Inspection Report
Life Safety
Census: 122
Capacity: 150
Deficiencies: 0
Jun 12, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted to verify compliance with fire safety and life safety code requirements.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101 Life Safety Code. The facility is fully sprinklered except for a detached storage and repair shed.
Report Facts
Resident sleeping rooms with battery operated smoke detectors: 59
Resident sleeping rooms with hard wired smoke detectors: 23
Facility capacity: 150
Census: 122
Inspection Report
Complaint Investigation
Census: 119
Capacity: 119
Deficiencies: 0
May 22, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00456216 and IN00459209 at the facility.
Findings
No deficiencies related to the allegations in complaints IN00456216 and IN00459209 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaints IN00456216 and IN00459209 found no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 119
Census total residents: 119
Census Medicare residents: 4
Census Medicaid residents: 75
Census other payor residents: 40
Inspection Report
Complaint Investigation
Census: 181
Deficiencies: 0
Mar 24, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00455337.
Findings
No deficiencies related to the allegations in Complaint IN00455337 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00455337 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 130
Census Bed Type - Residential: 51
Census Total: 181
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 80
Census Payor Type - Other: 44
Census Payor Type - Total: 130
Inspection Report
Life Safety
Census: 123
Capacity: 150
Deficiencies: 5
Mar 11, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 03/11/2025 to assess compliance with emergency preparedness and life safety requirements.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies included failure to ensure hazardous areas were properly enclosed with self-closing doors, sprinkler heads covered with lint, smoke barrier doors obstructed or not closing properly, failure to conduct fire drills at varied times, and soiled linen and trash containers exceeding allowed capacity in corridors.
Severity Breakdown
SS=E: 4
SS=C: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 9 hazardous areas such as a soiled linen or laundry rooms were separated by smoke resistant partitions and doors that are self-closing or automatic closing. | SS=E |
| Failed to ensure 1 of 1 sprinkler heads behind the Laundry room dryers covered with lint were replaced or cleaned in accordance with NFPA 25. | SS=E |
| Failed to ensure 1 of 5 sets of smoke barrier doors would restrict the movement of smoke for at least 20 minutes; doors were obstructed by a food cart and could not fully close. | SS=E |
| Failed to conduct quarterly fire drills at unexpected times under varying conditions on the second shift for 4 of 4 quarters. | SS=C |
| Failed to ensure 4 of 4 soiled linen or trash receptacles in the corridor did not exceed 32 gallons in capacity within a 64 square foot area. | SS=E |
Report Facts
Certified beds: 150
Census: 123
Hazardous areas: 9
Sprinkler heads: 1
Smoke barrier doors: 5
Fire drills: 4
Soiled linen/trash receptacles: 4
Receptacle capacity: 40
Allowed receptacle capacity: 32
Allowed area: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gina Couch | Executive Director | Signed report and involved in education and corrective action oversight |
| Maintenance Director | Acknowledged deficiencies related to hazardous area doors, sprinkler heads, smoke barrier doors, and fire drills; involved in corrective actions | |
| Field Maintenance Supervisor | Participated in exit conference and review of findings |
Inspection Report
Renewal
Deficiencies: 0
Feb 25, 2025
Visit Reason
The inspection was conducted as a paper compliance review for the Recertification and State Licensure Survey, including a Residential Survey completed on February 25, 2025.
Findings
American Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the Recertification and State Licensure Survey. Quality review was completed on March 24, 2025.
Inspection Report
Recertification
Census: 178
Deficiencies: 9
Feb 18, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Nursing Home Complaints IN00451302 and IN00452379, and a State Residential Licensure Survey and Investigation of Residential Complaint IN00450714.
Findings
The facility had multiple deficiencies including inaccurate Minimum Data Set assessments, failure to develop timely person-centered care plans, medication administration errors, failure to apply splints as care planned, inadequate social services follow-up related to abuse allegations, improper medication storage, and failure to use personal protective equipment during wound care.
Complaint Details
Complaint IN00451302 and IN00452379 - No deficiencies related to the allegations are cited. Complaint IN00450714 - No deficiencies related to the allegations are cited.
