Inspection Report Summary
The most recent inspection on May 15, 2025, identified a deficiency related to exit stairways not having at least 50 percent of exits leading directly outside as required by the Life Safety Code. Earlier inspections showed a recurring pattern of similar Life Safety Code issues, particularly with exit stairways and exit signage, along with occasional deficiencies in staff training on fire suppression. Complaint investigations included substantiated cases involving resident abuse and misappropriation of property by staff, with corrective actions implemented; most other complaints were found unsubstantiated. No fines, immediate jeopardy findings, or license suspensions were listed in the available reports. The facility’s record shows ongoing challenges with fire safety code compliance but corrective steps have been taken in response to abuse and property misappropriation, with no clear trend of improvement or worsening in recent inspections.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
10.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
157% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
66% occupied
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 1, 2025
Visit Reason
The inspection was conducted following a complaint related to a mechanical lift transfer incident involving Resident B, where improper staffing and technique allegedly caused injury.
Complaint Details
The visit was complaint-related due to an incident on 9/8/25 where Resident B was transferred alone by QMA 2 using a Sara lift, contrary to policy requiring two staff. The complaint was substantiated by interviews and record review.
Findings
The facility failed to ensure that mechanical lift transfers were performed with the required two staff members, resulting in Resident B sustaining a left humerus fracture during a transfer by a single staff member. Interviews and record reviews confirmed the deficiency in staff competency and adherence to policy.
Deficiencies (1)
Failure to ensure staffing followed competent skills during a mechanical lift transfer for Resident B, resulting in injury.
Report Facts
Residents reviewed: 3
Date of incident: Sep 8, 2025
Date of order: Apr 16, 2025
Date of IDT note: Sep 16, 2025
Date of checklist: Aug 6, 2025
Date of policy: 202501
Employees mentioned
| Name | Title | Context |
|---|---|---|
| QMA 2 | Qualified Medication Aide | Performed the mechanical lift transfer alone, causing injury |
| CNA 3 | Certified Nurse Assistant | Provided interview confirming two-person assist requirement |
| Administrator | Provided interviews and documentation confirming policy and incident details |
Inspection Report
Life Safety
Census: 110
Capacity: 166
Deficiencies: 1
Date: May 15, 2025
Visit Reason
A Fire Safety Evaluation System (FSES) Survey and a Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health.
Findings
Saint Anne Home was found in compliance with NFPA 101A Chapter 4 Fire Safety Evaluation System for Health Care Occupancies and achieved a passing score on the FSES survey. However, the facility failed to ensure that 2 of 2 exit stairways had at least 50 percent of the exits leading directly to the outside, which could affect staff and residents.
Deficiencies (1)
Facility failed to ensure 2 of 2 exit stairways had at least 50 percent of the exits lead directly to the outside as required by Life Safety Code 7.7.1 and 7.7.2.
Report Facts
Facility capacity: 166
Census: 110
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Manager | Interviewed regarding stairway exits | |
| Administrator | Interviewed and reviewed findings during exit conference |
Inspection Report
Annual Inspection
Census: 114
Capacity: 166
Deficiencies: 3
Date: Mar 24, 2025
Visit Reason
An annual Life Safety Code (LSC) Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) to assess compliance with fire safety and life safety requirements.
Findings
The facility was found not in compliance with several Life Safety Code requirements including stairway exits not discharging directly outside, exit signage lacking continuous illumination, and staff not trained on hood fire suppression activation. Corrective actions and plans of correction were submitted with completion dates of April 7, 2025.
Deficiencies (3)
Failed to ensure 2 of 2 exit stairways had at least 50 percent of the exits lead directly to the outside.
Failed to ensure 1 of 2 stairway exits contained exit signs with continuous illumination.
Failed to ensure kitchen staff knew location of hood fire suppression activation switch.
Report Facts
Deficiencies cited: 3
Residents potentially affected: 114
Facility capacity: 166
Residents affected by exit sign deficiency: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elaine Wilson | COO | Facility representative signing the report. |
| Facilities Director | Interviewed regarding stairway exits and exit signage deficiencies. | |
| Cook | Interviewed regarding knowledge of hood fire suppression activation. | |
| Maintenance Director | Acknowledged need for staff training on hood fire suppression. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 17, 2025
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey was conducted.
Findings
Saint Anne Home was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Routine
Census: 118
Deficiencies: 1
Date: Feb 28, 2025
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically focusing on water temperature monitoring and legionella testing as part of routine regulatory oversight.
