Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 5
Apr 3, 2025
Visit Reason
This visit was for a State Residential Licensure Survey and included the Investigation of Complaint IN00455383.
Findings
The facility was found deficient in multiple areas including failure to implement effective fire safety training for staff, failure to maintain a residential environment free from odors, unsanitary food storage and preparation practices, lack of timely pharmacy medication reviews, and failure to ensure medication carts were locked when not in use.
Complaint Details
Complaint IN00455383 was investigated and state deficiencies related to the allegation were cited at R0144.
Deficiencies (5)
| Description |
|---|
| Failed to implement and maintain an effective fire safety training program for all facility staff for 1 of 5 staff reviewed. |
| Failed to ensure the residential environment was free from odors for 1 of 6 hallways observed (strong urine odor in north first floor hallway). |
| Failed to ensure food was stored and prepared in a sanitary manner related to labeling, dating, disposing of expired foods and safe thawing techniques affecting all 49 residents. |
| Failed to ensure pharmacy medication reviews were completed every 60 days for 7 of 7 residents reviewed. |
| Failed to ensure the medication cart was locked when not in use for 1 of 2 medication carts reviewed. |
Report Facts
Residents present: 49
Staff reviewed for fire safety training: 5
Hallways observed for odors: 6
Residents affected by food service deficiency: 49
Residents reviewed for pharmacy medication reviews: 7
Medication carts reviewed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Leigh A Keirn | RN, RCA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Employee 3 | Staff member who lacked fire safety training and was interviewed regarding fire safety procedures | |
| Interim Director of Nursing | Interim Director of Nursing | Provided policy information and interviews related to fire safety and pharmacy medication reviews |
| Administrator | Administrator | Provided policy information related to medication administration and pharmacy medication reviews |
| QMA 2 | Interviewed regarding medication cart locking practices |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 0
Jan 29, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00448587.
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 IN00448587 was investigated and found to have no deficiencies related to the allegations.
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 0
Sep 3, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00436456.
Findings
No deficiencies related to the allegations in Complaint IN00436456 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Complaint Details
Complaint IN00436456 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Residential Census: 50
Inspection Report
Renewal
Deficiencies: 1
Jul 9, 2024
Visit Reason
This was an offsite Licensure Investigation Survey conducted to review the facility's compliance with license renewal requirements.
Findings
The facility failed to submit a timely renewal application for their residential care license before the expiration date of June 30, 2024. The renewal application and payment were postmarked July 3, 2024, which did not meet the required 45-day prior submission rule.
Deficiencies (1)
| Description |
|---|
| Failure to submit a renewal application at least 45 days prior to license expiration. |
Report Facts
Days prior to license expiration for renewal application: 45
License expiration date: Jun 30, 2024
Renewal application postmark date: Jul 3, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Leigh Keirn | RN, RCA | Signed as Laboratory Director or Provider/Supplier Representative |
Inspection Report
Annual Inspection
Census: 50
Deficiencies: 6
May 9, 2024
Visit Reason
This visit was for a State Residential Licensure Survey, including the investigation of two complaints (IN00432408 and IN00432035).
Findings
No deficiencies were cited related to the complaints. The facility was found noncompliant in several areas including failure to conduct twelve fire drills annually, failure to document semiannual resident weights, improper food storage and handling, unsecured medications for a self-medicating resident, and failure to refer and coordinate mental health services for a resident with major depressive disorder.
Complaint Details
Complaint IN00432408 and IN00432035 were investigated with no deficiencies related to the allegations cited.
Deficiencies (6)
| Description |
|---|
| Failed to ensure twelve fire drills were conducted annually as required. |
| Failed to ensure weights were obtained and documented semiannually for 1 of 7 residents reviewed. |
| Failed to ensure food was stored in a sanitary manner, including outdated foods, dented cans, unclean utensils, and improper beverage handling. |
| Failed to secure medications appropriately in a resident's room for a resident who self-administered medications. |
| Failed to refer a resident with major mental illness for mental health services. |
| Failed to develop a comprehensive care plan in coordination with mental health service providers for a resident with major depressive disorder. |
Report Facts
Residents present: 50
Fire drills required: 12
Residents reviewed for weight documentation: 7
Residents reviewed for mental health services: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Leigh Keirn | Laboratory Director or Provider/Supplier Representative | Signed the inspection report |
| Cook 4 | Interviewed regarding food storage and handling deficiencies | |
| CNA 2 | Interviewed regarding beverage handling | |
| Executive Director | Provided policies and interviews related to fire drills and food safety | |
| Director of Nursing | Interviewed regarding weight documentation, medication storage, and mental health service referrals | |
| QMA 4 | Interviewed regarding medication storage | |
| Resident 4 | Resident reviewed for weight documentation deficiency | |
| Resident 6 | Resident reviewed for medication storage deficiency | |
| Resident C | Resident reviewed for mental health service deficiencies | |
| Administrator | Provided policy on self-administration of medications | |
| Maintenance Director | Interviewed regarding fire drill documentation |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 0
Feb 21, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00425783.
Findings
No deficiencies related to the allegations in Complaint IN00425783 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaint IN00425783 found no deficiencies related to the allegations; the complaint was not substantiated.
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 0
Nov 13, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00420498 and IN00418375.
Findings
No deficiencies related to the allegations in complaints IN00420498 and IN00418375 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Complaint Details
Complaint IN00420498 and IN00418375 were investigated and found to have no deficiencies related to the allegations.
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 0
Sep 6, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00416430.
Findings
No deficiencies related to the allegations in Complaint IN00416430 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Complaint Details
Complaint IN00416430 was investigated and found to have no deficiencies related to the allegations.