Severity Breakdown
SS=D: 7
SS=E: 1
: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to accurately complete Minimum Data Set assessments for residents related to dental services, Preadmission Screening and Resident Review, and skin conditions. | SS=D |
| Failed to develop a person-centered care plan timely for refusal to change clothes for a resident. | SS=D |
| Failed to ensure lidocaine patches were administered as ordered and to obtain weights three times weekly and inform the physician of weight changes as ordered. | SS=D |
| Failed to apply splints as care planned for a resident with limited range of motion. | SS=D |
| Failed to timely develop a person-centered behavior management care plan with individualized interventions and document approaches to care for a resident with dementia exhibiting behaviors. | SS=D |
| Failed to ensure appropriate social services follow-up related to a previous allegation of abuse of a resident by a family member. | SS=D |
| Failed to remove discontinued resident medications, refrigerate medication requiring refrigeration, and label open medications in medication carts. | SS=E |
| Failed to ensure staff donned personal protective equipment prior to wound dressing for a resident on Enhanced Barrier Precautions. | SS=D |
| Failed to ensure residents with medications stored in their apartment were assessed for ability to self-administer medications and failed to assess a resident who used an electronic cigarette for appropriate utilization. | — |
Report Facts
Survey dates: February 18, 19, 20, 21, 24, and 25, 2025
Census SNF/NF: 128
Census Residential: 50
Total Census: 178
Medicare Census: 9
Medicaid Census: 81
Other Payor Census: 38
Medication administration missed doses: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gina Couch | Executive Director | Signed the report and involved in interviews |
| LPN 21 | Licensed Practical Nurse | Observed providing wound care without full PPE and unaware of Enhanced Barrier Precautions |
| LPN 4 | Licensed Practical Nurse | Observed medication cart with unlabeled and improperly stored medications |
| LPN 2 | Licensed Practical Nurse | Observed medication cart with unlabeled medications |
| LPN 20 | Licensed Practical Nurse | Observed medication administration without supervision of resident self-administration |
| Director of Nursing | Director of Nursing | Provided policies, interviews, and observations related to multiple deficiencies |
| Memory Care Support Specialist | Memory Care Support Specialist | Provided interviews related to resident behaviors and abuse concerns |
| Social Services Director | Social Services Director | Provided interview regarding abuse allegations and supervision of visits |
| Hospice Staff 1 | Provided interview regarding visitation supervision | |
| Hospice Staff 2 | Provided interview regarding visitation supervision and abuse concerns |
Inspection Report
Complaint Investigation
Census: 122
Capacity: 165
Deficiencies: 0
Dec 2, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00446848, IN00444433, and IN00443133.
Findings
No deficiencies related to the allegations in complaints IN00446848, IN00444433, and IN00443133 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaints IN00446848, IN00444433, and IN00443133 were investigated with no deficiencies found related to the allegations.
Report Facts
Census SNF/NF beds: 122
Census Residential beds: 43
Total licensed capacity: 165
Census Medicare residents: 5
Census Medicaid residents: 77
Census Other payor residents: 40
Total census residents: 122
Inspection Report
Complaint Investigation
Census: 165
Deficiencies: 0
Aug 6, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00437191, IN00438066, IN00439017, and IN00440159 at the facility.
Findings
No deficiencies related to the allegations in any of the complaints were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the investigation of the complaints.
Complaint Details
Complaints IN00437191, IN00438066, IN00439017, and IN00440159 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 122
Census Bed Type - Residential: 43
Total Census: 165
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 73
Census Payor Type - Other: 43
Total Census Payor: 122
Inspection Report
Complaint Investigation
Census: 123
Capacity: 166
Deficiencies: 0
Jun 17, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00435825 and IN00429787.
Findings
No deficiencies related to the allegations in complaints IN00435825 and IN00429787 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00435825 and Complaint IN00429787 were investigated with no deficiencies cited related to the allegations.
Report Facts
SNF/NF census: 123
Residential census: 43
Total capacity: 166
Medicare census: 6
Medicaid census: 68
Other payor census: 49
Total census: 123
Inspection Report
Follow-Up
Census: 120
Capacity: 150
Deficiencies: 0
Mar 26, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey that exited on 02/02/24.
Findings
At this PSR Emergency Preparedness survey, American Village was found in compliance with Emergency Preparedness Requirements. At the PSR Life Safety Code survey, the facility was found in compliance with Life Safety Code requirements, including fire safety and sprinkler systems.
Report Facts
Certified beds: 150
Census: 120
Resident sleeping rooms with battery operated smoke detectors: 59
Resident sleeping rooms with hard wired smoke detectors: 23
Resident sleeping rooms total: 82
Inspection Report
Renewal
Deficiencies: 0
Mar 6, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the Recertification, State Licensure, and Complaint Survey, including a Residential Survey completed on January 10, 2024.
