Inspection Reports for Manderley Health Care Center
806 S BUCKEYE ST, IN, 47037
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 18, 2025, found the facility in compliance with Life Safety Code requirements except for one deficiency related to HVAC compliance with NFPA 101, which had an annual waiver in place. Earlier inspections showed a pattern of Life Safety Code deficiencies involving fire safety equipment maintenance, HVAC system use of egress corridors, and fire drill scheduling, as well as multiple citations related to resident care, medication management, infection control, and food storage. Complaint investigations were generally unsubstantiated, with one substantiated complaint that did not result in deficiencies. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s recent inspections suggest some ongoing issues with Life Safety Code compliance but also indicate efforts to address prior deficiencies, as seen in the compliance noted during the latest revisit.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
12 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
186% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
72% occupied
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Census: 51
Capacity: 71
Deficiencies: 1
Date: Mar 18, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted to verify compliance with fire safety and licensure requirements.
Findings
The facility was found in compliance with the Life Safety Code requirements during this revisit. However, a deficiency related to HVAC compliance with NFPA 101 was noted, with an annual waiver request in place.
Deficiencies (1)
HVAC heating, ventilation, and air conditioning shall comply with 9.2 and be installed according to manufacturer's specifications; this requirement was not met as evidenced by the annual waiver request.
Report Facts
Facility capacity: 71
Census: 51
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 4, 2025
Visit Reason
The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Manderley Health Care 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 for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 52
Capacity: 71
Deficiencies: 9
Date: Feb 12, 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 in accordance with federal regulations.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements, with multiple deficiencies noted including obstructed exit discharge, missing 'No Exit' signage, improper cooking appliance placement, corridor doors not latching, HVAC return air system issues, inadequate fire drill scheduling, smoking policy violations, unsecured power cords, and incomplete maintenance documentation for electrical equipment.
Deficiencies (9)
Failed to ensure 1 of 5 exit discharges was free of obstructions; a significant gap in concrete at exit discharge.
Failed to ensure 1 of 1 courtyard doors was posted with a 'No Exit' sign.
Failed to provide an approved method for returning 1 of 1 kitchen hood extinguishing system cooking appliances to approved design location.
Failed to ensure 2 of over 30 corridor doors had no impediment to closing and latching into the door frame.
Failed to ensure 1 of 4 egress corridors were not used as a portion of a return air system/plenum for HVAC ductwork.
Failed to conduct quarterly fire drills on unexpected days and at unexpected times under varying conditions.
Failed enforcement of non-smoking policies; smoking observed within 8 feet of the building.
Failed to ensure 1 power strip in room 304 was secured and not dangling from the wall behind the TV.
Failed to conduct required maintenance and maintain complete documentation of inspections for Patient Care Related Electrical Equipment (PCREE).
Report Facts
Certified beds: 71
Census: 52
Exit discharges: 5
Corridor doors: 30
Fire drills: 12
Fire drills near month end: 8
Residents potentially affected by exit obstruction: 8
Residents potentially affected by missing no exit sign: 15
Staff potentially affected by cooking appliance issue: 6
Staff potentially affected by corridor door issue: 4
Residents potentially affected by smoking violation: 15
Residents potentially affected by power strip issue: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Monica Ogden | LHFA | Facility representative signing the report and plan of correction. |
| Maintenance Supervisor | Interviewed during observations and findings related to exit discharge, signage, cooking appliances, corridor doors, HVAC, and power strip issues. | |
| Administrator | Interviewed during observations and findings; involved in exit conferences and education. | |
| Maintenance Director | Named in corrective actions and education related to multiple deficiencies including exit discharge, signage, cooking appliances, corridor doors, HVAC, smoking policy, power strips, and electrical equipment maintenance. | |
| Dietary Manager | Educated regarding cooking appliance deficiency. |
Inspection Report
Annual Inspection
Census: 47
Capacity: 47
Deficiencies: 8
Date: Jan 31, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from January 27 to January 31, 2025.
