Inspection Reports for Hickory Creek at Sunset
1109 S Indiana St, Greencastle, IN 46135, United States, IN, 46135
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Inspection Report
Complaint Investigation
Census: 51
Capacity: 51
Deficiencies: 1
Feb 4, 2025
Visit Reason
This visit was conducted for the investigation of Complaints IN00451961 and IN00451216. Complaint IN00451216 resulted in federal/state deficiencies being cited related to accident hazards and supervision.
Findings
The facility failed to ensure a resident was safely transported in her wheelchair, resulting in a fall and nasal fracture for one resident. The incident involved the resident's foot catching on a dip in the floor while being pushed in a wheelchair without foot pedals, causing the resident to fall and sustain injuries. The deficient practice was corrected prior to the survey.
Complaint Details
Complaint IN00451216 was substantiated with federal/state deficiencies cited. Complaint IN00451961 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a resident was safely transported in her wheelchair, resulting in a fall and nasal fracture. | SS=D |
Report Facts
Census: 51
Total Capacity: 51
Medicare Census: 4
Medicaid Census: 36
Other Payor Census: 11
Date of Fall Incident: Jan 10, 2025
Date Deficient Practice Corrected: Jan 22, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) 4 | Interviewed regarding fall incident and wheelchair foot pedals | |
| Licensed Practical Nurse (LPN) 3 | Interviewed regarding wheelchair foot pedal requirements | |
| Certified Nurse Aide (CNA) 5 | Bus driver on day of resident fall incident | |
| Executive Director (ED) | Interviewed regarding facility policy on wheelchair foot pedals |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 50
Deficiencies: 0
Nov 8, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00444857.
Findings
No deficiencies related to the allegations in Complaint IN00444857 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00444857 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 5
Medicaid census: 34
Other payor census: 11
Inspection Report
Re-Inspection
Census: 48
Capacity: 68
Deficiencies: 0
Oct 29, 2024
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 licensure requirements.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The building is fully sprinklered except for three detached buildings used for employee lounge, maintenance, and storage.
Report Facts
Facility capacity: 68
Census: 48
Inspection Report
Life Safety
Census: 55
Capacity: 68
Deficiencies: 3
Sep 30, 2024
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 09/30/2024.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies included failure to maintain automatic sprinkler systems per NFPA 25, use of extension cords as substitutes for fixed wiring, and failure to ensure the oxygen trans-filling room door latched properly.
Severity Breakdown
SS=F: 1
SS=E: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to maintain automatic sprinkler systems in accordance with NFPA 25; two of four sampled sprinklers failed inspection. | SS=F |
| Extension cords were used as a substitute for fixed wiring in resident rooms, specifically an extension cord found in resident room 16. | SS=E |
| Oxygen trans-filling room door did not latch into the door frame as required for fire-resistive construction. | SS=E |
Report Facts
Certified beds: 68
Census: 55
Deficiencies cited: 3
Sprinkler sample failures: 2
Residents potentially affected: 20
Residents potentially affected: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tega Brume | Executive Director | Named during exit conference and plan of correction |
| Maintenance Director | Interviewed and involved in findings and corrective actions |
Inspection Report
Annual Inspection
Census: 53
Capacity: 53
Deficiencies: 4
Sep 11, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00442274 and IN00442280.
Findings
The facility was found deficient in ensuring resident rights during meal service, accuracy of Minimum Data Set (MDS) assessments, proper medication labeling and storage, and hand hygiene during meal service. Complaint IN00442274 had no deficiencies, while Complaint IN00442280 resulted in deficiencies related to resident rights.
Complaint Details
Complaint IN00442274 - No deficiencies related to the allegations were cited. Complaint IN00442280 - Federal/State deficiencies related to the allegations were cited at F550 (Resident Rights).
