Inspection Report
Life Safety
Census: 60
Capacity: 96
Deficiencies: 0
Apr 16, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
At the Emergency Preparedness survey, the facility was found in compliance with Emergency Preparedness Requirements. At the Life Safety Code survey, the facility was found in compliance with Requirements for Participation in Medicare/Medicaid and Life Safety from Fire according to NFPA 101 and state regulations.
Report Facts
Certified beds: 96
Census: 60
Inspection Report
Renewal
Census: 60
Capacity: 60
Deficiencies: 6
Mar 10, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from March 3 to March 10, 2025.
Findings
The facility was found deficient in multiple areas including resident dignity during meals, assessment of residents self-administering medications, respiratory care oxygen flow rates, medication storage and labeling, food storage and sanitation, and infection prevention and control practices.
Severity Breakdown
SS=D: 3
SS=E: 3
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure a resident was treated with dignity during a meal observation for 1 of 1 residents reviewed who required staff assistance to eat. | SS=D |
| Failed to ensure residents self-administering medications were assessed for capability to self-administer medications for 1 of 1 residents observed. | SS=D |
| Failed to ensure respiratory services were provided according to professional standards for 3 of 3 residents reviewed; oxygen flow rates were not consistent with physician orders. | SS=D |
| Failed to ensure proper storage and labeling of medications for 3 of 5 medication carts and 1 of 2 wound treatment carts; loose pills, food, and unlabeled medications were observed. | SS=E |
| Failed to safely store and produce food under professional standards related to food items not labeled or stored properly and sanitary kitchen surfaces for 1 of 1 dietary areas observed. | SS=E |
| Failed to ensure infection control practices and standards were performed during 3 of 3 random observations; staff failed to perform hand hygiene, use enhanced barrier protection, and change gloves during care. | SS=E |
Report Facts
Census: 60
Total Capacity: 60
Deficiencies cited: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Claudia Schmitt | Administrator | Signed the report and provided policies |
| QMA 14 | Qualified Medication Aide | Named in medication administration and infection control findings |
| CNA 5 | Certified Nursing Assistant | Named in resident dignity during meal assistance finding |
| CNA 9 | Certified Nursing Assistant | Named in resident dignity during meal assistance finding |
| Administrator | Administrator | Provided policies and interviews related to deficiencies |
| Licensed Practical Nurse 10 | LPN | Provided information on oxygen therapy orders |
| Assistant Director of Nursing | ADON | Interviewed regarding medication storage and labeling |
| Director of Nursing | DON | Provided information on Enhanced Barrier Precautions and infection control |
| CNA 6 | Certified Nursing Assistant | Named in infection control findings |
| CNA 7 | Certified Nursing Assistant | Named in infection control findings |
| Infection Preventionist | Infection Preventionist | Provided education and oversight on infection control practices |
Inspection Report
Renewal
Deficiencies: 0
Mar 10, 2025
Visit Reason
The inspection was a paper compliance survey conducted as part of the Recertification and State Licensure survey ending on March 10, 2025.
Findings
Park Terrace Village was found to be in compliance with 42 CFR 483 Subpart B and 410 IAC 16.2-3.1 in regard to the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 26, 2024
Visit Reason
Paper compliance survey conducted as part of the investigation of multiple complaints (IN00437729, IN00438896, IN00443903, IN00442130, IN00443544, and IN00443641).
Findings
Park Terrace Village was found to be in compliance with 42 CFR 483 Subpart B and 410 IAC 16.2-3.1 regarding the investigation of the listed complaints and an unrelated deficiency.
Complaint Details
Investigation of Complaints IN00437729, IN00438896, IN00443903, IN00442130, IN00443544, and IN00443641 resulted in compliance with no deficiencies related to these complaints; one unrelated deficiency ended on October 3, 2024.
Report Facts
Complaint investigation IDs: 6
Inspection Report
Complaint Investigation
Census: 62
Capacity: 62
Deficiencies: 1
Oct 3, 2024
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00437729, IN00438896, IN00443903, IN00442130, IN00443544, IN00443641) regarding the facility.
