Inspection Reports for Independence Village of Fishers East (Saxony)
IN, 46037
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 12, 2024, found no deficiencies related to the complaint investigated. Earlier inspections showed a pattern of deficiencies involving documentation, medication administration, staff training and certification, resident supervision, and infection control. Several substantiated complaints cited issues with resident abuse reporting, failure to update service plans, and timely notification of changes in condition, but fines or enforcement actions were not listed in the available reports. Most complaint investigations were unsubstantiated or corrected upon follow-up, with no immediate jeopardy findings or license actions noted. The facility’s inspection history indicates ongoing challenges in compliance, though the latest report suggests some improvement in addressing prior concerns.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
13.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
217% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
65 residents
Based on a December 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 0
Date: Dec 12, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00448755.
Complaint Details
Complaint IN00448755 was investigated and found to have no deficiencies related to the allegations.
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.
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 14
Date: Nov 26, 2024
Visit Reason
This visit was for a State Residential Licensure Survey including the investigation of complaints IN00447060 and IN00443453.
Complaint Details
Complaint IN00447060 - No deficiencies related to the allegations cited. Complaint IN00443453 - State deficiencies related to the allegations are cited.
Findings
The facility was found noncompliant in multiple areas including failure to ensure advanced directives upon admission, failure to notify the state of administrator changes timely, incomplete incident reporting after a resident fall, incomplete employee reference checks and job documentation, lack of CPR and First Aid certification on all shifts, unsigned service plans, improper medication administration including failure to prime insulin pens and incomplete documentation, improper storage of employee food in medication areas, failure to supervise residents in infection control practices, and incomplete tuberculosis skin testing.
Deficiencies (14)
Failed to ensure advanced directives were developed upon admission for 1 of 5 residents reviewed.
Failed to notify Indiana Department of Health of change in Administrator/Executive Director within three days.
Failed to complete incident report and implement new interventions after a resident fall.
Failed to perform reference checks for 3 of 5 employee records reviewed.
Failed to ensure one staff person was certified in CPR and First Aid on each shift.
Failed to have job specific orientation and job descriptions for 3 of 5 employee records reviewed.
Failed to ensure service plans were signed by resident or representative for 5 of 5 residents reviewed.
Failed to ensure priming of insulin flex pen for 1 of 5 residents reviewed for medication administration.
Failed to ensure staff's personal items were not in the food preparation area on dementia care unit.
Failed to ensure employee food was not stored in medication refrigerator.
Failed to ensure medical records were complete and accurate for 1 of 7 resident records reviewed.
Failed to ensure resident was supervised while setting silverware on tables in dementia unit.
Failed to ensure second step tuberculin skin test after admission for 1 of 5 residents reviewed.
Failed to ensure hand hygiene was maintained during medication administration for 3 of 5 residents observed.
Report Facts
Residents affected: 58
Dates of survey: 4
Residents reviewed for advanced directives: 5
Residents reviewed for falls: 3
Employees reviewed for reference checks: 5
Dates with no CPR/First Aid certified staff: 7
Residents reviewed for service plans: 5
Residents reviewed for medication administration: 5
Residents on dementia unit: 25
Residents reviewed for tuberculin skin testing: 5
Residents observed for hand hygiene during medication administration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mira Warner | Executive Director | Signed report and involved in interviews |
| Wellness Director | Interviewed multiple times regarding deficiencies and corrective actions | |
| Qualified Medication Aide 6 | Observed failing to perform hand hygiene during medication administration | |
| Certified Nursing Assistant 10 | Employee file reviewed for reference checks and job documentation | |
| Licensed Practical Nurse 11 | Employee file reviewed for reference checks and job documentation | |
| Qualified Medication Aide 12 | Employee file reviewed for reference checks and job documentation | |
| Executive Director 2 | Interviewed regarding administrator change notification | |
| Executive Director 3 | Former Executive Director referenced in administrator change | |
| Wellness Director Assistant | Observed administering insulin without priming pen | |
| Maintenance Technician 9 | Observed resident setting silverware unsupervised | |
| Executive Chef | Interviewed regarding food storage and infection control |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 0
Date: Aug 1, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00436173 and IN00439384.
