Indiana State Department of Health
Division of Long Term Care
 
CONSUMER REPORT
 
MAPLE MANOR CHRISTIAN HOME INC
 
NURSING HOME
SKILLED NURSING FACILITY / NURSING FACILITY DUALLY CERTIFIED
Created on: 06/08/2018
 
Posted to the Web on: 06/20/2018
 
 



Basic Information

FACILITY CONTACT INFORMATION:
Address: 643 W UTICA ST
City: SELLERSBURG
Telephone: (812) 246-4866
Web Site:  
 
NAME CHANGES:
Most recent name change: N/A
Date of most recent name change: N/A
 
LICENSE INFORMATION:
  License number: 18-000563-1
  License effective date: 08/01/2018
  License expiration date: 07/31/2019
 


Administration and Staff

Administrator: STEVEN CUNNINGHAM
  Start date: 03/31/2008
 
Director of Nursing: JACQUELYN PIKE
  Start date: 07/07/2017
 
Medical director: Kay Lowney
  Start date:   /  /  
 
Wound care specialist: Kelly Coffman
  Start date:   /  /  
 
Infection preventionist:  
  Start date:   /  /  
 


Ownership

CURENT OWNERSHIP:
 
Owning corporation: MAPLE MANOR CHRISTIAN HOME INC
643 W UTICA
SELLERSBURG IN 47172
 
Ownership type:  NON-PROFIT
 
Officer(s): NATHAN GRIMES
            NICK RAY
            KENNETH PETTIT
            SAM MARSH
            JAMES MCKINLEY
            HOUSTEN COCKRELL
            RICK SIMPSON
            ED MERTEN
            LARRY SMITH
            ROBERT CAMPBELL
            TERRY DRUIN
            JONATHON (JAY) RAKICH
            STEVE CUNNINGHAM
            EARL C. MULLINS, JR
            ROB JONES
 
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):        57
Number of non-certified comprehensive care beds (State Licensed only):     0
Total number of comprehensive care beds:     57
 
RESIDENTIAL CARE BEDS:
 
Total number of residential beds:            0
 
Total number of beds in facility:            57
 
CENSUS:
Facility census:  48
As reported by the facility on: 01/26/2018
 
Number of comprehensive care beds occupied in this facility. 0
As reported by the facility on: 01/26/2018
 
Residential care beds occupied:  0
As reported by the facility on: 01/26/2018
 
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: 40
Number of comprehensive care resident rooms with battery 
                    operated smoke detectors: 31
Number of comprehensive care resident rooms 
             with hard wired and/or wireless smoke detectors: 9
 
  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 - STEVEN CUNNINGHAM
Title of the person who completed the sprinkler, smoke detector form submitted to the ISDH. ADMINISTRATOR
Date form completed - 02/14/2018
 


Nurse Aide Training

NURSE AIDE TRAINING PROGRAM APPROVALS:
Nurse aide training and competency evaluation program (NATCEP) approved: 04/19/2001
Nurse aide training and competency evaluation program (NATCEP) expires: 04/01/2003
Nurse aide training and competency evaluation program (NATCEP) banned: Yes
Nurse aide training and competency evaluation program (NATCEP) ban expires: 03/23/2010
 
CLINICAL TRAINING SITES:
This facility is a Clinical training site for the following nurse aide training (NAT) classroom sites: 
     NURSES ON CALL NURSING AGENCY
         Approved: 10/09/2003
         Terminated: N/A
     PROSSER SCHOOL OF TECHNOLOGY
         Approved: 11/12/2003
         Terminated: N/A
     NURSE TECH
         Approved: 06/15/2004
         Terminated: N/A
     INDIANA HEALTH CAREERS VOCATIONAL TRAINING &  TEST
         Approved: 01/05/2012
         Terminated: N/A
     MAPLE MANOR CHRISTIAN HOME INC
         Approved: 04/19/2001
         Terminated: 08/08/2001
     AMERICAN RED CROSS-CLARK COUNTY INDIANA CHAPTER
         Approved: 10/28/2009
         Terminated: N/A
     IVY TECH STATE COLLEGE
         Approved: 03/17/1997
         Terminated: 08/08/2001
     SHANNON GIBBS AIDE TRAINING
         Approved: 09/06/2011
         Terminated: N/A
     LONG TERM CARE NURSING NETWORK
         Approved: N/A
         Terminated: 08/08/2001
     KENTUCKIANA CPR TRAINING CENTER
         Approved: 07/02/2013
         Terminated: N/A
 


Complaints

NUMBER OF SUBSTANTIATED COMPLAINTS: 
 
  Current year:  0
  Previous year:  0
  2 years previous:  1

 


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 grid
 
View 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: LI9C11
  Action - Citation / Fine
  Notice to facility: 08/16/2012
             Appeal: N/A
  Action Cease/Recind: 09/11/2012
         Case Closed: 09/11/2012
  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.

        
          

          

 
Event ID
Survey Type
Exit Date

66H411
Complaint
05/01/2018


RXW122
Recertification, Follow Up, Life Safety Code
12/29/2017


RXW121
Recertification, Life Safety Code
11/20/2017


RXW112
Recertification, Follow Up, State Licensure
11/08/2017


RXW111
Recertification, State Licensure
10/03/2017


4OJY11
Complaint
12/20/2016


0T8122
Recertification, Follow Up, Life Safety Code
11/01/2016


0T8112
Follow Up, Recertification, State Licensure
10/06/2016


0T8121
Life Safety Code, Recertification
10/05/2016


0T8111
Recertification, State Licensure
08/22/2016


8JIG12
Complaint, Follow Up
07/15/2016


8JIG11
Complaint
05/20/2016


Y9X811
Complaint
04/25/2016


ZIEC11
Complaint
03/07/2016


RXBM11
Complaint
02/03/2016


PB2V22
Recertification, Follow Up, Life Safety Code
09/15/2015


PB2V12
Recertification, Follow Up, State Licensure
09/10/2015


PB2V21
Life Safety Code, Recertification
08/28/2015


PB2V11
Recertification, State Licensure
07/31/2015


 
 


Links and Resources

 
CMS nursing home compare page 
 
    In addition to the information provided on this 
    web site, the Centers for Medicare & Medicaid Services (CMS) has a web site 
    which contains information on every Medicare and Medicaid certified nursing 
    home in the country. The CMS nursing home survey results contain summary information 
    about a facility's noncompliance of regulations regarding the care of residents 
    found in the nursing homes. You can locate nursing homes in your area and find 
    information about compliance with federal regulations.
 
Resources and links to other organizations
 
Choosing a Nursing Home
 
Overview of the Survey Process
 
State Wide Grouping of all Scores
   
Overview of current comprehensive facility scores
   
Spreadsheet of current comprehensive facility names and scores
   
Legal Disclaimer for Long Term Care Reports.