Provider Name: WITHAM EXTENDED CARE
Address: 2605 N LEBANON STREET, LEBANON, IN 46052
Phone: (765) 485-8300
County: Boone (050)
Ownership Type: Government - County
Certified Beds: 18
Average Residents Per Day: 12.7 ()
Provider Type: Medicare, Resides in Hospital: No
Legal Business Name: WITHAM MEMORIAL HOSPITAL
First Approved Date: May 7, 2015
Affiliated Entity: ()
Retirement Community: N, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: None
Sprinkler System Status: Yes
Overall Rating: 5 ()
Health Inspection Rating: 4 ()
QM Rating: 3 ()
Long Stay QM Rating: (2)
Short Stay QM Rating: 3 ()
Staffing Rating: 5 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 1.74582, LPN Staff Hours Per Day: 1.5933, RN Staff Hours Per Day: 2.5972, Licensed Staff Hours Per Day: 4.1906
Total Nurse Staff Hours Per Day, per resident: 5.93643
Weekend Nurse Staff Hours: 5.39488, Weekend RN Staff Hours: 2.3241
PT Staff Hours Per Day, per resident: 0.4360
Nurse Staff Turnover: 44.8, Nurse Turnover Note:
RN Turnover: 46.2, RN Turnover Note:
Admin Left Number: , Admin Turnover Note: 6
Case Mix Nurse Aide Hours Per Day, per resident: 2.2536, Case Mix LPN Hours Per Day: 0.8990, Case Mix RN Hours Per Day: 0.5375
Adjusted Nurse Aide Hours Per Day, per resident: 1.57821, Adjusted LPN Hours Per Day: 1.3078, Adjusted RN Hours Per Day: 1.8205
Total Adjusted Nurse Hours Per Day, per resident: 5.07064
Adjusted Weekend Nurse Hours Per Day, per resident: 4.60807
Health Survey Dates and Scores: Cycle 1: 2023-05-18 (Score: 20), Cycle 2: 2022-04-29 (Score: 8), Cycle 3: 2021-05-05 (Score: 24)
Total Weighted Health Score: 16.667
Reported Incidents: 0, Substantiated Complaints: 0
Infection Control Citations: 1
Fines and Penalties: Number of Fines: 1, Total Fines in Dollars: 650.00, Payment Denials Number: 0, Total Penalties Number: 1
Location and GPS: 2605 N LEBANON STREET,LEBANON,IN,46052 (40.0778, -86.475)
Process Date: 2024-03-01
Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Health, Deficiency: Allow residents to self-administer drugs if determined clinically appropriate.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-06-30
Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-06-30
Type: Health, Deficiency: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-06-30
Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-06-30
Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-06-01
Type: Health, Deficiency: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-06-01
Type: Health, Deficiency: Ensure staff are vaccinated for COVID-19
Severity: B - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-06-01
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-11-24
Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-05-25
Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Fire Safety, Tag: 0363, Version: New
Description: Install corridor and hallway doors that block smoke.
Severity: B - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2022-06-17