Inspection Report Summary
The most recent inspection on March 21, 2025, identified a deficiency related to the failure to ensure immediate physician orders for wounds for a newly admitted resident. Earlier inspections showed a pattern of deficiencies involving resident care, including missed activities of daily living such as bathing, medication administration errors, and issues with infection control and documentation. Complaint investigations were mostly unsubstantiated or found no deficiencies, except for a few substantiated complaints related to ADL care and medication documentation. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s record shows some improvement in compliance with Life Safety Code requirements and follow-up on prior deficiencies, though care and medication management issues have recurred over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
15 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
257% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
100% occupied
Based on a March 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 23, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to prevent falls for 2 of 3 residents reviewed for accidents.
Complaint Details
This citation relates to intake 2697971. The complaint investigation found that the facility failed to prevent falls for 2 of 3 residents reviewed, with specific issues in care plan updates and supervision leading to falls.
Findings
The facility failed to prevent falls for two residents, Resident C and Resident D, due to inadequate supervision and failure to update care plans reflecting residents' needs and risks. Root causes of falls were identified and interventions were put in place, but lapses in care and fall prevention were noted.
Deficiencies (1)
Failure to ensure a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Report Facts
Residents reviewed for accidents: 3
Residents affected: 2
Fall dates: 3
Fall dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 2 | Licensed Practical Nurse | Interviewed regarding Resident C's falls and condition |
| MDS nurse | Minimum Data Set Nurse | Interviewed regarding Resident C's care plan and assessments |
| Facility Administrator | Provided facility Fall Management Policy dated 6/2025 |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Nov 21, 2025
Visit Reason
The inspection was conducted as an annual survey of North Park Nursing Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 7, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to concerns about the facility's failure to implement a resident's plan of care to reduce fall risk and failure to ensure proper infection prevention and control practices.
Complaint Details
This citation relates to complaint 1253631.
Findings
The facility failed to implement a resident's care plan intervention to reduce fall risk for one resident with recent falls and failed to ensure staff performed proper hand hygiene and sanitation during care for multiple residents. Staff did not perform hand hygiene between glove changes or after care, increasing infection risk.
Deficiencies (2)
Failed to implement a resident's plan of care for fall risk reduction for 1 of 3 residents reviewed for accidents.
Failed to ensure staff performed proper hand hygiene and sanitation during care for 3 of 4 resident care observations.
Report Facts
Residents affected: 1
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 2 | Interviewed regarding resident fall and observed providing wound care with improper disposal practices | |
| LPN 5 | Interviewed regarding fall interventions and documentation of refusals | |
| RN 4 | Interviewed regarding care plan refusals and documentation procedures | |
| Infection Preventionist Nurse | Provided policies and commented on hand hygiene practices | |
| CNA 2 | Observed providing incontinence care with improper hand hygiene | |
| CNA 9 | Observed providing incontinence care with improper hand hygiene | |
| CNA 10 | Observed providing incontinence care with improper hand hygiene | |
| Infection Control Preventionist (ICP) | Interviewed regarding glove use and hand hygiene policies |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 13, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to a fall incident involving Resident C, focusing on whether the facility followed the resident's plan of care to prevent accidents.
Complaint Details
This citation relates to Complaint IN00461103. The complaint involved failure to follow the resident's fall prevention plan of care, resulting in a fall during transfer with insufficient staff assistance.
Findings
The facility failed to prevent accidents for 1 of 3 residents reviewed for falls. Specifically, the plan of care was not followed during a transfer of Resident C to a weight chair, resulting in a fall. The resident required two staff assists for transfers, but only one staff member assisted at the time of the fall.
Deficiencies (1)
Failed to ensure nursing home area was free from accident hazards and provide adequate supervision to prevent accidents for Resident C during transfer to weight chair.
Report Facts
Residents reviewed for falls: 3
Residents affected: 1
Staff assist required for transfers: 2
Date of fall incident: Jun 9, 2025
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 21, 2025
Visit Reason
The inspection was conducted due to a complaint (Complaint IN00455053) regarding the facility's failure to ensure a newly admitted resident had immediate doctor's orders for wound care.
Complaint Details
This citation relates to Complaint IN00455053. The complaint was substantiated as the facility failed to ensure immediate physician orders for wound care for a newly admitted resident.