Findings
The facility failed to monitor water temperatures in storage tanks and did not perform routine legionella testing as required by federal guidelines. Temperature logs for 2024 showed no recorded values, and no legionella testing records were available. The facility's policy on water management for legionella was not followed.
Deficiencies (1)
Failure to ensure water temperatures in facility storage tanks were monitored and legionella testing was performed routinely.
Report Facts
Residents affected: 118
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding water management and legionella testing policies and records | |
| Maintenance Director | Interviewed about inability to obtain water temperatures and legionella testing sample containers | |
| Administrator | Interviewed regarding federal guidelines and facility policy on legionella testing |
Inspection Report
Annual Inspection
Census: 118
Deficiencies: 1
Date: Feb 28, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey and the Investigation of healthcare Complaint IN00453718.
Complaint Details
Complaint IN00453718 was investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies related to the complaint allegations were cited. The facility failed to ensure water temperatures in the water storage tanks were monitored and legionella testing was performed routinely as required by policy. The facility sent water samples for legionella testing and implemented a plan to test annually at multiple locations with ongoing monitoring through quality assurance meetings. The facility was found to be in compliance with state residential licensure requirements.
Deficiencies (1)
Failed to ensure water temperatures in facility storage tanks were monitored and legionella testing was performed routinely.
Report Facts
Residents using facility water: 118
Survey dates: 4
Residential Census: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elaine Wilson | COO | Signed as Laboratory Director's or Provider/Supplier Representative. |
| Director of Nursing | Interviewed regarding water management policies and legionella testing. | |
| Maintenance Director | Interviewed regarding inability to obtain water temperatures due to lack of temperature gauges. | |
| Administrator | Interviewed regarding federal guidelines on water management and legionella testing policy. |
Inspection Report
Complaint Investigation
Census: 196
Deficiencies: 0
Date: Sep 9, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00441330 at Saint Anne Home.
Complaint Details
Complaint IN00441330 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00441330 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type - SNF/NF: 109
Census Bed Type - SNF: 6
Census Bed Type - Residential: 81
Census Bed Type - Total: 196
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 59
Census Payor Type - Other: 129
Census Payor Type - Total: 196
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 3, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of complaints IN00439077 and IN00440091.
Complaint Details
The visit was related to complaint investigations IN00439077 and IN00440091, with paper compliance completed on August 14, 2024. The facility was found to be in compliance.
Findings
Saint Anne Home was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance of the complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 14, 2024
Visit Reason
The inspection was conducted due to a complaint alleging misappropriation of property involving Resident B's credit card being used fraudulently by a staff member.
Complaint Details
This citation relates to Complaint IN00440091. The complaint was substantiated based on interviews, record reviews, and confirmation from Doordash and facility investigation.
Findings
The facility failed to ensure residents were free from misappropriation of property when CNA 2 was found to have made unauthorized Doordash purchases using Resident B's credit card. The facility initiated an investigation, confirmed the charges matched CNA 2's name and address, and a police report was filed. CNA 2 denied the allegations, blaming a neighbor.
Deficiencies (1)
Failure to protect Resident B from wrongful use of her credit card by a staff member.
Report Facts
Days CNA 2 assisted Resident B: 10
Brief Interview of Mental Status (BIMS) score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 2 | Certified Nurse Aide | Named in the finding for misappropriation of Resident B's credit card. |
| SW 4 | Social Worker | Conducted interviews related to the complaint and reviewed bank statements. |
| Administrator | Interviewed regarding the complaint and investigation. | |
| Human Resources | Confirmed information from family and Doordash and participated in interviews. | |
| AIT | Participated in interviews regarding the complaint. | |
| DON | Director of Nursing | Provided investigation file and participated in interviews. |
| Unit Secretary 3 | Interviewed and stated theft was against facility policy. |
Inspection Report
Complaint Investigation
Census: 194
Deficiencies: 1
Date: Aug 14, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00439077 and IN00440091. Complaint IN00439077 had no deficiencies cited, while Complaint IN00440091 resulted in federal/state deficiencies related to misappropriation of property.
Complaint Details
Complaint IN00440091 was substantiated with federal/state deficiencies cited at F602 related to misappropriation of Resident B's property. Complaint IN00439077 had no deficiencies cited.
Findings
The facility failed to ensure residents were free from misappropriation of property, specifically involving fraudulent charges made on Resident B's credit card by a Certified Nurse Aide (CNA 2). An investigation confirmed CNA 2 made unauthorized purchases using Resident B's credit card information. The facility implemented corrective actions including secured storage for valuables, resident and family education, staff in-service training, and ongoing monitoring.