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Jul 18, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00412721 and IN00412445 related to bedbug infestations at the facility.
Findings
The facility failed to ensure an appropriate pest control program to prevent bedbugs for 2 residents with active bedbugs observed. Multiple rooms had bedbug activity, and live bedbugs were observed during the inspection. The facility was on its fourth pest control company for treatment and had ongoing issues with bedbug infestations.
Complaint Details
The investigation was triggered by complaints IN00412721 and IN00412445. State deficiencies related to these allegations were cited at R0149.
Deficiencies (1)
| Description |
|---|
| Failed to ensure an appropriate pest control program was followed to prevent bedbugs for 2 residents with active bedbugs observed. |
Report Facts
Residential Census: 55
Bedbug treatments and inspections: 18
Rooms with bedbug activity: 10
Live bedbugs observed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Leigh Keirn | Director of Nursing | Provided information about pest control efforts and facility policy; named in findings regarding bedbug treatment. |
| CNA 1 | Interviewed about rooms with bedbug activity and observations. | |
| QMA 2 | Interviewed about rooms with bedbug activity and observations. | |
| Maintenance Director | Interviewed regarding pest control contract and response to bedbug identification. |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Jun 5, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00409284 regarding allegations of abuse at the facility.
Findings
The facility failed to implement their policy related to investigating and reporting allegations of abuse for one resident (Resident B). The Administrator did not report the abuse allegation to the State Agency and no investigation was conducted despite multiple reports and statements from the resident and staff.
Complaint Details
Complaint IN00409284 was substantiated with findings that the facility did not properly investigate or report abuse allegations involving Resident B. The Administrator and Director of Nursing failed to notify the State Agency and no investigation was conducted despite multiple reports and statements.
Deficiencies (1)
| Description |
|---|
| Failure to report and investigate allegations of abuse as required by policy and regulation. |
Report Facts
Residential Census: 55
Dates CNA 2 worked: 3
Date of complaint statement: May 19, 2023
Date survey completed: Jun 6, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Otis | Executive Director | Signed the report as the facility representative |
| Certified Nursing Assistant 2 | Named in abuse allegation involving Resident B | |
| Assistant Director of Nursing | Assistant Director of Nursing | Reported abuse allegations and gave complaint to Director of Nursing |
| Director of Nursing | Director of Nursing | Did not notify Administrator or State Agency of abuse allegations |
| Qualified Medication Aid 3 | Qualified Medication Aid | Reported abuse allegations to Director of Nursing |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 13
May 11, 2023
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaints IN00395874, IN00399909, IN00407327, and IN00407738.
Findings
The facility was found deficient in multiple areas including staffing with CPR certification, tuberculosis skin testing, medication administration errors, incomplete resident evaluations and service plans, sanitation issues in the kitchen, missing diet orders, incomplete emergency files, and failure to follow infection control practices during medication administration.
Complaint Details
Complaint IN00395874 - No deficiencies related to the allegations cited. Complaint IN00399909 - No deficiencies related to the allegations cited. Complaint IN00407327 - State deficiencies related to the allegations are cited at R0297. Complaint IN00407738 - No deficiencies related to the allegations cited.
Deficiencies (13)
| Description |
|---|
| Failed to ensure at least one staff member on each shift had current CPR and First Aid certification for 16 of 21 shifts. |
| Failed to ensure 4 of 8 personnel files contained documentation of two-step Mantoux tuberculosis skin testing. |
| Failed to ensure kitchen utensils and equipment were maintained in a clean manner; expired test strips used to test disinfectant levels. |
| Failed to ensure resident weights were obtained and documented for 5 of 7 residents reviewed and failed to complete self-administration medication evaluation for 1 resident. |
| Failed to ensure service plans were signed by residents or representatives for 2 of 7 residents reviewed. |
| Failed to ensure authorizations from licensed nurses for PRN medications administered by QMAs were documented for 2 of 7 residents. |
| Failed to provide pasteurized eggs in the kitchen. |
| Failed to ensure a diet order was written by the physician for 1 of 7 residents. |
| Failed to ensure medications were administered as ordered for 2 of 7 residents reviewed. |
| Failed to complete an accurate Resident Emergency File for 1 of 7 residents. |
| Failed to ensure annual health statements were completed for 5 of 7 residents reviewed. |
| Failed to ensure Mantoux testing was completed upon admission for 3 of 7 residents reviewed. |
| Failed to follow infection control practices during medication pass for 1 of 2 nursing staff observed. |
Report Facts
Shifts without CPR certified staff: 16
Residents affected: 55
Personnel files missing two-step Mantoux testing: 4
Residents missing documented weights: 5
Residents missing signed service plans: 2
Residents with undocumented PRN medication authorization: 2
Residents missing annual health statements: 5
Residents missing Mantoux testing on admission: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Leigh Brown | Director of Nursing | Interviewed regarding CPR certification, tuberculosis testing, medication administration, and other deficiencies. |
| QMA 13 | Qualified Medication Aide | Observed failing to wash hands during medication pass and handling dropped pills with bare hands. |
| QMA 14 | Qualified Medication Aide | Interviewed regarding missing medication (Colace) and medication cart observations. |
| Director of Nursing | Provided multiple interviews and explanations regarding deficiencies and corrective actions. | |
| Executive Director | Interviewed regarding kitchen sanitation and policies. | |
| Maintenance Director | Interviewed regarding dishwasher and kitchen equipment. |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 0
Sep 21, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00389739.
Findings
Complaint IN00389739 was substantiated, but no State Residential Findings 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
Complaint IN00389739 was substantiated; however, no state residential findings related to the allegations were cited.
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