Findings
The facility failed to provide immediate physician orders for wound care for Resident B upon admission. The resident had multiple pressure injuries and bruises documented, but the orders were delayed. The Director of Nursing and Infection Prevention Nurse were new and initially misinterpreted skin issues, leading to delayed skin event documentation. The facility's policies on skin integrity and wound management were reviewed and provided during the investigation.
Deficiencies (1)
Failed to provide doctor's orders for the resident's immediate care at the time the resident was admitted for wounds.
Report Facts
Deficiencies cited: 1
Bruise size: 1
Abrasion size: 4
Abrasion width: 3
Wound size length: 11
Wound size width: 6
Wound assessment right heel length: 1.5
Wound assessment right heel width: 1
Wound assessment right heel depth: 0.1
Wound assessment left foot length: 11.2
Wound assessment left foot width: 9.5
Wound assessment left foot depth: 0.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 2 | Registered Nurse | Indicated the process for skin assessment and notification of physician and Assistant Director of Nursing on new resident admission. |
| DON | Director of Nursing | Indicated involvement in Resident B's admission and acknowledged initial misunderstanding of skin issues; provided current skin management policy. |
| Regional Nurse Consultant | Nurse Consultant | Provided current policy on alterations in skin integrity and wound management during the investigation. |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 96
Deficiencies: 1
Date: Mar 21, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00455053 regarding federal and state deficiencies related to admission physician orders for immediate care.
Complaint Details
Complaint IN00455053 was substantiated with federal/state deficiencies cited at F635 related to admission physician orders for immediate care for wounds.
Findings
The facility failed to ensure a newly admitted resident (Resident B) had immediate physician orders for wounds. The investigation revealed documentation and treatment delays for skin integrity issues upon admission, with Resident B discharged prior to correction. The facility has implemented corrective actions including audits, staff in-service, and monitoring to prevent recurrence.
Deficiencies (1)
Failed to ensure a newly admitted resident had immediate orders for wounds.
Report Facts
Census: 96
Total Capacity: 96
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Branning | Executive Director | Signed the report |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 21, 2025
Visit Reason
Paper compliance review completed for the Investigation of Complaints IN00455053.
Complaint Details
Investigation of Complaints IN00455053 was completed and found the facility in compliance.
Findings
North Park Nursing Center was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Investigation of Complaints IN00455053.
Inspection Report
Re-Inspection
Census: 91
Capacity: 103
Deficiencies: 0
Date: Nov 25, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 09/10/24 was performed to verify compliance with fire safety and licensure requirements.
Findings
At this PSR to the Life Safety Code survey, North Park Nursing Center 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 sprinklered except for four detached wood framed sheds used for storage.
Inspection Report
Re-Inspection
Census: 82
Deficiencies: 0
Date: Oct 24, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on August 29, 2024, including a PSR to the Investigation of Complaint IN00435599 completed on August 29, 2024.
Complaint Details
Complaint IN00435599 was investigated and found to be corrected.
Findings
North Park Nursing Center 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 the PSR to the Investigation of Complaint IN00435599.
Report Facts
Census Bed Type - SNF: 3
Census Bed Type - NF: 79
Total Census: 82
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 69
Census Payor Type - Other: 12
Inspection Report
Life Safety
Census: 78
Capacity: 103
Deficiencies: 5
Date: Sep 10, 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
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies included mixed types of sprinkler heads in multiple areas, obstruction of sprinkler spray patterns due to storage, failure to maintain automatic sprinkler systems including overdue replacement of sprinkler heads, ceiling penetrations near sprinkler heads, and sprinkler piping supporting non-system components.
Deficiencies (5)
Facility failed to ensure only one type of sprinkler head was installed in multiple activity and dining areas.
Facility failed to ensure spray pattern for sprinkler heads were not obstructed in basement central storage room.
Facility failed to maintain automatic sprinkler systems per NFPA 25; 8 sprinkler heads needed replacement and had not been replaced.
Facility failed to maintain ceiling construction around sprinkler heads, with penetrations observed near dryers, washer, and water heater.
Facility failed to maintain sprinkler piping free from external loads; cables were resting on sprinkler pipe in attic.
