Inspection Reports for
Oak Grove Christian Retirement Village
221 W DIVISION ST, DEMOTTE, IN, 46310
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
36.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
764% worse than Indiana average
Indiana average: 4.2 deficiencies/year
Deficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
63% occupied
Based on a June 2025 inspection.
Occupancy rate over time
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Sep 22, 2025
Visit Reason
Annual inspection survey conducted to assess compliance with healthcare regulations and standards at Oak Grove Christian Retirement Village.
Findings
The facility had multiple deficiencies including failure to ensure proper medication self-administration assessments, inaccurate Minimum Data Set (MDS) assessments, incomplete care plans for residents with weight loss and medication needs, inadequate assistance with activities of daily living, improper treatment of constipation and skin conditions, failure to perform respiratory assessments, untimely posting of nurse staffing information, lack of individualized dementia care planning, unsanitary food handling practices, lapses in infection control practices, and inadequate antibiotic stewardship.
Deficiencies (12)
F 0554: The facility failed to ensure residents were assessed and had physician orders for self-administration of medications for 2 residents.
F 0641: The facility failed to ensure accurate MDS assessments related to antiplatelet and antianxiety medications for 1 resident.
F 0656: The facility failed to develop and implement comprehensive care plans for residents with significant weight loss and medication needs for 2 residents.
F 0677: The facility failed to provide twice weekly showers for a resident dependent on staff for activities of daily living.
F 0684: The facility failed to address signs and symptoms of constipation, complete skin treatments, and apply compression stockings as ordered for 3 residents.
F 0686: The facility failed to ensure wound care was performed according to physician orders for 1 resident with a pressure ulcer.
F 0695: The facility failed to assess a resident before, during, and after nebulizer treatments for effectiveness.
F 0732: The facility failed to post daily nurse staffing information in a timely manner.
F 0744: The facility failed to provide individualized dementia care plans and complete activity assessments for 2 residents.
F 0812: The facility failed to serve food under sanitary conditions including improper storage and uncovered food during transport.
F 0880: The facility failed to follow infection control guidelines including hand hygiene with glove changes and PPE use in an Enhanced Barrier Precaution room.
F 0881: The facility failed to implement an antibiotic stewardship program ensuring appropriate antibiotic use for 2 residents treated for urinary tract infections without documented indications.
Report Facts
Residents affected: 2
Residents affected: 16
Residents affected: 2
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 62
Residents affected: 2
Residents affected: 62
Residents affected: 2
Residents affected: 2
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 13, 2025
Visit Reason
The inspection was conducted in response to complaints regarding medication administration and respiratory care at Oak Grove Christian Retirement Village.
Complaint Details
The inspection relates to Complaint 2587154 regarding medication administration and oxygen therapy issues, and Complaint 2567618 regarding respiratory care deficiencies.
Findings
The facility failed to ensure medications were administered as ordered for one resident and failed to provide safe and appropriate respiratory care, including oxygen administration and monitoring, for two residents. Additionally, the facility did not maintain complete and accurate clinical records for medications and oxygen administered for two residents.
Deficiencies (3)
F 0684: The facility failed to administer medications as ordered for Resident C, including holding metoprolol tartrate without proper vital sign documentation.
F 0695: The facility failed to provide safe respiratory care for Residents B and D, including failure to check and maintain oxygen tanks, lack of respiratory assessments, and inadequate oxygen saturation monitoring.
F 0842: The facility failed to maintain complete and accurate clinical records related to medications and oxygen administration for Residents B and C, including missing documentation on Medication Administration Records.
Report Facts
Medication administration dates with held doses: 7
Oxygen saturation levels: 78
Oxygen saturation levels: 76
Oxygen saturation levels: 84
Medication Administration Record missing documentation dates: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration issues and missing documentation. |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding oxygen tank issues and respiratory care for Resident B. |
Inspection Report
Re-Inspection
Census: 57
Capacity: 91
Deficiencies: 0
Date: Jun 10, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00455274 completed on 2025-05-07.
Complaint Details
Complaint IN00455274 was investigated and found to be corrected.
Findings
Oak Grove Christian Retirement 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 Investigation of Complaint IN00455274.
Report Facts
Census Bed Type - SNF/NF: 34
Census Bed Type - SNF: 23
Census Bed Type - Residential: 34
Total Capacity: 91
Census Payor Type - Medicare: 14
Census Payor Type - Medicaid: 28
Census Payor Type - Other: 15
Current Census: 57
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 7, 2025
Visit Reason
The inspection was conducted in response to Complaint IN00455274 concerning quality of care and accident prevention for residents at the facility.
Complaint Details
This citation relates to Complaint IN00455274. The complaint involved failure to assess and monitor a resident with fractures and inadequate supervision leading to a fall and injury of another resident.
Findings
The facility failed to ensure proper assessment and monitoring of a resident with fractures after an incident, and failed to provide adequate supervision to prevent falls, resulting in injuries to two residents.
Deficiencies (2)
F0684: The facility failed to ensure a resident with new fractures was thoroughly and frequently assessed upon returning from the emergency room.
F0689: The facility failed to ensure proper assistance during transfers, causing fractures to a resident, and failed to adequately supervise a high fall-risk resident, resulting in a fall with head injury.
Report Facts
Residents reviewed for quality of care: 3
Staples placed on resident's head laceration: 5
Bruise size: 2
Medication dosage: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Agency CNA 1 | Named in transfer incident causing fractures to resident | |
| CNA 2 | Named in fall incident involving resident left unattended in bathroom | |
| CNA 3 | Reported bruising to resident's right shin and involved in transfer observations | |
| LPN 4 | Assessed resident's swollen area and interviewed regarding incident |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 86
Deficiencies: 2
Date: May 6, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00455274, which involved federal and state deficiencies related to allegations of inadequate resident care and supervision.
Complaint Details
Complaint IN00455274 was substantiated with federal and state deficiencies cited at tags F684 and F689 related to quality of care and accident prevention.
Findings
The facility failed to ensure proper assessments were completed for a resident with new fractures following a facility incident, failed to prevent injury during resident transfers by agency staff, and failed to adequately supervise a high-risk resident resulting in a fall with head injury. Multiple deficiencies related to quality of care and accident prevention were cited.