Findings
American Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding paper compliance to the Recertification, State Licensure, and Complaint Survey.
Inspection Report
Life Safety
Census: 120
Capacity: 150
Deficiencies: 20
Feb 2, 2024
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with federal and state regulations including fire safety, emergency preparedness, and facility maintenance.
Findings
The facility was found substantially compliant with emergency preparedness requirements but had multiple deficiencies related to life safety code including fire hazards, door latching issues, obstructed egress, sprinkler system maintenance, smoke barrier integrity, electrical safety, smoking policy violations, and improper use of portable heaters and power strips.
Severity Breakdown
Level 3: 20
Deficiencies (20)
| Description | Severity |
|---|---|
| Emergency preparedness communication plan lacked specific contact information for the State Long Term Care Ombudsman. | Level 3 |
| Electric range in therapy area had combustible materials on burners creating fire hazard. | Level 3 |
| Smoke barrier doors failed to latch properly. | Level 3 |
| Exit discharge sidewalk was obstructed by crates and charcoal grill. | Level 3 |
| Two exterior exit doors were not readily accessible or failed to open on first try. | Level 3 |
| Delayed egress locking arrangements were not installed or functioning properly on multiple exit doors. | Level 3 |
| Battery operated smoke detectors in resident rooms lacked documentation of maintenance and battery replacement. | Level 3 |
| 400 Hall linen closet door had holes compromising smoke resistance. | Level 3 |
| Electric range in therapy area lacked accessible shutoff switch. | Level 3 |
| Fire alarm control panel displayed incorrect date. | Level 3 |
| Canvas canopy outside 100 Hall East Exit was not sprinkled and lacked documentation of fire retardant material. | Level 3 |
| Portable fire extinguisher in therapy area was unsecured and sitting on floor. | Level 3 |
| Several corridor doors failed to latch properly or were propped open. | Level 3 |
| Smoke barrier walls had holes and unsealed penetrations allowing passage of smoke. | Level 3 |
| Electrical junction box above ceiling near service hall entrance lacked cover and exposed wiring. | Level 3 |
| Smoking policy was not enforced; cigarette smoke odor detected in facility and cigarette butts found in designated smoking area near entrance. | Level 3 |
| Annual inspection and testing of oxygen transfilling room fire door assembly was not completed. | Level 3 |
| Portable space heater was in use in therapy office contrary to facility policy. | Level 3 |
| Power strips in resident rooms lacked required UL rating of 1363A or 60601-1. | Level 3 |
| Oxygen transfilling room ceiling had a hole compromising fire-resistive construction. | Level 3 |
Report Facts
Certified beds: 150
Census: 120
Deficiencies cited: 20
Battery operated smoke detectors: 59
Resident sleeping rooms: 82
Canvas canopy size: 240
Hole size: 4
Hole size: 400
Hole size: 1
Spare sprinklers: 5
Inspection Report
Recertification
Census: 37
Capacity: 37
Deficiencies: 17
Jan 10, 2024
Visit Reason
This visit was for a State Residential Licensure Survey including a Recertification and Investigation of Complaints IN00422553, IN00425026 and IN00420608.
Findings
The facility was found to have multiple deficiencies including failure to provide care in a manner that promotes dignity and respect, failure to timely assess and document medication self-administration, failure to provide care consistent with resident preferences, failure to provide timely assistance with ADLs, failure to administer medications as ordered, failure to maintain infection control practices, failure to maintain medication storage and labeling standards, failure to ensure sufficient staffing, failure to notify hospice timely of resident falls, and failure to maintain sanitation and safety standards including proper garbage disposal and food storage.
Complaint Details
Complaint investigations IN00422553, IN00425026, and IN00420608 were included in this survey. Deficiencies were cited related to dignity and respect, medication administration, ADL care, medication management, infection control, hospice notification, staffing, and sanitation.
