Inspection Report
Complaint Investigation
Census: 114
Capacity: 114
Deficiencies: 1
Jun 18, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00461086 regarding allegations of resident safety during transfers.
Findings
The facility failed to ensure a resident was kept safe during a transfer, resulting in a 3 cm laceration to Resident B's posterior scalp. The root cause was determined to be equipment malfunction and improper securing of the Hoyer lift straps. The deficient practice was corrected prior to the survey.
Complaint Details
Complaint IN00461086 was investigated and substantiated with federal/state deficiencies cited at F689 related to the allegations.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a resident was kept safe during a transfer, resulting in a 3 cm laceration to the posterior scalp. | SS=G |
Report Facts
Resident census: 114
Total licensed capacity: 114
Laceration size: 3
Staples applied: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 4 | Certified Nursing Assistant | Involved in securing Hoyer lift straps during the transfer resulting in resident fall |
| CNA 5 | Certified Nursing Assistant | Assisted in transferring Resident B and securing Hoyer lift straps |
| QMA 6 | Qualified Medication Aide | Observed and ensured Hoyer sling was secured during transfer |
| QMA 7 | Qualified Medication Aide | Observed and ensured Hoyer sling was secured during transfer |
| Interim Director of Nursing | Director of Nursing | Confirmed Hoyer equipment was checked and functioning properly |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 116
Deficiencies: 0
May 28, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00458912.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00458912 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 116
Total Capacity: 116
Medicare Census: 2
Medicaid Census: 59
Other Payor Census: 55
Inspection Report
Complaint Investigation
Census: 113
Capacity: 113
Deficiencies: 1
Apr 10, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00456532 regarding allegations of improper use of physical restraints on a resident.
Findings
The facility failed to ensure a resident with dementia was free from a physical restraint used to inhibit freedom of movement. Specifically, Resident B's bed was elevated with a pillow placed under the mattress to prevent him from getting out of bed. The deficient practice was corrected prior to the survey start date.
Complaint Details
Complaint IN00456532 was substantiated with federal and state deficiencies cited related to the allegations of improper physical restraint use on Resident B.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a resident with dementia was free from a physical restraint used to inhibit freedom of movement. | SS=D |
Report Facts
Census: 113
Total Capacity: 113
Medicare Residents: 2
Medicaid Residents: 56
Other Residents: 55
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 10 | Licensed Practical Nurse | Interviewed regarding observation of physical restraint on Resident B |
| CNA 11 | Certified Nursing Assistant | Interviewed regarding observation of physical restraint on Resident B |
| CNA 12 | Certified Nursing Assistant | Interviewed regarding observation of physical restraint on Resident B |
| CNA 13 | Certified Nursing Assistant | Interviewed regarding observation of physical restraint on Resident B |
| Assistant Director of Nursing 4 | Assistant Director of Nursing | Interviewed regarding investigation and staff in-service on abuse and restraints |
| Superintendent | Superintendent | Interviewed regarding restraint policy and monitoring |
Inspection Report
Complaint Investigation
Census: 115
Capacity: 115
Deficiencies: 0
Mar 27, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00452907, IN00448665, and IN00451060.
Findings
No deficiencies related to the allegations in complaints IN00452907, IN00448665, and IN00451060 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaints IN00452907, IN00448665, and IN00451060 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 115
Total Capacity: 115
Medicare Census: 1
Medicaid Census: 61
Other Payor Census: 53
Inspection Report
Re-Inspection
Census: 124
Capacity: 212
Deficiencies: 0
Feb 18, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 01/07/25 was performed by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR survey, Indiana Veterans Home 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. The facility's buildings were appropriately sprinklered except for the detached generator building and maintenance shop.
Report Facts
Facility capacity: 212
Census: 124
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 9, 2025
Visit Reason
Paper compliance review to the Recertification and State Licensure survey and the Investigation of Complaint IN00448381 completed on December 9, 2024.
Findings
Indiana Veterans Home was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the Recertification and State Licensure survey and the Investigation of Complaint IN00448381.
Complaint Details
Investigation of Complaint IN00448381 was included in the review.
Inspection Report
Life Safety
Census: 116
Capacity: 212
Deficiencies: 4
Jan 7, 2025
Visit Reason
The survey was conducted as a Life Safety Code Recertification and State Licensure Survey in accordance with 42 CFR 483.90(a) and 42 CFR 483.73 for Emergency Preparedness.
Findings
The facility was found not in compliance with Life Safety Code requirements, citing deficiencies related to emergency lighting maintenance, fire drill scheduling and documentation, improper use of power cords, and lack of mechanical ventilation in the oxygen transfill room. Corrective actions and plans of correction were submitted.
