Deficiencies (last 4 years)
Deficiencies (over 4 years)
14.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
245% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 82
Capacity: 82
Deficiencies: 0
Jun 6, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00460145.
Findings
No deficiencies related to the allegations in Complaint IN00460145 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00460145 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 82
Census Payor Type: 82
SNF/NF beds: 77
SNF beds: 5
Medicare residents: 5
Medicaid residents: 31
Other residents: 46
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 0
Apr 10, 2025
Visit Reason
This visit was conducted for the Investigation of Complaint IN00448919.
Findings
No deficiencies related to the allegations in Complaint IN00448919 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00448919 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 86
Census Bed Type - SNF/NF: 85
Census Bed Type - SNF: 1
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 36
Census Payor Type - Other: 47
Inspection Report
Census: 83
Capacity: 106
Deficiencies: 0
Nov 7, 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 in accordance with 42 CFR 483.73 and 42 CFR 483.90(a), respectively.
Findings
At the Emergency Preparedness survey, Maple Park Village was found to be in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. At the Life Safety Code survey, the facility was found in compliance with Requirements for Participation in Medicare/Medicaid and the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code.
Report Facts
Certified beds: 106
Census: 83
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 1
Oct 18, 2024
Visit Reason
This visit was for the investigation of Complaint IN00445223 regarding federal and state deficiencies related to enteral feeding practices.
Findings
The facility failed to ensure a resident with a Jejunostomy tube received the ordered amount of nutrient formula at the correct rate and time frame, resulting in aspiration and respiratory distress leading to hospitalization and death. The deficient practice was corrected prior to the survey date.
Complaint Details
Complaint IN00445223 was substantiated with federal and state deficiencies cited at F693 related to enteral feeding management and restoration of eating skills.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a resident with continuous feeding through a Jejunostomy tube received the ordered amount of nutrient formula at the correct rate in the ordered time frame. | SS=D |
Report Facts
Census: 83
Residents reviewed for enteral feedings: 2
Ordered feeding rate: 45
Feeding volume received: 1000
Oxygen saturation: 58
Fluid in belly: 200
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Night Nurse | Administered feeding and medications to Resident B; involved in feeding pump management |
| RN 2 | Registered Nurse | Responded to Resident B's distress, assessed vital signs, and notified provider |
| Physician 4 | Physician | Attended Resident B during emergency and provided medical assessment |
| Executive Director | Provided information about feeding pump and investigation | |
| Director of Nursing | Present during feeding pump assessment | |
| Corporate Support Nurse | Provided information on medication administration policy and facility practices |
Inspection Report
Annual Inspection
Census: 84
Capacity: 84
Deficiencies: 4
Oct 11, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which also included the Investigation of Complaint IN00443865.
Findings
The facility was found deficient in conducting quarterly care plan meetings for residents, medication administration not following physician's hold parameters, improper medication and food storage, and unsanitary food preparation practices. No deficiencies were cited related to the complaint investigation.
Complaint Details
Complaint IN00443865 was investigated with no Federal or State deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to conduct care plan meetings at least quarterly for 2 of 2 residents reviewed (Residents 5 and 59). | SS=D |
| Failed to ensure medications were held according to physician's ordered hold parameters for 2 of 2 residents reviewed (Residents 36 and 55). | SS=D |
| Failed to ensure unlabeled food was not stored in a medication room refrigerator and medications were stored in original containers in 1 of 2 medication rooms and 1 of 3 medication carts reviewed. | SS=D |
| Failed to ensure staff prepared pureed food in a sanitary manner for 1 of 1 staff member observed (Cook 6). | SS=D |
Report Facts
Census: 84
Total Capacity: 84
Deficiencies cited: 4
Survey dates: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tony Link | Executive Director | Signed the report and involved in plan of correction |
| Cook 6 | Cook | Observed preparing pureed food unsanitarily |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration and storage deficiencies |
| Social Service Director | Social Service Director | Interviewed regarding care plan meetings for residents |
| Registered Nurse 3 | Registered Nurse | Interviewed regarding unlabeled food in medication refrigerator |
| RN 5 | Registered Nurse | Interviewed regarding medication cart condition |
Inspection Report
Renewal
Deficiencies: 0
Oct 11, 2024
Visit Reason
The visit was a paper compliance review for the Recertification and State Licensure survey completed on October 11, 2024.
