Deficiencies per Year
12
9
6
3
0
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 3
Jun 17, 2025
Visit Reason
This visit was for the investigation of complaints IN00461573 and IN00458918. Complaint IN00461573 had no deficiencies cited, while Complaint IN00458918 resulted in state deficiencies related to allegations cited at R0052, R0090, and R0243.
Findings
The facility failed to prevent resident neglect when a staff member refused to administer scheduled pain medication due to the resident declining to use the bathroom. The facility also failed to ensure timely reporting of the neglect allegation to the State Agency and failed to document medication administration accurately. The facility self-reported the incident and took corrective actions including staff education and audits.
Complaint Details
Complaint IN00461573 - No deficiencies related to the allegations are cited. Complaint IN00458918 - Deficiencies cited related to neglect and medication administration issues. The neglect incident involved QMA 1 withholding pain medication from Resident B because the resident refused to get up. The incident was reported late to the State Agency. Medication administration documentation was inaccurate as QMA 1 documented giving medication that was actually administered by QMA 2.
Deficiencies (3)
| Description |
|---|
| Failed to prevent resident neglect when a staff member refused to administer scheduled pain medication due to the resident declining to use the bathroom (Resident B and QMA 1). |
| Failed to ensure an allegation of neglect was reported timely to the State Agency. |
| Failed to ensure the administration of medication was documented accurately by the person who prepared the medication (Resident B, QMA 1, and QMA 2). |
Report Facts
Residents present: 26
Medication scheduled times: 4
Hours delay in reporting: 28.17
Incident time: 5.09
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daphne New | Administrator | Signed report and involved in reporting incident to state agency |
| Director of Nursing (DON) | Received incident report from QMA 2, involved in reporting and interviews | |
| QMA 1 | Staff member who withheld medication and documented administration inaccurately | |
| QMA 2 | Staff member who reported incident to DON and administered medication |
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 1
Apr 3, 2025
Visit Reason
This visit was conducted for the investigation of complaint IN00456210 regarding medication administration practices at Heritage Assisted Living of Yorktown.
Findings
The facility failed to ensure proper oversight of qualified medication aides (QMAs) administering PRN medications for 3 of 4 residents reviewed and failed to follow physician orders regarding administration times for 1 resident. Documentation was lacking for nurse authorization and co-signature for PRN medication administration.
Complaint Details
Complaint IN00456210 was substantiated with state deficiencies cited related to medication administration oversight and adherence to physician orders.
Deficiencies (1)
| Description |
|---|
| Failed to ensure oversight of a QMA when administering PRN medication for 3 of 4 residents and failed to follow physician's orders regarding administration times for PRN medication for 1 resident. |
Report Facts
Residential Census: 26
Dates of medication administration errors: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daphne New | Administrator | Signed the report and identified as facility administrator |
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 4
Feb 7, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00452576, IN00452327, IN00451696, and IN00448891 at Heritage Assisted Living of Yorktown.
Findings
The facility was found deficient in maintaining the physical environment, providing adequate heating, maintaining accurate medication records, and ensuring medications and invasive devices were administered by qualified personnel. Some complaints were substantiated with state deficiencies cited, while others had no deficiencies related to the allegations.
Complaint Details
Complaint IN00452576 - No deficiencies related to the allegations.
Complaint IN00452327 - State deficiencies cited at R0148, R0178, R0243, and R0245.
Complaint IN00451696 - State deficiencies cited at R0243.
Complaint IN00448891 - No deficiencies related to the allegations.
Deficiencies (4)
| Description |
|---|
| Failed to maintain the physical building in good repair for 1 of 4 residents reviewed for physical environment (Resident E). |
| Failed to provide an adequate heating system to provide comfortable temperatures for 1 of 3 residents reviewed for environment (Resident D). |
| Failed to maintain complete and accurate records of medications administered to 1 of 3 residents reviewed for medication administration (Resident B). |
| Failed to ensure injectable medication(s) and invasive medical device(s) were administered/applied by qualified personnel for 2 of 4 residents reviewed for medication administration (Residents B and D). |
Report Facts
Residents affected: 21
Rooms needing door frame repair: 35
Temperature checks frequency: 3
Medication administration audit frequency: 8
Medication administration audit frequency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Catron N Allison | RDCS | Signed the report as Laboratory Director or Provider/Supplier Representative. |
| QMA 6 | Qualified Medication Aide | Named in medication administration deficiency for administering injectable medications and applying invasive devices without certification. |
| Director of Maintenance | Interviewed regarding physical plant deficiencies and maintenance issues. | |
| Director of Nursing | DON | Interviewed regarding medication administration deficiencies and staff education. |
Inspection Report
Follow-Up
Census: 29
Deficiencies: 0
Dec 2, 2024
Visit Reason
This visit was for the Post Revisit Survey (PSR) to the Investigation of Complaint IN00444035 completed on October 9, 2024.