Severity Breakdown
SS=D: 2
SS=F: 1
SS=E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Battery powered emergency lights failed to function when tested at multiple locations including the Mitchell Hall dock exit, restrooms near the dock exit, and the first floor mechanical room. | SS=D |
| Facility failed to conduct quarterly fire drills for one of four quarters and did not vary the time of fire drills as required. | SS=F |
| Use of power cord daisy chains as a substitute for fixed wiring was observed in resident room 321 in MacArthur Hall. | SS=E |
| Oxygen storage room used for transferring lacked properly working mechanical ventilation, with the exhaust fan not operating during observation. | SS=D |
Report Facts
Certified beds: 212
Census: 116
Fire drill quarters missed: 1
Power cord daisy chains observed: 2
Oxygen containers: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ay Gibson | Superintendent | Named in relation to exit conference and review of findings |
| Maintenance Director | Interviewed and involved in observations of emergency lighting, power cords, and oxygen room ventilation | |
| Facility Maintenance Manager | Participated in observations and exit conference | |
| Maintenance Supervisor | Interviewed regarding fire drill records and scheduling |
Inspection Report
Annual Inspection
Census: 115
Capacity: 115
Deficiencies: 4
Dec 9, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of multiple complaints.
Findings
The facility was found to have deficiencies related to quality of care, supervision, respiratory care, infection control, and medication administration. Several complaints were investigated with one complaint resulting in cited deficiencies. The facility failed to notify physicians of abnormal blood sugar readings, failed to follow medication hold parameters, left a resident unsupervised in a multi-sensory room, administered incorrect oxygen flow, and failed to wear PPE in an enhanced barrier precaution room.
Complaint Details
Multiple complaints were investigated (IN00429556, IN00432213, IN00435458, IN00438643, IN00439998, IN00441727, IN00441751, IN00448381). Deficiencies were cited related to complaint IN00448381.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure physician notification for blood sugar readings outside call parameters and to hold medications per physician orders for 3 residents. | SS=D |
| Failed to ensure staff did not leave a resident unsupervised in a multi-sensory room for longer than 30 minutes and failed to ensure resident was not left lying on a fall mat for extended periods. | SS=D |
| Failed to ensure correct oxygen flow was administered to a resident receiving respiratory care. | SS=D |
| Failed to wear PPE (gown and gloves) when providing care to a resident on enhanced barrier precautions. | SS=D |
Report Facts
Census: 115
Total Capacity: 115
Complaint Investigations: 8
Blood sugar readings: 2
Medication administration below hold parameters: 14
Audit frequency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Gibson | Superintendent | Signed the report |
| Nursing Supervisor 4 | Interviewed regarding blood sugar notification | |
| Dementia Care Director 3 | Interviewed regarding blood sugar notification and supervision | |
| Director of Nursing | DON | Interviewed regarding medication administration and policies |
| LPN 2 | Interviewed regarding medication hold parameters | |
| LPN 7 | Interviewed regarding blood sugar notification procedures | |
| CNA 8 | Interviewed regarding supervision in multi-sensory room and oxygen administration | |
| CNA 9 | Interviewed regarding supervision in multi-sensory room | |
| CNA 10 | Interviewed regarding supervision in multi-sensory room | |
| QMA 6 | Interviewed regarding supervision in multi-sensory room | |
| LPN 11 | Interviewed regarding oxygen administration | |
| RN 13 | Observed not wearing PPE in enhanced barrier precaution room | |
| Nursing Supervisor 12 | Interviewed regarding PPE requirements | |
| Assistant Director of Nursing | ADON | Provided facility policy on enhanced barrier precautions |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 11, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00427195 completed on February 12, 2024.
Findings
Indiana Veterans Home was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00427195 completed on February 12, 2024; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 112
Capacity: 112
Deficiencies: 1
Feb 12, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00427195, IN00427614, and IN00427908. Deficiencies related to complaint IN00427195 were cited, while no deficiencies were found related to the other complaints.
Findings
The facility failed to ensure a moderately impaired resident (Resident B) was free from physical restraints when a dining room chair was placed under the footrest of his recliner to keep his legs elevated, which was considered a restraint. The chair was removed upon discovery, and the resident was monitored for distress. Staff involved were educated and corrective actions were implemented to prevent recurrence.