Findings
Maple Park Village 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
Deficiencies: 0
Sep 17, 2024
Visit Reason
Paper compliance review related to the Investigation of Complaint IN00441461 completed on August 29, 2024.
Findings
Maple Park Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the complaint investigation.
Complaint Details
Investigation of Complaint IN00441461 completed on August 29, 2024; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 2
Aug 29, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00439443 and IN00441461. Complaint IN00439443 resulted in federal/state deficiencies cited, while Complaint IN00441461 had no deficiencies related to the allegations.
Findings
The facility failed to ensure a narcotic pain patch was administered at the correct time with proper site rotation for one resident and failed to ensure staff signed narcotic count sheets for multiple medication cart narcotic logs. Several missing signatures were found on narcotic count sheets across multiple units.
Complaint Details
Complaint IN00439443 was substantiated with federal/state deficiencies cited at F755. Complaint IN00441461 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure a narcotic pain patch was administered at the correct time and new sites were used for the transdermal patch for 1 of 1 resident reviewed. | SS=D |
| Failed to ensure staff were signing the narcotic count sheets for 4 of 6 medication cart narcotic logs reviewed. | SS=D |
Report Facts
Resident census: 88
Narcotic count sheet missing signatures: 3
Narcotic count sheet missing signatures: 7
Narcotic count sheet missing signatures: 1
Narcotic count sheet missing signatures: 2
Narcotic count sheet missing signatures: 4
Narcotic count sheet missing signatures: 4
Narcotic count sheet missing signatures: 2
Narcotic count sheet missing signatures: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tony Link | Executive Director | Provided interviews and facility policies related to narcotic administration and counts |
| RN 1 | Named in findings related to early administration of Fentanyl patch and narcotic count signing | |
| RN 4 | Provided interview regarding narcotic card counts and medication administration | |
| RN 6 | Provided interview regarding medication destruction and narcotic count procedures | |
| LPN 5 | Provided interview regarding medication orders and narcotic counts |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 85
Deficiencies: 0
Jul 15, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00431769.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00431769 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 85
Medicare Census: 3
Medicaid Census: 38
Other Payor Census: 44
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 0
Feb 9, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00427177.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00427177 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 87
Census Bed Type Total: 87
Census Payor Type Total: 87
SNF/NF Beds: 85
SNF Beds: 2
Medicare Residents: 2
Medicaid Residents: 43
Other Payor Residents: 42
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 9, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey and Investigation of Complaint IN00418152.
Findings
Maple Park Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Recertification and State Licensure Survey and Investigation of Complaint IN00418152.
Complaint Details
Investigation of Complaint IN00418152 was completed.
Inspection Report
Complaint Investigation
Census: 80
Capacity: 80
Deficiencies: 0
Nov 1, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00420603, IN00420279, IN00419794, and IN00419633 at Maple Park Village.
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 and 410 IAC 16.2-3.1.
Complaint Details
Complaints IN00420603, IN00420279, IN00419794, and IN00419633 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 80
Census Payor Type - Medicare: 14
Census Payor Type - Medicaid: 56
Census Payor Type - Other: 10
Inspection Report
Life Safety
Census: 80
Capacity: 106
Deficiencies: 4
Oct 31, 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 10/31/2023.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies included obstruction of a portable fire extinguisher, a resident room door failing to close and latch properly, cigarette butts improperly disposed in the staff smoking area, and obstruction of an electrical panel by equipment.
Severity Breakdown
SS=E: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| 1 of 25 portable fire extinguishers was obstructed by a Hoyer lift, making it not readily accessible. | SS=E |
| 1 of 56 resident room doors to the corridor failed to close completely and latch into the door frame. | SS=E |
| 1 of 1 staff smoking area was not maintained properly; cigarette butts were mixed with dry leaves and not disposed of in approved metal ashtrays. | SS=E |
| Access and working space was obstructed in 1 of 7 electrical panel enclosures by a Hoyer lift stored in the corridor. | SS=E |
Report Facts
Certified beds: 106
Census: 80
Portable fire extinguishers inspected: 25
Resident room doors inspected: 56
Electrical panel enclosures inspected: 7
Residents potentially affected: 24
Staff potentially affected: 4
Visitors potentially affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Link | Executive Director | Signed the report and participated in observations and interviews |
Inspection Report
Life Safety
Deficiencies: 0
Oct 31, 2023
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey conducted on 10/31/23.
Findings
Maple Park Village 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, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Annual Inspection
Census: 79
Deficiencies: 10
Oct 12, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00418152.