Deficiencies (2)
Failure to ensure a resident with new fractures received thorough and frequent assessments following return from the hospital.
Failure to provide proper assistance during transfer causing pain and fractures to a resident, and failure to adequately supervise a high-risk resident resulting in a fall with head laceration.
Report Facts
Census SNF/NF beds: 43
Census SNF beds: 10
Census Residential beds: 33
Total licensed capacity: 86
Census Medicare residents: 10
Census Medicaid residents: 29
Census Other payor residents: 14
Total census residents: 53
Staples for head laceration: 5
Bruise size: 2
Bruise size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beth Ingram | Administrator | Signed plan of correction and provided statements regarding agency staff orientation and facility policies |
| Agency CNA 1 | Agency CNA involved in improper transfer causing resident injury; placed on 'do not return' status | |
| CNA 2 | CNA involved in resident fall in bathroom resulting in head laceration | |
| CNA 3 | Reported bruising on resident's right shin and alerted nurse | |
| LPN 4 | Assessed resident's swollen right leg and provided statement regarding incident |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 21, 2025
Visit Reason
Paper compliance review to the Post Survey Revisit (PSR) completed on 12/5/24 related to the Recertification and State Licensure survey completed on 10/22/24.
Findings
Oak Grove Christian Retirement 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 PSR to the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 48
Capacity: 73
Deficiencies: 1
Date: Jan 8, 2025
Visit Reason
A Fire Safety Evaluation (FSES) Survey and a Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with NFPA 101A and Life Safety Code requirements.
Findings
The facility was found in compliance with NFPA 101A Chapter 4 and Life Safety Code requirements, achieving a passing score on the FSES survey. However, a deficiency was noted regarding the lack of a 2-hour fire resistive separation between the first floor Healthcare Occupancy and the second floor Assisted Living areas, which was acknowledged by the Plant Manager and subsequently corrected.
Deficiencies (1)
Facility failed to provide a 2-hour fire resistive barrier separating the first floor Healthcare Occupancy from the second floor Assisted Living areas as required by LSC Section 19.1.3.3.
Report Facts
Facility capacity: 73
Census: 48
Power generator capacity: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Plant Manager | Interviewed regarding fire resistive barrier deficiency and acknowledged awareness of the issue |
Inspection Report
Re-Inspection
Census: 54
Capacity: 84
Deficiencies: 5
Date: Dec 5, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey and the Investigation of Complaint IN00442131 completed on October 22, 2024. The visit included the PSR to the State Residential Licensure Survey completed on October 22, 2024.
Complaint Details
Complaint IN00442131 was investigated and corrected as of this revisit.
Findings
The facility had deficiencies related to infection prevention and control, failure to complete semi-annual evaluations, failure to update service plans for urinary catheter management and glucose monitoring, incomplete medical diagnoses in resident records, and incomplete resident emergency binders. The facility implemented plans of correction including re-education of staff and auditing procedures to prevent recurrence.
Deficiencies (5)
Failed to ensure infection control guidelines were in place and implemented related to hand hygiene and glove use during wound treatment for 1 of 1 treatment observed.
Failed to ensure a semi-annual evaluation was completed for 1 of 3 resident records reviewed (Resident 3).
Failed to ensure Service Plans were updated related to urinary catheter management and glucose monitoring for 2 of 3 resident records reviewed (Residents 2 and 5).
Failed to ensure a resident's record was accurate and complete related to lack of medical diagnoses for 1 of 3 records reviewed (Resident 3).
Failed to ensure the resident Emergency Binder contained all necessary information for 3 of 5 residents reviewed (Residents 2, 3, and 4).
Report Facts
Census Bed Type - SNF/NF: 44
Census Bed Type - SNF: 10
Census Bed Type - Residential: 30
Total Licensed Capacity: 84
Census Payor Type - Medicare: 10
Census Payor Type - Medicaid: 28
Census Payor Type - Other: 16
Total Census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beth Ingram | VP of Operations | Signed plan of correction and mentioned in report |
| Beth Ingram | Administrator | Signed report and mentioned in interviews |
| Director of Nursing | Interviewed regarding infection control and record deficiencies |
Inspection Report
Life Safety
Census: 48
Capacity: 73
Deficiencies: 4
Date: Oct 28, 2024
Visit Reason
The Indiana State Department of Health conducted a Life Safety Code Recertification and State Licensure Survey on 10/28/2024 to assess compliance with 42 CFR 483.90(a) and NFPA 101 Life Safety Code standards.
Findings
The facility was found not in compliance with Life Safety Code requirements, including inadequate fire separation between healthcare and assisted living areas, obstructions in corridors, improperly secured egress doors, and lack of self-closing devices on hazardous area doors.
Deficiencies (4)
Failure to provide 2-hour fire resistive separation between healthcare occupancy and assisted living areas as required by LSC Section 19.1.3.3.
Failed to maintain means of egress free from obstructions in 3 of 12 corridors; plastic three drawer chests containing PPE were stored in corridors and not on wheels.
Failed to ensure means of egress through 1 of 10 exits was readily accessible; break room door was magnetically locked with code not posted.
Failed to ensure corridor door to hazardous area (House Keeping/Bio-hazard room) had a self-closing device causing door not to automatically close and latch.
Report Facts
Certified beds: 73
Census: 48
Corridors with obstructions: 3
Exits observed: 10
Hazardous area doors: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beth Ingram | VP of Operations | Named in relation to plan of correction submissions |
| Beth Ingram | Administrator | Signed the report and participated in exit conference |
| Plant Manager | Interviewed and involved in observations and corrective action discussions |
Inspection Report
Recertification
Census: 52
Capacity: 81
Deficiencies: 18
Date: Oct 22, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey and the Investigation of Complaint IN00442131. This visit included a State Residential Licensure Survey.
Complaint Details
Complaint IN00442131 - Federal/State deficiencies related to the allegations are cited at F695.
Findings
The facility was found deficient in multiple areas including failure to provide required transfer/discharge notices, incomplete and inaccurate Minimum Data Set (MDS) assessments, failure to update care plans, inadequate physician notification parameters, improper wound care and infection control practices, improper catheter care, oxygen equipment maintenance, medication management including psychotropic medication monitoring, and sanitary issues in the kitchen related to dishwasher temperatures.