Complaint Details
Complaint IN00427195 was substantiated with federal/state deficiencies cited at F604 related to the allegation of improper use of physical restraints. Complaints IN00427614 and IN00427908 were not substantiated with no deficiencies cited.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a resident was free from physical restraints when a dining room chair was placed under the footrest of the recliner to elevate the resident's legs. | SS=D |
Report Facts
Census: 112
Total Capacity: 112
Residents reviewed for abuse: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Gibson | Superintendent | Signed the report |
| CNA 9 | Agency staff member involved in placing the chair under resident's recliner footrest; removed from care of residents | |
| CNA 8 | Reported the incident of restraint and removed the chair | |
| ADON 5 | Assistant Director of Nursing | Interviewed regarding the restraint incident and staff actions |
| RN 6 | Registered Nurse | Interviewed regarding resident's mobility and restraint incident |
| Director of Nursing | Director of Nursing | Interviewed regarding resident care plan and staff employment status after incident |
Inspection Report
Life Safety
Census: 106
Capacity: 331
Deficiencies: 0
Jan 11, 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 Indiana Veterans Home was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 NFPA 101 Life Safety Code. The facility is fully sprinklered except for the detached generator building and maintenance shop.
Inspection Report
Complaint Investigation
Census: 119
Capacity: 119
Deficiencies: 0
Jan 11, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00425343 at the Indiana Veterans Home.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00425343 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 119
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 68
Census Payor Type - Other: 50
Inspection Report
Life Safety
Census: 116
Capacity: 331
Deficiencies: 5
Nov 28, 2023
Visit Reason
The survey was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 standards.
Findings
The Indiana Veterans Home was found not in compliance with Life Safety Code requirements, including obstructions in corridors, failure to inspect sprinkler piping internally every 5 years, corridor doors with holes or not latching properly, and an exposed electrical outlet without a cover plate. Corrective actions were planned or completed for all deficiencies.
Severity Breakdown
SS=E: 2
SS=F: 1
SS=D: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to maintain means of egress free from obstructions; two reclining chairs in corridor reduced clear width to approximately 36 inches. | SS=E |
| Failed to ensure all automatic sprinkler piping systems were examined for internal obstructions every 5 years as required by NFPA 25. | SS=F |
| Trust Department corridor door had a one-half inch diameter hole, failing to resist passage of smoke. | SS=D |
| Corridor door to resident room 227 failed to close and latch positively into the door frame. | SS=D |
| Electrical outlet hanging from wall without a cover plate, exposing wires adjacent to a water source. | SS=E |
Report Facts
Certified beds: 331
Census: 116
Corridors with obstructions: 1
Residents potentially affected by corridor obstruction: 15
Staff potentially affected by corridor obstruction: 4
Visitors potentially affected by corridor obstruction: 2
Date of last 5-year sprinkler pipe inspection for Pyle Hall: 2017
Date of last 5-year sprinkler pipe inspection for MacArthur Building: 2017
Number of electrical outlets inspected: 1000
Number of corridor doors inspected: 30
Inspection Report
Annual Inspection
Census: 114
Capacity: 114
Deficiencies: 9
Oct 26, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including investigation of four complaints (IN00415054, IN00418944, IN00419799, IN00420264).
Findings
The facility was found to have multiple deficiencies including failure to ensure resident dignity (bathroom door missing), failure to prevent abuse, inaccurate assessments, failure to notify providers of critical blood sugar levels, unsafe resident transport practices, improper oxygen tubing labeling, incomplete behavioral health care planning, failure to schedule dental follow-up care, and food safety issues such as unclean ice machines and uncovered drinks.
Complaint Details
Complaint IN00415054 - No deficiencies related to the allegations were cited. Complaint IN00418944 - Federal/State deficiencies related to the allegations were cited at F740. Complaint IN00419799 - No deficiencies related to the allegations were cited. Complaint IN00420264 - No deficiencies related to the allegations were cited.
