SKILLED NURSING FACILITY / NURSING FACILITY DISTINCT PART
Created on: 06/08/2018
Posted to the Web on: 06/20/2018
Basic Information
FACILITY CONTACT INFORMATION:
Address: 1325 ROCKPORT RD
City: BOONVILLE
Telephone: (812) 897-4114
Web Site:
NAME CHANGES:
Most recent name change: N/A
Date of most recent name change: N/A
LICENSE INFORMATION:
License number: 17-002724-1
License effective date: 11/01/2017
License expiration date: 10/31/2018
Administration and Staff
Administrator: ROBYN MEADOR
Start date: 07/16/2014
Director of Nursing: KIMBERLY GIBSON
Start date: 09/05/2017
Medical director:
Start date: / /
Wound care specialist:
Start date: / /
Infection preventionist:
Start date: / /
Ownership
CURENT OWNERSHIP:
Owning corporation: GOOD SAMARITAN HOSPITAL
520 S SEVENTH STREET
VINCENNES IN 47561
Ownership type: OTHER
Officer(s): ROBERT MCLIN
KAREN HAAK
THOMAS COOK
MOLLY WEISS
PREVIOUS OWNERSHIP CHANGES:
Name of previous owner: TRILOGY HEALTH SERVICES LLC
Date of last change of ownership: 11/01/2014
Bed Counts and Census
COMPREHENSIVE CARE BEDS:
Number of Medicaid beds (NF): 0
Number of Medicare beds (SNF): 18
Number of Medicare/Medicaid beds (SNF/NF): 42
Number of non-certified comprehensive care beds (State Licensed only): 0
Total number of comprehensive care beds: 60
RESIDENTIAL CARE BEDS:
Total number of residential beds: 39
Total number of beds in facility: 99
CENSUS:
Facility census: 77
As reported by the facility on: 01/05/2018
Number of comprehensive care beds occupied in this facility. 0
As reported by the facility on: 01/05/2018
Residential care beds occupied: 27
As reported by the facility on: 01/05/2018
Alzheimer Beds: 13
Alzheimer Beds Occupied: 10
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: 32
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: 32
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 - LISA FIGHTMASTER
Title of the person who completed the sprinkler, smoke detector form submitted to the ISDH. LICENSURE ANALYST
Date form completed - 02/20/2018
Nurse Aide Training
NURSE AIDE TRAINING PROGRAM APPROVALS:
Nurse aide training and competency evaluation program (NATCEP) approved: 01/25/2008
Nurse aide training and competency evaluation program (NATCEP) expires: 04/01/2010
Nurse aide training and competency evaluation program (NATCEP) banned: Yes
Nurse aide training and competency evaluation program (NATCEP) ban expires: 06/05/2018
CLINICAL TRAINING SITES:
This facility is a Clinical training site for the following nurse aide training (NAT) classroom sites:
WOODMONT HEALTH CAMPUS
Approved: 01/25/2008
Terminated: 03/03/2009
Complaints
NUMBER OF SUBSTANTIATED COMPLAINTS:
Current year: 1
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 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
Yes
Owner Change
No
No
Yes
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: BLO311
Action - Citation / Fine
Notice to facility: 05/23/2016
Appeal: N/A
Action Cease/Recind: 06/06/2016
Case Closed: 06/06/2016
Initial Amount: $3000
Event ID: 5FSO11
Action - Citation / Fine
Notice to facility: 01/26/2016
Appeal: N/A
Action Cease/Recind: 02/09/2016
Case Closed: 02/09/2016
Initial Amount: $3000
Event ID: 1YUT11
Action - Citation / Fine
Notice to facility: 12/26/2001
Appeal: 01/16/2002
Action Cease/Recind: 04/01/2003
Case Closed: 04/01/2003
Initial Amount: $2500
Federal Certification Actions Imposed
Civil Money Penalty
Date Imposed: 11/15/2016 Date Ended: 12/04/2016
Amount proposed per day: 1103
Civil Money Penalty
Date Imposed: 01/25/2016 Date Ended: 02/15/2016
Amount proposed per day: 550
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.