Deficiencies (18)
Failed to ensure resident and/or responsible party were notified in writing related to hospital transfer.
Failed to ensure resident and/or responsible party were sent the facility's bed hold and reserve bed payment policy before and upon transfer to hospital.
Failed to complete and export Minimum Data Set (MDS) assessment in a timely manner for 1 of 22 residents.
Failed to ensure MDS comprehensive assessment was accurately completed related to section GG functional assessment and IV medication use for 3 of 22 residents.
Failed to ensure care plans were reviewed and revised to include changes related to IV fluids for 1 of 22 residents.
Failed to ensure physician notification parameters were in place for weight monitoring for 1 resident.
Failed to ensure resident with pressure ulcers received treatment and services necessary to promote healing related to updating and following physician's orders.
Failed to ensure indwelling Foley catheter collection bag was covered and not hanging off a garbage can for 1 resident.
Failed to ensure respiratory equipment was changed as ordered and oxygen flow rate was correct for 3 of 4 residents.
Failed to ensure medication regimen was managed and monitored to promote or maintain resident's well-being related to lack of non-pharmacological interventions and monitoring for side effects of psychotropic medications for 2 residents.
Failed to ensure sanitary kitchen related to dishwasher temperatures not reaching required temperature and lack of temperature monitoring.
Failed to ensure clinical records were complete and accurately documented related to lack of resident's name on self-medication administration assessment.
Failed to ensure infection control guidelines were implemented related to hand hygiene and glove use during wound treatment.
Failed to ensure semi-annual evaluations were completed for 2 of 7 records and self-medication assessments for 1 of 7 records.
Failed to ensure Service Plans were completed and/or updated related to urinary catheter management, wound care and insulin use for 4 of 7 residents.
Failed to ensure qualified medication aides received authorization from licensed nurse or physician prior to giving PRN medications for 2 of 7 residents.
Failed to ensure resident records were accurate and complete related to lack of medical diagnoses, lack of physician's order for home health care and lack of physician notification of blood glucose levels outside parameters for 2 of 7 residents.
Failed to ensure resident Emergency Binder contained all necessary information for 3 of 5 residents.
Report Facts
Census: 52
Total Capacity: 81
Deficiencies cited: 17
Dishwasher wash temperature: 105
Dishwasher rinse temperature: 191
Resident count for MDS review: 22
Resident count for psychotropic medication review: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beth Ingram | VP of Operations | Signed Plan of Correction |
| Beth Ingram | Administrator | Named in report signature |
| RN 4 | Interviewed regarding transfer notification and bed hold policy | |
| Director of Nursing | Interviewed regarding MDS assessments, care plans, wound care, oxygen use, and medication management | |
| Assistant Director of Nursing | Interviewed regarding catheter care and oxygen flow rates | |
| Dietary Manager | Interviewed regarding dishwasher temperatures and kitchen sanitation | |
| Wound Care Nurse | Observed and interviewed regarding wound care practices | |
| LPN 1 | Interviewed regarding oxygen equipment maintenance | |
| Social Service Director | Interviewed regarding Emergency Binder contents |
Inspection Report
Routine
Deficiencies: 12
Date: Oct 22, 2024
Visit Reason
Routine inspection of Oak Grove Christian Retirement Village to assess compliance with healthcare regulations and standards.
Findings
The facility had multiple deficiencies including failure to notify residents or representatives of hospital transfers, incomplete care plans, inadequate wound care practices, improper respiratory equipment maintenance, narcotic medication documentation irregularities, insufficient monitoring of psychotropic medications, unsanitary kitchen conditions due to dishwasher temperature issues, incomplete clinical records, and lapses in infection control during wound care.
Deficiencies (12)
F 0623: The facility failed to provide timely written notification to a resident and their representative regarding hospital transfer for 1 of 2 residents reviewed.
F 0625: The facility failed to notify a resident or representative in writing about the bed hold policy before and upon hospital transfer for 1 of 2 residents reviewed.
F 0657: The facility failed to review and revise care plans to reflect changes related to IV fluids for 1 of 22 residents reviewed.
F 0684: The facility failed to ensure parameters were in place for physician notification related to weight monitoring for 1 resident with edema.
F 0686: The facility failed to provide appropriate wound care and follow physician orders for 1 of 3 residents with pressure ulcers.
F 0690: The facility failed to ensure an indwelling Foley catheter bag was covered and properly positioned for 1 resident reviewed.
F 0695: The facility failed to provide appropriate respiratory care related to outdated equipment and incorrect oxygen flow rates for 3 of 4 residents reviewed.
F 0755: The facility failed to maintain accurate narcotic medication documentation and reconcile controlled drugs for 1 of 3 residents reviewed.
F 0758: The facility failed to ensure non-pharmacological interventions were used prior to anti-anxiety medication and failed to monitor for side effects of antidepressants for 2 of 5 residents reviewed.
F 0812: The facility failed to maintain dishwasher temperatures within required ranges and lacked consistent temperature monitoring, risking food sanitation for all residents.
F 0842: The facility failed to ensure clinical records were complete and accurately documented related to a missing resident name on a self-medication assessment for 1 of 5 residents reviewed.
F 0880: The facility failed to follow infection control guidelines during wound care, including hand hygiene and glove use, for 1 treatment observed.
Report Facts
Deficiencies cited: 12
Dishwasher wash temperature: 105
Dishwasher rinse temperature: 191
Dishwasher temperature log values: Various recorded temperatures ranging from 118 to 187 degrees Fahrenheit for wash and rinse cycles in October 2024.
Narcotic medication missing count: 4
Oxycodone dosage: 10
Oxycodone frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Named in narcotic medication documentation irregularity investigation. |
| RN 5 | Registered Nurse | Identified in narcotic documentation discrepancies and no longer employed. |
| Director of Nursing | Director of Nursing | Provided interviews and information related to multiple deficiencies including narcotic audits and medication monitoring. |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided interviews related to catheter care and oxygen flow rate observations. |
| Wound Care Nurse | Wound Care Nurse | Observed performing wound care with infection control lapses. |
| Dietary Manager | Dietary Manager | Provided information about dishwasher temperature issues. |
| Administrator | Facility Administrator | Involved in narcotic investigation and provided interview on wound care infection control. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 22, 2024
Visit Reason
The inspection was conducted due to a complaint (IN00442131) regarding the facility's failure to provide safe and appropriate respiratory care to residents.