Severity Breakdown
SS=D: 8
SS=G: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Resident J did not have a door to the bathroom in his room, compromising dignity. | SS=D |
| Facility failed to ensure a cognitively impaired resident receiving hospice was free from abuse by a staff member. | SS=D |
| Facility failed to accurately complete a Minimum Data Set (MDS) assessment for Resident 101, incorrectly coding bipolar disorder. | SS=D |
| Facility failed to notify provider when Resident 62 had blood sugars above call parameters. | SS=D |
| Resident O was not assisted safely off a facility vehicle, resulting in a fall and subdural hematoma. | SS=G |
| Oxygen tubing for Residents C and 23 was not dated or initialed as required. | SS=D |
| Facility failed to include family in decisions about staff visits outside work hours and failed to include negative interactions with male staff in Resident J's care plan. | SS=D |
| Facility failed to schedule follow-up dental care for Resident G as recommended by the dentist. | SS=D |
| Ice machine was dirty and room tray drinks were delivered uncovered on MacArthur 2 unit. | SS=D |
Report Facts
Census: 114
Total Capacity: 114
Blood sugar readings: 381
Blood sugar readings: 375
Blood sugar readings: 361
Blood sugar readings: 400
Survey dates: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN 14 | Registered Nurse | Named in behavioral health deficiency related to visiting Resident J outside work hours and emotional attachment |
| QMA 2 | Qualified Medication Aide | Named in abuse deficiency for inappropriate medication administration to Resident B |
| Driver 7 | Facility Driver | Named in fall deficiency for unsafe assistance of Resident O off facility vehicle |
| Social Services 9 | Social Services Staff | Interviewed regarding Resident J's bathroom door and behavioral health |
| Social Services 10 | Social Services Staff | Interviewed regarding Resident J's behavioral health and visitation |
| Respiratory Therapy Supervisor 12 | Respiratory Therapy Supervisor | Interviewed regarding oxygen tubing practices |
| RN 11 | Registered Nurse | Interviewed regarding oxygen tubing practices |
| CNA 8 | Certified Nursing Assistant | Interviewed regarding Resident J's bathroom door and behavioral health |
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 26, 2023
Visit Reason
Paper compliance review related to the Recertification and State Licensure survey and the Investigation of Complaint IN00418944 completed on October 26, 2023.
Findings
Indiana Veterans Home was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the Recertification and State Licensure survey and the Investigation of Complaint IN00418944.
Complaint Details
Investigation of Complaint IN00418944 was included in the review.
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 12, 2023
Visit Reason
Paper compliance review related to the Investigation of Complaint IN00412481 completed on July 18, 2023, and the Recertification and State Licensure survey.
Findings
Indiana Veterans Home was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review.
Complaint Details
Investigation of Complaint IN00412481 completed on July 18, 2023; paper compliance confirmed.
Inspection Report
Complaint Investigation
Census: 119
Capacity: 119
Deficiencies: 1
Jul 17, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00412481 regarding allegations of improper use of physical restraints on a resident.
Findings
The facility failed to ensure a resident was free from physical restraints when CNA 2 elevated the foot of Resident C's bed to prevent him from getting out of bed during the night. The action was determined to be a restraint and considered abuse. CNA 2 was suspended and reported to the Attorney General.
Complaint Details
Complaint IN00412481 was substantiated with federal/state deficiencies cited related to allegations of restraint and abuse involving Resident C. CNA 2 elevated the resident's bed foot to prevent him from getting out of bed, which was considered abuse.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a resident was free from physical restraints; CNA elevated foot of bed to prevent resident from getting out of bed. | SS=D |
Report Facts
Census: 119
Total Capacity: 119
Medicare Census: 3
Medicaid Census: 71
Other Payor Census: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Gibson | Superintendent | Signed the report |
| CNA 2 | Certified Nursing Assistant | Elevated resident's bed foot causing restraint and abuse |
| ADON 5 | Assistant Director of Nursing | Conducted interview with CNA 2 and confirmed restraint |
| LPN 3 | Licensed Practical Nurse | Assessed resident after incident |
Inspection Report
Complaint Investigation
Census: 123
Capacity: 123
Deficiencies: 0
May 18, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00408217.
Findings
No deficiencies related to the allegations in Complaint IN00408217 were cited. The Indiana Veterans Home was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00408217 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 123
Total Capacity: 123
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 70
Census Payor Type - Other: 46
Inspection Report
Complaint Investigation
Census: 117
Capacity: 117
Deficiencies: 0
Apr 6, 2023
Visit Reason
This visit was conducted for the investigation of multiple complaints identified as IN00404722, IN00404729, IN00404792, IN00404714, and IN00404425.
Findings
No deficiencies related to the allegations in any of the complaints were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B.
Complaint Details
Complaints IN00404722, IN00404729, IN00404792, IN00404714, and IN00404425 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 117
Total Capacity: 117
Medicare Census: 2
Medicaid Census: 70
Other Payor Census: 45
Inspection Report
Complaint Investigation
Census: 112
Capacity: 112
Deficiencies: 0
Jan 9, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00397786.
Findings
The complaint IN00397786 was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00397786 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Census: 112
Total Capacity: 112
Medicare Census: 1
Medicaid Census: 72
Other Payor Census: 39
Inspection Report
Life Safety
Census: 116
Capacity: 331
Deficiencies: 0
Dec 29, 2022
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 11/07/22 by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The Indiana Veterans Home 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. The facility is fully sprinklered except for the detached generator building and maintenance shop.
Report Facts
Facility capacity: 331
Census: 116
Inspection Report
Complaint Investigation
Census: 111
Capacity: 111
Deficiencies: 0
Dec 20, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00394290.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00394290 was substantiated, but no deficiencies related to the allegations were cited.