Findings
The facility was found deficient in multiple areas including resident dignity during meal service, privacy breaches with medication carts, failure to follow medication hold parameters, delayed treatment of urinary tract infection, improper medication storage, failure to obtain timely lab tests, unsanitary food storage, and inadequate infection control related to urinary catheter care.
Deficiencies (8)
Failed to treat a resident in a dignified manner during meal service by standing over the resident instead of sitting next to them.
Failed to maintain resident records in a private manner with medication cart screens left unattended and resident information visible.
Failed to follow physician's orders related to hold parameters for medications for 2 residents.
Failed to treat a urinary tract infection in a timely manner for 1 resident.
Failed to store medications appropriately; medication cart left unlocked and unattended.
Failed to obtain a blood test and urinalysis timely for 1 resident.
Failed to store foods in a sanitary manner; unlabeled and outdated foods found in kitchen.
Failed to follow infection control guidelines related to urinary catheter care; catheter bag was on the floor and staff failed to don gown when required.
Report Facts
Census: 47
Total Capacity: 47
Deficiencies cited: 8
Audit frequency: 5
Audit duration: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Monica Ogden | Laboratory Director/Facility Administrator | Signed the report and involved in plan of correction |
| RN 3 | Observed leaving medication cart unlocked and unattended | |
| CNA 6 | Certified Nurse Aide | Observed treating resident without dignity during meal service |
| CNA 4 | Certified Nurse Aide | Interviewed about proper meal assistance procedures |
| QMA 8 | Qualified Medication Aide | Interviewed about medication cart privacy practices |
| RN 2 | Registered Nurse | Interviewed about medication hold parameters and lab specimen collection |
| CNA 9 | Certified Nurse Aide | Observed providing urinary catheter care without proper gown use |
| CNA 10 | Certified Nurse Aide | Observed assisting with urinary catheter care without donning gown |
| Cook 5 | Cook | Interviewed about expired food items in kitchen |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 51
Deficiencies: 0
Date: Nov 14, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00447188.
Complaint Details
Complaint IN00447188 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00447188 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Report Facts
Census SNF/NF beds: 51
Census total residents: 51
Census Medicare residents: 2
Census Medicaid residents: 42
Census other payor residents: 7
Inspection Report
Re-Inspection
Census: 50
Capacity: 71
Deficiencies: 1
Date: May 30, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and Life Safety Code survey previously conducted on 04/15/2024 by the Indiana State Department of Health.
Findings
At this Emergency Preparedness survey, the facility was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. At the Life Safety Code survey, the facility was found in compliance with applicable fire safety codes and regulations, except for an HVAC deficiency which had an annual waiver requested.
Deficiencies (1)
HVAC heating, ventilation, and air conditioning did not comply with manufacturer's specifications as required by NFPA 101.
Report Facts
Certified beds: 71
Census: 43
Census: 50
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 17, 2024
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Manderley Health Care 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 for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 50
Capacity: 71
Deficiencies: 7
Date: Apr 15, 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 federal regulations and state law.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies were identified related to fire alarm system testing and maintenance, sprinkler system maintenance, corridor wall construction, HVAC system use of egress corridors as return air plenums, improper use of power strips, and combustible materials stored too close to oxygen storage.
Deficiencies (7)
Failed to maintain 1 of 1 fire alarm systems with required semi-annual visual inspections and accurate time information.
Failed to replace sprinkler heads showing rust/corrosion in multiple locations and failed to maintain spare sprinkler heads properly.
Failed to maintain ceiling construction in 2 locations in shower room 1 affecting sprinkler operation.
Failed to ensure corridor walls in 2 of 5 smoke compartments were constructed to resist the transfer of smoke.
Failed to ensure 4 of 4 egress corridors were not used as a portion of a return air system/plenum for HVAC ductwork.
Failed to ensure 1 of 1 power strips in room 204 was not used as a substitute for fixed wiring.