Findings
No deficiencies were found related to the specific complaints investigated. However, an unrelated deficiency was cited concerning infection prevention and control practices, specifically improper use of PPE and failure to contain COVID-19 transmission.
Complaint Details
The investigation of complaints IN00437729, IN00438896, IN00443903, IN00442130, IN00443544, and IN00443641 found no deficiencies related to the allegations. An unrelated deficiency was cited.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to properly prevent and/or contain COVID-19; staff observed not properly wearing PPE and practicing infection control. | SS=D |
Report Facts
Residents COVID-19 positive: 16
Census: 62
Total licensed capacity: 62
Medicare residents: 3
Medicaid residents: 48
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Provided information about COVID-19 positive residents and transmission-based precautions policy. | |
| LPN 2 | Observed improperly donning and doffing PPE in COVID-19 positive rooms. | |
| LPN 3 | Provided information on proper PPE use before entering COVID-19 positive rooms. | |
| Housekeeper 2 | Observed donning PPE and entering COVID-19 positive room. |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 0
Jun 10, 2024
Visit Reason
This visit was for the investigation of complaints IN00435533 and IN00435072.
Findings
No deficiencies related to the allegations in complaints IN00435533 and IN00435072 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaint IN00435533 and IN00435072 found no deficiencies related to the allegations.
Report Facts
Census Bed Type: 58
Medicaid residents: 45
Other residents: 13
Medicare residents: 0
Inspection Report
Re-Inspection
Census: 59
Capacity: 96
Deficiencies: 0
May 9, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 03/18/24 was performed to verify compliance with life safety requirements.
Findings
At this PSR to the Life Safety Code survey, Park Terrace Village was found in compliance with Medicare/Medicaid participation requirements, the Life Safety Code, and state regulations. The facility was fully sprinklered with appropriate fire alarm systems in place.
Inspection Report
Complaint Investigation
Census: 61
Capacity: 61
Deficiencies: 0
May 6, 2024
Visit Reason
This visit was conducted for the investigation of four complaints: IN00432525, IN00432654, IN00432818, and IN00432913.
Findings
No deficiencies related to the allegations in any of the four complaints were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaints IN00432525, IN00432654, IN00432818, and IN00432913 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 61
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 44
Census Payor Type - Other: 15
Inspection Report
Life Safety
Census: 64
Capacity: 96
Deficiencies: 1
Mar 18, 2024
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 standards.
Findings
The facility was found not in compliance due to a non-working mechanically vented exhaust fan in the oxygen storage room where oxygen transferring takes place, potentially affecting up to 40 residents, staff, and visitors in the 200 (south) Unit.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The mechanically vented exhaust fan in the oxygen storage room where oxygen transferring takes place was not working. | SS=E |
Report Facts
Certified beds: 96
Census: 64
Residents potentially affected: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Claudia Schafer | Laboratory Director or Provider/Supplier Representative | Signed the report |
| Maintenance Supervisor | Interviewed regarding the non-working exhaust fan | |
| Administrator | Informed of the finding during exit conference | |
| Maintenance Director | In-serviced on performing routine vent checks and responsible for QAPI tool completion |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 66
Deficiencies: 0
Mar 6, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00429042.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00429042 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 48
Census Payor Type - Other: 16
Inspection Report
Complaint Investigation
Census: 67
Capacity: 67
Deficiencies: 0
Feb 21, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00428384 and was conducted in conjunction with Recertification and State Licensure Survey and Investigation of Complaint IN00427103.
Findings
No deficiencies related to Complaint IN00428384 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Complaint IN00428384 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 67
Total census: 67
Medicare census: 1
Medicaid census: 46
Other payor census: 20
Inspection Report
Annual Inspection
Census: 67
Capacity: 67
Deficiencies: 11
Feb 21, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00427103 and IN00428384.
