Inspection Reports for
St Augustine Home for the Aged
2345 W 86TH ST, INDIANAPOLIS, IN, 46260
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
11.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
169% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
32 residents
Based on a January 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jul 2, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to complete a new Preadmission Screening and Resident Review (PASARR) after an increase in antipsychotic medication, failure to hold medication according to physician's orders, and improper medication storage and labeling.
Complaint Details
The complaint investigation found substantiated deficiencies related to PASARR screening, medication administration errors, and medication storage and labeling issues.
Findings
The facility failed to ensure a new PASARR was completed after an increase in antipsychotic medication for one resident, failed to hold metoprolol medication according to physician's orders for one resident, and failed to properly date opened medications, dispose of expired blood glucose control solution, and properly store chemicals in medication storage areas.
Deficiencies (3)
Failed to ensure a new PASARR was completed after an increase of an antipsychotic medication for Resident 2.
Failed to ensure a medication was held according to the physician's order for Resident 8.
Failed to ensure medications were dated after opening, expired blood glucose control solution was disposed of, and chemicals were properly stored.
Report Facts
Medication administration errors: 8
Medication cart and storage review: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 4 | Registered Nurse | Interviewed regarding medication hold procedures for Resident 8. |
| Social Services Director | Social Services Director | Interviewed regarding PASARR referral procedures. |
| QMA 2 | Qualified Medication Aide | Interviewed regarding medication cart and storage room observations. |
| Director of Nursing | Director of Nursing | Provided facility policies and interviewed regarding medication administration and PASARR procedures. |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 1
Date: Jan 13, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00449365 regarding allegations of abuse at the facility.
Complaint Details
Complaint IN00449365 was substantiated with federal and state deficiencies cited related to abuse allegations against CNA 1 involving Resident B.
Findings
The facility failed to protect a resident's right to be free from physical abuse by a CNA. The investigation found that CNA 1 physically abused Resident B by hitting him on the forehead, which was substantiated by consistent resident statements, staff interviews, and physical evidence. CNA 1 was terminated and a resident abuse in-service was completed for all employees.
Deficiencies (1)
Facility failed to protect resident's right to be free from physical abuse by a CNA.
Report Facts
Census SNF/NF beds: 18
Census Residential beds: 14
Total Census: 32
Census Medicaid: 18
Skin discoloration size: 1.5
Skin protrusion size: 0.5
Date of CNA termination: Sep 19, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in physical abuse finding and terminated for abuse |
| RN 2 | Registered Nurse | Signed facility statement regarding Resident B's injury |
| RN 4 | Registered Nurse | Witnessed interactions and provided statements related to abuse investigation |
| RN 5 | Registered Nurse | Provided facility statement about CNA 1's emotional state and incident |
| CNA 3 | Certified Nursing Assistant | Observed CNA 1 leaving Resident B's room and reported incident |
| CNA 7 | Certified Nursing Assistant | Reported Resident B's statement about being hit |
| CNA 9 | Certified Nursing Assistant | Provided statement about Resident B's condition before and after incident |
| Human Resource Director | Interviewed regarding CNA 1 termination and investigation findings | |
| Executive Director | Interviewed regarding abuse investigation and CNA 1 termination | |
| Director of Nursing | Interviewed regarding care plan and policy adherence related to abuse incident |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 13, 2025
Visit Reason
The inspection was conducted due to a complaint alleging physical abuse by a Certified Nursing Assistant (CNA 1) against Resident B at the facility.
Complaint Details
The complaint IN00449365 alleged that CNA 1 physically abused Resident B by hitting him on the forehead. The allegation was substantiated after investigation, including interviews and skin assessment findings.
Findings
The facility failed to protect Resident B from physical abuse by CNA 1, who was found to have hit the resident on the forehead causing a discoloration and swelling. The abuse was substantiated, CNA 1 was terminated, and the facility implemented corrective actions including staff and resident interviews and abuse in-service training.
Deficiencies (1)
Failed to protect the resident's right to be free from physical abuse by a CNA for 1 of 2 residents reviewed for abuse.
Report Facts
Residents Affected: 2
Skin lesion size: 1.5
Skin lesion size: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in physical abuse finding and terminated for abuse |
| RN 4 | Registered Nurse | Witnessed interactions and statements related to abuse incident |
| RN 5 | Registered Nurse | Interviewed and provided statements regarding incident and CNA 1 |
| Human Resource Director | Provided interview confirming CNA 1 termination for abuse | |
| Executive Director | Provided interview confirming CNA 1 termination and abuse findings | |
| Director of Nursing | Interviewed regarding incident and policy on caring for residents in pairs |
Inspection Report
Life Safety
Census: 20
Capacity: 23
Deficiencies: 4
Date: Oct 3, 2024
Visit Reason
The survey 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 related NFPA 101 standards.
Findings
The facility was found not in compliance with Life Safety Code requirements, including corridor width clearance, fire alarm system testing and maintenance, biohazard storage room safety, and emergency generator load testing and cool down documentation. Corrective actions and plans of correction were submitted for each deficiency.
Deficiencies (4)
Failed to meet clear corridor width requirements due to furniture not affixed to floor or wall, obstructing corridor width.
Failed to maintain fire alarm system with required semi-annual visual inspections as per NFPA 72.
Trash receptacle in biohazard storage room was not stored in a room protected as a hazardous area; door was not self-closing.
Failed to document emergency generator monthly load testing with required load and cool-down times for the most recent 12 months.