Deficiencies (1)
Failed to ensure residents were free from misappropriation of property, involving fraudulent charges on Resident B's credit card by a staff member.
Report Facts
Census: 194
SNF/NF beds: 108
SNF beds: 6
Residential beds: 80
Medicare residents: 10
Medicaid residents: 56
Other residents: 128
Days CNA 2 assisted Resident B: 10
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 2 | Certified Nurse Aide | Named in misappropriation of property finding involving fraudulent charges on Resident B's credit card |
| Social Worker 4 | Social Worker | Interviewed Resident B and POA regarding fraudulent charges |
| Administrator | Administrator | Interviewed regarding complaint and confirmed fraudulent charges information |
| Unit Secretary 3 | Unit Secretary | Interviewed and stated theft was against facility policy |
Inspection Report
Life Safety
Census: 110
Capacity: 166
Deficiencies: 1
Date: Jun 21, 2024
Visit Reason
A Fire Safety Evaluation System (FSES) Survey and a Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health.
Findings
Saint Anne Home was found in compliance with NFPA 101A Chapter 4 for Health Care Occupancies and achieved a passing score on the FSES survey. However, the facility failed to ensure that 2 of 2 exit stairways had at least 50 percent of the exits leading directly to the outside, which could affect staff and residents. This deficiency was noted but correction was obviated by the passing FSES score.
Deficiencies (1)
Facility failed to ensure 2 of 2 exit stairways had at least 50 percent of the exits lead directly to the outside as required by LSC 7.7.1 and 7.7.2.
Report Facts
Facility capacity: 166
Census: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Facilities Director | Interviewed regarding stairway exits and FSES passing score |
Inspection Report
Complaint Investigation
Census: 193
Deficiencies: 0
Date: Jun 3, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00435008 at Saint Anne Home.
Complaint Details
Investigation of Complaint IN00435008 found no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 193
SNF/NF beds: 104
SNF beds: 9
Residential beds: 80
Medicare residents: 9
Medicaid residents: 53
Other payor residents: 131
Inspection Report
Annual Inspection
Census: 110
Capacity: 166
Deficiencies: 2
Date: Apr 23, 2024
Visit Reason
An annual Life Safety Code (LSC) Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) on 04/23/2024.
Findings
The facility was found not in compliance with certain Life Safety Code requirements, including issues with self-closing doors in a hazardous storage room and exit stairways not leading directly outside. The Emergency Preparedness survey found the facility in compliance.
Deficiencies (2)
Failed to ensure 1 of 4 hazardous storage room's corridor doors in the basement were not obstructed from closing; doors were held open by a device that did not release with the fire alarm.
Failed to ensure 2 of 2 exit stairways had at least 50 percent of the exits lead directly to the outside; stairway exits discharged onto the first floor and not directly outside.
Report Facts
Certified beds: 166
Census: 110
Deficiency completion date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elaine Wilson | COO | Facility representative signing the report |
| Facilities Director | Interviewed regarding hazardous storage room door and stairway exits | |
| Maintenance Director | Interviewed regarding hazardous storage room door |
Inspection Report
Renewal
Census: 107
Deficiencies: 0
Date: Apr 1, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Complaint IN00431119, including a State Residential Licensure Survey.
Complaint Details
Complaint IN00431119 - No deficiencies related to the allegations are cited.
Findings
Saint Anne Home was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1. No deficiencies related to the complaint allegations were cited.
Report Facts
Census Bed Type Total: 107
Census Payor Type Total: 107
SNF/NF Census: 98
SNF Census: 9
Medicare Census: 9
Medicaid Census: 49
Other Payor Census: 49
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 1, 2024
Visit Reason
The document is an annual inspection report for Saint Anne Home conducted as part of regulatory oversight to assess compliance with health and safety standards.
Findings
No health deficiencies were found during the inspection, indicating the facility met the required standards at the time of the survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 11, 2024
Visit Reason
Paper compliance review related to the Investigation of Complaint IN00424824 completed on February 7, 2024.
Complaint Details
Investigation of Complaint IN00424824 completed on February 7, 2024; facility found in compliance.
Findings
Saint Anne Home 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: 1
Date: Feb 7, 2024
Visit Reason
The inspection was conducted in response to a complaint (IN00424824) regarding alleged physical abuse of Resident D by staff at the facility.