Severity Breakdown
SS=E: 8
SS=D: 6
SS=C: 2
Deficiencies (17)
| Description | Severity |
|---|---|
| Failure to provide care services in a manner that promoted privacy, respect, and dignity for 11 of 12 residents reviewed for dignity. | SS=E |
| Failure to timely have the interdisciplinary team determine and document that self-administration of medications was clinically appropriate for 2 residents. | SS=D |
| Failure to ensure residents got out of bed and showered as preference for 2 residents. | SS=D |
| Failure to provide timely assistance with eating, incontinent care, grooming, and personal hygiene for 8 residents. | SS=E |
| Failure to administer medications as ordered for 7 residents and failure to follow physician orders for elevation of bilateral lower extremities and pressure relief boots for 1 resident. | SS=E |
| Failure to provide proper foot care and treatment for 1 resident. | SS=D |
| Failure to ensure wheelchair had 2 functioning anti-tippers and fall interventions in place for 3 residents. | SS=D |
| Failure to ensure residents with urinary catheters had physician orders, monitoring and documentation of urinary output, and timely notification of decreased output and leakage for 2 residents. | SS=D |
| Failure to assure weights were obtained accurately for 1 resident. | SS=D |
| Failure to administer oxygen as ordered and ensure accuracy of oxygen orders for 1 resident. | SS=D |
| Failure to provide sufficient nursing staff with appropriate competencies and skill sets to provide ADL care and medication administration in accordance with plans of care for multiple residents. | SS=E |
| Failure to ensure medication labels were not altered, expired supplies were removed, medications for discharged residents were returned to pharmacy, and medication carts were locked during administration. | SS=D |
| Failure to ensure appropriate justification and follow-up for continued use of antipsychotic medication and abnormal AIMS assessment for 1 resident. | SS=D |
| Failure to timely notify hospice of resident falls for 1 resident. | SS=D |
| Failure to maintain infection control by not ensuring gloves were changed and hand hygiene was completed appropriately during incontinent care, dining assistance, and medication pass for multiple residents. | SS=E |
| Failure to ensure trash was contained in receptacles and dumpsters were properly maintained and covered. | SS=C |
| Failure to properly store food in refrigerator and ensure dishwasher detergent system was functioning properly. | SS=D |
Report Facts
Residents reviewed for ADL care: 12
Residents reviewed for medication administration: 14
Residents reviewed for infection control: 12
Residents reviewed for hospice notification: 1
Residents reviewed for sanitation: 124
Residents reviewed for food storage: 37
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gina Couch | Executive Director | Signed the Statement of Deficiencies |
| LPN 15 | Licensed Practical Nurse | Observed and interviewed regarding medication administration and oxygen therapy |
| CNA 24 | Certified Nursing Assistant | Observed and interviewed regarding incontinent care and infection control |
| LPN 26 | Licensed Practical Nurse | Interviewed regarding medication administration system issues |
| Resident Rights policy | Policy | Referenced multiple times regarding resident dignity and care |
| Director of Nursing | Director of Nursing | Interviewed multiple times regarding various care and policy issues |
| Hospice RN 13 | Hospice Registered Nurse | Interviewed regarding hospice notification failures |
| Unit Manager 23 | Unit Manager | Observed weights and interviewed regarding weight discrepancies |
| Dietary Manager | Dietary Manager | Interviewed regarding food storage and dishwasher issues |
Inspection Report
Complaint Investigation
Census: 163
Deficiencies: 0
Oct 5, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00418780.
Findings
No deficiencies related to the allegations in Complaint IN00418780 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00418780 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 124
Census Bed Type - Residential: 39
Census Bed Type - Total: 163
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 77
Census Payor Type - Other: 42
Census Payor Type - Total: 124
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 25, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to a Complaint Survey IN00415131 completed on August 29, 2023.
Findings
American Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance to the Complaint Survey.
Complaint Details
The visit was complaint-related, specifically a paper compliance review of Complaint Survey IN00415131. The facility was found to be in compliance.
Inspection Report
Complaint Investigation
Census: 125
Capacity: 125
Deficiencies: 2
Aug 29, 2023
Visit Reason
This visit was conducted for the investigation of two complaints, IN00415131 and IN00416297. Complaint IN00415131 resulted in federal/state deficiencies being cited, while Complaint IN00416297 had no deficiencies cited.
Findings
The facility was found deficient in monitoring and recording fluid intake and urinary output accurately for one resident with a urinary catheter, and in timely obtaining laboratory tests as ordered by the physician for the same resident. These deficiencies were related to hydration status maintenance and laboratory services.