Findings
Heritage Assisted Living of Yorktown was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to the Investigation of Complaint IN00444035. The complaint was corrected.
Complaint Details
Complaint IN00444035 - Corrected.
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 2
Oct 9, 2024
Visit Reason
This visit was for the investigation of complaints IN00444035, IN00443192, and IN00441171. The investigation focused on allegations related to resident neglect and clinical record maintenance.
Findings
The facility failed to prevent neglect of a cognitively impaired resident who eloped from a secured memory care unit due to inadequate supervision and security, resulting in the resident being found alone off facility property for over an hour. Additionally, the facility failed to maintain and provide staff access to accurate and up-to-date clinical records for residents, affecting current and discharged residents.
Complaint Details
Complaint IN00444035 had state deficiencies related to the allegations cited at R0052 and R0349. Complaints IN00443192 and IN00441171 had no deficiencies related to the allegations cited.
Deficiencies (2)
| Description |
|---|
| Failed to prevent neglect of a cognitively impaired resident who eloped from a secured memory care unit due to failure to provide supervision and ensure a secure environment. |
| Failed to maintain and provide staff access to accurate and up-to-date clinical records for the care of facility residents. |
Report Facts
Residential Census: 30
Duration resident was missing: 105
Distance resident found from building: 450
Distance resident found from pond: 150
Distance resident found from State Road 32: 200
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robin Huston | Executive Director | Signed the report as Executive Director. |
| Director of Nursing | Interviewed regarding lack of access to electronic medical records and facility policies. | |
| Maintenance Director | Reviewed security video footage and assisted with resident search. | |
| QMA 5 | Staff member on duty during the elopement incident; observed on video not supervising resident adequately. | |
| QMA 2 | Interviewed about staff education on phone use and resident wandering history. | |
| CNA 3 | Interviewed about resident's history of wandering and door security practices. | |
| Assistant Director of Nursing (ADON) | Involved in search for missing resident and reported incident to police. |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 10
Aug 7, 2024
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaint IN00439462.
Findings
No deficiencies were cited related to the complaint allegations. Several deficiencies were cited including failure to post survey results publicly, incomplete fire drills on each shift quarterly, failure to notify the Indiana Department of Health about operational secured Alzheimer's/dementia units, inadequate dementia training for staff, lack of CPR and first aid certification for some shifts, expired CNA certification, lack of job-specific orientation, and unsigned resident service plans.
Complaint Details
Complaint IN00439462 was investigated with no deficiencies related to the allegations cited.
Deficiencies (10)
| Description |
|---|
| Failed to provide posted and readily accessible survey results for review by the public and residents. |
| Failed to ensure a fire drill was completed on each shift quarterly to ensure resident safety in the event of a fire emergency. |
| Failed to notify the Indiana Department of Health when each secured Alzheimer's/dementia unit became operational for 2 of 2 units. |
| Failed to ensure proper qualifications were maintained by the Dementia Unit Director who provided oversight for 2 secured Alzheimer's/dementia units. |
| Failed to ensure a nursing staff member was CPR certified for 5 of 21 shifts and first aid certified for 16 of 21 shifts reviewed. |
| Failed to ensure a Certified Nursing Assistant provided care with an active certification; CNA certification expired. |
| Failed to provide required education regarding care of residents with dementia for staff working in a dementia care facility for 5 of 5 employees reviewed. |
| Failed to administer TB skin testing prior to starting employment for 1 of 5 staff reviewed (DON). |
| Failed to provide job specific orientation to employees hired to work at the facility for 5 of 5 employee files reviewed. |
| Failed to ensure service plans were signed by a resident and/or their representative for 6 of 7 clinical records reviewed. |
Report Facts
Residential Census: 29
Shifts without CPR certification: 5
Shifts without first aid certification: 16
Residents affected by dementia unit oversight deficiency: 16
Residents with unsigned service plans: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Collins | Executive Director | Named as Executive Director and involved in monitoring compliance and corrective actions. |
| Director of Nursing | Director of Nursing | Identified as Dementia Care Coordinator and involved in deficiencies related to dementia training and TB testing. |
| Administrator | Interviewed regarding survey results posting, fire drills, and staff training. | |
| Administrator in Training | AIT | Interviewed regarding secured Alzheimer's/dementia units operational dates. |
| Maintenance Manager | Interviewed regarding fire drill documentation and compliance. | |
| CNA 6 | Certified Nursing Assistant | Had expired certification and was removed from call list until recertified. |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 0
Jul 18, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00437638.
