Inspection Report
Renewal
Census: 24
Deficiencies: 0
Nov 22, 2024
Visit Reason
This visit was for a State Residential Licensure Survey conducted on November 21 and 22, 2024.
Findings
Brookdale Bloomington was found to be in compliance with 410 IAC 16.2-5 in regard to the State Residential Licensure Survey.
Inspection Report
Renewal
Census: 26
Deficiencies: 5
Dec 19, 2023
Visit Reason
This visit was for a State Residential Licensure Survey conducted on December 19 and 20, 2023, to assess compliance with state regulations.
Findings
The facility was found deficient in several areas including failure to post the most recent State survey results, incomplete employee reference checks, lack of staff with current CPR and first aid certification onsite at all times, incomplete tuberculosis skin testing for employees, and improper labeling and dating of pre-prepared beverages and expired food items in the kitchen.
Deficiencies (5)
| Description |
|---|
| Failure to post the most recent State survey results and notice of availability for 2 of 2 days of the survey. |
| Failure to ensure references were completed for 1 of 5 employee files reviewed (QMA). |
| Failure to ensure a staff member with current CPR and first aid certification worked onsite at all times for 7 of 7 days reviewed. |
| Failure to obtain a 2-step tuberculin skin test for 1 of 5 sampled employees (Cook 1). |
| Failure to ensure pre-prepared beverages were labeled and dated and expired half and half was discarded on or before the use-by date for 2 of 2 days of the survey. |
Report Facts
Residential Census: 26
Deficiency completion date: Jan 11, 2024
Deficiency completion date: Jan 19, 2024
Deficiency completion date: Feb 5, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Meghan Berinati | Administrator | Named as Administrator responsible for facility management and involved in interviews and plan of correction |
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 1
Sep 12, 2023
Visit Reason
This visit was conducted for the investigation of three complaints (IN00411847, IN00413875, and IN00415113). Complaints IN00411847 and IN00413875 had no deficiencies related to the allegations, while complaint IN00415113 resulted in state deficiencies being cited.
Findings
The facility failed to protect resident property from theft for 1 of 3 residents reviewed. A licensed practical nurse (LPN 1) was witnessed taking medications from the residents' supply on two separate days. The LPN admitted to taking metoprolol and replacing it with her own medication. The LPN was suspended and subsequently terminated. The facility implemented corrective actions including staff re-education and monitoring to prevent recurrence.
Complaint Details
Complaint IN00415113 was substantiated with state deficiencies cited. Complaints IN00411847 and IN00413875 had no deficiencies related to the allegations.
Deficiencies (1)
| Description |
|---|
| Failed to protect residents' property from theft; staff witnessed a nurse taking medications from residents' supply on two separate days. |
Report Facts
Residential Census: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tonia Lea Davis | Executive Director | Signed as Laboratory Director's or Provider/Supplier Representative |
| LPN 1 | Nurse witnessed taking medications from residents' supply and subsequently terminated | |
| QMA 1 | Qualified Medication Aide | Witnessed LPN 1 taking medication and reported the incident |
| QMA 2 | Qualified Medication Aide | Witnessed LPN 1 taking medications and reported the incident |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 0
Jun 29, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00411703.
Findings
No deficiencies related to the allegations are cited. Brookdale Bloomington was found to be in compliance with 410 IAC 16.2-5 in regard to the Investigation of Complaint IN00411703.
Complaint Details
Complaint IN00411703 - No deficiencies related to the allegations are cited.
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 5
Feb 2, 2023
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaints IN00395317 and IN00395454.
Findings
The facility was found noncompliant in several areas including failure to post residents' rights and contact information in accessible areas, insufficient fire drills and lack of local fire department involvement, absence of staff with current CPR and First Aid certification on all shifts, and unlabeled and undated pre-prepared beverages in the kitchen.
Complaint Details
Complaint IN00395317 and IN00395454 were investigated and found unsubstantiated due to lack of evidence.
Deficiencies (5)
| Description |
|---|
| Failure to ensure a copy of the residents' rights was available in a publicly accessible area for all residents. |
| Failure to post known addresses and telephone numbers of regulatory and protective agencies in an accessible area for residents. |
| Failure to conduct at least 12 fire drills annually and to involve the local fire department in drills at least every 6 months. |
| Failure to ensure a minimum of one employee with current CPR and First Aid certification on each shift for the days reviewed. |
| Failure to label and date pre-prepared beverages stored in the resident dining area refrigerator. |
Report Facts
Residents present: 33
Fire drills conducted: 9
Fire drills missed: 3
Inspection dates: February 2 and 3, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Woodcox | Area Director | Signed the report |
| Business Office Manager | Provided facility policies and interview information related to residents' rights and certifications | |
| Maintenance Supervisor | Interviewed regarding fire drills and local fire department involvement | |
| Dietary Manager | Interviewed regarding labeling and dating of pre-prepared beverages |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 0
Oct 25, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00387524 and IN00389940.
Findings
Both complaints IN00387524 and IN00389940 were found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations regarding these complaints.
Complaint Details
Complaint IN00387524 - Unsubstantiated due to lack of evidence. Complaint IN00389940 - Unsubstantiated due to lack of evidence.
Inspection Report
Follow-Up
Census: 40
Deficiencies: 0
Aug 23, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to investigate complaints IN00385412, IN00385605, and IN00385872 completed on July 22, 2022.
Findings
The facility was found to be in compliance with 410 IAC 16.2-5 regarding the PSR to the investigation of the three complaints, all of which were corrected.
Complaint Details
Complaints IN00385412, IN00385605, and IN00385872 were investigated and found to be corrected.
Report Facts
Residential Census: 40
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