Complaint Details
Complaint IN00415131 was substantiated with federal/state deficiencies cited at F0692 and F0770 related to hydration status maintenance and laboratory services. Complaint IN00416297 had no federal/state deficiencies cited.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to monitor and record fluid intake and urine output from a urinary catheter accurately for 1 of 3 residents reviewed for hospitalization (Resident B). | SS=D |
| Failed to timely obtain labs, as ordered by the physician for 1 of 3 residents reviewed for hospitalization (Resident B). | SS=D |
Report Facts
Census: 125
Total Capacity: 125
Medicare Census: 8
Medicaid Census: 77
Other Payor Census: 40
Fluid need estimate: 1510
Fluid need estimate: 1760
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gina Couch | Executive Director | Signed the report |
| Director of Nursing | Interviewed regarding urinary output recording and lab order issues related to Resident B | |
| LPN 2 | Licensed Practical Nurse | Interviewed about assistance with Resident B's meals and fluids |
| Nurse Consultant | Provided urinary catheter care policy | |
| LB 3 | Lab Representative | Interviewed about lab specimen issues |
| NP 4 | Nurse Practitioner | Interviewed about lab draws and treatment plans for Resident B |
Inspection Report
Complaint Investigation
Census: 167
Deficiencies: 0
Aug 7, 2023
Visit Reason
This visit was conducted to investigate complaints IN00412785, IN00414340, and IN00414681 at the facility.
Findings
No deficiencies related to the allegations in complaints IN00412785, IN00414340, and IN00414681 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaints IN00412785, IN00414340, and IN00414681 were investigated and no deficiencies related to the allegations were found.
Report Facts
SNF/NF Census: 130
Residential Census: 37
Total Census: 167
Medicare Census: 13
Medicaid Census: 74
Other Payor Census: 29
Total Payor Census: 130
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 20, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to a complaint survey completed on June 20, 2023.
Findings
American Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance to the Complaint Survey.
Complaint Details
Paper compliance to the Complaint Survey IN00410705 completed on June 20, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 122
Capacity: 122
Deficiencies: 2
Jun 19, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00410705 and IN00409482. Complaint IN00410705 resulted in federal/state deficiencies cited, while no deficiencies were found related to complaint IN00409482.
Findings
The facility failed to ensure adequate toileting and incontinent care on night shift for 4 of 14 residents reviewed, and failed to ensure a resident utilizing oxygen therapy had physician orders for oxygen. Resident and staff interviews, record reviews, and observations confirmed these deficiencies.
Complaint Details
Complaint IN00410705 was substantiated with federal/state deficiencies cited at F684 (Quality of Care) and F695 (Respiratory/Tracheostomy Care and Suctioning). Complaint IN00409482 had no deficiencies related to the allegations.
Severity Breakdown
SS=E: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure residents' needs were met on night shift with toileting and incontinent care for 4 residents (Residents J, K, M, and N). | SS=E |
| Failed to ensure a resident utilizing oxygen therapy had physician orders for oxygen (Resident B). | SS=D |
Report Facts
Residents reviewed for care needs with Activities of Daily Living: 14
Residents affected by toileting/incontinence deficiency: 4
Census: 122
Total licensed capacity: 122
Residents using oxygen therapy reviewed: 3
Dates oxygen saturation documented: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gina Couch | Executive Director | Signed the report and involved in oversight |
| LPN 1 | Licensed Practical Nurse | Received report of night shift care concerns from Resident J |
| CNA 2 | Certified Nursing Assistant | Reported Resident N was found saturated with urine on multiple occasions |
| CNA 3 | Certified Nursing Assistant | Reported lack of night shift report and observed Resident N saturated with urine |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 26, 2023
Visit Reason
Paper compliance review to the Complaint Survey IN00403574 completed on March 28, 2023.
Findings
American Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance to the Complaint Survey.
Inspection Report
Complaint Investigation
Census: 159
Deficiencies: 3
Mar 28, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00403574 and IN00404205. Complaint IN00403574 resulted in federal/state deficiencies cited, while complaint IN00404205 had no deficiencies related to the allegations.
Findings
The facility was found deficient in promoting resident dignity and respect, including failure to ensure residents' clothing was dry and catheter dignity bags were used. Additionally, call lights were not within reach for some residents, and there were incomplete documentation issues with weekly skin assessments and medication administration records.