Complaint Details
This citation relates to Complaint IN00442131.
Findings
The facility failed to ensure residents received necessary respiratory care, including failure to change respiratory equipment as ordered and incorrect oxygen flow rates for 3 of 4 residents reviewed.
Deficiencies (1)
F 0695: The facility failed to provide safe and appropriate respiratory care when respiratory equipment was not changed as ordered and oxygen flow rates were incorrect for residents B, C, and D.
Report Facts
Residents affected: 3
Oxygen flow rate: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Indicated the nebulizer mask and humidifier bottle were outdated and should have been changed. | |
| Assistant Director of Nursing (ADON) | Observed Resident C's oxygen flow rate and indicated it was set incorrectly. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 20, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00439002 completed on July 24, 2024.
Complaint Details
Investigation of Complaint IN00439002 completed with findings of compliance.
Findings
Oak Grove Christian Retirement 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 complaint investigation.
Inspection Report
Complaint Investigation
Census: 52
Capacity: 80
Deficiencies: 1
Date: Jul 24, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00439002 regarding federal and state deficiencies related to resident records and oxygen administration documentation.
Complaint Details
Complaint IN00439002 was substantiated with federal/state deficiencies cited at F842 related to resident records and oxygen documentation.
Findings
The facility failed to ensure medical records were complete and accurately documented related to oxygen administration and saturation levels for 2 of 3 residents reviewed. Specific documentation gaps were found for Residents B and C regarding oxygen therapy and saturation monitoring.
Deficiencies (1)
Failed to ensure medical records were complete and accurately documented related to oxygen administration and saturation levels for Residents B and C.
Report Facts
Census total: 52
Total capacity: 80
Oxygen documentation missing shifts: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beth Ingram | Administrator and VP of Operations | Signed report and plan of correction; mentioned in relation to facility compliance |
| Director of Nursing | Interviewed regarding missing oxygen documentation; unable to provide further information |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 24, 2024
Visit Reason
The inspection was conducted in response to Complaint IN00439002 regarding concerns about oxygen administration and documentation at the facility.
Complaint Details
This citation relates to Complaint IN00439002.
Findings
The facility failed to ensure medical records were complete and accurately documented related to oxygen administration and saturation levels for 2 of 3 residents reviewed. Documentation was missing for multiple shifts and dates, and the Director of Nursing could not provide further information.
Deficiencies (1)
F 0842: The facility failed to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards. Specifically, oxygen administration and saturation levels were not documented for Residents B and C on multiple shifts and dates as ordered.
Report Facts
Residents affected: 2
Dates with missing documentation: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding missing oxygen administration documentation but could not provide further information. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 10, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00434136 completed on May 14, 2024.
Complaint Details
Investigation of Complaint IN00434136 completed on May 14, 2024; facility found in compliance.
Findings
Oak Grove Christian Retirement 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 complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 14, 2024
Visit Reason
The inspection was conducted in response to a complaint (IN00434136) regarding failure to report an allegation of abuse/neglect and inadequate supervision leading to resident falls and injury.
Complaint Details
This citation relates to Complaint IN00434136. The complaint involved failure to report an allegation of abuse/neglect and inadequate supervision resulting in resident falls and injury.
Findings
The facility failed to report an allegation of abuse/neglect to the Administrator and state authorities for one resident. Additionally, the facility failed to ensure adequate supervision and follow care plan interventions to prevent falls and injury for two residents.
Deficiencies (2)
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities for 1 of 1 resident with an abuse/neglect allegation.
F 0689: The facility failed to ensure adequate supervision and follow care plan interventions to prevent falls and injury for 2 of 3 residents reviewed for accidents and supervision.
Report Facts
Residents reviewed for accidents and supervision: 3
Falls documented for Resident D: 4
Laceration size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Agency LPN 1 | Summoned to resident's room for coffee spill incident and made calls to Responsible Party. | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding failure to report abuse allegation and supervision issues. |
| RN 2 | Called to resident's room after fall and coordinated emergency response. | |
| CNA 4 | Applied pressure to resident's head after fall and was present during incident. | |
| QMA 3 | Administered medication to resident prior to fall and responded to incident. |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 83
Deficiencies: 2
Date: May 13, 2024
Visit Reason
This visit was for the investigation of complaints IN00433724, IN00433725, and IN00434136. Complaints IN00433724 and IN00433725 had no deficiencies related to the allegations, while Complaint IN00434136 resulted in federal/state deficiencies.
Complaint Details
Complaint IN00434136 was substantiated with federal/state deficiencies cited. Complaints IN00433724 and IN00433725 had no deficiencies related to the allegations.
Findings
The facility failed to report an allegation of abuse/neglect for one resident and failed to ensure adequate supervision and care plan adherence to prevent accidents for two residents. Deficiencies were cited related to reporting alleged violations and accident prevention.
Deficiencies (2)
Failed to report an allegation of abuse/neglect to the Administrator for 1 of 1 resident with an allegation voiced by a family member (Resident B).
Failed to ensure adequate supervision and follow care plan interventions to prevent a fall (Resident D) and spillage of hot coffee on the skin (Resident C) for 2 of 3 residents reviewed for accidents and supervision.
Report Facts
Census SNF/NF beds: 46
Census SNF beds: 10
Census Residential beds: 27
Total licensed capacity: 83
Census Medicare residents: 13
Census Medicaid residents: 28
Census Other payor residents: 15
Total census residents: 56
Fall incidents: 4
Audit frequency: 5
Audit frequency: 15
Audit frequency: 10
Audit frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beth Ingram | Director | Signed Plan of Correction |
| Agency LPN 1 | Summoned to Resident B's room and involved in reporting incident | |
| Director of Nursing | Director of Nursing | Interviewed regarding abuse allegation and fall incidents |
| RN MDS Nurse | Interviewed about Resident D's fall and MDS assessment | |
| QMA 3 | Witnessed Resident D's fall | |
| CNA 4 | Witnessed Resident D's fall and involved in care |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 11, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00431990 completed on April 17, 2024.
Complaint Details
Investigation of Complaint IN00431990 completed on April 17, 2024; facility found in compliance.