Complaint Details
Investigation of complaints IN00436173 and IN00439384 found no deficiencies related to the allegations; both complaints were not substantiated.
Findings
No deficiencies related to the allegations in complaints IN00436173 and IN00439384 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 0
Date: Apr 4, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00430809.
Complaint Details
Complaint IN00430809 was investigated and found to have no related deficiencies; the complaint was not substantiated.
Findings
No deficiencies related to the allegations in Complaint IN00430809 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Inspection Report
Re-Inspection
Census: 68
Deficiencies: 1
Date: Feb 1, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to investigate multiple complaints and to follow up on previous deficiencies cited in complaint investigations completed on 10/06/2023 and 8/2/2023.
Complaint Details
This re-inspection was related to complaints IN00419078 and IN00418345 where state deficiencies were cited. Other complaints were corrected or had no deficiencies related to the allegations.
Findings
The facility failed to implement its Abuse, Neglect or Exploitation policy by not documenting an altercation between two residents in their clinical records and not notifying the residents' physicians. The incident involved Resident H and Resident J, and the facility did not properly document or notify all parties as required.
Deficiencies (1)
Failure to document an altercation between two residents in clinical records and failure to notify physicians as required by the Abuse, Neglect or Exploitation policy.
Report Facts
Residential Census: 68
Survey dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Richard Robison | Executive Director | Provided Incident Reporting Form and Abuse, Neglect, or Exploitation policy during the inspection |
Inspection Report
Follow-Up
Census: 68
Deficiencies: 0
Date: Feb 1, 2024
Visit Reason
This visit was for the Post Survey Revisit (PSR) to the State Residential Licensure Survey and Investigation of Complaint IN00410420 on 8/2/23, conducted in conjunction with PSRs and investigations of multiple other complaints completed on 2/1/2024.
Complaint Details
Complaint IN00410420 was corrected. Complaints IN00417996 and IN00417289 were corrected. Complaints IN00419078 and IN00418345 had state deficiencies cited at R0091. Complaints IN00421699, IN00421835, IN00423264, IN00423452, and IN00423726 had no deficiencies related to the allegations.
Findings
Independence Village of East Fishers was found to be in compliance with 410 IAC 16.2-5 regarding the PSR and Investigation of Complaint IN00410420. Several complaints were corrected, some had state deficiencies cited, and others had no deficiencies related to the allegations.
Report Facts
Residential Census: 68
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 0
Date: Feb 1, 2024
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00421699, IN00421835, IN00423264, IN00423452, IN00423726) and in conjunction with post survey revisits related to previous complaints and licensure surveys.
Complaint Details
Complaints IN00421699, IN00421835, IN00423264, IN00423452, and IN00423726 had no deficiencies related to the allegations. Complaints IN00410420, IN00417996, and IN00417289 were corrected. Complaints IN00419078 and IN00418345 had state deficiencies cited related to the allegations.
Findings
No deficiencies were cited related to most of the complaints investigated, with some complaints corrected and state deficiencies related to allegations cited only for complaints IN00419078 and IN00418345.
Report Facts
Residential Census: 68
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 6
Date: Oct 4, 2023
Visit Reason
This visit was for the Investigation of Complaints IN00419078, IN00417996, IN00418354 and IN00417289.
Complaint Details
Complaints IN00419078, IN00417996, IN00418354 and IN00417289 were investigated. Deficiencies related to these complaints were cited at various tags including R036, R052, R091, R217, and R241.
Findings
The facility failed to timely discharge a resident no longer suitable for assisted living, failed to notify a resident's representative or medical provider of a change in condition, failed to protect residents from physical abuse by other residents, failed to timely report incidents of resident-to-resident abuse and bruises of unknown origin, and failed to administer medications as ordered including PRN medication prior to showers for a cognitively impaired resident.