Complaint Details
This citation relates to Complaint IN00424824. The complaint involved allegations of physical abuse of Resident D by Qualified Medication Aide (QMA) 4, confirmed by video review, staff interviews, and incident reports.
Findings
The facility failed to ensure residents were free from physical abuse for 1 of 3 residents reviewed (Resident D). Video evidence and staff statements showed that QMA 4 attempted to redirect Resident D, who became agitated and combative, resulting in Resident D falling after a physical struggle. The Director of Nursing and other staff confirmed the incident and reviewed relevant documentation and policies.
Deficiencies (1)
Failure to protect Resident D from physical abuse by staff, including inappropriate handling and scolding after a fall.
Report Facts
Residents reviewed: 3
Residents affected: 1
Brief Interview Mental Status score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| QMA 4 | Qualified Medication Aide | Named in physical abuse incident involving Resident D |
| LPN 5 | Licensed Practical Nurse | Witness and reporter of the incident involving Resident D |
| DON | Director of Nursing | Provided investigation file and reviewed video footage |
| CNA 2 | Certified Nurse Aide | Interviewed regarding Resident D's behavior and care |
| RN 3 | Registered Nurse | Interviewed regarding Resident D's behavior and care |
Inspection Report
Complaint Investigation
Census: 174
Deficiencies: 1
Date: Feb 7, 2024
Visit Reason
This visit was for the investigation of complaints IN00424824 and IN00425355. Complaint IN00424824 resulted in federal/state deficiencies related to abuse, while complaint IN00425355 had no deficiencies cited.
Complaint Details
Complaint IN00424824 was substantiated with federal/state deficiencies cited related to abuse. Complaint IN00425355 was not substantiated with no deficiencies cited.
Findings
The facility failed to ensure residents were free from physical abuse for one of three residents reviewed (Resident D). Video evidence and staff interviews documented an incident where Resident D was physically handled inappropriately by a Qualified Medication Aide, resulting in the resident falling and being scolded. The facility implemented corrective actions including staff in-service training on abuse and monitoring to prevent recurrence.
Deficiencies (1)
Failure to ensure residents were free from physical abuse, specifically involving Resident D who was physically handled inappropriately by staff resulting in a fall.
Report Facts
Census: 174
Medicare residents: 6
Medicaid residents: 50
Other residents: 118
SNF/NF beds: 94
SNF beds: 5
Residential beds: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elaine Wilson | COO | Signed report as provider/supplier representative |
| LPN 5 | Involved in incident report and witness to abuse incident involving Resident D | |
| QMA 4 | Qualified Medication Aide | Staff member involved in abuse incident with Resident D |
| DON | Director of Nursing | Provided investigation file and interviewed regarding abuse incident |
| CNA 2 | Certified Nurse Aide | Interviewed regarding Resident D's behavior and care |
| RN 3 | Registered Nurse | Interviewed regarding Resident D's behavior and care |
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 0
Date: Nov 15, 2023
Visit Reason
This visit was conducted for the Investigation of Complaint IN00421153.
Complaint Details
Complaint IN00421153 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00421153 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type Total: 103
SNF/NF Census: 93
SNF Census: 10
Census Payor Type Medicaid: 51
Census Payor Type Other: 52
Census Payor Type Medicare: 0
Inspection Report
Re-Inspection
Census: 165
Deficiencies: 0
Date: May 4, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on March 3, 2023.
Findings
Saint Anne Home was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey.
Report Facts
Census SNF/NF: 87
Census SNF: 5
Census Residential: 73
Total Census: 165
Census Medicare: 8
Census Medicaid: 53
Census Other: 104
Inspection Report
Annual Inspection
Census: 94
Capacity: 166
Deficiencies: 1
Date: Mar 16, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code (LSC) Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal regulations.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements due to stairways not discharging directly to the outside as required.
Deficiencies (1)
Failed to ensure 2 of 2 exit stairways had at least 50 percent of the exits lead directly to the outside, with stairwells discharging onto the first floor and not directly outside.
Report Facts
Certified beds: 166
Census: 94
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elaine Wilson | COO | Signed as Laboratory Director's or Provider/Supplier Representative |
| Facilities Director | Interviewed regarding stairwell exits |
Inspection Report
Life Safety
Deficiencies: 1
Date: Mar 16, 2023
Visit Reason
The visit was conducted as a Life Safety Code Recertification and State Licensure Survey to evaluate compliance with fire safety regulations.