Findings
Oak Grove Christian Retirement 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 complaint investigation.
Inspection Report
Complaint Investigation
Census: 49
Capacity: 77
Deficiencies: 1
Date: Apr 17, 2024
Visit Reason
This visit was conducted for the investigation of Complaints IN00430687 and IN00431990. Complaint IN00430687 found no deficiencies, while Complaint IN00431990 resulted in federal/state deficiencies related to inadequate post-fall assessment.
Complaint Details
Complaint IN00431990 was substantiated with federal/state deficiencies cited at F684 related to inadequate post-fall assessment. Complaint IN00430687 had no deficiencies related to the allegations.
Findings
The facility failed to ensure a resident (Resident B) received a thorough and timely assessment after a fall on 3/29/2024, resulting in delayed identification of a right tibia/fibula fracture. The facility's post-fall assessment policy was not followed, and corrective actions were implemented including staff education and monitoring.
Deficiencies (1)
Failure to ensure a resident received the necessary treatment and services related to the lack of a thorough and timely assessment completed after a resident had fallen.
Report Facts
Census total residents present: 49
Total licensed capacity: 77
Survey dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Jones | Administrator | Named as facility Administrator and involved in telephone interview |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 17, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to the facility's failure to ensure a resident received necessary treatment and timely assessment after a fall.
Complaint Details
This citation relates to Complaint IN00431990.
Findings
The facility failed to complete a thorough and timely post-fall assessment for one of three residents reviewed, resulting in delayed identification of a fracture. The resident was not assessed properly until the morning after the fall, contrary to facility policy requiring observation for 48 hours post-fall.
Deficiencies (1)
F 0684: The facility failed to provide appropriate treatment and care according to orders and resident preferences. The post-fall assessment was not thorough and did not include vital signs or significant findings until the next day.
Inspection Report
Life Safety
Census: 50
Capacity: 73
Deficiencies: 1
Date: Feb 15, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted to verify compliance with NFPA 101A and Life Safety Code requirements.
Findings
The facility was found in compliance with the Fire Safety Evaluation System (FSES) Survey conducted on 01/04/2024, achieving a passing score. However, a deficiency was noted regarding the construction type and fire separation between the first floor Healthcare Occupancy and the second floor Assisted Living areas, which lacked a 2-hour fire resistive barrier as required.
Deficiencies (1)
Failed to provide protection in accordance with Life Safety Code Section 19.1.3.3 requiring a minimum 2-hour fire resistance rating separation between healthcare occupancy and assisted living areas.
Report Facts
Facility capacity: 73
Census: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Plant Manager | Interviewed regarding building construction and fire separation | |
| Director of Maintenance | Conducted facility tour noting atrium and stairwell connection between floors |
Inspection Report
Life Safety
Census: 49
Capacity: 73
Deficiencies: 5
Date: Dec 18, 2023
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana State Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 standards.
Findings
The facility was found not in compliance with Life Safety Code requirements including issues with construction type separation, sprinkler system maintenance, smoke barrier doors, electrical room access, and oxygen storage safety. Corrective actions and systemic changes were planned to address these deficiencies.
Deficiencies (5)
Failed to provide protection in accordance with LSC Section 19.1.3.3 regarding separation of healthcare and assisted living occupancies.
Failed to maintain sprinkler escutcheon in Administrator's office, leaving a gap around sprinkler.
Failed to ensure smoke barrier doors fully close to restrict smoke movement.
Failed to maintain access and working space in main electrical room due to storage blocking electrical panels.
Failed to ensure minimum distance of at least five feet between combustible materials and oxygen storage equipment.
Report Facts
Certified beds: 73
Census: 49
Deficiencies cited: 5
Inspection Report
Annual Inspection
Census: 87
Deficiencies: 18
Date: Nov 20, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey including a State Residential Licensure Survey conducted from November 13 to 20, 2023.
Findings
The facility was found out of compliance in multiple areas including resident dignity, care planning, medication management, infection control, staff licensure, and food safety. Specific deficiencies included uncovered urinary catheter bags, failure to honor resident preferences, incomplete transfer notifications, inaccurate assessments, incomplete care plans, improper medication monitoring, unsanitary kitchen conditions, expired nurse license, improper disposal of lancets, and incomplete clinical records.
Deficiencies (18)
Failed to ensure a resident's dignity was maintained related to an uncovered urinary catheter bag.
Failed to ensure a resident's preference was honored related to not receiving a beverage of choice per request.
Failed to ensure resident and/or responsible party were notified in writing related to hospital transfers.
Failed to ensure Minimum Data Set (MDS) assessments were accurately completed related to pressure ulcer staging and diabetic medication use.
Failed to develop and implement a baseline care plan within 48 hours of admission for a resident.
Failed to develop and implement a care plan for a resident with denture problems.
Failed to ensure necessary care and services were provided to a dependent resident related to assistance with dentures daily.
Failed to ensure a resident received proper respiratory care related to an empty oxygen humidifier bottle and tubing not changed as ordered.
Failed to ensure each resident's medication regimen was managed and monitored to promote or maintain highest practicable well-being related to not following up on pharmacy recommendations in a timely manner.
Failed to ensure each resident's medication regimen was managed and monitored related to not monitoring pulse prior to medication administration with ordered parameters.
Failed to ensure a sanitary kitchen related to built up burnt food debris and grease in 2 ovens.
Failed to ensure a staff member working as a Registered Nurse had an active license.
Failed to ensure infection control guidelines were implemented related to improper disposal of a lancet.
Failed to complete a Pre-Admission Evaluation for a resident prior to admission.
Failed to obtain resident weights semi-annually, complete self-medication assessments, and semi-annual evaluations.
Failed to ensure the Service Plan was completed and signed by the resident and/or responsible party.
Failed to complete Pharmacy reviews every 60 days for residents whose medication was managed by the facility.
Failed to ensure clinical records were complete and accurate related to missing Physician's orders for medications.