Findings
The facility was found deficient in multiple areas including medication self-administration assessments, accuracy of MDS assessments, comprehensive care plan implementation, prevention of pressure ulcers, fall prevention, respiratory care, pharmacy services, nursing staffing postings, behavioral health services, food temperature management, infection control, and reporting of unusual occurrences.
Complaint Details
Complaint IN00427103 involved state deficiencies related to allegations including failure to report an unusual occurrence involving a needle and syringe found under a resident's bed.
Severity Breakdown
SS=D: 8
SS=E: 3
Deficiencies (11)
| Description | Severity |
|---|---|
| Facility failed to ensure residents self-administering medications were assessed for capability. | SS=D |
| Facility failed to ensure MDS assessment was completed accurately for Resident 32. | SS=D |
| Facility failed to ensure comprehensive care plan interventions were implemented for urinary catheter care. | SS=D |
| Facility failed to prevent a friction abrasion from occurring due to defective mattress and lack of grab bar. | SS=D |
| Facility failed to ensure residents received supervision and consistent fall prevention interventions. | SS=D |
| Facility failed to ensure proper respiratory care including oxygen equipment labeling, medication administration, and tracheostomy suctioning. | SS=E |
| Facility failed to ensure routine medications were available and dispensed according to physician's orders. | SS=D |
| Facility failed to ensure medications were secure, labeled correctly, stored at proper temperatures, and temperature logs were complete. | SS=E |
| Facility failed to ensure food was served at palatable temperatures. | SS=E |
| Facility failed to ensure infection control practices including hand hygiene and glove changes during care. | SS=D |
| Facility failed to report an unusual occurrence involving a needle and syringe found under a resident's bed to the Indiana Department of Health within 24 hours. | — |
Report Facts
Survey dates: February 12, 13, 14, 15, 16, 19, 20, & 21, 2024
Resident census: 67
Total capacity: 67
Falls: 14
Medication doses missed: 3
Temperature readings: 112
Temperature readings: 139
Temperature readings: 46
Temperature readings: 42
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Claudia Schafer | Executive Director | Signed the report on 03/15/2024 |
| QMA 7 | Qualified Medication Aide | Observed leaving medication cup unattended during medication administration to Resident 32 |
| LPN 14 | Licensed Practical Nurse | Indicated no residents were allowed to self-administer all medications |
| Administrator | Provided policies and acknowledged deficiencies and reporting issues | |
| RN 3 | Registered Nurse | Observed not performing hand hygiene during tracheostomy care |
| RN 18 | Registered Nurse | Observed not performing adequate hand hygiene during wound care |
| LPN 23 | Licensed Practical Nurse | Indicated hand hygiene should be performed before and after changing gloves |
| Clinical Regional Nurse | Provided policies and observations related to tracheostomy care and infection control | |
| Administrator | Acknowledged failure to report unusual occurrence involving needle and syringe |
Inspection Report
Deficiencies: 0
Feb 21, 2024
Visit Reason
Paper compliance survey to the Recertification, State Licensure and Investigation of Complaint IN00427103 survey ending on February 21, 2024.
Findings
Park Terrace Village was found to be in compliance with 42 CFR 483 Subpart B and 410 IAC 16.2-3.1 in regard to the Recertification, State Licensure and Investigation of Complaints IN00427103 survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 12, 2024
Visit Reason
Investigation of Complaint IN00425344 survey ending on January 12, 2024.
Findings
Park Terrace Village was found to be in compliance with 42 CFR 483 Subpart B and 410 IAC 16.2-3.1 in regard to the Investigation of Complaints IN00425344 survey.
Complaint Details
Investigation of Complaint IN00425344; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 65
Capacity: 65
Deficiencies: 2
Jan 11, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00425344 regarding federal and state deficiencies related to the allegations cited at F659 and F677.
Findings
The facility failed to ensure physician orders were followed for 1 of 3 residents reviewed, specifically a resident was not made NPO before an ordered medical test. Additionally, the facility failed to provide bathing care to 3 of 3 residents reviewed, with bathing not provided as scheduled or per resident preference.