Failed to ensure a minimum distance of at least 20 feet separated combustible materials from oxygen storage equipment in 1 of 1 oxygen storage areas.
Report Facts
Certified beds: 71
Census: 50
Deficiencies cited: 7
Completion dates: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed regarding fire alarm system inspection, sprinkler heads, corridor wall penetrations, HVAC system, and power strip usage | |
| Maintenance Director | Performed audits, education, and corrective actions related to fire alarm system, sprinkler system, corridor walls, HVAC waiver, power strips, and oxygen storage | |
| Administrator | Participated in exit conference and education regarding deficiencies and corrective actions |
Inspection Report
Annual Inspection
Census: 45
Capacity: 45
Deficiencies: 7
Date: Mar 8, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from March 4 to March 8, 2024.
Findings
The facility was found deficient in multiple areas including failure to maintain resident privacy, failure to follow physician orders for medication and lab tests, failure to monitor nutrition and hydration adequately, failure to provide safe food preparation and serving, and failure to maintain functioning resident call systems.
Deficiencies (7)
Failed to maintain resident records in a private manner with records left unattended and visible for 3 residents.
Failed to follow physician's orders related to hold parameters for blood pressure medication for 1 resident.
Failed to address and monitor weight loss concerns and fluid intake for 3 residents.
Failed to follow physician's order related to medication reduction for 1 resident.
Failed to follow physician's orders to obtain blood tests for 1 resident.
Failed to prepare and serve food in a safe and sanitary manner for 2 dining observations, including undercooked meatloaf and inadequate hand sanitation by staff.
Failed to provide a functioning call light for 1 resident.
Report Facts
Survey dates: 5
Census: 45
Total capacity: 45
Residents affected by privacy deficiency: 3
Residents reviewed for quality of care: 15
Residents reviewed for nutrition and hydration: 5
Residents reviewed for pharmacy services: 5
Residents reviewed for laboratory services: 5
Residents reviewed for call light function: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Monica Ogden | LNHA | Signed plan of correction |
| Carla Poynter | Director of Nursing | Signed report and provided policies |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 53
Deficiencies: 0
Date: Nov 16, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00420160.
Complaint Details
Complaint IN00420160 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
Medicare census: 12
Medicaid census: 35
Other payor census: 6
Inspection Report
Complaint Investigation
Census: 47
Capacity: 47
Deficiencies: 0
Date: Sep 18, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00413498.
Complaint Details
Complaint IN00413498 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
Medicare census: 4
Medicaid census: 38
Other payor census: 5
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 0
Date: May 18, 2023
Visit Reason
This visit was conducted for the investigation of three complaints: IN00407229, IN00405979, and IN00401642.
Complaint Details
Complaints IN00407229, IN00405979, and IN00401642 were investigated with no deficiencies found related to the allegations.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 43
Medicare residents: 3
Medicaid residents: 29
Other residents: 11
Inspection Report
Re-Inspection
Census: 46
Capacity: 71
Deficiencies: 0
Date: Apr 6, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 02/08/23 by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR survey, Manderley Health Care 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 with a fire alarm system and smoke detectors in all required areas.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 14, 2023
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Manderley Health Care 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 for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 42
Capacity: 71
Deficiencies: 9
Date: Feb 8, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 02/08/2023 to assess compliance with Emergency Preparedness Requirements and Life Safety Code regulations.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies were identified related to smoke detector maintenance, sprinkler system spare parts, HVAC system use of egress corridors as return air plenums, fire drill timing, fire door inspection documentation, electrical receptacle grading, use of extension cords, and oxygen cylinder storage.
Deficiencies (9)
Failed to ensure documentation for preventative maintenance of smoke detectors in all resident rooms.
Failed to replace smoke alarms installed in 3 of 36 resident sleeping rooms that were more than 10 years old.
Failed to ensure the sprinkler system spare cabinet contained the minimum number of spare sprinklers for all types and temperature ratings.