Report Facts
Survey dates: 6
Residents reviewed: 7
Residents with medication review deficiencies: 3
Residents with missing weights: 2
Residents with missing service plan signatures: 2
Residents with incomplete assessments: 3
Residents with denture care plan deficiency: 1
Residents with uncovered catheter bag: 1
Residents with preference not honored: 1
Residents with improper hospital transfer notification: 2
Residents with inaccurate MDS: 2
Residents with baseline care plan deficiency: 1
Residents with denture assistance deficiency: 1
Residents with respiratory care deficiency: 1
Residents with medication pulse monitoring deficiency: 1
Ovens with built up burnt food debris: 2
Nurses with expired license: 1
Residents with improper lancet disposal observed: 1
Residents with missing pharmacy reviews: 3
Residents with incomplete medication orders: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosemary Weeks | VP Operations | Signed the report |
| RN 1 | Registered Nurse | Interviewed regarding catheter bag dignity and resident beverage preference |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including catheter bag, hospital transfer notification, denture care, medication monitoring, and infection control |
| LPN 1 | Licensed Practical Nurse | Interviewed regarding resident beverage preference and oxygen equipment |
| DON | Director of Nursing | Interviewed regarding fall follow-up, lancet disposal, pharmacy reviews, and clinical records |
| HR Director | Human Resources Director | Interviewed regarding nurse licensure |
| RN 2 | Registered Nurse | Had expired license but worked until 11/16/23 |
| RN 3 | Registered Nurse | Observed disposing lancet improperly |
| Cook 1 | Cook | Interviewed regarding oven cleaning |
| Dietary Manager | Dietary Manager | Interviewed regarding oven cleaning |
| Medical Records Coordinator | Medical Records Coordinator | Interviewed regarding medication lists and pharmacy reviews |
| Nurse Practitioner | Nurse Practitioner | Interviewed regarding pharmacy recommendation for medication discontinuation |
Inspection Report
Renewal
Deficiencies: 0
Date: Nov 20, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure survey completed on November 20, 2023.
Findings
Oak Grove Christian Retirement 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.
Inspection Report
Routine
Deficiencies: 13
Date: Nov 20, 2023
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements for nursing home care and facility operations.
Findings
The facility was found deficient in multiple areas including resident dignity, care planning, medication management, respiratory care, infection control, and staff licensure. Several residents did not receive appropriate care or documentation, and environmental concerns were noted in the kitchen.
Deficiencies (13)
F 0550: The facility failed to ensure a resident's dignity was maintained related to an uncovered urinary catheter bag for 1 of 1 residents reviewed for dignity.
F 0561: The facility failed to ensure a resident's preference was honored related to not receiving a beverage of choice per her request for 1 of 2 residents reviewed for choices.
F 0623: The facility failed to ensure a resident and/or their Responsible Party were notified in writing related to a transfer to the hospital for 2 of 3 residents reviewed for hospitalization.
F 0655: The facility failed to ensure a baseline care plan was developed and implemented within 48 hours of admission for 1 of 18 residents reviewed for care plans.
F 0656: The facility failed to develop and implement a care plan for a resident with denture problems for 1 of 20 resident care plans reviewed.
F 0677: The facility failed to ensure the necessary care and services were provided to a dependent resident related to assistance with dentures daily for 1 of 3 residents reviewed for activities of daily living.
F 0684: The facility failed to ensure a resident received the necessary treatment and services related to the lack of a thorough assessment completed after a fall for 1 of 1 residents reviewed for falls.
F 0695: The facility failed to ensure a resident received the proper care and treatment for respiratory services related to an empty oxygen humidifier bottle and oxygen tubing not changed as ordered for 1 of 1 residents reviewed for respiratory care.
F 0756: The facility failed to ensure each resident's medication regimen was managed and monitored to promote or maintain the resident's highest practicable well-being related to not following up on pharmacy recommendations in a timely manner for 1 of 5 residents reviewed for unnecessary medications.
F 0757: The facility failed to ensure each resident's drug regimen was free from unnecessary drugs related to not monitoring the pulse prior to medication administration with ordered parameters for 1 of 5 residents reviewed for unnecessary medications.
F 0812: The facility failed to ensure a sanitary kitchen related to built up burnt food debris and grease in 2 ovens for 1 of 1 kitchens observed.
F 0839: The facility failed to ensure a staff member who worked as a Registered Nurse had an active license, potentially affecting all residents.
F 0880: The facility failed to ensure infection control guidelines were implemented related to a lancet disposed of improperly during a blood sugar check.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 54
Residents affected: 54
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Named in findings related to dignity bag, beverage assistance, and denture care |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including dignity, hospital transfer notification, denture care, fall assessment, and infection control |
| LPN 1 | Licensed Practical Nurse | Interviewed regarding beverage assistance and respiratory care |
| CNA 1 | Certified Nursing Assistant | Interviewed regarding denture care assistance |
| Nurse Practitioner | Nurse Practitioner | Interviewed regarding pharmacy recommendation follow-up |
| RN 3 | Registered Nurse | Named in improper lancet disposal observation |
| HR Director | Human Resources Director | Interviewed regarding unlicensed RN staff member |
| Dietary Manager | Dietary Manager | Interviewed regarding kitchen sanitation |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 84
Deficiencies: 3
Date: Sep 26, 2023
Visit Reason
This visit was for the investigation of Complaints IN00413465 and IN00414951. Complaint IN00413465 had no deficiencies related to the allegations, while Complaint IN00414951 resulted in federal/state deficiencies related to the allegations cited at F806 and F808.
Complaint Details
Complaint IN00413465 had no deficiencies related to the allegations. Complaint IN00414951 was substantiated with federal/state deficiencies cited at F806 and F808 related to medication self-administration, dietary preferences, and therapeutic diet compliance.
Findings
The facility was found deficient in determining the appropriateness of resident self-administration of medications, failing to ensure dietary preferences were followed, and not providing therapeutic diets as ordered by the physician. Specific issues included medications left with residents without proper assessment, failure to provide preferred dietary items, and failure to serve therapeutic diets including extra protein supplements and health shakes.
Deficiencies (3)
Failed to determine self-administration of medications was appropriate for residents; medications were left with residents without assessment or physician orders for self-administration.
Failed to ensure dietary preferences were followed; items listed on individual meal cards were not provided.
Failed to ensure residents were served therapeutic diets as ordered by the physician, including dietary and extra protein supplements.