Complaint Details
Complaint IN00425344 was investigated, with federal and state deficiencies cited related to the allegations at tags F659 and F677.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure physician orders were followed for a resident who was not made NPO before an ordered medical test. | SS=D |
| Failure to provide activities of daily living (ADL) care, specifically bathing, to 3 residents as scheduled or per preference. | SS=D |
Report Facts
Census: 65
Total Capacity: 65
Residents reviewed for bathing deficiency: 3
Residents reviewed for NPO order deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Claudia Schafer | Administrator | Signed the report |
| LPN 1 | Interviewed regarding NPO order procedures | |
| Regional Director of Clinical Services | Provided policy information and interview regarding orders and bathing | |
| DNS/designee | Responsible for corrective action monitoring and education on NPO orders and bathing | |
| CNA 1 | Interviewed regarding shower refusals and bathing practices | |
| DON | Director of Nursing | Interviewed regarding bathing during COVID-19 isolation and facility policies |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 14, 2023
Visit Reason
Paper compliance survey conducted to investigate Complaint IN00418845 ending on December 14, 2023.
Findings
Park Terrace Village was found to be in compliance with 42 CFR 483 Subpart B and 410 IAC 16.2-3.1 regarding the Investigation of Complaint IN00418845 survey.
Complaint Details
Investigation of Complaint IN00418845; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 1
Dec 14, 2023
Visit Reason
This visit was for the investigation of Complaint IN00418845 and Complaint IN00418079. Complaint IN00418845 resulted in federal/state deficiencies related to the allegations, while Complaint IN00418079 had no deficiencies cited.
Findings
The facility failed to ensure infection control practices were maintained to mitigate the spread of COVID-19 in 2 of 4 observations. Staff were observed entering COVID-19 positive resident rooms without proper PPE, specifically lacking N95 respirators or eye protection as required by isolation protocols.
Complaint Details
Complaint IN00418845 was substantiated with federal/state deficiencies cited at F880. Complaint IN00418079 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure infection control practices were maintained to mitigate the spread of COVID-19; staff entered isolation rooms without proper PPE including N95 respirators and eye protection. | SS=D |
Report Facts
Census: 62
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Doug Lynch | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| LPN 1 | Named in infection control deficiency for improper PPE use | |
| Therapy 1 | Named in infection control deficiency for improper PPE use | |
| DON | Director of Nursing | Provided PPE Donning and Doffing document during inspection |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 6, 2023
Visit Reason
The inspection was a paper compliance survey conducted to investigate complaints IN00415879 and IN00416642.
Findings
Park Terrace Village was found to be in compliance with 42 CFR 483 Subpart B and 410 IAC 16.2-3.1 regarding the investigation of the complaints.
Complaint Details
Investigation of complaints IN00415879 and IN00416642; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 56
Capacity: 56
Deficiencies: 1
Sep 5, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00416642 and IN00415879 regarding dialysis care at the facility.
Findings
The facility failed to ensure that the plan of care was followed for 2 of 3 residents reviewed receiving dialysis services. Physician orders were not followed and routine assessments were not completed for residents receiving peritoneal dialysis, resulting in residents receiving dialysis treatments that were on hold or not as ordered.
Complaint Details
The investigation was triggered by complaints IN00416642 and IN00415879. Both complaints resulted in federal and state findings related to dialysis care deficiencies.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to follow physician orders and complete routine assessments for residents receiving peritoneal dialysis. | SS=D |
Report Facts
Census: 56
Total Capacity: 56
Dialysis residents reviewed: 3
Residents affected: 2
Plan of correction completion date: Sep 19, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Oppah Maluleke | ED | Facility representative who signed the report |
| Director of Nursing | Interviewed regarding dialysis care and documentation | |
| Regional RN | Interviewed regarding dialysis treatment error on 8/25/23 | |
| QMA 5 | Interviewed regarding documentation of resident weights |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 56
Deficiencies: 0
Jul 25, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00413123.
