Inspection Reports for
Indiana Veterans‘ Home

This citation relates to Intake 2624760. The complaint involved allegations of staff failing to inform residents before care and making rude statements to residents. The complaint was substantiated based on interviews, incident reports, and record reviews.

The facility failed to ensure residents were treated with respect and dignity, as evidenced by staff administering medication without resident consent and staff making rude and inappropriate statements to residents. The investigation found minimal harm with a few residents affected.

This citation relates to Intake 2624760. The complaint involved failure to respect resident rights and failure to follow medication hold parameters.

The facility failed to ensure residents were treated with respect and dignity, including administering a suppository without resident consent and staff speaking inappropriately to residents. Additionally, the facility failed to follow physician orders to hold medications based on vital sign parameters for two residents.

Complaint IN00461086 was investigated and substantiated with federal/state deficiencies cited at F689 related to the allegations.

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.

This citation relates to Complaint IN00461086.

The facility failed to ensure a resident was kept safe during a transfer, resulting in a 3 cm laceration to the resident's posterior scalp. The deficient practice was corrected prior to the survey by staff education and competency checks.

This citation relates to Complaint IN00456532. The complaint involved the use of physical restraints on Resident B, which was substantiated by interviews and record reviews.

The facility failed to ensure a resident with dementia was free from physical restraints used to inhibit freedom of movement. The issue involved elevating the foot of the resident's bed and placing a pillow under the mattress to prevent the resident from getting out of bed. The deficient practice was corrected prior to the survey.

Complaint IN00456532 was substantiated with federal and state deficiencies cited related to the allegations of improper physical restraint use on Resident B.

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.

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.

The citation relates to Complaint IN00448381 regarding failure to follow physician orders, inadequate supervision, improper respiratory care, and infection control breaches.

The facility failed to notify physicians of out-of-range blood sugar readings and hold medications per physician orders for 3 residents. Staff left a resident unsupervised in a multi-sensory room beyond policy limits without a call light and allowed the resident to lie on a fall mat for extended periods. Oxygen was administered incorrectly to one resident, and staff failed to wear required PPE for a resident under enhanced barrier precautions.

Multiple complaints were investigated (IN00429556, IN00432213, IN00435458, IN00438643, IN00439998, IN00441727, IN00441751, IN00448381). Deficiencies were cited related to complaint IN00448381.

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.

This citation relates to Complaint IN00448381. The complaint involved concerns about supervision and safety of Resident J in the Snoezelin room and fall prevention practices.

The facility failed to ensure adequate supervision of a resident in the multi-sensory room, including not providing a call light or other means to summon staff, and leaving the resident lying on a fall mat on the floor for extended periods. Staff did not follow facility policy regarding supervision and care plans for the resident.

This citation relates to Complaint IN00427195. The complaint involved the use of a physical restraint on Resident B by placing a dining room chair under the footrest of the recliner to keep the resident's feet elevated against his will.

The facility failed to ensure a moderately impaired resident was free from physical restraints when a dining room chair was used to elevate the footrest of the resident's recliner without medical necessity. Staff interviews and record reviews confirmed the chair placement was a restraint and the resident was unable to move the chair himself.

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.

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.

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.

This Federal Tag relates to Complaint IN00418944. The complaint involved multiple issues including resident dignity, abuse, assessment accuracy, medication notification failures, safety incidents, behavioral health care, dental care, and food service sanitation.

The facility was found deficient in multiple areas including failure to ensure resident dignity with bathroom privacy, verbal abuse by staff, inaccurate resident assessments, failure to notify providers of critical blood sugar levels, unsafe resident transportation practices, improper respiratory care, inadequate behavioral health care planning, failure to schedule dental follow-up, and food service sanitation issues.

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.

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.

This Federal Tag relates to Complaint IN00418944. The complaint involved allegations of abuse, unsafe resident transfer, and inadequate behavioral health care planning.

The facility was found to have failed to prevent abuse of a cognitively impaired resident receiving hospice services, failed to ensure safe transfer of a resident from a facility vehicle resulting in injury, and failed to include a resident's family and negative staff interactions in the care plan for a resident with dementia.

This Federal tag relates to Complaint IN00412481. The complaint was substantiated as CNA 2 willfully restrained Resident C to prevent him from getting out of bed, which was considered abuse.

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 during the night. The action was determined to be a restraint and considered abuse, resulting in suspension of CNA 2 and notification to the Attorney General.

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.

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.

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.

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.