Severity Breakdown
SS=D: 2
SS=A: 1
SS=E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure the dignity of a resident during meal service, including delayed meal delivery and lack of tray service. | SS=D |
| Failure to ensure a Minimum Data Set (MDS) assessment was coded correctly for a resident regarding eating assistance. | SS=A |
| Failure to ensure medications and biologicals were dated when opened and to properly dispose of discontinued medication. | SS=D |
| Failure to ensure proper handwashing procedure during meal service. | SS=E |
Report Facts
Census: 53
Total Capacity: 53
Survey Dates: 5
Residents requiring eating assistance reviewed: 19
Medication carts observed: 2
Medication rooms observed: 1
Medication expiration days: 28
Medication expiration days: 30
Medication expiration days: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tega Brume | Executive Director | Signed report and provided interview regarding meal service and resident rights |
| Certified Food Manager (CFM) | Interviewed regarding meal preparation and delivery delay for Resident B | |
| Registered Nurse 4 | Interviewed regarding medication storage and expiration practices | |
| Director of Nursing (DON) | Provided policies and interviews regarding medication storage and hand hygiene | |
| Nursing Assistant in Training (NAIT) 5 | Observed and interviewed regarding meal service and handwashing deficiencies | |
| MDS Coordinator | Interviewed regarding MDS assessment coding errors | |
| Corporate RAI Specialist | Interviewed regarding proper MDS coding standards |
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 11, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey and the Investigation of Complaint IN00442280 completed on September 11, 2024.
Findings
Hickory Creek at Sunset was found to be in compliance with 42 CFR Part 483, Subpart B and IAC 16.2-3.1 regarding the paper compliance review to the Recertification and State Licensure Survey and the Investigation of Complaint IN00442280.
Complaint Details
Investigation of Complaint IN00442280 was included in the review and found to be in compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 30, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00435710 completed on June 28, 2024.
Findings
Hickory Creek at Sunset was found to be in compliance with 42 CFR Part 483, Subpart B and IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00435710; paper compliance review found the facility in compliance.
Inspection Report
Complaint Investigation
Census: 52
Capacity: 52
Deficiencies: 3
Jun 27, 2024
Visit Reason
This visit was for the investigation of complaints IN00435710, IN00436109, IN00436745, and IN00437354. Deficiencies related to complaint IN00435710 were cited.
Findings
The facility was found deficient in ensuring appropriate mental and psychosocial services for a resident with PTSD and anxiety, assisting a resident with transportation arrangements from a hospital appointment, and honoring a resident's dietary dislikes and food preferences. The resident experienced psychosocial distress due to being left unattended in the shower room multiple times, was left without transportation after a hospital MRI appointment, and was served foods he could not tolerate despite communicating his preferences.
Complaint Details
Complaint IN00435710 was substantiated with federal/state deficiencies cited at F742, F778, and F806. Complaints IN00436745, IN00437354, and IN00436109 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure a resident with PTSD and anxiety received appropriate mental and psychosocial services resulting in psychosocial distress. | SS=D |
| Failed to assist a resident in obtaining transportation from a hospital appointment. | SS=D |
| Failed to honor a resident's dietary dislikes and food preferences. | SS=D |
Report Facts
Census: 52
Total Capacity: 52
Deficiencies cited: 3
Inspection Report
Complaint Investigation
Census: 43
Capacity: 43
Deficiencies: 0
Apr 1, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00430874.
Findings
No deficiencies related to the allegations in Complaint IN00430874 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00430874 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare residents: 3
Medicaid residents: 27
Other payor residents: 13
Inspection Report
Re-Inspection
Census: 40
Capacity: 68
Deficiencies: 0
Sep 19, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 08/17/23 was performed to verify compliance with fire safety and licensure requirements.
Findings
At this PSR survey, Hickory Creek at Sunset was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Life Safety
Census: 37
Capacity: 68
Deficiencies: 4
Aug 17, 2023
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 08/17/2023 to assess compliance with emergency preparedness and life safety code requirements.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies included failure to conduct preventative maintenance for battery-operated smoke alarms according to manufacturer's instructions, installation of mixed sprinkler head types within a smoke compartment, and incomplete documentation of sprinkler system inspections and generator load testing.