Findings
No deficiencies related to the allegations in Complaint IN00413123 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00413123 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 2
Medicaid census: 46
Other payor census: 8
Inspection Report
Complaint Investigation
Census: 60
Capacity: 60
Deficiencies: 0
May 24, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00403716 and IN00403871.
Findings
No deficiencies related to the allegations in complaints IN00403716 and IN00403871 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00403716 and IN00403871 were investigated; no deficiencies related to the allegations were cited.
Report Facts
Census: 60
Total Capacity: 60
Medicare Census: 2
Medicaid Census: 49
Other Payor Census: 9
Inspection Report
Complaint Investigation
Census: 59
Capacity: 59
Deficiencies: 1
Mar 9, 2023
Visit Reason
This visit was for the investigation of complaints IN00397874, IN00398803, and IN00402939. The investigation focused on allegations related to misappropriation of resident property and other concerns.
Findings
The facility failed to prevent the misappropriation of narcotic medication for 2 of 4 residents reviewed (Resident E and Resident H). The investigation revealed that RN 1 took Resident E's narcotic medication and attempted to return it, and LPN 1 and LPN 2 were involved in discrepancies related to Resident H's narcotic medication. The Sheriff, Attorney General, and State Department of Health were notified.
Complaint Details
Complaint IN00397874 was substantiated with federal/state deficiencies cited. Complaints IN00398803 and IN00402939 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to prevent misappropriation of resident narcotic medication for 2 residents. | SS=D |
Report Facts
Census: 59
Total Capacity: 59
Medicare Census: 8
Medicaid Census: 41
Other Payor Census: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Oppah Maluleke | ED | Facility representative signing the report |
| RN 1 | Involved in misappropriation of Resident E's narcotic medication | |
| LPN 1 | Involved in discrepancy of narcotic medication for Resident H | |
| LPN 2 | Involved in discrepancy of narcotic medication for Resident H | |
| ADON | Assistant Director of Nursing | Provided physician order for Resident H's medication |
| DON | Director of Nursing | Provided current policy on abuse prohibition, reporting and investigation |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 9, 2023
Visit Reason
Paper compliance survey conducted as part of the investigation of Complaint IN00397874 ending on March 9, 2023.
Findings
Park Terrace Village was found to be in compliance with 42 CFR 483 Subpart B and 410 IAC 16.2-3.1 in regard to the investigation of Complaint IN00397874.
Complaint Details
Investigation of Complaint IN00397874; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 62
Capacity: 62
Deficiencies: 0
Dec 20, 2022
Visit Reason
This visit was conducted for the investigation of four complaints: IN00393484, IN00394437, IN00395355, and IN00396292.
Findings
Two complaints (IN00393484 and IN00396292) were substantiated but no deficiencies related to the allegations were cited. The other two complaints (IN00394437 and IN00395355) were unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00393484 was substantiated with no deficiencies cited. Complaint IN00394437 was unsubstantiated due to lack of evidence. Complaint IN00395355 was unsubstantiated due to lack of evidence. Complaint IN00396292 was substantiated with no deficiencies cited.
Report Facts
Census SNF/NF beds: 62
Total census: 62
Medicare census: 7
Medicaid census: 43
Other payor census: 12
Inspection Report
Life Safety
Census: 59
Capacity: 96
Deficiencies: 0
Nov 15, 2022
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 10/04/22 by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR survey, Park Terrace Village was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Re-Inspection
Census: 61
Capacity: 61
Deficiencies: 0
Nov 1, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 2022-09-23, including a PSR to the Investigation of Complaint IN00381871 completed on 2022-09-23.
Findings
Park Terrace Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey and the PSR to the Investigation of Complaint IN00381871.
Complaint Details
Complaint IN00381871 was investigated and found to be corrected.