Report Facts
Certified beds: 103
Census: 78
Sprinkler heads needing replacement: 8
Sprinkler heads observed in B hall activity room: 6
Sprinkler heads in E hall: 9
Sprinkler heads in D hall dining/activities: 10
Sprinkler heads in C hall dining/activities: 7
Cables resting on sprinkler pipe: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Branning | Executive Director | Named in exit conference and report signature |
| Maintenance Director | Interviewed and involved in observations and corrective actions |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 29, 2024
Visit Reason
The inspection was conducted due to a complaint investigation related to medication administration practices, specifically concerning insulin administration by unqualified staff and a significant medication error involving insulin overdose.
Complaint Details
The citation relates to complaint IN00435599. The complaint involved unqualified QMAs administering insulin and a significant medication error where a resident without diabetes was given an insulin overdose.
Findings
The facility failed to ensure that Qualified Medication Aides (QMAs) who were not insulin certified administered insulin to residents without proper physician orders or nurse notification. Additionally, a resident without diabetes received an insulin overdose resulting in a significant change in condition requiring emergency hospital care.
Deficiencies (2)
Staff failed to ensure only qualified personnel administered insulin; QMAs administered insulin without certification and held insulin without physician order or nurse notification for 3 residents.
A resident without diabetes received an overdose of rapid-acting and long-acting insulins, resulting in a significant change in condition requiring emergent intensive care.
Report Facts
Residents reviewed for insulin administration: 6
Insulin overdose units: 45
Insulin overdose units: 12
Blood sugar levels: 49
Blood sugar levels: 47
Blood sugar levels: 110
Blood sugar levels: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| QMA 8 | Qualified Medication Aide | Administered insulin without certification and prepared insulin doses involved in medication error |
| QMA 12 | Qualified Medication Aide | Administered insulin without certification and held insulin without physician notification |
| QMA 6 | Qualified Medication Aide | Administered insulin without certification |
| RN 32 | Registered Nurse | Administered insulin doses prepared by QMA 8 leading to insulin overdose in Resident L |
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Aug 29, 2024
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements including care planning, medication administration, activities of daily living assistance, infection control, and other resident care standards.
Complaint Details
This citation relates to complaint IN00435599.
Findings
The facility was found deficient in multiple areas including failure to complete care plan conferences, unqualified staff administering insulin, inadequate assistance with activities of daily living such as showering, incomplete assessments for residents on diuretics, inaccurate nurse staffing postings, significant medication errors including insulin overdose, improper medication storage and labeling, serving food at improper temperatures, unsanitary food preparation practices, incomplete medication administration documentation, and failure to perform proper hand hygiene and equipment disinfection.
Deficiencies (11)
Failed to ensure care plan conferences were completed for 3 of 3 residents reviewed.
Qualified Medication Aides who were not insulin certified administered insulin and held insulin without physician order or nurse notification for 3 of 6 residents reviewed.
Failed to ensure residents dependent on staff for ADL were showered for 2 of 2 residents reviewed.
Failed to ensure through assessments were completed for 1 of 1 residents receiving a diuretic; daily weights were not obtained as ordered.
Failed to post accurate actual hours worked for licensed and unlicensed nursing staff per shift daily for 5 of 7 days.
Resident received an overdose of rapid-acting and long-acting insulins resulting in a significant change in condition requiring emergent intensive care.
Failed to ensure medications were properly stored and labeled in 2 of 6 medication carts and 2 of 2 treatment carts observed.
Failed to ensure food was served at palatable temperatures for 1 of 1 trays tested.
Dishwasher temperatures did not reach required levels; hairnets did not cover all hair; staff touched food with bare hands.
Failed to ensure documentation was complete for 5 of 6 residents reviewed for medications; medications were not documented as given.
Failed to ensure staff performed proper hand hygiene and disinfection of equipment during 2 of 2 random observations of resident care.
