Deficiencies per Year
4
3
2
1
0
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 0
Sep 5, 2024
Visit Reason
This survey was conducted as a State Residential Licensure Survey and included the investigation of Complaint IN00440657.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with the State Residential Licensure Survey requirements.
Complaint Details
Complaint IN00440657 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Residential census: 35
Inspection Report
Renewal
Census: 27
Deficiencies: 2
Aug 22, 2023
Visit Reason
This visit was for a State Residential Licensure Survey conducted on August 22 and 23, 2023, to assess compliance with state residential licensure requirements.
Findings
The facility was found deficient for employing a Certified Nursing Assistant (CNA) without a valid license for over one year and for failing to properly label residents' medications on the medication cart. Corrective actions and audits were planned to address these issues.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure a Certified Nursing Assistant (CNA) had a valid license while employed for over one year. |
| Facility failed to label residents' medications properly on the medication cart, including missing resident names on bottles and test strips. |
Report Facts
Residential Census: 27
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Stonestreet | Care Service Manager | Signed as provider/supplier representative on the report |
| CNA 2 | Certified Nursing Assistant (unlicensed during employment period) | Named in deficiency for lacking valid CNA license while employed |
| Executive Director | Attempted to obtain CNA 2's licensure information and implemented corrective actions | |
| Regional Director of Care Services | Provided re-education regarding licensing requirements and medication labeling | |
| Director of Health Services | Indicated facility did not have a policy for medication labeling | |
| QMA 1 | Interviewed regarding medication labeling requirements |
Inspection Report
Follow-Up
Census: 28
Deficiencies: 0
Jun 22, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the PSR completed on April 19, 2023, related to the Investigation of Complaint IN00400575 completed on February 9, 2023.
Findings
Kokomo Place was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Investigation of Complaint IN00400575. The complaint was corrected.
Complaint Details
Complaint IN00400575 was investigated and found to be corrected.
Inspection Report
Re-Inspection
Census: 34
Deficiencies: 1
Apr 19, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00400575 completed on February 9, 2023, to determine if the previously cited deficiencies were corrected.
Findings
The facility failed to ensure a resident was free from physical, verbal, and mental abuse by a staff member while providing bedtime personal care. The abuse allegation against Resident Care Partner (RCP) 5 was substantiated, and he was terminated. The facility failed to implement a systemic plan of correction to prevent recurrence.
Complaint Details
The visit was complaint-related, following Complaint IN00400575. The abuse allegation against RCP 5 was substantiated. The resident was physically, verbally, and mentally abused on 3/15/2023. The facility substantiated the abuse and terminated RCP 5 effective 3/22/2023.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure a resident was free from abuse related to physical, verbal, and mental abuse by a staff member while providing bedtime personal care. |
Report Facts
Residential Census: 34
Date of abuse incident: Mar 15, 2023
Termination date of RCP 5: Mar 22, 2023
Plan of correction completion date: May 19, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RCP 5 | Resident Care Partner | Named in abuse allegation and terminated for physical, verbal, and mental abuse of Resident B. |
| RCP 3 | Resident Care Partner | Witnessed abuse by RCP 5 and reported the incident. |
| Adriana Albright | Regional Care Specialist | Signed the report and involved in quality review. |
| LPN 4 | Licensed Practical Nurse | Charge nurse for the shift; received abuse report. |
| LPN 7 | Licensed Practical Nurse | Reported hearing RCP 5 frustrated and aware of resident's history. |
| RCP 6 | Resident Care Partner | Witnessed rough care by RCP 5 and reported concerns prior to abuse incident. |
| Executive Director | Executive Director | Re-educated staff and involved in corrective actions and monitoring. |
| Care Service Manager | Care Service Manager | Conducted interviews, reviewed records, and involved in abuse investigation. |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 1
Feb 9, 2023
Visit Reason
This visit was conducted for the investigation of complaint IN00400575, which was substantiated with state deficiencies cited related to the allegations.
Findings
The facility failed to ensure residents were free from neglect, as six residents were denied personal care services on their first request and services were not provided in a timely manner. The investigation found that a QMA refused to provide care while bussing tables, made derogatory statements about residents, and was subsequently terminated.
Complaint Details
Complaint IN00400575 was substantiated. The abuse investigation confirmed that QMA 6 refused to provide care to residents in the dining room on 1/25/23, made statements indicating dislike of 'old people,' and was terminated for offensive behavior.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure residents were free from neglect related to denial and delay of personal care services for 6 residents. |
Report Facts
Residents affected: 6
Residential Census: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amber Stout | CSM (Director of Nursing) | Provided the Indiana State Department of Health Survey Report System document and was involved in the investigation. |
| QMA 6 | Employee who refused to provide care, made derogatory statements, and was terminated. | |
| LPN 3 | Licensed Practical Nurse | Interviewed regarding the incident and assisted residents during the event. |
| CNA 4 | Certified Nursing Assistant | Interviewed about QMA 6's behavior and the incident. |
| CNA 5 | Certified Nursing Assistant | Interviewed about the incident and resident care. |
| Executive Director | ED | Interviewed and involved in the investigation and corrective actions. |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 0
Jan 23, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00398539.
Findings
The complaint IN00398539 was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00398539 - Substantiated. No deficiencies related to the allegations are cited.
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