Complaint Details
Complaint IN00403574 resulted in federal/state deficiencies cited at F557 related to dignity and respect. Complaint IN00404205 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to promote dignity by not assuring a resident's clothing was dry and not assuring a resident with an indwelling catheter had a dignity bag. | SS=D |
| Failure to ensure call lights were in reach for residents. | SS=D |
| Failure to ensure complete documentation of weekly skin assessments and electronic medication administration records. | SS=D |
Report Facts
Census SNF/NF beds: 113
Census Residential beds: 46
Total Census: 159
Census Medicare: 16
Census Medicaid: 85
Census Other payor: 12
Medication administration record holes: 7
Weekly skin assessments missing: 2
Wait time for assistance: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gina Couch | Executive Director | Signed the report and identified as facility representative |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 21, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to Complaint Surveys IN00398923 and IN00401490 completed on February 15, 2023.
Findings
American Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding paper compliance to the Complaint Survey.
Complaint Details
The visit was complaint-related, reviewing paper compliance for Complaint Surveys IN00398923 and IN00401490. The facility was found to be in compliance.
Inspection Report
Complaint Investigation
Census: 172
Deficiencies: 2
Feb 13, 2023
Visit Reason
This visit was for the investigation of multiple nursing home complaints and a COVID-19 Focused Infection Control Survey, including an investigation of a residential complaint.
Findings
The facility was found to have deficiencies related to substantiated complaints involving failure to ensure bilateral boots were in place for a resident with an arterial ulcer and failure to ensure a medication was obtained and administered for another resident. Some complaints were unsubstantiated or substantiated with no deficiencies cited.
Complaint Details
Multiple complaints were investigated: IN00391300 (unsubstantiated), IN00394673 (substantiated, no deficiencies), IN00397247 (substantiated, no deficiencies), IN00398169 (substantiated, no deficiencies), IN00398408 (unsubstantiated), IN00398923 (substantiated with deficiencies cited at F755), IN00400811 (substantiated, no deficiencies), IN00401490 (substantiated with deficiencies cited at F684), and IN00395699 (residential complaint, unsubstantiated).
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure bilateral boots were in place for a resident with an arterial ulcer (Resident H). | SS=D |
| Failed to ensure a medication (Aranesp) was obtained and administered for a resident (Resident G). | SS=D |
Report Facts
Census bed type: 123
Census bed type: 49
Total census beds: 172
Census payor type: 10
Census payor type: 83
Census payor type: 30
Total census payor: 123
Hemoglobin level: 6.8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gina Couch | Executive Director | Signed the report and referenced in quality assurance oversight |
| Director of Nursing | Director of Nursing | Interviewed regarding Resident H's refusal to wear boots and medication issues for Resident G |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 10, 2023
Visit Reason
Paper compliance review related to the Complaint Survey IN00399028 completed on January 18, 2023.
Findings
American Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding paper compliance to the Complaint Survey.
Complaint Details
Complaint Survey IN00399028 was reviewed and found to be in compliance.
Inspection Report
Complaint Investigation
Census: 128
Capacity: 128
Deficiencies: 1
Jan 17, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00399028, which was substantiated with a federal/state deficiency cited.
Findings
The facility failed to accurately code the cognitive abilities of one resident (Resident B) in the Minimum Data Set (MDS) assessments, incorrectly listing her as in a persistent vegetative state when she had shown cognitive improvement.
Complaint Details
Complaint IN00399028 was substantiated. The deficiency related to inaccurate cognitive coding in MDS assessments for Resident B.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to accurately code the cognitive abilities of Resident B in MDS assessments. | SS=D |
Report Facts
Census: 128
Total Capacity: 128
Medicare Census: 14
Medicaid Census: 78
Other Payor Census: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gina Couch | Executive Director | Signed the report |
| Director of Nursing | Interviewed regarding Resident B's condition and MDS assessments | |
| MDS Coordinator | Interviewed regarding MDS assessments and leave status during Resident B's assessments |
Inspection Report
Re-Inspection
Census: 113
Capacity: 150
Deficiencies: 0
Dec 8, 2022
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 10/18/22 was performed to verify compliance with fire safety and licensure requirements.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 NFPA 101 Life Safety Code. The building is fully sprinklered except for a detached storage and repair shed.
Report Facts
Resident census: 113
Total capacity: 150
Resident sleeping rooms with battery operated smoke detectors: 59
Resident sleeping rooms with hard wired smoke detectors: 23
Total resident sleeping rooms: 82
Inspection Report
Complaint Investigation
Census: 114
Capacity: 114
Deficiencies: 0
Dec 6, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00395877.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00395877 was substantiated, but no deficiencies related to the allegations were cited.