Report Facts
Residents affected: 3
Residents affected: 3
Residents affected: 2
Residents affected: 1
Days with inaccurate nurse staffing postings: 5
Insulin overdose units: 45
Insulin overdose units: 12
Dishwasher final rinse temperature: 173
Dishwasher final rinse temperature range: 168-178
Food temperatures: 114
Food temperatures: 109
Food temperatures: 55.5
Food temperatures: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| QMA 8 | Qualified Medication Aide | Named in insulin administration and medication error findings. |
| QMA 12 | Qualified Medication Aide | Named in insulin administration findings. |
| QMA 6 | Qualified Medication Aide | Named in insulin administration findings. |
| RN 32 | Registered Nurse | Named in insulin medication error finding. |
| CNA 18 | Certified Nursing Aide | Named in infection control and hand hygiene findings. |
| CNA 4 | Certified Nursing Aide | Named in infection control and hand hygiene findings. |
| LPN 27 | Licensed Practical Nurse | Named in infection control and hand hygiene findings. |
| RN 37 | Registered Nurse | Interviewed regarding medication storage and labeling. |
| Dietary Manager | Interviewed regarding food temperatures and food preparation practices. | |
| Administrator | Provided multiple policies and interviewed regarding various findings. | |
| Clinical Support 5 | Interviewed regarding insulin administration and infection control. | |
| Clinical Support 7 | Interviewed regarding insulin administration. | |
| Director of Nursing | Director of Nursing | Interviewed regarding insulin administration, medication documentation, and infection control. |
Inspection Report
Annual Inspection
Census: 83
Deficiencies: 11
Date: Aug 29, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00435599 and IN00439126.
Complaint Details
Complaint IN00435599 resulted in federal/state deficiencies related to allegations cited at F659 and F760. Complaint IN00439126 had no deficiencies related to the allegations.
Findings
The facility was found deficient in multiple areas including failure to complete care plan conferences, unqualified staff administering insulin, inadequate ADL care, missed medication documentation, improper medication storage and labeling, food served at improper temperatures, inadequate infection control practices, and inaccurate nurse staffing postings.
Deficiencies (11)
Failed to ensure care plan conferences were completed for 3 of 3 residents reviewed.
Staff not qualified to administer insulin; QMAs administered insulin without certification or physician orders.
Failed to ensure residents dependent on staff for ADL were showered as scheduled.
Failed to ensure daily weights were obtained as ordered for a resident receiving diuretics.
Failed to post accurate nurse staffing data for 5 of 7 days during the survey period.
Resident received significant medication error resulting in insulin overdose and hospitalization.
Medications were not properly stored and labeled in medication and treatment carts.
Food was served at temperatures below palatable levels.
Dishwasher temperatures did not consistently meet required levels; staff failed to wear proper hairnets and gloves when handling food.
Medication administration documentation was incomplete for 5 of 6 residents reviewed.
Failed to ensure proper hand hygiene and equipment disinfection during resident care.
Report Facts
Survey dates: August 21, 22, 23, 26, 27, 28, & 29, 2024
Resident census: 83
Medication errors: 1
Missed medication documentation: 5
Dishwasher final rinse temperature: 173
Dishwasher final rinse temperature range: 168-178
Employees mentioned
| Name | Title | Context |
|---|---|---|
| QMA 8 | Qualified Medication Aide | Named in insulin administration and medication error findings |
| RN 32 | Registered Nurse | Named in insulin medication error finding |
| CNA 18 | Certified Nursing Aide | Named in infection control and hand hygiene deficiency |
| CNA 4 | Certified Nursing Aide | Named in infection control and hand hygiene deficiency |
| LPN 27 | Licensed Practical Nurse | Named in infection control deficiency |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 0
Date: Mar 22, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00429148.
Complaint Details
Complaint IN00429148 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations are cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the complaint investigation.
Report Facts
Census: 89
Census Bed Type - SNF/NF: 84
Census Bed Type - SNF: 5
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 72
Census Payor Type - Other: 16
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 1, 2024
Visit Reason
Paper compliance review completed for the Investigation of Complaints IN00426893 completed on January 30, 2024.
Complaint Details
Investigation of Complaints IN00426893 completed on January 30, 2024; facility found in compliance.
Findings
North Park Nursing Center was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Investigation of Complaints IN00426893.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 30, 2024
Visit Reason
The inspection was conducted in response to a complaint alleging failure to provide adequate activities of daily living (ADL) care, specifically bathing, to residents.
Complaint Details
This citation relates to Complaint IN00426893.