Findings
The facility was found generally in compliance with NFPA 101A standards; however, a deficiency was identified where both exit stairways did not lead directly to the outside, which could affect staff and residents.
Deficiencies (1)
Facility failed to ensure 2 of 2 exit stairways had at least 50 percent of the exits lead directly to the outside as required by Life Safety Code 7.7.1.
Report Facts
Number of exit stairways: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Facilities Director | Interviewed regarding stairway exit discharge locations and findings were reviewed with this individual during the exit conference. |
Inspection Report
Routine
Deficiencies: 12
Date: Mar 3, 2023
Visit Reason
The inspection was a routine regulatory survey conducted to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including resident dignity and privacy, accurate assessments, timely response to call lights, communication and hearing loss management, pressure ulcer care, fall prevention, respiratory care, pain management, trauma-informed care, medication labeling and storage, and kitchen sanitation.
Deficiencies (12)
Failed to ensure a resident's indwelling urinary catheter bag was covered to maintain dignity.
Failed to ensure privacy for a resident when bathroom door was wedged open exposing the resident.
Failed to ensure accurate assessment for a resident, specifically PASRR Level II status was not properly documented.
Failed to ensure timely response to call light for a resident, with documented delays up to 32 minutes.
Failed to address communication and hearing loss needs for residents, including failure to ensure hearing aids were used and communication strategies documented.
Failed to implement standard procedures for pressure ulcer treatment, including inconsistent wound staging and improper dressing change technique.
Failed to implement interventions to prevent falls for residents, including lack of supervision and failure to follow safety check orders.
Failed to ensure oxygen tubing was properly labeled and stored when not in use.
Failed to provide nonpharmacological interventions and proper pain assessment for a resident receiving pain management.
Failed to properly label and store medications, including unsecured medication cart and medications without open dates or physician names.
Failed to maintain kitchen sanitation, including water dripping near clean dishes, dirty floors, torn refrigerator gasket, and incomplete temperature logs.
Failed to provide trauma informed and culturally competent care by not identifying triggers or specific approaches for a resident with trauma history.
Report Facts
Residents affected: 1
Residents affected: 1
Residents reviewed: 26
Residents affected: 1
Residents reviewed: 3
Residents reviewed: 2
Residents reviewed: 7
Residents reviewed: 3
Residents reviewed: 1
Residents affected: 5
Residents residing: 101
Residents reviewed: 1
Call light activation duration: 32
Medication bottles: 11
Refrigerator temperature: 32
Freezer temperature: -10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager 16 | Unit Manager and wound care nurse | Named in pressure ulcer care deficiency and wound care observations |
| RN 12 | Registered Nurse | Named in catheter bag dignity, pressure ulcer care, and medication administration observations |
| LPN 10 | Licensed Practical Nurse | Named in call light response and trauma informed care interviews |
| CNA 9 | Certified Nursing Assistant | Named in call light response observation and interview |
| Social Services 1 | Social Services | Named in PASRR assessment interview |
| Administrator | Administrator | Named in privacy policy and kitchen sanitation interviews |
| Infection Preventionist | Infection Preventionist | Named in catheter bag dignity and oxygen tubing storage interviews |
| LPN 18 | Licensed Practical Nurse | Named in medication labeling observation |
| CNA 22 | Certified Nursing Assistant | Named in fall prevention and medication observation |
| LPN 20 | Licensed Practical Nurse | Named in fall prevention and pain management interviews |
| DON | Director of Nursing | Named in fall prevention and medication storage interviews |
| Activities 15 | Activities Staff | Named in fall prevention interview |
| Infection Control Nurse | Infection Control Nurse | Named in pressure ulcer care interview |
| Social Services Director 5 | Social Services Director | Named in trauma informed care progress note |
| Nurse Practitioner 50 | Nurse Practitioner | Named in trauma informed care progress note |
| Executive Director | Executive Director | Named in catheter bag dignity and pain management policy provision |
| Dietary Manager | Dietary Manager | Named in kitchen sanitation interview |
Inspection Report
Annual Inspection
Census: 75
Deficiencies: 12
Date: Mar 3, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey including a State Residential Licensure Survey conducted from February 27 to March 3, 2023.
Findings
The facility was found to have multiple deficiencies including failure to maintain resident dignity, privacy, accurate assessments, timely call light response, communication needs, pressure ulcer treatment, fall prevention, respiratory care, pain management, trauma-informed care, medication labeling and storage, and kitchen sanitation. Corrective actions and systemic changes were planned or implemented for each deficiency.