Findings
The facility was found deficient in multiple areas including resident rights related to use of non-disposable utensils, accuracy of assessments, medication administration timeliness, accident hazards related to wanderguard use, bowel/bladder incontinence care, nutrition and hydration management, respiratory care, psychotropic medication management, medication labeling and storage, and infection prevention and control.
Complaint Details
Complaint IN00418152 was investigated and federal/state deficiencies related to the allegations were cited at F684 for medication administration timeliness.
Severity Breakdown
SS=E: 3
SS=D: 7
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to ensure residents received non-disposable utensils for meals on the locked dementia unit for 17 of 17 residents. | SS=E |
| Failed to ensure Minimum Data Set (MDS) assessment included wanderguard use for 1 of 1 resident reviewed. | SS=D |
| Failed to give medications within prescribed time for 6 of 6 residents reviewed. | SS=E |
| Failed to ensure a resident with a wanderguard had a physician's order, daily assessment, and care plan for the alarm. | SS=D |
| Failed to identify and implement resident specific preventative nursing measures for a resident with multiple repeat urinary tract infections. | SS=D |
| Failed to identify significant weight changes, implement timely interventions, and notify provider and family timely for 2 of 4 residents reviewed for nutrition. | SS=D |
| Failed to ensure residents' oxygen tubing was dated and replaced as required for 2 of 3 residents reviewed for respiratory care. | SS=D |
| Failed to ensure symptom monitoring and gradual dose reduction consideration for antipsychotic medication for 1 of 5 residents reviewed. | SS=D |
| Failed to label medications with an open date on medications with shortened expiration date once opened in medication storage and carts. | SS=D |
| Failed to ensure catheter bag was not touching the ground for 1 of 1 resident reviewed for infection control related to catheters. | SS=D |
Report Facts
Census: 79
Medication administration late doses: 20
Weight loss percentage: 9.03
Weight gain percentage: 23.71
Oxygen tubing replacement frequency: 7
Psychotropic drug PRN order limit: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Link | Executive Director | Signed the report |
| Director of Nursing Services (DNS) | Interviewed regarding multiple findings including medication administration, wanderguard use, nutrition, and psychotropic medication management | |
| Dementia Unit Manager (UM) | Interviewed regarding resident behaviors and care plans | |
| RN 3 | Interviewed regarding medication labeling and late medication administration | |
| LPN 2 | Interviewed regarding medication labeling and storage | |
| RN 9 | Interviewed regarding oxygen tubing replacement | |
| Assistant Director of Nursing (ADON) | Interviewed regarding catheter bag infection control | |
| Dementia Unit Manager | Provided psychotropic medication management policy |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 78
Deficiencies: 2
Sep 20, 2023
Visit Reason
This visit was conducted for the investigation of two complaints, IN00417153 and IN00415768, regarding resident safety and care practices.
Findings
The facility was found to have failed to protect residents from injury by not ensuring proper supervision and safety precautions, resulting in a resident fall with injury and another incident requiring staff intervention. The deficient practices were corrected prior to the survey.
Complaint Details
Complaint IN00417153 was substantiated with related deficiencies cited. Complaint IN00415768 was substantiated but no deficiencies were cited related to it.
Severity Breakdown
SS=G: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to protect a resident from injury when left unattended in a bed not in the lowest position and without a fall mat, resulting in a fall with laceration and femoral neck fracture. | SS=G |
| Facility failed to ensure staff followed care sheets or electronic records for safety precautions, resulting in another resident needing to be lowered to the floor safely. | SS=G |
Report Facts
Census: 78
Total Capacity: 78
Medicare Residents: 7
Medicaid Residents: 41
Other Residents: 30
Cut size: 3.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in fall incident involving Resident B and disciplined |
| LPN 2 | Licensed Practical Nurse | Provided care sheet information regarding bed position |
| Director of Nursing | Provided interviews about staff responsibilities and care plan policies | |
| Executive Director | Provided multiple statements regarding resident incidents and facility practices | |
| CNA 7 | Certified Nursing Assistant | Involved in assisting Resident C during fall incident |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 0
Aug 9, 2023
Visit Reason
This visit was for the investigation of Complaint IN00414150.
Findings
No deficiencies related to the allegations were cited. 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.