Findings
The facility failed to provide adequate bathing care to 3 of 3 residents reviewed (Residents B, C, and D). Documentation and interviews revealed missed showers, incomplete bathing, and inconsistent shower attempts or refusals not properly documented. The facility lacked a specific bathing or ADL policy, and some shower refusals were not properly signed or initialed by staff or residents.
Deficiencies (1)
Failure to provide care and assistance to perform activities of daily living, specifically bathing, for residents who are unable.
Report Facts
Residents affected: 3
Shower days scheduled: 2
Shower refusals: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Interviewed regarding shower refusal procedures |
| DON | Director of Nursing | Provided information about facility policies and bathing procedures |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 1
Date: Jan 29, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00426893 regarding allegations of deficient care related to activities of daily living (ADL) for dependent residents.
Complaint Details
Complaint IN00426893 was substantiated with federal/state deficiencies cited at F677 related to failure to provide necessary ADL care including bathing for dependent residents.
Findings
The facility failed to provide adequate ADL care, specifically bathing, for 3 of 3 residents reviewed (Residents B, C, and D). Residents reported missed showers or bed baths, and documentation showed inconsistencies in shower attempts and refusals. The facility lacked a specific bathing policy and had deficiencies in ensuring residents received scheduled showers or baths.
Deficiencies (1)
Failed to provide ADL care, specifically bathing, to 3 of 3 residents reviewed.
Report Facts
Census: 92
SNF beds: 9
SNF/NF beds: 83
Medicare residents: 3
Medicaid residents: 63
Other payor residents: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandie Snyder | DNS | Named as Laboratory Director or Provider/Supplier Representative |
| CNA 1 | Interviewed regarding shower refusal and reattempt procedures | |
| DON | Director of Nursing | Interviewed regarding facility policies on bathing and ADLs |
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 0
Date: Dec 12, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00421803 at North Park Nursing Center.
Complaint Details
Complaint IN00421803 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations in Complaint IN00421803 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 90
Census Bed Type - SNF/NF: 84
Census Bed Type - SNF: 6
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 67
Census Payor Type - Other: 17
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 0
Date: Nov 2, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00420099 and IN00420003 at North Park Nursing Center.
Complaint Details
Complaint IN00420099: No deficiencies related to the allegations were cited. Complaint IN00420003: No deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations in complaints IN00420099 and IN00420003 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 87
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 67
Census Payor Type - Other: 16
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 12, 2023
Visit Reason
Paper compliance review completed for the Investigation of Complaints IN00416094.
Complaint Details
Investigation of Complaints IN00416094 completed on October 12, 2023; facility found in compliance.
Findings
North Park Nursing Center was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Investigation of Complaints IN00416094.
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Oct 12, 2023
Visit Reason
The inspection was conducted in response to a complaint (IN00416094) regarding medication administration documentation at North Park Nursing Center.
Complaint Details
This Federal tag relates to Complaint IN00416094.
Findings
The facility failed to ensure accurate and complete documentation on the Electronic Medication Administration Record (EMAR) for 5 of 7 residents reviewed. Multiple medications were not documented as given on various dates, indicating a failure in medication administration record-keeping.
Deficiencies (6)
Failure to document administration of clonazepam and hydrocodone-acetaminophen for Resident D on 8/23/23.
Failure to document administration of insulin glargine, hydralazine, metoprolol tartate, and sodium chloride for Resident E on multiple dates.
Failure to document administration of senna and tizanidine for Resident F on 10/8/23.
Failure to document administration of multiple medications including insulin, lisinopril, medroxyprogesterone, melatonin, trazodone, zoloft, metoprolol succinate, metformin for Resident H on 10/8/23.
Failure to document administration of multiple medications including atorvastatin, budesonide, colace, Eliquis, formoterol fumarate, hydrocodone-acetaminophen for Resident J on 10/8/23.
Failure to document administration of loratadine, metaprolol tartrate, polyethylene glycol, tamsulosin, triamcinolone acetonide cream for various residents on 10/8/23.