Report Facts
Census total: 49
Total capacity: 84
Residents observed with medication self-administration issues: 3
Residents reviewed for food preferences: 3
Residents reviewed for therapeutic diets: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosemary Weeks | VP Operations | Signed as Laboratory Director's or Provider/Supplier Representative |
| Nurse 1 | Mentioned in relation to medication and dietary observations | |
| Nurse 2 | Mentioned in relation to therapeutic diet and medication administration | |
| Nurse 3 | Mentioned in relation to medication self-administration observation and re-education | |
| Nurse 4 | Mentioned in relation to medication self-administration observation | |
| CNA 1 | Mentioned in relation to dietary service | |
| CNA 2 | Mentioned in relation to medication handling | |
| Dietary Aide 1 | Mentioned in relation to dietary observations |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 26, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00414951 completed on September 26, 2023.
Complaint Details
Investigation of Complaint IN00414951; paper compliance review found the facility in compliance.
Findings
Oak Grove Christian Retirement 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 paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Sep 26, 2023
Visit Reason
The inspection was conducted in response to complaints regarding medication self-administration, dietary preferences, and therapeutic diet compliance at the facility.
Complaint Details
This Federal tag relates to Complaint IN00414951.
Findings
The facility failed to properly assess and authorize residents for self-administration of medications, did not consistently provide dietary preferences as indicated on individual meal cards, and failed to ensure therapeutic diets and supplements were provided as ordered by physicians for several residents.
Deficiencies (3)
F 0554: The facility failed to determine self-administration of medications was appropriate for residents, related to medications left with residents without assessments or physician orders for self-administration for 3 residents.
F 0806: The facility failed to ensure dietary preferences were followed, related to not providing items listed on the individual meal card for 1 resident.
F 0808: The facility failed to ensure residents were served therapeutic diets as ordered by the physician, related to dietary and extra protein supplements for 2 residents.
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 2
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 11, 2023
Visit Reason
Paper compliance review to the Investigation of Complaints IN00403128, IN00406313, and IN00412035 completed on July 11, 2023.
Complaint Details
Paper compliance review related to complaints IN00403128, IN00406313, and IN00412035; facility found in compliance.
Findings
Oak Grove Christian Retirement 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.
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Jul 11, 2023
Visit Reason
The inspection was conducted in response to complaints regarding resident care and facility compliance with regulations.
Complaint Details
The deficiencies cited relate to multiple complaints including IN00406313, IN00412035, and IN00403128.
Findings
The facility was found to have multiple deficiencies including failure to accommodate residents' needs related to call light accessibility, inadequate bowel management, improper pressure ulcer care, insufficient urinary catheter care, improper PICC line care, administration of unnecessary medications, and food service issues including serving unpalatable meals and improper food handling. Additionally, contracted agency staff had not received required orientation and education on facility policies.
Deficiencies (9)
F 0558: The facility failed to ensure call lights were within reach for 4 residents, violating care plan interventions.
F 0684: The facility failed to initiate bowel management for residents who had no bowel movement for over three days for 2 of 3 residents reviewed.
F 0686: The facility failed to provide pressure ulcer treatments, interventions, and nutritional supplements as ordered for 2 of 3 residents reviewed.
F 0690: The facility failed to provide urinary catheter care every shift and administer antibiotics as ordered for 1 of 2 residents reviewed.
F 0694: The facility failed to properly care for a PICC line including assessments, flushes, and measurements for 1 resident reviewed.
F 0757: The facility failed to ensure residents were free from unnecessary medications due to inadequate monitoring and administration errors for 2 of 4 residents reviewed.
F 0804: The facility failed to serve palatable and properly portioned food, serving dry spaghetti noodles without sauce to 33 residents in one dining room.
F 0812: The facility failed to follow food service safety standards by serving food with gloved hands without changing gloves between tasks in one dining room.
F 0895: The facility failed to ensure contracted agency staff received orientation and education on facility policies for 6 agency staff members reviewed.
Report Facts
Residents affected: 4
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 33
Agency staff affected: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Employee 2 | Interviewed regarding call light accessibility for residents Q, P, and J | |
| Director of Nursing | Director of Nursing | Acknowledged deficiencies in treatments, medication administration, and staff orientation |
| Dietary Employee 1 | Observed serving spaghetti noodles without sauce and improper food handling | |
| Dietary Manager | Dietary Manager | Interviewed about food service issues and meal preparation |
| Nursing Staff Scheduler | Interviewed about lack of orientation for agency staff |
Inspection Report
Deficiencies: 0
Date: Jul 11, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Oak Grove Christian Retirement Village, documenting the results of a regulatory survey completed on July 11, 2023.
Findings
No health deficiencies were found during the survey.
Inspection Report
Complaint Investigation
Census: 52
Capacity: 86
Deficiencies: 11
Date: Jul 6, 2023
Visit Reason
Investigation of multiple nursing home and residential complaints including allegations of misappropriation, quality of care, infection control, and other regulatory concerns.
Complaint Details
This visit was triggered by multiple complaints including IN00400228, IN00403128, IN00406313, IN00408550, IN00411197, and IN00412035. Several complaints were substantiated with deficiencies cited, including issues with call light accessibility, bowel management, pressure ulcer care, catheter care, medication management, food service, staff education, and resident property protection. Some complaints had no deficiencies cited.
Findings
The facility was found to have multiple deficiencies including failure to accommodate resident needs related to call light accessibility, inadequate bowel management, failure to provide pressure ulcer treatments and nutritional supplements as ordered, improper urinary catheter care, failure to ensure unnecessary medications were avoided, improper food service practices, and failure to protect residents' property from theft with inadequate investigations.
Deficiencies (11)
Failed to accommodate the needs of residents related to call lights being out of reach for 4 random resident observations.
Failed to ensure a bowel management program was initiated for residents who had not had a bowel movement in over three days for 2 of 3 residents reviewed.
Failed to ensure residents received pressure ulcer treatments, interventions, and nutritional supplements as ordered by the physician for 2 of 3 residents reviewed for pressure ulcers.
Failed to ensure urinary catheter care was provided every shift and an antibiotic was administered as ordered for a resident with a urinary tract infection.
Failed to care for PICC line in accordance with professional standards related to measurement of the catheter, flushes, and assessments of the insertion site.