Deficiencies (6)
Failed to timely discharge a resident no longer suitable for assisted living (Resident D).
Failed to notify resident's representative or medical provider of a change in condition (Resident C).
Failed to protect residents from physical abuse by other residents (Residents E, F, G).
Failed to timely report incidents of resident-to-resident abuse and bruises of unknown origin to administration and physician (Residents C, E, G).
Failed to implement a resident's service plan related to frequent falls (Resident D).
Failed to administer clotrimazole cream as ordered and failed to administer Ativan prior to shower as ordered for a cognitively impaired resident with anxiety and agitation (Resident C and Resident D).
Report Facts
Resident falls: 39
Medication non-administration days: 38
Companion care hours: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| QMA 3 | Qualified Medication Aide | Involved in shower incident with Resident C resulting in bruising; failed to administer PRN Ativan prior to shower. |
| QMA 1 | Qualified Medication Aide | Observed bruising on Resident C and reported incident to Assistant Director of Wellness and others. |
| QMA 2 | Qualified Medication Aide | Observed bruising on Resident C and failed to report incident to administration or medical provider. |
| CNA 5 | Certified Nursing Assistant | Assisted with shower of Resident C and witnessed combative behavior. |
| LPN 4 | Licensed Practical Nurse | Conducted skin assessment on Resident C and observed bruising. |
| Executive Director | Interviewed regarding Resident D's supervision and incident reporting. | |
| Wellness Director | Interviewed regarding supervision, incident reporting, and policy implementation. | |
| Assistant Wellness Director | Provided policies and information on service plans and incident reporting. | |
| Physician Assistant 7 | Physician Assistant | Provided medical opinions and orders related to Resident C and Resident D. |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 13
Date: Aug 2, 2023
Visit Reason
This visit was for a State Residential Licensure Survey which included the Investigation of Complaint IN00410420.
Complaint Details
Complaint IN00410420 - State deficiencies related to the allegations are cited at R117, R217, R240, R407 and R414.
Findings
The facility was found deficient in multiple areas including failure to timely address changes in resident condition, insufficient staff certifications, inadequate dementia training, unsafe water temperatures, outdated service plans, failure to ensure personal care and medication administration, improper food temperature and storage, incomplete pharmacy medication reviews, missing physician contact information, and poor infection control practices.
Deficiencies (13)
Failure to timely address a change in a resident's condition resulting in hospitalization for sepsis.
Failed to ensure one awake staff person with first aid certification was on site at all times.
Failed to ensure staff had required dementia-specific training within 6 months of employment.
Water temperatures exceeded 120 degrees Fahrenheit at point of use in resident bathrooms.
Failed to revise service plans to reflect current resident needs for bathing and toileting.
Failed to ensure staff assistance with showers, proper medication ordering, and medication ingestion.
Failed to serve food at appropriate temperatures on the Memory Care Unit.
Failed to store refrigerated items properly, label and date items, and prevent personal items in food prep areas.
Failed to ensure pharmacy reviewed residents' drug regimens at least every 60 days and timely addressed recommendations.
Failed to include primary care physician phone number on resident face sheet.
Failed to ensure staff used serving utensils and maintained infection control during food service.
Failed to ensure medications and food items in medication rooms and carts were labeled and dated.
Failed to ensure infection control during medication administration including hand hygiene and disinfecting insulin pen hubs.