Deficiencies (12)
Failure to ensure a resident's indwelling urinary catheter bag was covered to maintain dignity.
Failure to ensure privacy for a resident in the bathroom with the door open.
Failure to ensure accurate assessment for a resident regarding PASRR Level II screening.
Failure to ensure timely response to call lights for a resident.
Failure to ensure communication and hearing loss needs were addressed for residents.
Failure to implement standard procedures for pressure ulcer treatment for a resident.
Failure to implement interventions to prevent falls for residents.
Failure to ensure oxygen tubing was properly labeled and stored when not in use.
Failure to provide nonpharmacological interventions and assessment of pain for a resident.
Failure to identify triggers and initiate trauma-informed care for a resident.
Failure to properly label and store medications in medication storage rooms.
Failure to ensure kitchen sanitation was maintained including leaking ceiling, debris, and inadequate temperature logs.
Report Facts
Survey dates: 5
Residents present: 75
Deficiency counts: 12
Temperature log out of range: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 12 | Registered Nurse | Named in findings related to catheter bag dignity, privacy breach, wound care, medication administration, and call light response. |
| Unit Manager 16 | Unit Manager/Wound Care Nurse | Named in findings related to privacy breach, wound care, and fall prevention. |
| LPN 10 | Licensed Practical Nurse | Named in findings related to privacy breach, medication administration, and call light response. |
| CNA 9 | Certified Nursing Assistant | Named in call light response finding. |
| Social Services Director 5 | Social Services Director | Named in trauma-informed care finding. |
| Nurse Practitioner 50 | Nurse Practitioner | Named in trauma-informed care finding. |
| LPN 18 | Licensed Practical Nurse | Named in medication labeling and storage finding. |
| LPN 19 | Licensed Practical Nurse | Named in medication labeling and storage finding. |
| DON | Director of Nursing | Named in medication self-administration and wound care findings. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 25, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00396697 completed on December 19, 2022.
Complaint Details
Investigation of Complaint IN00396697 completed with paper compliance found.
Findings
Saint Anne Home 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: 88
Capacity: 88
Deficiencies: 3
Date: Dec 19, 2022
Visit Reason
This visit was for the investigation of complaints IN00396574 and IN00396697. Complaint IN00396574 was substantiated with no deficiencies cited, and Complaint IN00396697 was substantiated with federal/state deficiencies cited.
Complaint Details
Complaint IN00396574 was substantiated with no deficiencies cited. Complaint IN00396697 was substantiated with deficiencies cited at F600, F607, and F610 related to abuse by a staff member (Employee 3) who kissed Resident J on the lips. The investigation was incomplete, missing interviews with other residents and staff on the affected unit.
Findings
The facility failed to ensure residents were free from staff abuse, specifically involving a male staff member (Employee 3) who gave a resident (Resident J) a hug and kissed her on the lips. The facility also failed to implement policies and procedures to prevent abuse, and failed to conduct a thorough investigation of the abuse allegation. Employee 3 resigned following the incident. The resident was not distressed but concerned about others. The investigation did not include interviews with all potentially affected residents or staff.
Deficiencies (3)
Failed to ensure residents were free from staff abuse (Resident J kissed on lips by staff).
Failed to implement policies and procedures to prevent abuse.
Failed to conduct a thorough investigation of an allegation of abuse.
Report Facts
Census: 88
Total Capacity: 88
Residents interviewed: 7
Residents reviewed: 5
Date of survey completion: Dec 20, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee 3 | Male staff member who gave Resident J a hug and kissed her on the lips; resigned following incident | |
| Employee 5 | Confidential interviewee who described Employee 3's behavior and relationship with Resident J | |
| Employee 6 | Day shift nurse | Interviewed about Resident J's report of abuse |
| Administrator | Notified of incident, encouraged Employee 3 to resign, and oversaw investigation | |
| Social Services Director | SSD | Conducted resident interviews during investigation |
| Licensed Social Worker | Talk therapist | Met with Resident J post-incident to assess emotional trauma |
| HR Director | Interviewed regarding Employee 3's resignation and missing criminal background check |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 0
Date: Oct 11, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00390326.
Complaint Details
Complaint IN00390326 was substantiated but no deficiencies related to the allegations were cited.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type Total: 86
Census Payor Type Total: 86
Medicare Census: 8
Medicaid Census: 52
Other Payor Census: 26
SNF/NF Beds: 80
SNF Beds: 6
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