Inspection Reports for Residences At Deer Creek

IN, 46375

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Deficiencies per Year

8 6 4 2 0
2023
2024
2025
Unclassified

Census Over Time

90 95 100 105 110 115 Aug '23 Apr '24 Jun '24 Aug '24 Jan '25
Inspection Report Complaint Investigation Census: 97 Deficiencies: 0 Jan 30, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00451183.
Findings
No deficiencies related to the allegations of Complaint IN00451183 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Complaint Details
Complaint IN00451183 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Residential Census: 97
Inspection Report Complaint Investigation Census: 102 Deficiencies: 0 Oct 3, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00441943.
Findings
No deficiencies related to the allegations in Complaint IN00441943 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Complaint Details
Complaint IN00441943 was investigated and found to have no deficiencies related to the allegations.
Inspection Report Complaint Investigation Census: 106 Deficiencies: 1 Aug 22, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00441295 regarding an allegation of failure to report an unusual occurrence involving unexplained bruising of a cognitively impaired resident's eye.
Findings
The facility failed to notify the Indiana Department of Health of an unusual occurrence related to unexplained bruising under the right eye of Resident B. The bruise was observed and investigated, but reporting was delayed until the date of the survey. The resident was not harmed and ongoing care was provided. The facility reviewed all residents' records and conducted staff inservices to ensure compliance with reporting policies.
Complaint Details
Complaint IN00441295 was substantiated with a state deficiency cited at R0090 related to failure to report an unusual occurrence involving unexplained bruising of Resident B's eye.
Deficiencies (1)
Description
Failure to ensure the Indiana Department of Health was notified of an unusual occurrence related to unexplained bruising of a cognitively impaired resident's eye.
Report Facts
Residential Census: 106 Bruise size: 2.5 Plan of Correction Completion Date: Sep 4, 2024
Employees Mentioned
NameTitleContext
Karen AyersmanExecutive DirectorSigned the report and involved in review of resident records and policy compliance
Director of NursingInterviewed regarding the bruising incident and reporting procedures
AdministratorInterviewed regarding the bruising investigation and reporting
Inspection Report Complaint Investigation Census: 104 Deficiencies: 0 Jul 24, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00437949 and IN00438269.
Findings
No deficiencies related to the allegations in complaints IN00437949 and IN00438269 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00437949 and Complaint IN00438269 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Residential Census: 104
Inspection Report Complaint Investigation Census: 101 Deficiencies: 0 Jun 18, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00436811.
Findings
No deficiencies related to the allegations in Complaint IN00436811 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00436811 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Residential Census: 101
Inspection Report Re-Inspection Census: 106 Deficiencies: 0 Apr 24, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the State Residential Licensure Survey and the Investigation of Complaint IN00424859 completed on 2024-02-28, conducted in conjunction with the Investigation of Complaint IN00433098.
Findings
Residences at Deer Creek was found to be in compliance with 410 IAC 16.2-5 regarding the PSR to the State Residential Licensure Survey and the PSR to Complaint IN00424859. No deficiencies related to Complaint IN00433098 were cited.
Complaint Details
Complaint IN00424859 was corrected. Complaint IN00433098 had no deficiencies related to the allegations cited.
Report Facts
Residential Census: 106
Inspection Report Complaint Investigation Census: 106 Deficiencies: 0 Apr 24, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00433098 and was conducted in conjunction with the Post Survey Revisit to the State Residential Licensure Survey and the Investigation of Complaint IN00424859 completed on 2/28/24.
Findings
No deficiencies related to Complaint IN00433098 were cited, and Complaint IN00424859 was corrected. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the investigation of Complaint IN00433098.
Complaint Details
Complaint IN00433098 - No deficiencies related to the allegations are cited. Complaint IN00424859 - Corrected.
Report Facts
Residential Census: 106
Inspection Report Complaint Investigation Census: 107 Deficiencies: 5 Feb 28, 2024
Visit Reason
This visit was for a State Residential Licensure Survey including the investigation of three complaints (IN00423953, IN00424859, and IN00425475).
Findings
The facility was cited for deficiencies related to failure to timely notify responsible parties and physicians after a fall, inadequate supervision leading to a resident eloping, incomplete annual dementia training for staff, lack of job-specific orientation for new employees, and incomplete clinical records including failure to document neurological checks after falls.
Complaint Details
Complaint IN00423953 - No deficiencies related to the allegations were cited. Complaint IN00424859 - State deficiency related to the allegations cited at R052. Complaint IN00425475 - No deficiencies related to the allegations were cited.
Deficiencies (5)
Description
Failed to ensure the resident's Responsible Party and/or Physician were notified timely after a fall for 1 of 10 records reviewed (Resident B).
Failed to ensure a resident was free from neglect related to inadequate supervision resulting in elopement for 1 of 3 residents reviewed (Resident B).
Failed to ensure required personnel annual dementia inservices were completed for 4 of 6 staff members reviewed (LPN 1, LPN 2, RN 1, Concierge).
Failed to ensure new employees had job specific orientation for 2 of 5 new employee files reviewed (Housekeeper 1 and Dishwasher 1).
Failed to ensure clinical records were complete and accurately documented related to monitoring bruises, follow-up documentation after falls, and neurological checks for 4 of 10 sampled residents (Residents 9, 10, 3, and 4).
Report Facts
Residential Census: 107 Staff missing dementia training: 4 New employees missing job specific orientation: 2 Residents sampled for clinical record review: 10 Residents with clinical record deficiencies: 4
Employees Mentioned
NameTitleContext
Director of NursingDirector of NursingInterviewed regarding notification of falls, staff training, and clinical documentation.
LPN 1Licensed Practical NurseStaff member missing required annual dementia training.
LPN 2Licensed Practical NurseStaff member missing required annual dementia training.
RN 1Registered NurseStaff member missing required annual dementia training; no longer employed at facility.
ConciergeConciergeStaff member missing required annual dementia training.
Business Office ManagerBusiness Office ManagerInterviewed regarding lack of job specific orientation for new employees.
Inspection Report Complaint Investigation Census: 104 Deficiencies: 0 Aug 16, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00403015 and IN00403757.
Findings
No deficiencies related to the allegations in complaints IN00403015 and IN00403757 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaints IN00403015 and IN00403757 found no deficiencies related to the allegations; both complaints were not substantiated.

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