Report Facts
Census Bed Type: 111
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 69
Census Payor Type - Other: 41
Inspection Report
Life Safety
Census: 106
Capacity: 331
Deficiencies: 5
Nov 7, 2022
Visit Reason
The survey was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The Indiana Veterans Home was found not in compliance with several Life Safety Code requirements including emergency lighting maintenance, vertical openings enclosure, sprinkler system maintenance, and soiled linen/trash container capacity in corridors.
Severity Breakdown
SS=E: 3
SS=F: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Battery-operated emergency light by resident room 215 failed to function during test. | SS=E |
| Failed to maintain protection of 1 of 5 interior stairwells; fire resistance rating label painted over and illegible. | SS=E |
| Failed to maintain spare sprinklers, sprinkler cabinet, and sprinkler wrench on premises as required. | SS=F |
| Failed to document sprinkler system inspections including monthly wet sprinkler system gauge and control valve inspections. | SS=F |
| Soiled linen and trash containers in corridors exceeded 32 gallons capacity within a 64 square foot area. | SS=E |
Report Facts
Certified beds: 331
Census: 106
Deficient emergency lights: 1
Interior stairwells: 1
Sprinkler systems: 1
Soiled linen/trash containers: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Gibson | HFA, Superintendent | Signed the report as Laboratory Director's or Provider/Supplier Representative |
| Stephen M. Juday Sr. | Mentioned in relation to sprinkler system inspection documentation deficiency |
Inspection Report
Annual Inspection
Census: 106
Capacity: 106
Deficiencies: 11
Sep 14, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from September 6 to 14, 2022.
Findings
The facility was found deficient in multiple areas including advanced directives documentation, care plan updates after falls, skin condition documentation, vision services follow-up, fall interventions, elopement prevention, medication administration, catheter care, nutrition monitoring, psychotropic medication use, dental services, pureed food preparation, and dishwasher temperature maintenance.
Severity Breakdown
SS=D: 10
SS=E: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to ensure a resident or resident representative's preferences for advanced directives was assessed and clearly documented. | SS=D |
| Failed to update the care plan with new interventions after a fall for a resident. | SS=D |
| Failed to identify and document bruising for a resident reviewed for non-pressure skin conditions. | SS=D |
| Failed to document, inform the resident and follow up on cataract surgery for a resident reviewed for vision services. | SS=D |
| Failed to ensure interventions were implemented after a fall, cognitively impaired residents were safe from elopement, and medications were not left unattended during medication administration. | SS=D |
| Failed to prevent urinary tract infections for residents with catheters. | SS=D |
| Failed to recognize and notify the physician of significant weight loss for a resident. | SS=D |
| Failed to ensure diagnoses were appropriate for the use of psychotropic medications for residents. | SS=D |
| Failed to provide routine dental services for a resident. | SS=D |
| Failed to ensure pureed foods were prepared according to the recipes for residents who required a pureed diet. | SS=D |
| Failed to ensure the dishwasher reached and maintained the appropriate temperature during the final rinse cycle. | SS=E |
Report Facts
Census: 106
Total Capacity: 106
Survey Dates: 2022-09-06 to 2022-09-14
Weight loss: 7.19
Medication count: 14
Dishwasher temperature: 120
Dishwasher temperature required: 180
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cook 1 | Observed not following puree food recipes; educated by Registered Dietitian | |
| Registered Dietician | Provided education on puree food recipes and dish machine temperature | |
| Assistant Superintendent | Interviewed regarding advanced directives, urinary infections, and dental services | |
| Director of Nursing | Interviewed regarding fall care plans, elopement, medication pass, and psychotropic medication use | |
| Social Services Director | Interviewed regarding advanced directives and resident code status | |
| Maintenance 3 | Interviewed regarding resident found outside unattended | |
| QMA 2 | Observed leaving medication unattended at bedside | |
| Psychiatrist | Reviewed residents for gradual dose reduction of psychotropic medications | |
| Assistant Administrator | Interviewed regarding dental services and roam alert system | |
| Unit Manager 6 | Interviewed regarding weight loss documentation |
Inspection Report
Renewal
Deficiencies: 0
Sep 14, 2022
Visit Reason
Paper compliance review to the Recertification and State Licensure survey completed on September 14, 2022.
Findings
Indiana Veterans Home was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 105
Capacity: 105
Deficiencies: 0
Aug 31, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00388603.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00388603 was substantiated, but no deficiencies related to the allegations were cited.
Report Facts
Medicare census: 3
Medicaid census: 63
Other payor census: 39
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