Created on: 06/08/2018
Posted to the Web on: 06/20/2018
Basic Information
FACILITY CONTACT INFORMATION:
Address: 200 CONNIE AVE
City: SALEM
Telephone: (812) 883-1877
Web Site:
NAME CHANGES:
Most recent name change: N/A
Date of most recent name change: N/A
LICENSE INFORMATION:
License number: 17-000223-1
License effective date: 10/01/2017
License expiration date: 09/30/2018
Administration and Staff
Administrator: HOLLY MAUCK
Start date: 08/06/2012
Director of Nursing: CRYSTAL GROSVENOR
Start date: 11/10/2017
Medical director:
Start date: / /
Wound care specialist:
Start date: / /
Infection preventionist:
Start date: / /
Ownership
CURENT OWNERSHIP:
Owning corporation: HEALTH AND HOSPITAL CORPORATION OF MARION COUNTY
3838 N RURAL ST
INDIANAPOLIS IN 46205
Ownership type: OTHER
Officer(s): GREGORY FEHRIBACH
MATTHEW GUTWEIN
DANIEL SELLERS
JAMES MINER
DAVID CANAL
CHARLES EBERHARDT II
JOYCE ROGERS
VIRGINIA CAINE
LISA HARRIS
CARL DRUMMER
SHELIA GUENIN
ELLEN QUIGLEY
PREVIOUS OWNERSHIP CHANGES:
Name of previous owner: HERITAGE HOUSE OF SALEM INC
Date of last change of ownership:
Bed Counts and Census
COMPREHENSIVE CARE BEDS:
Number of Medicaid beds (NF): 0
Number of Medicare beds (SNF): 0
Number of Medicare/Medicaid beds (SNF/NF): 92
Number of non-certified comprehensive care beds (State Licensed only): 0
Total number of comprehensive care beds: 92
RESIDENTIAL CARE BEDS:
Total number of residential beds: 0
Total number of beds in facility: 92
CENSUS:
Facility census: 79
As reported by the facility on: 01/08/2018
Number of comprehensive care beds occupied in this facility. 0
As reported by the facility on: 01/08/2018
Residential care beds occupied: 0
As reported by the facility on: 01/08/2018
Alzheimer Beds: 30
Alzheimer Beds Occupied: 29
As reported by the facility on: / /
Ventilator Beds: 0
Ventilator Beds Occupied: 0
As reported by the facility on: / /
Sprinklers and Smoke Detectors
This facility is: FULLY SPRINKLERED
Number of comprehensive care resident rooms: 48
Number of comprehensive care resident rooms with battery
operated smoke detectors: 48
Number of comprehensive care resident rooms
with hard wired and/or wireless smoke detectors: 0
Person completing form - HOLLY LEE
Title of the person who completed the sprinkler, smoke detector form submitted to the ISDH. EXECUTIVE DIRECTOR
Date form completed - 03/23/2018
Nurse Aide Training
NURSE AIDE TRAINING PROGRAM APPROVALS:
Nurse aide training and competency evaluation program (NATCEP) approved: 03/19/1996
Nurse aide training and competency evaluation program (NATCEP) expires: 04/01/2000
Nurse aide training and competency evaluation program (NATCEP) banned: Yes
Nurse aide training and competency evaluation program (NATCEP) ban expires: 01/22/2019
CLINICAL TRAINING SITES:
This facility is a Clinical training site for the following nurse aide training (NAT) classroom sites:
HEALTHCARE VOCATIONAL TRAINING
Approved: 04/23/2010
Terminated: 01/23/2017
TOP CARE CERTIFIED NURSE AIDE PROGRAM
Approved: 03/10/2010
Terminated: 01/23/2017
SALEM CROSSING
Approved: 03/18/1998
Terminated: 01/23/2017
LOST RIVER CAREER COOPERATIVE
Approved: N/A
Terminated: 02/05/2007
ASC TRAINING CENTER
Approved: 06/10/2013
Terminated: 01/23/2017
INDIANA HEALTH CAREERS VOCATIONAL TRAINING & TEST
Approved: 10/13/2016
Terminated: 01/23/2017
PROSSER SCHOOL OF TECHNOLOGY
Approved: 08/17/2017
Terminated: 01/23/2017
Complaints
NUMBER OF SUBSTANTIATED COMPLAINTS:
Current year: 0
Previous year: 1
2 years previous: 0
Facility Report Card
We are experiencing technical issues with the consumer report card system.
We are working to resolve the issue.
The statewide average line is being provided to give you a reference
for looking at the scores of the selected facility. This row
contains the mean average calculated scores for all facilities as of
above date resulting in a scoring range of 0 to 587.
Scores are considered to be better the closer to zero they are.
Percentile rank of 100 represents the lowest report card score or best performing facility,
with a rank of 1 being the highest report card score.
View the Scope and Severity gridView the scoring methodology
Overview of Survey findings
The Most Recent Set
2ND Most Recent Set
3RD Most Recent Set
Immediate Jeopardy
No
No
No
Substandard Quality of Care
No
No
No
Administrator Change
No
No
No
Owner Change
No
No
No
Number of Substantiated Complaints With Deficiencies
0
0
0
Deficiency Free Standard Health Survey
No
No
No
The term 'Recent Set' referenced above relates to the referenced annual survey,
and any other surveys performed between it and the previous annual survey.
Enforcement Actions
Event ID: OPNT11
Action - Citation / Fine
Notice to facility: N/A
Appeal: N/A
Action Cease/Recind: 01/12/2016
Case Closed: 01/12/2016
Initial Amount: $3000
Federal Certification Actions Imposed
Civil Money Penalty
Date Imposed: 09/14/2017 Date Ended: 09/14/2017
Amount proposed per day: 505
Amount proposed per day:
Civil Money Penalty
Date Imposed: 09/09/2016 Date Ended: 10/06/2016
Amount proposed per day: 703
Date terminated from Medicare/Medicaid: N/A
Survey History
The survey report is not posted until the report has been provided to the facility and their plan of correction submitted and approved.
The survey report therefore will likely not be posted until four to six weeks after the exit date.
In the grid below click on an event ID that is underlined to see the survey report for that event.