Complaint Details
Complaint IN00414150 - No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type Total: 85
Census Payor Type Medicare: 6
Census Payor Type Medicaid: 47
Census Payor Type Other: 32
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 0
Jun 14, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00410010.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00410010 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type Total: 83
Census Bed Type SNF/NF: 76
Census Bed Type SNF: 7
Census Payor Type Medicare: 6
Census Payor Type Medicaid: 57
Census Payor Type Other: 20
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 0
May 24, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00406718.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00406718 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 87
SNF/NF beds: 83
SNF beds: 4
Medicare residents: 4
Medicaid residents: 48
Other payor residents: 35
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 18, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00403435 completed on March 22, 2023.
Findings
Maple Park Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00403435 completed on March 22, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 0
Apr 10, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00404838 and IN00405289.
Findings
No deficiencies related to the allegations in complaints IN00404838 and IN00405289 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00404838 and Complaint IN00405289 were investigated with no deficiencies cited related to the allegations.
Report Facts
Census: 85
Census Bed Type - SNF: 1
Census Bed Type - SNF/NF: 84
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 49
Census Payor Type - Other: 32
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 2
Mar 22, 2023
Visit Reason
The visit was conducted for the investigation of Complaints IN00403435 and IN00403818. Complaint IN00403435 resulted in federal/state deficiencies cited, while Complaint IN00403818 had no deficiencies related to the allegations.
Findings
The facility failed to ensure prescribed medications were acquired in a timely manner from the pharmacy for one resident and failed to ensure accurate and complete documentation of medication administration for three residents. Deficiencies were related to pharmacy services and resident records identifiable information.
Complaint Details
Complaint IN00403435 was substantiated with federal/state deficiencies cited at F755 (Pharmacy Services) and F842 (Resident Records - Identifiable Information). Complaint IN00403818 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure prescribed medications ordered by a physician were acquired from the facility pharmacy in a timely manner for 1 of 3 residents reviewed for pharmaceutical services (Resident B). | SS=D |
| Facility failed to ensure medications were accurately and completely documented on the Electronic Medication Administration Record (EMAR) for 3 of 3 residents reviewed (Residents B, C, and D). | SS=D |
Report Facts
Census: 85
SNF beds: 3
SNF/NF beds: 82
Medicare residents: 5
Medicaid residents: 51
Other payor residents: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Link | Executive Director | Signed report and plan of correction |
| DNS | Director of Nursing Services | Provided documents and interviews related to medication and pharmacy services deficiencies |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 0
Jan 24, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00399804 and IN00399974 at Maple Park Village.
Findings
Complaint IN00399804 was substantiated but no deficiencies related to the allegations were cited. Complaint IN00399974 was unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00399804 - Substantiated with no deficiencies cited. Complaint IN00399974 - Unsubstantiated due to lack of evidence.
Report Facts
Census Bed Type: 91
Census Payor Type: 91
Medicare residents: 5
Medicaid residents: 51
Other residents: 35
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 0
Jan 19, 2023
Visit Reason
This visit was conducted for the investigation of two complaints, IN00399481 and IN00399147.
Findings
Both complaints were substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00399481 - Substantiated with no deficiencies cited. Complaint IN00399147 - Substantiated with no deficiencies cited.
Report Facts
Census Bed Type - SNF/NF: 88
Census Bed Type - SNF: 4
Census Total: 92
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 52
Census Payor Type - Other: 36
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 6, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00396664 completed on December 15, 2022.
Findings
Maple Park Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00396664; paper compliance review completed and found in compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 6, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00394244 completed on November 21, 2022.
Findings
Maple Park Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00394244; paper compliance review completed; facility found in compliance.
Inspection Report
Life Safety
Census: 94
Capacity: 106
Deficiencies: 0
Jan 5, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 11/14/22 was performed to verify compliance with Life Safety Code requirements.
Findings
Maple Park Village was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire regulations, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinkled and had appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 106
Census: 94
Inspection Report
Complaint Investigation
Deficiencies: 4
Dec 15, 2022
Visit Reason
The inspection was conducted based on a complaint investigation related to failure to notify physicians and resident representatives timely about skin injuries and failure to report incidents as required by policy.
Findings
The facility failed to notify the physician and resident representative timely for two residents with burns, failed to report incidents according to the Long Term Care Incident Reporting Policy, and failed to develop and implement appropriate care plans and monitoring for a resident with a burn injury.