Failed to ensure 4 of 4 egress corridors were not used as a portion of a return air system/plenum for HVAC ductwork.
Failed to conduct quarterly fire drills at unexpected times under varying conditions on the first and third shifts.
Failed to ensure annual inspection and testing of all fire door assemblies were completed with itemized location and all testing items per NFPA 80.
Failed to ensure nonhospital-grade electrical receptacles that failed annual testing in 7 of 36 resident sleeping rooms were replaced with hospital-grade receptacles.
Failed to ensure extension cords including power strips were not used as a substitute for fixed wiring; a power strip was used in a patient care vicinity for non-PCREE equipment.
Failed to ensure 2 of 2 cylinders of nonflammable gases such as oxygen were properly secured from falling.
Report Facts
Certified beds: 71
Census: 42
Resident sleeping rooms with smoke alarms older than 10 years: 3
Resident sleeping rooms with failed electrical receptacles replaced: 7
Fire drills not conducted at unexpected times: 3
Fire drills not conducted at unexpected times: 4
Spare sprinklers in cabinet: 6
Oxygen cylinders improperly stored: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tina Estes | HFA, RDO | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Maintenance Director | Interviewed regarding smoke detector maintenance, sprinkler system, fire drills, fire door inspections, electrical receptacles, extension cords, and oxygen cylinder storage | |
| Administrator | Interviewed and participated in exit conference regarding all findings |
Inspection Report
Annual Inspection
Census: 41
Capacity: 41
Deficiencies: 6
Date: Jan 27, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00398708 which was unsubstantiated due to lack of evidence.
Complaint Details
Complaint IN00398708 was investigated and found unsubstantiated due to lack of evidence.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of medication refusals, improper insulin pen usage, failure to prevent pressure ulcers, inadequate dialysis site monitoring, medication availability issues, and unsanitary food storage and kitchen environment.
Deficiencies (6)
Failed to notify the physician of a resident's refusal of medications for 1 of 14 residents reviewed.
Failed to follow manufacturer's guidelines related to insulin pen usage for 1 of 14 residents reviewed.
Failed to prevent the development and worsening of a pressure ulcer for 1 of 5 residents reviewed for pressure ulcers.
Failed to adequately monitor dialysis access sites and fluid intake amounts for 3 of 3 residents reviewed for dialysis.
Failed to ensure a resident's medications were available related to their diagnoses for 1 of 7 residents reviewed for medications.
Failed to store food and provide a clean kitchen environment for 2 kitchen observations, potentially affecting all residents receiving food from the kitchen.
Report Facts
Census: 41
Total Capacity: 41
Medication refusal dates: 30
Pressure ulcer wound size: 3.6
Pressure ulcer wound size: 2.5
Medication administration missed dates: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Molly Negangard | Health Facility Administrator | Signed the report |
| RN 2 | Interviewed regarding medication refusals and insulin pen usage | |
| LPN 3 | Interviewed regarding dialysis site monitoring and fluid restriction | |
| LPN 4 | Interviewed regarding medication availability and Emergency Drug Kit usage | |
| Dietary Manager | Interviewed regarding kitchen sanitation and food storage | |
| Director of Nursing | DON | Provided policies and interviewed regarding multiple deficiencies |
| Assistant Director of Nursing | ADON | Provided documentation and interviewed regarding multiple deficiencies |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 37
Deficiencies: 0
Date: Dec 7, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00390567 and IN00395609.
Complaint Details
Complaint IN00390567 - Substantiated with no deficiencies cited. Complaint IN00395609 - Unsubstantiated due to lack of evidence.
Findings
Complaint IN00390567 was substantiated but no deficiencies related to the allegations were cited. Complaint IN00395609 was unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 37
Total Capacity: 37
Medicare Census: 6
Medicaid Census: 23
Other Payor Census: 8
Report
Jul 21, 2025
Report
Jan 31, 2025
Report
Mar 8, 2024
Report
Aug 28, 2023
Report
Jan 27, 2023
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