Report Facts
Census Bed Type: 114
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 74
Census Payor Type - Other: 34
Inspection Report
Re-Inspection
Census: 160
Deficiencies: 0
Nov 10, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on September 28, 2022, including a PSR to the Investigation of Complaints IN00390169 and IN00389737 and the Residential survey completed on September 28, 2022.
Findings
American Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey and the PSR to the Investigation of Complaints IN00390169 and IN00389737.
Complaint Details
Complaint IN00390169 and Complaint IN00389737 were investigated and found to be corrected.
Report Facts
Census Bed Type - SNF/NF: 109
Census Bed Type - Residential: 51
Census Bed Type - Total: 160
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 73
Census Payor Type - Other: 32
Census Payor Type - Total: 109
Inspection Report
Life Safety
Census: 113
Capacity: 150
Deficiencies: 5
Oct 18, 2022
Visit Reason
The Indiana Department of Health conducted a Life Safety Code Recertification and State Licensure Survey on 10/18/2022 to assess compliance with 42 CFR 483.90(a) and NFPA 101 standards.
Findings
The facility was found not in compliance with several Life Safety Code requirements including emergency lighting testing, preventative maintenance of battery-operated smoke alarms, obstruction of portable fire extinguishers, inspection and maintenance of fire dampers, and use of prohibited portable space heaters. Corrective actions and plans of correction were submitted for each deficiency.
Severity Breakdown
SS=F: 3
SS=E: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure 14 of 14 battery backup emergency lights were tested monthly for 30 seconds as required. | SS=F |
| Failed to ensure documentation for preventative maintenance of 59 of 59 battery operated smoke alarms in resident rooms was complete. | SS=F |
| Failed to ensure 1 of 1 portable fire extinguishers in the lobby was installed and accessible in accordance with NFPA 10; extinguisher was obstructed by a walker and relocation chair. | SS=E |
| Failed to ensure 7 of 7 fire dampers were inspected and maintained at least every four years as required by NFPA 90A. | SS=F |
| Failed to ensure 1 of 1 portable space heater was not used within the facility, violating prohibition of portable space heaters in health care occupancies. | SS=E |
Report Facts
Certified beds: 150
Census: 113
Battery backup emergency lights: 14
Battery operated smoke alarms: 59
Portable fire extinguishers: 1
Fire dampers: 7
Portable space heaters: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gina Couch | Executive Director | Signed the inspection report and participated in exit conference |
| Maintenance Director | Outgoing and incoming Maintenance Directors acknowledged deficiencies and corrective actions related to emergency lighting, smoke alarms, fire extinguishers, fire dampers, and space heaters | |
| Facility Administrator | Participated in exit conference and discussions regarding deficiencies and corrective actions |
Inspection Report
Routine
Census: 50
Deficiencies: 20
Sep 28, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Complaints IN00390169 and IN00389737. This visit included a State Residential Licensure Survey.
Findings
The facility was found deficient in multiple areas including resident dignity, medication administration, call light functionality, environmental conditions, infection control, behavioral health services, and regulatory compliance related to transfers and medication management.
Complaint Details
Complaint IN00390169 - Substantiated. Federal/State deficiencies related to the allegations are cited at F686 and F694. Complaint IN00389737 - Unsubstantiated due to lack of evidence.