Failed to ensure a resident was free from unnecessary medications related to inadequate monitoring of blood pressure and pulse, medications administered when pulse and blood pressure were out of prescribed parameters, and medications not given as ordered related to blood pressure medications and insulin.
Failed to serve food that was palatable and attractive and to ensure the correct amount of food was served for 1 of 2 meals in 1 of 3 dining rooms.
Failed to ensure a lunch meal was served in accordance with professional standards for food service safety, related to touching residents' food with a gloved hand without changing gloves between tasks.
Failed to ensure contracted staff were educated on the facility's baseline policies and procedures.
Failed to protect residents' property and financial information from theft related to misappropriation by staff and failed to conduct thorough investigations per policy to help prevent continued misappropriation for 6 of 6 residents reviewed.
Failed to ensure all allegations of misappropriation were reported to the Indiana Department of Health for 2 of 6 residents reviewed.
Report Facts
Survey dates: July 6, 7, 10, and 11, 2023
Census SNF/NF: 32
Census SNF: 20
Census Residential: 34
Total Capacity: 86
Census Payor Type Total: 52
Deficiencies cited: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Shower Tech | Identified in police report and investigation as suspect in misappropriation of resident property |
| Rosemary Weeks | VP Operations | Facility representative signing report and involved in investigation oversight |
Inspection Report
Life Safety
Deficiencies: 1
Date: Oct 31, 2022
Visit Reason
The visit was conducted as a Life Safety Code Recertification and State Licensure Survey to evaluate the facility's compliance with fire safety standards.
Findings
The facility was found in compliance with NFPA 101A Chapter 4 based on the Fire Safety Evaluation System Survey. However, a deficiency was noted regarding the building construction type and fire resistance rating between healthcare and assisted living areas, specifically the lack of a 2-hour fire resistive barrier separating these occupancies.
Deficiencies (1)
Failed to provide protection in accordance with LSC Section 19.1.3.3 requiring a minimum 2-hour fire resistance rating barrier separating healthcare occupancy from assisted living areas.
Report Facts
Fire Safety Evaluation System Survey date: Oct 18, 2022
Survey completion date: Oct 31, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Interviewed regarding building construction and fire resistance rating | |
| facility Administrator | Reviewed findings at exit conference |
Inspection Report
Life Safety
Census: 46
Capacity: 73
Deficiencies: 5
Date: Oct 3, 2022
Visit Reason
The inspection was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and 42 CFR 483.73 for Emergency Preparedness.
Findings
The facility was found not in compliance with several Life Safety Code requirements including construction type separation, sprinkler system maintenance, portable fire extinguisher installation height, smoke barrier penetrations, and improper use of extension cords in the laundry room. The Emergency Preparedness survey found the facility in compliance with requirements.
Deficiencies (5)
Failed to provide protection in accordance with LSC Section 19.1.3.3 regarding separation of healthcare and assisted living occupancies by a 2-hour fire resistive barrier.
Failed to maintain a spare sprinkler cabinet large enough to fit all spare sprinkler heads as required by NFPA 25.
Portable fire extinguisher in the kitchen was mounted with the top 64 inches above the floor, exceeding the 5 feet maximum height requirement.
Penetrations caused by sprinkler pipe through smoke barrier walls were not sealed to maintain smoke resistance.
Use of flexible cords (extension cord) as a substitute for fixed wiring in the laundry room for a dryer.
Report Facts
Certified beds: 73
Census: 46
Spare sprinklers required: 6
Fire extinguisher mounting height: 64
Fire extinguisher mounting height limit: 60
Annular space around sprinkler pipe: 1
Extension cords in laundry: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosemary Weeks | VP Operations | Signed as provider/supplier representative on report |
| Director of Maintenance | Interviewed and involved in observations related to deficiencies | |
| Facility Administrator | Participated in exit conference reviewing findings |
Inspection Report
Recertification
Census: 31
Capacity: 74
Deficiencies: 8
Date: Sep 14, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey and the Investigation of Nursing Home Complaint IN00386370.
Complaint Details
Complaint IN00386370 was substantiated. The complaint involved failure to conduct a thorough investigation of missing narcotics and related deficiencies cited at F689.
Findings
The facility was found to have multiple deficiencies including failure to conduct a thorough investigation of missing narcotics, inaccurate Minimum Data Set discharge assessments, incomplete medication-related care plans, inadequate care related to diarrhea management, improper supervision during showering leading to a fall, failure to properly screen visitors for COVID-19, incomplete annual abuse and dementia training for staff, and missing resident emergency information in the Emergency Binder.
Deficiencies (8)
Failed to ensure a complete and thorough investigation related to missing narcotics for 1 of 2 residents reviewed for abuse/misappropriation.
Failed to ensure the Minimum Data Set (MDS) discharge assessment was accurately completed for 1 of 15 MDS assessments reviewed.
Failed to ensure comprehensive care plans were implemented related to medications for 2 of 15 resident care plans reviewed.
Failed to ensure a resident received necessary care and treatment related to diarrhea.
Failed to ensure proper supervision was provided with showering for 1 of 2 residents reviewed for accidents.
Failed to ensure infection control guidelines were implemented, including proper visitor screening for COVID-19.
Failed to ensure annual abuse and dementia training was completed for 5 of 10 employee records reviewed.
Failed to ensure resident emergency information was available in the Emergency Binder for 2 of 5 residents reviewed.
Report Facts
Survey dates: 6
Census: 31
Total capacity: 74
Residents reviewed for MDS assessments: 15
Residents reviewed for care plans: 15
Visitors reviewed: 5
Employees reviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| QMA 1 | Named in medication misappropriation investigation with forged signature on MAR. | |
| Director of Nursing | Director of Nursing | Interviewed regarding narcotics investigation and supervision during showering fall. |
| LPN 1 | Named in training deficiency for dementia training. | |
| Housekeeping 1 | Named in training deficiency for abuse and dementia training. | |
| Cook 1 | Named in training deficiency for dementia training. | |
| CNA 1 | Named in training deficiency for dementia training. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 14, 2022
Visit Reason
Paper compliance review to the Recertification and State Licensure survey and the Investigation of Complaint IN00386370 completed on September 14, 2022.
Complaint Details
Investigation of Complaint IN00386370 completed on September 14, 2022.
Findings
Oak Grove Christian Retirement 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.
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