Findings
No deficiencies related to the allegations in Complaint IN00437638 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Complaint Details
Complaint IN00437638 was investigated and found to have no deficiencies related to the allegations.
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 1
Jun 14, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00432070 and IN00436620 at Heritage Assisted Living of Yorktown.
Findings
The facility failed to ensure criminal history background checks for 7 out of 7 employees were performed in accordance with state regulation requirements, resulting in the employment of an unlicensed dietary employee with a felony conviction. No residents were affected by the cited deficiency, but all residents have the potential to be affected.
Complaint Details
Complaint IN00432070 resulted in state deficiencies related to the allegations cited at R0116. Complaint IN00436620 had no state residential findings related to the allegations.
Deficiencies (1)
| Description |
|---|
| Failed to ensure criminal history background checks for 7 out of 7 employees were performed in accordance with state regulation requirements. |
Report Facts
Employees with incomplete background checks: 7
Residential Census: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Wiley | RDCS | Laboratory Director's or Provider/Supplier Representative's signature on the report. |
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 2
Apr 1, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00430311 regarding allegations of misappropriation of resident property and failure to report medication diversion.
Findings
The facility failed to prevent the misappropriation of narcotic medications for one resident and failed to report the incident to appropriate state agencies in a timely manner. An investigation revealed missing narcotic medications and procedural failures in narcotic counts and reporting.
Complaint Details
Complaint IN00430311 was substantiated with state deficiencies cited at R0064 and R0090 related to misappropriation of resident property and failure to timely report medication diversion.
Deficiencies (2)
| Description |
|---|
| Failed to prevent misappropriation of resident property as evidenced by missing narcotic medications for Resident B. |
| Failed to report medication diversion allegations to appropriate state agencies within required timeframes. |
Report Facts
Residents reviewed for misappropriation: 3
Resident census: 23
Date narcotic order: Nov 28, 2023
Date narcotic box missing: Mar 8, 2024
Date report submitted: Mar 11, 2024
Plan of correction completion date: Apr 20, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Fenton | Administrator in Training | Provided interviews and policy information related to the investigation |
| LPN 2 | Interviewed regarding narcotic counts and missing medication box | |
| QMA 1 | Interviewed regarding narcotic counts and medication box absence | |
| LPN 4 | Interviewed regarding narcotic counts and medication box presence | |
| DON | Director of Nursing | Interviewed about narcotic counts, medication handling, and reporting delays |
| Regional Clinical Director | Involved in medication counts and oversight |
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 3
Mar 10, 2024
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00455204, IN00454796, IN00454482, IN00453997, IN00453923, IN00453810, IN00453578, IN00453610, and IN00453358) at Heritage Assisted Living of Yorktown.
Findings
The facility was found deficient in tuberculosis testing for new employees, ensuring cognitively impaired residents had a method to summon staff, and maintaining complete and accurate clinical records related to an undocumented fall. Some complaints had no deficiencies related to the allegations, while others resulted in cited deficiencies.
Complaint Details
The investigation involved multiple complaints. Deficiencies were cited related to complaints IN00455204 (tuberculosis testing), IN00453997 (clinical record documentation of fall), and unrelated deficiencies. Other complaints had no deficiencies related to the allegations. The fall incident involved Resident C who was found on the floor for approximately 45 minutes without documentation of the event.