Severity Breakdown
SS=D: 16
SS=E: 2
Deficiencies (20)
| Description | Severity |
|---|---|
| Failed to promote dignity by not assuring cognitively impaired residents were fully dressed when in the common area for 2 of 3 residents reviewed for dignity. | SS=D |
| Failed to ensure a resident was determined clinically appropriate by the interdisciplinary team to self-administer medications for 1 of 1 residents observed with medications left at bedside. | SS=D |
| Failed to assure a call light was within reach of a resident for 1 of 2 residents reviewed for call lights in reach. | SS=D |
| Failed to provide a clean, sanitary, and homelike environment by not maintaining walls in good repair and in clean condition for 5 of 8 residents reviewed for environmental concerns and failed to provide clean linen for 1 of 1 residents reviewed for catheter care. | SS=D |
| Failed to provide evidence of a thoroughly investigated reportable incident for 1 of 2 reportable incidents reviewed. | SS=D |
| Failed to provide a transfer form to the receiving facility for 1 of 1 resident reviewed for hospitalization. | SS=D |
| Failed to provide the necessary services to maintain good grooming, oral care, personal hygiene, and providing timely assistance with dressing in street clothes for residents who are unable to carry out activities of daily living for 5 of 6 residents reviewed for ADL and 1 of 1 residents reviewed for tube feeding. | SS=E |
| Failed to ensure residents who are bedfast or chairfast have their body position changed every 2 hours as ordered for 3 of 3 residents reviewed for positioning/mobility; failed to timely schedule a neurology appointment and administer medications, as ordered, by the physician for 1 of 1 residents reviewed for ADL decline and 3 of 6 residents reviewed for unnecessary medications. | SS=E |
| Failed to provide care, consistent with professional standards of practice, to prevent a stage II pressure ulcer from developing and failed to administer Vitamin C and Zinc, as ordered, to 2 of 2 residents reviewed for pressure ulcers. | SS=D |
| Failed to assure hot water temperatures were at safe levels, at point of use, with the potential to affect 15 cognitively impaired and ambulatory residents of the 91 residents who reside in the 200, 300, and 400 halls at the facility. | SS=D |
| Failed to ensure staff provided catheter care, monitored of outputs and timely obtained a culture and sensitivity urinalysis as ordered for 1 of 1 residents reviewed for catheter. | SS=D |
| Failed to ensure assessment, flushing, and dressing change to a resident's PICC for 1 of 1 resident reviewed for death. | SS=D |
| Failed to administer a resident's medication, as ordered, to 1 of 1 resident reviewed for dialysis. | SS=D |
| Failed to ensure accurate and complete reconciliation of controlled medications for 1 of 2 reportable incidents reviewed. | SS=D |
| Failed to timely act upon a pharmacist's recommendation on the monthly medication regimen review for 1 of 6 residents reviewed for unnecessary medications. | SS=D |
| Failed to attempt non-pharmacological interventions prior to initiating an anti-psychotic medication for 1 of 1 resident reviewed for behaviors. | SS=D |
| Failed to ensure medications stored in the medication carts were labeled with the residents' names, dated with open dates, not expired, and discharged residents' medications removed for 1 of 3 medications carts observed. | SS=D |
| Failed to assure a bathroom call light was functional for 2 of 8 residents reviewed for environmental concerns. | SS=D |
| Failed to ensure a resident/resident representative was given a written notification of an intrafacility transfer at least two days before her relocation nor did the facility ensure a copy of the notice was in the resident's clinical record for 1 of 2 residents reviewed for transfer/discharge rights. | SS=D |
| Failed to properly prevent and/or contain COVID-19 by not ensuring staff members were screened prior to entry to the facility for symptoms, test results, and exposure to COVID-19. | SS=D |
Report Facts
Survey dates: 7
Census: 50
Residents on medication refusal: 7
Residents with hot water temperature above 120F: 3
Residents observed not turned every 2 hours: 3
Residents with missing catheter care: 1
Residents with medication reconciliation issues: 1
Residents with delayed psychiatric evaluation: 1
Residents with non-functional call light: 2
Residents with missing transfer notice: 1
Staff missing COVID-19 screening: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 4 | Certified Nursing Assistant | Assisted Resident 50 who was not fully dressed |
| QMA 2 | Qualified Medication Aide | Observed Resident 50 and Resident 264 clothing issues |
| Director of Nursing | Provided multiple interviews and policies related to deficiencies | |
| LPN 14 | Licensed Practical Nurse | Named in medication diversion investigation |
| QMA 15 | Qualified Medication Aide | Named in medication diversion investigation |
| Maintenance Supervisor | Checked water temperatures and repaired call lights | |
| CNA 12 | Certified Nursing Assistant | Provided catheter care and shaving assistance |
| UM 7 | Unit Manager | Provided interviews related to medication administration and dialysis |
| SSD | Social Services Director | Provided interviews related to behavioral health and transfers |
| RN 28 | Registered Nurse | Interviewed about medication cart storage |
| LPN 27 | Licensed Practical Nurse | Interviewed about medication cart storage |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 111
Deficiencies: 0
Aug 18, 2022
Visit Reason
This visit was conducted for the investigation of three complaints: IN00386621, IN00387363, and IN00387395.
Findings
All three complaints were substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00386621 - Substantiated with no deficiencies cited. Complaint IN00387363 - Substantiated with no deficiencies cited. Complaint IN00387395 - Substantiated with no deficiencies cited.
Report Facts
Medicare census: 6
Medicaid census: 66
Other payor census: 39
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