Created on: 3/8/2024
Posted to the Web on: 3/20/2024
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: 24-000563-1
License effective date: 2/1/2024
License expiration date: 1/31/2025
Administration and Staff
Administrator: STEVEN CUNNINGHAM
Start date: 3/31/2008
Director of Nursing: JACQUELYN PIKE
Start date: 1/12/2019
Medical director: Stephen Nale
Start date: / /
Wound care specialist: Wendy East
Start date: / /
Infection preventionist: Monica Broady
Start date: / /
Ownership
CURENT OWNERSHIP:
Owning corporation: PULASKI MEMORIAL HOSPITAL
616 E 13TH STREET
WINAMAC IN 46996
Ownership type: NON-PROFIT
Officer(s): MICHAEL MCKAY
VALERIE LEMAN
LINDA WEBB
CHARLES HUTTON
GREGG MALOTT
CLINT KAUFFMAN
STEVE JAROSINSKI
ADAM BENNETT
JENNIFER SMITH
CAITLIN BARRY
TAYLOR WHITE
PREVIOUS OWNERSHIP CHANGES:
Name of previous owner: MAPLE MANOR CHRISTIAN HOME INC
Date of last change of ownership: 2/1/2019
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: 1/9/2024 9
Number of comprehensive care beds occupied in this facility. 0
As reported by the facility on: 1/9/2024 9
Residential care beds occupied: 0
As reported by the facility on: 1/9/2024 9
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: 42
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: 11
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 - 3/17/2023
Nurse Aide Training
NURSE AIDE TRAINING PROGRAM APPROVALS:
Nurse aide training and competency evaluation program (NATCEP) approved: 4/19/2001
Nurse aide training and competency evaluation program (NATCEP) expires: 4/1/2003
Nurse aide training and competency evaluation program (NATCEP) banned: Yes
Nurse aide training and competency evaluation program (NATCEP) ban expires: 3/23/2010
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: 10/9/2003
Terminated: N/A
PROSSER SCHOOL OF TECHNOLOGY
Approved: 11/12/2003
Terminated: N/A
NURSE TECH
Approved: 6/15/2004
Terminated: N/A
INDIANA HEALTH CAREERS VOCATIONAL TRAINING & TEST
Approved: 1/5/2012
Terminated: 6/11/2021
MAPLE MANOR CHRISTIAN HOME INC
Approved: 4/19/2001
Terminated: 8/8/2001
AMERICAN RED CROSS-CLARK COUNTY INDIANA CHAPTER
Approved: 10/28/2009
Terminated: 6/13/2012
IVY TECH STATE COLLEGE
Approved: 3/17/1997
Terminated: 8/8/2001
SHANNON GIBBS AIDE TRAINING
Approved: 9/6/2011
Terminated: 4/1/2015
LONG TERM CARE NURSING NETWORK
Approved: N/A
Terminated: 8/8/2001
KENTUCKIANA CPR TRAINING CENTER
Approved: 7/2/2013
Terminated: N/A
KAISER HEALTHCARE CERTIFICATION LLC
Approved: 1/13/2022
Terminated: N/A
Complaints
NUMBER OF SUBSTANTIATED COMPLAINTS:
Current year: 0
Previous year: 0
2 years previous: 0
Facility Report Card
3/1/2020 Current QTR
12/1/2019 Previous QTR
9/1/2019 Previous QTR
6/1/2019 Previous QTR
Report Card Score
344
398
404
380
Rank of Score
53
28
27
41
Average Score
302
296
295
296
*Facility report card scores have not been updated since March 1, 2020 due to changes in the survey process during the ongoing COVID-19 pandemic.
The facility report card score is calculated four times per calendar year
for the two most recent nursing home health surveys. The facility report card score
also includes all complaint surveys, life safety code surveys, emergency preparedness surveys,
and any follow-up surveys that occur within the two most recent nursing home health surveys.
The facility report card score ranges from 500 to 0, with 500 being the best score possible.
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
Yes
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
Federal Certification Actions Imposed
Civil Money Penalty
Date Imposed: 8/2/2021 Date Ended: 8/2/2021
Amount proposed per day: 1000
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.
