Census Bed Type - SNF/NF: 105
Census Bed Type - SNF: 13
Census Payor Type - Medicare: 9
Census Payor Type - Medicaid: 86
Census Payor Type - Other: 23
Inspection Report
Complaint Investigation
Census: 113
Capacity: 160
Deficiencies: 0
Date: Aug 15, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00414306 and IN00412948 at Harbour Manor Health & Living Community.
Complaint Details
Complaint IN00414306 and IN00412948 were investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies related to the allegations in complaints IN00414306 and IN00412948 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census Bed Type - SNF/NF: 107
Census Bed Type - SNF: 6
Census Bed Type - Residential: 47
Total Capacity: 160
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 86
Census Payor Type - Other: 21
Total Census: 113
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 0
Date: May 8, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00402825 and IN00403636.
Complaint Details
Complaint IN00402825 and IN00403636 were investigated; no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations in complaints IN00402825 and IN00403636 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type Total: 103
Census Payor Type Medicare: 3
Census Payor Type Medicaid: 81
Census Payor Type Other: 19
Inspection Report
Complaint Investigation
Census: 118
Capacity: 167
Deficiencies: 0
Date: Dec 27, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00397634.
Complaint Details
Complaint IN00397634 - Unsubstantiated due to lack of evidence.
Findings
The complaint IN00397634 was found to be unsubstantiated due to lack of evidence. 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 complaint investigation.
Report Facts
Census SNF/NF: 111
Census SNF: 7
Census Residential: 49
Total Capacity: 167
Census Medicare: 12
Census Medicaid: 90
Census Other: 16
Total Census: 118
Inspection Report
Complaint Investigation
Census: 120
Capacity: 169
Deficiencies: 0
Date: Dec 15, 2022
Visit Reason
This visit was for the investigation of Complaint IN00394300.
Complaint Details
Complaint IN00394300 - Substantiated. No deficiencies related to the allegations were cited.
Findings
Complaint IN00394300 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 Bed Type Total Capacity: 169
Census: 120
Inspection Report
Complaint Investigation
Census: 171
Deficiencies: 0
Date: Nov 7, 2022
Visit Reason
This visit was conducted for the investigation of three complaints: IN00393276, IN00393641, and IN00393467.
Complaint Details
Complaints IN00393276, IN00393641, and IN00393467 were all substantiated, but no deficiencies related to the allegations were cited.
Findings
All three complaints were substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant federal and state regulations regarding the investigation of these complaints.
Report Facts
SNF/NF Census: 112
SNF Census: 11
Residential Census: 48
Total Census: 171
Medicare Census: 9
Medicaid Census: 88
Other Payor Census: 26
Total Payor Census: 123
Inspection Report
Follow-Up
Census: 123
Capacity: 129
Deficiencies: 0
Date: Oct 28, 2022
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 09/01/22.
Findings
At this PSR Emergency Preparedness survey, the facility was found in compliance with Emergency Preparedness Requirements. At the PSR Life Safety Code survey, the facility was found in compliance with Requirements for Participation in Medicare/Medicaid and Life Safety Code standards.
Report Facts
Certified beds: 129
Census: 123
Inspection Report
Complaint Investigation
Census: 123
Capacity: 123
Deficiencies: 1
Date: Oct 26, 2022
Visit Reason
This visit was for the investigation of complaints IN00392401, IN00391287, and IN00392875. Complaints IN00392401 and IN00391287 were unsubstantiated due to lack of evidence, while complaint IN00392875 was substantiated with related deficiencies cited.
Complaint Details
Complaint IN00392401 - Unsubstantiated due to lack of evidence. Complaint IN00391287 - Unsubstantiated due to lack of evidence. Complaint IN00392875 - Substantiated with federal/state deficiencies cited at F606.
Findings
The facility failed to ensure a criminal background check was completed for one of five employee records sampled (Registered Nurse 2). The agency responsible for the nurse had not provided a criminal background check until the survey date. The facility has a policy requiring background checks and plans corrective actions including audits and education to prevent recurrence.
Deficiencies (1)
Failed to ensure a criminal background check was completed for one employee (Registered Nurse 2).
Report Facts
Census: 123
Total Capacity: 123
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacob Atkinson | Executive Director | Signed report and facility representative |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 26, 2022
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00392875.
Complaint Details
Investigation of Complaint IN00392875 completed on October 26, 2022; facility found in compliance.
Findings
Harbour Manor Health and Living Community 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: 116
Capacity: 167
Deficiencies: 0
Date: Sep 15, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on August 16, 2022.
Findings
Harbour Manor Health & Living Community 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 Bed Type - SNF/NF: 107
Census Bed Type - SNF: 9
Census Bed Type - Residential: 51
Census Bed Type - Total: 167
Census Payor Type - Medicare: 10
Census Payor Type - Medicaid: 87
Census Payor Type - Other: 19
Census Payor Type - Total: 116
Inspection Report
Complaint Investigation
Census: 115
Capacity: 166
Deficiencies: 0
Date: Sep 12, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00389361.
Complaint Details
Complaint IN00389361 was investigated and found unsubstantiated due to lack of evidence.
Findings
The complaint IN00389361 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type Total: 166
Census Payor Type Total: 115
Inspection Report
Life Safety
Census: 117
Capacity: 129
Deficiencies: 8
Date: Sep 1, 2022
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal regulations.
Findings
The facility was found in substantial compliance with Emergency Preparedness Requirements but had multiple deficiencies related to Life Safety Code including failure to maintain emergency preparedness communication plan, hazardous area door self-closing devices, sprinkler head ceiling gaps, corridor door latching, smoke barrier penetrations, uncovered electrical junction box, improper power cord installation, and fire drill scheduling.
Deficiencies (8)
Failed to develop and maintain a complete emergency preparedness communication plan with updated contact information.
Failed to ensure hazardous area door in Business Office had properly working self-closing device.
Failed to maintain ceiling construction causing sprinkler heads to sag and create gaps.
Resident room corridor door did not latch properly and resist passage of smoke.
Penetrations through smoke barrier walls were not properly sealed to maintain smoke resistance.
Electrical junction box in attic lacked cover and had exposed wiring.
Failed to conduct quarterly fire drills at unexpected times and dates.
Power strip in MDS office was unsecured and dangling, risking damage to power cord.
Report Facts
Certified beds: 129
Census: 117
Residents potentially affected: 16
Residents potentially affected: 28
Residents potentially affected: 4
Residents potentially affected: 2
Residents potentially affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Interviewed and acknowledged multiple deficiencies including emergency preparedness communication plan, sprinkler head gaps, door latching, smoke barrier penetrations, electrical junction box, and power cord issues. | |
| Executive Director | Present at exit conference and acknowledged findings. |
Inspection Report
Renewal
Census: 49
Deficiencies: 0
Date: Aug 16, 2022
Visit Reason
This visit was for a State Residential Licensure Survey, including a Recertification and State Licensure Survey conducted over multiple days in August 2022.
Findings
Harbour Manor Health and Living Community was found to be in compliance with 410 IAC 16.2-5 regarding the State Residential Licensure Survey.
Report Facts
Residential Census: 49
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