COMMUNITY NURSING AND REHABILITATION CENTER

Nursing Home Inspector

5600 E 16TH ST
INDIANAPOLIS, IN 46218
Marion County
Phone: 317-356-0911
Provider Number: 155029
Last Inspection: 02/20/2017

About the Nursing Home

Number of Beds: 115
Number of Residents: 97
Beds Available: 18
Percent Occupancy: 84%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

41

Facility
24

County
18

IN
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

41

2017
3

2015
32

2014

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

2/20/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 3/13/2017
 
Failed To: Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. Isolated : Minimal 3 3/13/2017
 
Failed To: Provide medically-related social services to help each resident achieve the highest possible quality of life. Isolated : Minimal 3 3/13/2017
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 3/13/2017
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 3/13/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 3/13/2017
 
Failed To: Provide routine and 24-hour emergency dental care for each resident. Isolated : Minimal 3 3/13/2017
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 3/13/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 3/13/2017
 
Failed To: 1) Receive registry verification that a nurse aide has met the required training and skills that the State requires; and 2) ensure nurse aides receive the required retraining after 24 months if nursing related services were not provided for monetary compe Isolated : Minimal 3 3/13/2017
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 3/13/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 3/13/2017
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Pattern : Minimal 4 4/4/2017
 

12/21/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Isolated : Minimal 3 2/13/2016
 

10/30/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 11/29/2014
 
Failed To: Give notice to the resident before a room or roommate change. Isolated : Minimal 3 11/29/2014
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 11/29/2014
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 11/29/2014
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 11/29/2014
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 11/29/2014
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 11/29/2014
 
Failed To: Dispose of garbage and refuse properly. Widespread : Potential 4 11/29/2014
 
Failed To: Provide or obtain dental services for each resident. Isolated : Minimal 3 11/29/2014
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 11/29/2014
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

10/6/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Protect each resident from all abuse, physical punishment, and involuntary separation from others. Isolated : Minimal 3 10/27/2017
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 10/27/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 10/27/2017
 

4/12/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 4/24/2017
 

3/22/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 4/4/2017
 

1/20/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Protect each resident from all abuse, physical punishment, and involuntary separation from others. Isolated : Actual 4 2/13/2016
 

9/2/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 9/23/2015
 
Failed To: Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. Isolated : Minimal 3 9/23/2015
 

6/18/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 7/18/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg IN State Avg
Number of Residents 97 74.29 70.33
Registered Nurses 0.77 0.82 0.88
Licensed Practical / Vocational Nurses 0.87 1.02 0.89
Certified Nursing Assistants 2.01 2.14 2.17
Total Staff Hours 3.66 3.99 3.95

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% IN State Avg%
of high risk long-stay residents with pressure ulcers 6 6 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 99 91 92
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 99 92 93
of long-stay residents experiencing one or more falls with major injury 3 2 3
of long-stay residents who have depressive symptoms 40 12 8
of long-stay residents who lose too much weight 7 8 7
of long-stay residents who received an antianxiety or hypnotic medication 8 14 22
of long-stay residents who received an antipsychotic medication 27 15 15
of long-stay residents who self-report moderate to severe pain 1 5 5
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 12 17 17
of long-stay residents whose need for help with daily activities has increased 10 18 16
of long-stay residents with a catheter inserted and left in their bladder 0 1 1
of long-stay residents with a urinary tract infection 4 2 3
of low risk long-stay residents who lose control of their bowels or bladder 59 56 51
of short-stay residents assessed and appropriately given the pneumococcal vaccine 88 76 81
of short-stay residents who had an outpatient emergency department visit 14 11 11
of short-stay residents who made improvements in function 30 60 65
of short-stay residents who newly received an antipsychotic medication 1 1 2
of short-stay residents who self-report moderate to severe pain 4 12 14
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 88 75 80
of short-stay residents who were rehospitalized after a nursing home admission 13 20 19
of short-stay residents who were successfully discharged to the community 44 52 53
of short-stay residents with pressure ulcers that are new or worsened 0 1 1