Severity Breakdown
SS=F: 1
SS=E: 1
SS=C: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure preventative maintenance for all battery operated smoke alarms in resident rooms was conducted according to manufacturer's published instructions. | SS=F |
| Failure to ensure only one type of sprinkler head (quick response or standard) was installed in one of four smoke compartments. | SS=E |
| Failure to document sprinkler system inspections in accordance with NFPA 25, including missing weekly dry sprinkler system gauge inspection documentation. | SS=C |
| Failure to maintain a complete written record of monthly generator load testing for 1 of 12 months and weekly inspection for 5 of 52 weeks. | SS=C |
Report Facts
Certified beds: 68
Census: 37
Deficiency completion dates: Sep 8, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tega Brume | Executive Director | Named in relation to exit conferences and corrective action oversight |
| Maintenance Director | Interviewed regarding deficiencies and responsible for corrective actions | |
| Field Maintenance Supervisor | Participated in observations and exit conference |
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 28, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on July 28, 2023.
Findings
Hickory Creek at Sunset was found to be in compliance with 42 CFR Part 483, Subpart B and IAC 16.2-3.1 regarding the paper compliance review to the Recertification and State Licensure Survey.
Inspection Report
Annual Inspection
Census: 36
Capacity: 36
Deficiencies: 5
Jul 24, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00413927.
Findings
The facility was found deficient in multiple areas including resident dignity and incontinence care, insulin administration errors, respiratory care, and food safety practices. Complaint allegations were not substantiated. Corrective actions and staff education plans were outlined.
Complaint Details
Complaint IN00413927 was investigated and no deficiencies related to the allegations were cited.
Severity Breakdown
SS=D: 4
SS=E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure a resident's dignity was maintained when the resident was not changed after an incontinence episode and was fed in a soiled brief. | SS=D |
| Failure to ensure incontinence care was provided for dependent residents. | SS=D |
| Failure to ensure proper storage of respiratory BiPAP equipment and failure to follow physician's order for oxygen therapy. | SS=D |
| Medication error rate exceeded 5% related to insulin administration errors. | SS=D |
| Failure to ensure proper handling of linens in the kitchen and lack of paper towels for proper handwashing. | SS=E |
Report Facts
Survey dates: 5
Census: 36
Total Capacity: 36
Medication error rate: 8.57
Blood glucose readings: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tega Brume | Executive Director | Signed the report |
| RN 11 | Registered Nurse | Observed administering insulin with errors |
| CNA 17 | Certified Nursing Assistant | Involved in failure to provide timely incontinence care to Resident 5 |
| CNA 10 | Certified Nursing Assistant | Involved in failure to provide timely incontinence care to Resident 5 |
| PT 5 | Physical Therapist | Observed Resident 5 wet and notified staff |
| RN 8 | Registered Nurse/Unit Manager | Interviewed regarding respiratory care and oxygen orders |
| Housekeeper 6 | Observed carrying linens improperly into kitchen | |
| Cook 7 | Observed improper handwashing and handling of towels in kitchen |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 38
Deficiencies: 0
Apr 14, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00404889 and IN00405624.
Findings
No deficiencies related to the allegations in complaints IN00404889 and IN00405624 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00404889 and Complaint IN00405624 were investigated; no deficiencies related to the allegations were cited.
Report Facts
Census Bed Type: 38
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 27
Census Payor Type - Other: 9
Inspection Report
Complaint Investigation
Census: 39
Capacity: 39
Deficiencies: 0
Feb 14, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00396121.
Findings
The complaint IN00396121 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00396121 was investigated and found to be unsubstantiated due to lack of evidence.
Report Facts
Census: 39
Total Capacity: 39
Medicare Census: 6
Medicaid Census: 23
Other Payor Census: 10
Inspection Report
Complaint Investigation
Census: 41
Capacity: 41
Deficiencies: 0
Dec 1, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00388710 and included a COVID-19 Focused Infection Control Survey.
Findings
Complaint IN00388710 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation and the COVID-19 survey.
Complaint Details
Complaint IN00388710 was unsubstantiated due to lack of evidence.
Report Facts
Census SNF/NF beds: 41
Total census: 41
Medicare census: 5
Medicaid census: 26
Other payor census: 10
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