Report Facts
Residents reviewed for medications: 7
Residents affected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| interim DON | Indicated the facility had issues with medication documentation on EMAR | |
| Administrator | Indicated nurses are supposed to document medications given on EMAR and provided current medication administration policy | |
| LPN 1 | Indicated medications given are supposed to be signed off as given on the EMAR |
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 1
Date: Oct 12, 2023
Visit Reason
This visit was for the investigation of complaints IN00416094, IN00418489, and IN00417966. Deficiencies related to complaint IN00416094 were cited, while no deficiencies were found related to the other complaints.
Complaint Details
Complaint IN00416094 had federal/state deficiencies related to the allegations cited at F842. Complaints IN00418489 and IN00417966 had no deficiencies related to the allegations.
Findings
The facility failed to ensure accurate and complete documentation on the Electronic Medication Administration Record (EMAR) for 5 of 7 residents reviewed. Several medication doses were not documented as given on multiple dates for residents D, E, F, H, and J.
Deficiencies (1)
Failure to ensure accurate and complete documentation on the EMAR for medication administration for 5 of 7 residents reviewed.
Report Facts
Residents reviewed for medication documentation: 7
Residents affected: 5
Total census: 88
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Heidorn-kofler | Executive Director | Signed the report |
| Interim Director of Nursing | Interviewed regarding medication documentation issues | |
| LPN 1 | Licensed Practical Nurse | Interviewed regarding medication documentation on EMAR |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 0
Date: Aug 9, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00413554.
Complaint Details
Investigation of Complaint IN00413554 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00413554 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type Total: 93
Census Payor Type Medicaid: 73
Census Payor Type Other: 20
Census Payor Type Medicare: 0
Inspection Report
Re-Inspection
Census: 88
Deficiencies: 0
Date: Jul 6, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 2023-05-25.
Findings
North Park Nursing Center 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.
Report Facts
Census Bed Type - SNF/NF: 5
Census Bed Type - SNF: 83
Census Bed Type - Total: 88
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 70
Census Payor Type - Other: 17
Census Payor Type - Total: 88
Inspection Report
Life Safety
Census: 87
Capacity: 103
Deficiencies: 0
Date: Jun 21, 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 in accordance with 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
The facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility is fully sprinklered except for four detached wood framed sheds used for storage, and has a fire alarm system with hard wired smoke detectors and battery operated smoke alarms in resident sleeping rooms.
Report Facts
Certified beds: 103
Census: 87
Inspection Report
Routine
Deficiencies: 8
Date: May 25, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication self-administration, resident dignity, notification of changes, resident privacy, fall prevention, medication storage, food storage, and infection control practices.
Findings
The facility was found deficient in multiple areas including failure to assess and order medication self-administration for residents, failure to maintain resident dignity and privacy, failure to timely notify family representatives of incidents, inadequate supervision and fall prevention leading to a resident's fracture, improper storage of medications and food, and lapses in infection control practices such as glove use and cleaning of glucometers.
Deficiencies (8)
Failed to ensure residents self-administering medications were assessed and had physician orders for self-administration (Residents 36 and 51).
Failed to maintain resident dignity during incontinence care and meal assistance (Residents 62, 41, 75, 70, 31).
Failed to provide timely notification of change to resident representatives after incidents including falls and doctor changes (Residents 62, 35).
Failed to maintain resident privacy during medication administration, incontinence care, and computer use (Residents 346, 62).
Failed to provide adequate supervision and consistent fall prevention interventions resulting in a fracture to Resident 31.
Failed to ensure proper storage of medications; loose pills found in medication carts (Cottage Unit, A Hall, F Hall).
Failed to ensure food was stored appropriately; unlabeled and undated food items found in dry storage, walk-in freezer, and kitchen shelves.
Failed to follow infection control practices including glove use and proper cleaning of glucometers (Residents 62, 29, Hall A medication cart).
Report Facts
Deficiencies cited: 8
Fall events: 5
Medication cart loose pills: 29
Food storage issues: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 3 | LPN | Observed administering insulin without privacy and cleaning glucometers improperly. |
| Certified Nurse Aide 25 | CNA | Observed failing to maintain resident dignity and privacy, and improper glove use during incontinence care. |
| Qualified Medication Aide 54 | QMA | Observed assisting with incontinence care and involved in dignity issues. |
| Director of Nursing | DON | Provided facility policies and interviews regarding deficiencies and corrective actions. |
| Registered Nurse 23 | RN | Provided interviews regarding fall prevention and glucometer cleaning. |
| Licensed Practical Nurse 5 | LPN | Observed performing wound care without changing gloves. |
| Administrator | Administrator | Interviewed regarding privacy and notification policies. |
| Infection Preventionist | Infection Preventionist | Interviewed regarding infection control practices and glove use. |
Inspection Report
Annual Inspection
Census: 88
Deficiencies: 8
Date: May 25, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including investigation of Complaints IN00403761 and IN00404545.
