Inspection Reports for Evergreen Village at Bloomington

IN, 3607 S Heirloom Dr, Bloomington, IN 47401, United States

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Inspection Report Complaint Investigation Census: 113 Deficiencies: 0 May 1, 2025
Visit Reason
This visit was for a State Residential Licensure Survey and included the Investigation of Complaint IN00458525.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the State Residential Licensure Survey and the complaint investigation.
Complaint Details
Complaint IN00458525 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Residential Census: 113
Inspection Report Renewal Census: 119 Deficiencies: 2 Jul 25, 2024
Visit Reason
This visit was for a State Residential Licensure Survey conducted on July 24 and 25, 2024, to assess compliance with state regulations for Evergreen Village at Bloomington.
Findings
The facility was found noncompliant with requirements related to posting of resident rights information and accessibility of the facility survey book. Specifically, signage with important contact information was posted too high to be easily viewed by residents, and the survey book was not readily accessible or clearly located for residents.
Deficiencies (2)
Description
Failure to ensure known addresses and telephone numbers of relevant agencies were posted in an area easily accessible to residents.
Failure to ensure the results of the most recent annual survey, plan of correction, and subsequent surveys were in an identified location accessible to residents.
Report Facts
Residential Census: 119
Employees Mentioned
NameTitleContext
Nichole McNallyExecutive DirectorSigned the report as the facility representative
Inspection Report Complaint Investigation Census: 113 Deficiencies: 0 May 21, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00433797.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Complaint Details
Complaint IN00433797 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Residential Census: 113
Inspection Report Complaint Investigation Census: 114 Deficiencies: 1 Dec 7, 2023
Visit Reason
The visit was conducted for the investigation of Complaint IN00418647 regarding allegations of medication loss and theft.
Findings
The facility failed to exercise reasonable care for the protection of residents' medication from loss and theft for 2 of 2 residents reviewed. Controlled substance logs were incomplete and narcotic medications were missing.
Complaint Details
Complaint IN00418647 was substantiated with state deficiencies cited at R64 related to medication loss and theft.
Deficiencies (1)
Description
Failed to exercise reasonable care for the protection of residents' medication from loss and theft for 2 of 2 residents reviewed. Controlled substance logs were not completed and narcotic medications were missing.
Report Facts
Residential Census: 114 Controlled Substance Log audit frequency: 3 Controlled Substance Log audit frequency: 2 Controlled Substance Log audit frequency: 1 Compliance date: Dec 27, 2023
Employees Mentioned
NameTitleContext
Josh DoddsExecutive DirectorSigned the report
Director of NursingInterviewed regarding missing medications for Resident B and Resident C
LPN 1Licensed Practical NurseObserved signing Controlled Substance Log during medication room observation
Inspection Report Complaint Investigation Census: 107 Deficiencies: 0 Sep 20, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00415735.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Complaint Details
Complaint IN00415735 was investigated and found to have no deficiencies related to the allegations.
Inspection Report Renewal Census: 115 Deficiencies: 0 Aug 16, 2023
Visit Reason
This visit was for a State Residential Licensure Survey conducted on August 15 and 16, 2023.
Findings
Evergreen Village At Bloomington was found to be in compliance with 410 IAC 16.2-5 in regard to the State Residential Licensure Survey.
Inspection Report Complaint Investigation Census: 113 Deficiencies: 0 Jun 22, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00410963.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Complaint Details
Complaint IN00410963 was investigated and found to have no deficiencies related to the allegations.
Inspection Report Complaint Investigation Census: 115 Deficiencies: 0 May 10, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00407573.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Complaint Details
Investigation of Complaint IN00407573 found no deficiencies related to the allegations.
Inspection Report Census: 115 Deficiencies: 0 Nov 11, 2022
Visit Reason
This visit was for a Quality Assurance Walk Through Survey.
Findings
Evergreen Village At Bloomington was found to be in compliance with 410 IAC 16.2-5 in regard to the Quality Assurance Walk Through Survey.
Inspection Report Census: 114 Deficiencies: 0 Nov 10, 2022
Visit Reason
This visit was for a State Residential Licensure Survey conducted on November 9 and 10, 2022.
Findings
Evergreen Village At Bloomington was found to be in compliance with 410 IAC 16.2-5 in regard to the State Residential Licensure Survey.
Inspection Report Complaint Investigation Census: 116 Deficiencies: 1 Sep 28, 2022
Visit Reason
This visit was for the investigation of Complaint IN00385338, which was substantiated with state deficiencies related to the allegations cited at R64.
Findings
The facility failed to properly secure medications for one of three residents reviewed (Resident C), resulting in a medication discrepancy where a narcotic medication was unaccounted for and replaced with a non-narcotic pill. The QMA responsible was terminated, and systemic corrective actions including audits and narcotic counts were implemented.
Complaint Details
Complaint IN00385338 was substantiated. The facility failed to properly secure medications for Resident C, leading to a narcotic medication discrepancy and subsequent termination of QMA 1.
Deficiencies (1)
Description
Facility failed to properly secure medications for Resident C, resulting in a narcotic medication discrepancy.
Report Facts
Residential Census: 116
Employees Mentioned
NameTitleContext
QMA 1Qualified Medication AideTerminated based on findings related to medication discrepancy
QMA 2Qualified Nursing AssistantReported the torn medication care pack for Resident C
DONDirector of NursingProvided facility policy and oversaw corrective actions and audits

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