Report Facts
Census: 61
Total Capacity: 61
Payor Type Census: 1
Payor Type Census: 43
Payor Type Census: 17
Inspection Report
Complaint Investigation
Census: 59
Capacity: 59
Deficiencies: 0
Oct 7, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00391406.
Findings
The complaint IN00391406 was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00391406 was substantiated, but no deficiencies related to the allegations were cited.
Report Facts
Medicare residents: 3
Medicaid residents: 42
Private pay residents: 8
Other pay residents: 6
Inspection Report
Life Safety
Census: 61
Capacity: 96
Deficiencies: 1
Oct 4, 2022
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Life Safety Code requirements due to failure to ensure that the corridor door to one hazardous area (Activity storage room) was provided with a self-closing device, which could affect at least 20 residents, staff, and visitors.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure the corridor door to the Activity storage room was provided with a self-closing device. | SS=E |
Report Facts
Certified beds: 96
Current census: 61
Hazardous area doors: 1
Residents potentially affected: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed and acknowledged the door lacked a self-closing device; involved in exit conference | |
| Executive Director | Participated in exit conference and review of findings |
Inspection Report
Annual Inspection
Census: 66
Capacity: 66
Deficiencies: 10
Sep 23, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00381871.
Findings
The facility was found deficient in multiple areas including timely completion of quarterly MDS assessments, implementation of care plans for pain and falls, holding resident care conferences, providing showers per resident preference, maintaining a safe environment free of accident hazards, accurate nurse staffing postings, appropriate use of psychotropic medications, following pureed meal recipes, infection control practices, and COVID-19 vaccination compliance among staff.
Complaint Details
Complaint IN00381871 was substantiated with federal/state deficiencies cited at F677 related to the complaint.
Severity Breakdown
SS=D: 6
SS=E: 2
SS=C: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to ensure timely completion of quarterly MDS assessments for 2 of 22 residents reviewed. | SS=D |
| Failed to implement the plan of care for pain management and fall interventions for residents. | SS=D |
| Failed to ensure resident care conferences were held at least quarterly for 4 of 6 residents reviewed. | SS=D |
| Failed to ensure residents who required assistance with ADLs received showers as scheduled for 7 of 9 residents reviewed. | SS=E |
| Failed to provide an environment free of accident hazards for 1 of 4 residents reviewed for accidents. | SS=D |
| Failed to ensure accurately completed nurse staffing sheets were posted daily for 5 of 5 days during the survey. | SS=C |
| Failed to ensure residents were free from unnecessary psychotropic medications for 1 of 5 residents reviewed. | SS=D |
| Failed to ensure kitchen staff followed recipes and measured ingredients accurately for pureed meals. | SS=E |
| Failed to maintain infection control practices including proper PPE use, medication handling, and mask wearing. | SS=D |
| Failed to ensure all staff were fully vaccinated for COVID-19 or had approved exemptions. | SS=D |
Report Facts
Census: 66
Total Capacity: 66
Residents reviewed for quarterly MDS assessments: 22
Residents reviewed for care conferences: 6
Residents reviewed for ADL showers: 9
Residents reviewed for accident hazards: 4
Days with incomplete nurse staffing sheets: 5
Residents reviewed for unnecessary psychotropic medications: 5
Pureed meals observed: 4
Residents observed during medication pass: 7
Resident rooms on isolation precautions observed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 5 | Licensed Practical Nurse | Observed handling medications with bare hands and improper PPE use |
| CNA 3 | Certified Nurse Aide | Observed improper PPE use entering isolation room and eating near resident without mask |
| CNA 4 | Certified Nurse Aide | Observed eating near resident without mask |
| Resident 11 | Resident involved in accident hazard finding related to smoking materials in room | |
| Resident 19 | Resident involved in unnecessary psychotropic medication finding | |
| Resident 109 | Resident observed during medication pass with infection control concerns | |
| Staff 2 | Partially vaccinated staff without completed COVID-19 vaccination |
Loading inspection reports...