Complaint Details
Complaint IN00396664 regarding failure to notify and report skin injuries and burns, and failure to implement appropriate care plans and monitoring.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to notify physician and resident representative timely for burns sustained by residents. | SS=D |
| Failure to follow Long Term Care Incident Reporting Policy for reporting incidents involving burns. | SS=D |
| Failure to develop and implement a care plan with interventions to prevent future burns for a resident. | SS=D |
| Failure to notify wound nurse and monitor healing process of a burn injury. | SS=D |
Report Facts
Burn size: 12
Burn size: 13
Burn size: 4
Scar size: 0.8
Scar size: 0.6
Audit frequency: 5
Audit duration: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Voss | Executive Director | Interviewed and involved in findings related to notification and reporting failures. |
| RN 4 | Involved in incidents where burns occurred and failed to notify wound nurse or follow skin management program. | |
| DNS | Director of Nursing Services | Interviewed regarding incidents and failures in notification and reporting. |
| LPN 4 | Wound Nurse | Responsible for oversight of skin management program; was not notified timely of burn injury. |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 90
Deficiencies: 2
Nov 21, 2022
Visit Reason
This visit was for the investigation of complaints IN00394244 and IN00393266. Complaint IN00394244 was substantiated with related deficiencies cited, while complaint IN00393266 was unsubstantiated due to lack of evidence.
Findings
The facility failed to ensure appropriate assistive devices were used to prevent a fall for one resident, and failed to keep accurate fluid intake records for one resident on fluid restriction. Corrective actions and education were planned to address these deficiencies.
Complaint Details
Complaint IN00394244 was substantiated with federal/state deficiencies cited at F689 and F692. Complaint IN00393266 was unsubstantiated due to lack of evidence.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure appropriate assistive devices were used to prevent a fall for 1 of 3 residents reviewed for accidents (Resident C). | SS=D |
| Failed to keep accurate fluid intake records for 1 of 1 resident reviewed for a fluid restriction (Resident C). | SS=D |
Report Facts
Census: 90
Total Capacity: 90
Residents reviewed for accidents: 3
Residents reviewed for fluid restriction: 1
Fluid restriction amount: 1.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Voss | Executive Director | Signed the report |
| Director of Nursing | Interviewed regarding staff use of assistive devices and policies | |
| RN 1 | Interviewed regarding fluid intake documentation responsibilities | |
| RN 2 | Interviewed regarding fluid tracking and resident rights |
Inspection Report
Routine
Census: 89
Capacity: 106
Deficiencies: 14
Nov 14, 2022
Visit Reason
Routine Life Safety Code Recertification and Emergency Preparedness Survey conducted by the Indiana Department of Health in accordance with federal regulations.
Findings
The facility was found to be in compliance with Emergency Preparedness requirements but had multiple deficiencies related to Life Safety Code including corridor obstructions, exit discharge issues, exit signage, cooking facility staff training, sprinkler system maintenance, fire department connection signage, corridor door integrity, smoke barrier door functionality, electrical safety, fire drill documentation, smoking area maintenance, and improper use of power strips.
Severity Breakdown
SS=E: 10
SS=F: 4
Deficiencies (14)
| Description | Severity |
|---|---|
| Corridor width obstruction due to a large table not affixed to wall or floor. | SS=E |
| Exit discharge at Breezeway North Exit uneven and obstructed by fence. | SS=E |
| Exit signage confusion due to improper placement of 'Not an Exit' signs. | SS=E |
| Staff not properly instructed on use of UL 300 hood fire suppression system in kitchen. | SS=E |
| Fire department connection (FDC) lacked adequate directional signage. | SS=F |
| Sprinkler heads in kitchen were loaded or covered with dust. | SS=E |
| Corridor doors had holes and one door failed to latch properly, compromising smoke resistance. | SS=E |
| Smoke barrier doors did not close completely and latch. | SS=E |
| Electrical panels in corridors were unlocked and exposed wiring found in riser room. | SS=E |
| Missing documentation of fire drills for all second quarter shifts. | SS=F |
| Smoking areas not maintained; cigarette butts disposed on ground instead of in proper containers. | SS=F |
| Power strip used as substitute for fixed wiring to power microwave in Medical Records office. | SS=E |
| Power strip in resident room did not meet UL rating and was used for personal and medical equipment. | SS=E |
| Electrical outlet receptacle testing documentation not available for past 12 months. | SS=F |
Report Facts
Certified beds: 106
Census: 89
Residents potentially affected by corridor obstruction: 20
Residents potentially affected by exit discharge issue: 25
Residents potentially affected by exit signage issue: 25
Residents potentially affected by sprinkler head loading: 5
Residents potentially affected by corridor door holes: 8
Residents potentially affected by smoke barrier door issue: 24
Residents potentially affected by electrical panel issue: 12
Residents potentially affected by fire drill deficiency: all
Cigarette butts counted: 190
Residents potentially affected by improper power strip use: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed and acknowledged multiple findings including corridor obstruction, exit discharge, exit signage, sprinkler issues, electrical safety, and fire drill deficiencies. | |
| Executive Director | Present at exit conference and acknowledged findings. | |
| Dietary Manager | Received training on UL 300 hood system use. | |
| Maintenance Director | Responsible for fire drills and electrical testing compliance. |
Inspection Report
Re-Inspection
Census: 92
Deficiencies: 0
Nov 10, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on October 6, 2022, including a PSR to the Investigation of Complaint IN00388366 completed on October 6, 2022.
