Created on: 06/08/2018
Posted to the Web on: 06/20/2018
Basic Information
FACILITY CONTACT INFORMATION:
Address: 1300 MERCER AVE
City: DECATUR
Telephone: (260) 724-3311
Web Site:
NAME CHANGES:
Most recent name change: N/A
Date of most recent name change: N/A
LICENSE INFORMATION:
License number: 18-000556-1
License effective date: 02/01/2018
License expiration date: 01/31/2019
Administration and Staff
Administrator: CRAIG PROKUPEK
Start date: 11/01/2016
Director of Nursing: ROSE KREMER
Start date: 03/11/2013
Medical director: Mark Gresla
Start date: / /
Wound care specialist:
Start date: / /
Infection preventionist:
Start date: / /
Ownership
CURENT OWNERSHIP:
Owning corporation: ADAMS COUNTY MEMORIAL HOSPITAL
1100 MERCER AVENUE
DECATUR IN 46733
Ownership type: OTHER
Officer(s): RUSS FLUECKIGER
JO ELLEN EIDAM
DAN WHEELER
PREVIOUS OWNERSHIP CHANGES:
Name of previous owner: N/A
Date of last change of ownership: N/A
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): 143
Number of non-certified comprehensive care beds (State Licensed only): 0
Total number of comprehensive care beds: 143
RESIDENTIAL CARE BEDS:
Total number of residential beds: 0
Total number of beds in facility: 143
CENSUS:
Facility census: 104
As reported by the facility on: 01/02/2018
Number of comprehensive care beds occupied in this facility. 0
As reported by the facility on: 01/02/2018
Residential care beds occupied: 0
As reported by the facility on: 01/02/2018
Alzheimer Beds: 0
Alzheimer Beds Occupied: 0
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: 82
Number of comprehensive care resident rooms with battery
operated smoke detectors: 0
Number of comprehensive care resident rooms
with hard wired and/or wireless smoke detectors: 82
If hard wired and/or wireless smoke detectors are provided in resident's room, do they:
(A) Provide a visual and audible signal at the nurses'stations that attend each room? - Yes
(B) Transmit to a central station service - Yes
(C) Connect to the health facility's fire alarm system - Yes
Person completing form - CRAIG PROKUPEK
Title of the person who completed the sprinkler, smoke detector form submitted to the ISDH. ADMINISTRATOR
Date form completed - 02/12/2018
Nurse Aide Training
NURSE AIDE TRAINING PROGRAM APPROVALS:
Nurse aide training and competency evaluation program (NATCEP) approved: 03/13/2001
Nurse aide training and competency evaluation program (NATCEP) expires: 04/01/2003
Nurse aide training and competency evaluation program (NATCEP) banned: No
Nurse aide training and competency evaluation program (NATCEP) ban expires: N/A
CLINICAL TRAINING SITES:
This facility is a Clinical training site for the following nurse aide training (NAT) classroom sites:
ADAMS WOODCREST
Approved: 12/15/1999
Terminated: N/A
MANNIA GREEN HEALTHCARE ADVANTAGE, INC
Approved: 10/02/2000
Terminated: 03/12/2003
NORTH ADAMS VOCATIONAL SCHOOL
Approved: 10/20/1999
Terminated: N/A
NORTHERN WELLS COMMUNITY SCHOOLS/NORWELL HIGH SCHO
Approved: N/A
Terminated: N/A
R & R MEDICAL STAFFING, INC
Approved: 04/04/2012
Terminated: N/A
PREMIER NURSING ACADEMY
Approved: 04/25/2018
Terminated: N/A
Complaints
NUMBER OF SUBSTANTIATED COMPLAINTS:
Current year: 0
Previous year: 0
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
Yes
No
Yes
Owner Change
No
No
No
Number of Substantiated Complaints With Deficiencies
0
0
0
Deficiency Free Standard Health Survey
No
Yes
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: R7SR11
Action - Citation / Fine
Notice to facility: 01/28/2004
Appeal: N/A
Action Cease/Recind: 04/15/2004
Case Closed: 04/15/2004
Initial Amount: $5000
Event ID: HJN111
Action - Citation / Fine
Notice to facility: 04/26/2002
Appeal: 05/15/2002
Action Cease/Recind: 12/26/2002
Case Closed: 12/26/2002
Initial Amount: $2500
Federal Certification Actions Imposed
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.