Complaint Details
Complaint IN00403761 and IN00404545 were investigated with no deficiencies related to the allegations cited.
Findings
The facility was found deficient in multiple areas including failure to assess residents for medication self-administration, failure to maintain resident dignity during care and dining, failure to notify representatives timely of changes or incidents, failure to maintain resident privacy, inadequate supervision to prevent falls resulting in injury, improper medication storage, improper food storage and labeling, and lapses in infection control practices including glove use and glucometer cleaning.
Deficiencies (8)
Failed to ensure residents self-administering medications were assessed and had orders for self-administration.
Failed to maintain resident dignity during incontinence care and meal service.
Failed to notify resident representatives timely of accidents and changes in physician.
Failed to maintain resident privacy during medication administration, incontinence care, and with computer screens displaying resident information.
Failed to ensure adequate supervision and consistent implementation of fall prevention interventions, resulting in a fall with fracture.
Failed to ensure proper storage of medications; loose pills found in medication carts.
Failed to ensure food was stored appropriately; unlabeled and undated food items found in kitchen storage and freezer.
Failed to ensure infection control practices; improper glove use during incontinence care and wound care, and improper cleaning of glucometers.
Report Facts
Census: 88
Survey dates: 5
Deficiencies cited: 8
Residents observed for medication self-administration: 2
Residents observed for dignity: 4
Residents reviewed for notification: 5
Residents observed for privacy: 4
Residents reviewed for falls: 3
Medication carts observed: 3
Food storage observations: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 25 | Certified Nurse Aide | Named in dignity, privacy, and infection control findings |
| QMA 54 | Qualified Medication Aide | Named in dignity, privacy, and infection control findings |
| DON | Director of Nursing | Interviewed regarding multiple findings including medication self-administration, dignity, notification, privacy, and infection control |
| LPN 3 | Licensed Practical Nurse | Observed and interviewed regarding medication storage and glucometer cleaning |
| RN 7 | Registered Nurse | Observed and interviewed regarding glucometer cleaning and privacy |
| RN 23 | Registered Nurse | Interviewed regarding notification and fall prevention |
| LPN 5 | Licensed Practical Nurse | Observed and interviewed regarding wound care and glove use |
| Dietary Manager | Interviewed regarding food storage and labeling | |
| Administrator | Interviewed regarding privacy and notification policies | |
| Social Services Director | Interviewed regarding notification of resident representative |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 0
Date: Feb 1, 2023
Visit Reason
This visit was conducted for the investigation of complaint IN00399823.
Complaint Details
Complaint IN00399823 was substantiated but no deficiencies related to the allegations were cited.
Findings
The complaint IN00399823 was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 92
Medicare residents: 5
Medicaid residents: 73
Other payor residents: 14
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 0
Date: Jan 20, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00398749 and IN00396715.
Complaint Details
Complaint IN00398749 - Substantiated with no deficiencies cited. Complaint IN00396715 - Unsubstantiated due to lack of evidence.
Findings
Complaint IN00398749 was substantiated but no deficiencies related to the allegations were cited. Complaint IN00396715 was unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 94
SNF beds: 12
SNF/NF beds: 82
Medicare residents: 8
Medicaid residents: 73
Other payor residents: 13
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 0
Date: Aug 18, 2022
Visit Reason
This visit was conducted for the investigation of two complaints, IN00369712 and IN00385991.
Complaint Details
Complaint IN00369712 - Substantiated with no deficiencies cited. Complaint IN00385991 - Substantiated with no deficiencies cited.
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.
Report Facts
Census Bed Type: 91
Census Payor Type - Medicare: 68
Census Payor Type - Medicaid: 4
Census Payor Type - Other: 19
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