Findings
Maple Park Village 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 Recertification and State Licensure Survey and to the Investigation of Complaint IN00388366.
Complaint Details
Complaint IN00388366 was investigated and found to be corrected.
Report Facts
Census Bed Type: 92
SNF/NF beds: 85
SNF beds: 7
Census Payor Type: 92
Medicare residents: 5
Medicaid residents: 65
Other payor residents: 22
Inspection Report
Recertification
Census: 89
Deficiencies: 13
Oct 6, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00388366 and IN00390225.
Findings
Multiple deficiencies were cited including failure to assist residents with dignity during meals, improper medication administration, lack of comprehensive care plans, inadequate ADL assistance, pressure ulcer prevention failures, fall intervention lapses, catheter care issues, improper tube feeding practices, respiratory care deficiencies, medication storage errors, food safety violations, and unsanitary resident environment.
Complaint Details
Complaint IN00388366 was substantiated with federal/state deficiencies cited at F690 and F921. Complaint IN00390225 was unsubstantiated due to lack of evidence.
Severity Breakdown
SS=G: 2
SS=D: 10
SS=E: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Residents were assisted to eat in the dining room without dignity when staff stood over them during meals. | SS=D |
| Facility failed to ensure interdisciplinary team determined which medications may be self-administered and failed to obtain physician's order for bedside medications. | SS=D |
| Facility failed to ensure residents had current comprehensive person-centered care plans for enhanced barrier precautions and respiratory care for CPAP treatments. | SS=D |
| Facility failed to provide assistance with activities of daily living related to shaving and nail care. | SS=D |
| Facility failed to assess, monitor and implement interventions to prevent pressure ulcers from developing. | SS=D |
| Facility failed to ensure staff followed fall interventions for residents at risk for falls and sustained injuries. | SS=D |
| Facility failed to ensure residents received treatment and care in accordance with professional standards and notify physician with change of condition for catheter care. | SS=G |
| Facility failed to ensure head of bed was properly elevated during infusion of gastrostomy tube feeding and feeding equipment was labeled and dated. | SS=D |
| Facility failed to thoroughly assess and document resident's change in respiratory status, notify physician of respiratory distress, ensure BIPAP/CPAP availability and proper infection control measures for tracheostomy care. | SS=G |
| Facility failed to ensure medication error rate was less than 5%, with 6 errors out of 30 attempts. | SS=D |
| Facility failed to ensure medication carts and medications were secured to prevent resident access. | SS=D |
| Facility failed to ensure drinking cups were free of lime build up, meals were covered and protected during transport, and staff did not touch mouthpiece of straws with bare hands. | SS=E |
| Facility failed to provide a safe, clean, and comfortable interior environment for a resident's room, including dirty floors, stains, and soiled bedside table. | SS=D |
Report Facts
Census: 89
Medication error rate: 26.67
Falls: 69
Unwitnessed falls: 49
Residents served meals: 87
Medication carts unsecured: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Voss | Executive Director | Signed report and involved in interviews |
| Nurse Practitioner 22 | Nurse Practitioner | Interviewed regarding catheter care and respiratory care |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple care deficiencies and policies |
| Licensed Practical Nurse 25 | LPN | Observed administering medications and involved in respiratory care |
| Registered Nurse 24 | RN | Observed medication administration and respiratory care |
| Certified Nursing Assistant 6 | CNA | Observed touching straw tops during meal service |
| Director of Housekeeping | Director of Housekeeping | Interviewed regarding housekeeping staffing and cleaning |
| Infection Preventionist | Infection Preventionist | Interviewed regarding infection control and respiratory equipment |
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