Deficiencies (3)
| Description |
|---|
| Failed to implement regulatory guidelines for tuberculosis testing of new employees for 7 of 9 direct care employees reviewed. |
| Failed to ensure cognitively impaired residents in a secured unit had a method to always summon staff for assistance for 3 of 5 residents reviewed. |
| Failed to ensure complete and accurate clinical records related to an undocumented fall of a cognitively impaired resident. |
Report Facts
Number of direct care employees reviewed for tuberculosis screening: 9
Number of residents reviewed for safety call system: 5
Number of residents reviewed for falls: 3
Residential Census: 23
Duration resident was on floor: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daphne New | Administrator | Signed the report and is the facility administrator. |
| QMA 10 | Agency staff member who found Resident C on the floor and reported the fall. | |
| CNA 11 | Present when Resident C was found on the floor. |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 0
Feb 1, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00425994.
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 IN00425994 was investigated and found to have no deficiencies related to the allegations.
Inspection Report
Re-Inspection
Census: 9
Deficiencies: 0
Nov 21, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00419023 completed on October 10, 2023.
Findings
Heritage Assisted Living of Yorktown was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of Complaint IN00419023.
Complaint Details
Complaint IN00419023 was corrected.
Inspection Report
Complaint Investigation
Census: 7
Deficiencies: 2
Oct 10, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00419023 regarding allegations of resident abuse and staffing deficiencies.
Findings
The facility failed to report witnessed aggressive physical contact between two residents to the Administrator, resulting in delayed investigation and reporting. Additionally, the facility failed to provide adequate qualified staffing on the dementia unit, resulting in non-nursing staff providing resident care without proper training.
Complaint Details
Complaint IN00419023 was substantiated with state deficiencies cited related to allegations of abuse and staffing issues. The facility did not report the incident of resident-to-resident abuse and had staffing shortages on 10/5/2023 with no nursing staff present from 6:00 a.m. to 11:00 a.m.
Deficiencies (2)
| Description |
|---|
| Failed to report witnessed aggressive physical contact between two residents to the Administrator per facility policy, delaying investigation and reporting to the State agency. |
| Failed to provide adequate qualified staffing for residents on the dementia unit, resulting in non-nursing staff providing resident care and mobility transfers without proper training. |
Report Facts
Residential Census: 7
Nursing staff absence duration: 5
Monitoring period: 60
Inspection Report
Original Licensing
Census: 2
Deficiencies: 4
Aug 30, 2023
Visit Reason
This visit was for an Initial State Residential Licensure Survey conducted on 8/29/23 and 8/30/23 at Heritage Assisted Living of Yorktown.
Findings
The facility was found deficient in several areas including failure to perform acceptable pre-employment screening for 3 of 5 unlicensed staff, failure to ensure each shift was staffed with at least one CPR and First Aid certified staff member, and failure to complete proper orientation and job description documentation for all employees reviewed.
Deficiencies (4)
| Description |
|---|
| Failed to use acceptable pre-employment screening databases prior to employment for 3 unlicensed staff of 5 staff members reviewed. |
| Failed to ensure each shift was staffed with at least one staff member certified in CPR and First Aid. |
| Failed to ensure general orientation and specific orientation were completed for 5 of 5 employee files reviewed. |
| Failed to ensure job descriptions were reviewed and acknowledged for 5 of 5 employee files reviewed. |
Report Facts
Residential Census: 2
Staff members reviewed: 5
Staff lacking acceptable pre-employment screening: 3
Dates lacking CPR certified staff: 3
Dates lacking First Aid certified staff: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robin Huston | Executive Director | Signed the report and mentioned as Executive Director responsible for monitoring staff schedule compliance |
| LPN 2 | Employee file reviewed; lacked general and job-specific orientation and acknowledged job description | |
| QMA 3 | Employee file reviewed; lacked general and job-specific orientation and acknowledged job description; hire date 7/17/23; lacked acceptable pre-employment screening | |
| LPN 4 | Employee file reviewed; lacked general and job-specific orientation and acknowledged job description | |
| CNA 5 | Employee file reviewed; lacked general and job-specific orientation and acknowledged job description; hire date 8/7/23; lacked acceptable pre-employment screening | |
| CNA 6 | Employee file reviewed; lacked job-specific orientation and acknowledged job description; hire date 8/14/23; lacked acceptable pre-employment screening |
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