Report Facts
Residential Census: 87
Dates of Survey: July 31, August 1, and 2, 2023
Number of residents on Memory Care Unit: 21
Number of residents on Memory Care Unit ambulatory: 18
Number of residents reviewed for dementia training: 5
Number of residents reviewed for personal care and medication: 6
Number of residents observed for infection control: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| QMA 10 | Qualified Medication Aide | Named in findings related to first aid certification coverage and medication administration |
| QMA 13 | Qualified Medication Aide | Named in findings related to medication administration, infection control, and insulin pen handling |
| WD | Wellness Director | Interviewed regarding multiple deficiencies including change of condition reporting, staff training, and infection control |
| ED | Executive Director | Interviewed regarding staff certifications and dementia training |
| DS 15 | Dietary Staff | Observed during food service and interviewed regarding food temperature and storage |
| FC 16 | Facility Cook | Observed during food service with improper glove use |
| Triage LPN 12 | Licensed Practical Nurse | Documented resident fall and involved in change of condition reporting |
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 3
Date: Feb 16, 2023
Visit Reason
This visit was for the investigation of complaint IN00401007, which was substantiated with state deficiencies cited related to the allegations.
Complaint Details
Complaint IN00401007 was substantiated with deficiencies cited at R091, R240, and R354 related to falls, therapy follow-up, medication administration, change of condition notification, and transfer documentation.
Findings
The facility failed to follow its fall policy regarding incident logs and post-fall interventions for 2 of 3 residents reviewed for falls (Residents B and D). Additionally, the facility failed to follow up timely on therapy recommendations, administer hypertension medication as ordered, obtain blood pressures as ordered, notify medical providers timely of changes in condition, and failed to utilize proper transfer forms when residents were sent to the hospital.
Deficiencies (3)
Failed to follow the facility's fall policy regarding incident logs with post fall interventions for 2 of 3 residents reviewed for falls (Resident B and D).
Failed to follow up on therapy recommendation timely, administer hypertension medication as ordered, obtain blood pressures standing and sitting as ordered, and notify medical provider of resident's change of condition timely for 1 of 3 residents reviewed (Resident B).
Failed to utilize a transfer form including required information when residents were sent to the hospital for 2 of 3 residents reviewed (Residents B and D).
Report Facts
Residential Census: 67
Falls for Resident B: 4
Medication doses: 225
Medication doses: 425
Medication doses: 450
Blood pressure checks missed: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Richard Robison | Executive Director | Signed the report |
| Director of Nursing | Interviewed multiple times regarding fall policy, therapy services, medication administration, and transfer documentation | |
| Therapy Director 5 | Therapy Director | Interviewed regarding therapy services for Resident B |
| Regional Therapy Director 6 | Regional Therapy Director | Interviewed regarding therapy services and orders for Resident B |
| Certified Occupational Therapy Assistant 7 | Certified Occupational Therapy Assistant | Interviewed regarding therapy orders and services for Resident B |
| Health Staff 9 | Assessed Resident B during illness and requested hospital evaluation |
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 3
Date: Nov 9, 2022
Visit Reason
This visit was for the investigation of complaint IN00393589, which was substantiated with state residential findings related to privacy, abuse reporting, and service plan deficiencies.
Complaint Details
Complaint IN00393589 was substantiated. The complaint involved multiple incidents where Resident C wandered into Resident B's apartment uninvited, including physical contact such as grabbing Resident B's hand causing pain. The facility did not immediately report the abuse allegation to the Executive Director or the Indiana Department of Health as required. Family members reported multiple incidents of wandering and abuse.
Findings
The facility failed to provide privacy for a resident in her apartment, failed to report allegations of abuse immediately as required by policy, and failed to update service plans to address wandering behaviors for two residents. Multiple incidents of residents wandering into another resident's room were documented, including physical contact and emotional distress.
Deficiencies (3)
Failed to provide resident privacy in her personal apartment for 1 of 3 residents reviewed for privacy (Resident B).
Failed to report an allegation of abuse immediately to the Executive Director and Indiana Department of Health for 2 of 3 residents reviewed for abuse (Residents B and C).
Failed to update a resident's service plan to address wandering behavior for 2 of 3 residents reviewed (Residents C and D).
Report Facts
Residential Census: 67
Survey dates: November 9 and 10, 2022
Deficiency completion date: Corrective actions to be completed by December 15, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Richard Robison | Executive Director | Named as Executive Director involved in abuse reporting and investigation |
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