Report Facts
Certified beds: 23
Census: 20
Deficiencies cited: 4
Fire alarm system inspections: 2
Generator rating: 100
Generator manufacture date: 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Steven M Still | Administrator | Reviewed findings during exit conference |
Inspection Report
Life Safety
Deficiencies: 0
Date: Oct 3, 2024
Visit Reason
The visit was conducted as a Life Safety Code Recertification and State Licensure Survey for St. Augustine Home for the Aged.
Findings
The facility was found in compliance with the 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, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Annual Inspection
Census: 13
Capacity: 33
Deficiencies: 5
Date: Sep 20, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted from September 16 to 20, 2024.
Findings
The facility was found to have multiple deficiencies including failure to document residents' code status, inadequate assessment and treatment for constipation and congestive heart failure complications, failure to monitor urinary output for catheter care, failure to date oxygen tubing changes, and lack of antibiotic stewardship monitoring. The facility submitted plans of correction addressing these issues with staff in-service, audits, and quality assurance programs.
Deficiencies (5)
Failed to ensure a resident's code status was obtained and accurately documented in the clinical record for 1 of 1 resident reviewed for advanced directives.
Failed to ensure residents were assessed and treated for constipation, assessed for complications of congestive heart failure, and physician notified of weight gains outside ordered parameters for 3 of 3 residents reviewed for quality of care.
Failed to ensure urinary output was monitored as ordered by the physician for 1 of 1 resident reviewed for catheter care.
Failed to ensure oxygen tubing was dated for the day it was changed for 3 of 3 residents reviewed for respiratory care.
Failed to monitor the use of antibiotics including use of standardized tools for appropriateness of antibiotics prescribed for 1 of 5 residents reviewed for unnecessary medications.
Report Facts
Survey dates: 5
Census SNF/NF beds: 20
Census Residential beds: 13
Total licensed capacity: 33
Resident weight gain: 5.1
Resident weight gain: 4.8
Missing urinary output documentation: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Steven M. Still | Administrator | Signed the inspection report |
| RN 3 | Interviewed regarding code status documentation for Resident 171 | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding code status, bowel and weight protocols, oxygen tubing, and antibiotic stewardship |
| RN 1 | Interviewed regarding bowel movement documentation and urinary output | |
| RN 6 | Interviewed regarding congestive heart failure assessments |
Inspection Report
Renewal
Deficiencies: 0
Date: Sep 20, 2024
Visit Reason
The inspection was conducted as a paper compliance review for the Recertification and State Licensure survey.
Findings
St Augustine Home for the Aged 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.
Report Facts
Facility Number: 389
Provider Number: 155825
AIM Number: 100288920
Inspection Report
Routine
Deficiencies: 5
Date: Sep 20, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, quality of care, catheter care, respiratory care, and infection prevention at St Augustine Home for the Aged.
Findings
The facility was found deficient in multiple areas including failure to document resident code status, inadequate monitoring and treatment of weight changes and constipation, incomplete urinary output documentation for catheter care, failure to date oxygen tubing changes, and lack of antibiotic use surveillance.
Deficiencies (5)
Failed to ensure a resident's code status was obtained and accurately documented in the clinical record.
Failed to provide appropriate treatment and care according to orders, resident’s preferences and goals related to weight monitoring and constipation management.
Failed to ensure urinary output was monitored as ordered by the physician for catheter care.
Failed to ensure oxygen tubing was dated for the day it was changed for residents receiving respiratory care.
Failed to monitor the use of antibiotics including the use of standardized tools for appropriateness of antibiotics prescribed.
Report Facts
Weight gain: 4.8
Weight gain: 5.1
Missing urinary output documentation: 4
Oxygen flow rate: 2
Antibiotic dosage: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 3 | Registered Nurse | Indicated newly admitted resident should have code status documented within 24 hours. |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding deficiencies in code status documentation, weight monitoring, bowel care, respiratory care, and antibiotic stewardship. |
| RN 1 | Registered Nurse | Indicated urinary output documentation requirements and provided facility policy on oxygenator. |
| RN 6 | Registered Nurse | Indicated procedures for monitoring residents with congestive heart failure. |
Inspection Report
Re-Inspection
Census: 21
Capacity: 42
Deficiencies: 0
Date: Sep 19, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 08/01/23 was performed by the Indiana Department of Health.
Findings
At this PSR Life Safety Code survey, St. Augustine Home for the Aged was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code.
Inspection Report
Life Safety
Census: 23
Capacity: 42
Deficiencies: 4
Date: Aug 1, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 08/01/2023.
Findings
The facility was found in compliance with Emergency Preparedness requirements but was not in compliance with Life Safety Code requirements. Deficiencies included failure to maintain the automatic sprinkler system, corridor doors not resisting passage of smoke, failure to conduct fire drills at unexpected times, and improper use of power strips for high current draw equipment.
Deficiencies (4)
Failed to maintain 1 of 1 automatic sprinkler systems; anti-freeze solution tested above requirements and had not been replaced.
Failed to ensure 1 of over 30 corridor doors would resist the passage of smoke; a corridor door had a 3/8-inch hole penetrating completely through the door.
Failed to conduct quarterly fire drills on unexpected days and at unexpected times under varying conditions.
Failed to ensure power strips were not used as a substitute for fixed wiring to provide power to equipment with a high current draw; a power strip was used to power a window air conditioning unit.
Report Facts
Certified beds: 42
Census: 23
Corridor doors inspected: 30
Quarterly fire drills reviewed: 12
Fire drills conducted near end of month: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Steven M. Still | Administrator | Signed the report |
| Maintenance Director | Interviewed regarding sprinkler system, corridor door deficiency, fire drills, and power strip usage; acknowledged findings and corrective actions |
Inspection Report
Annual Inspection
Census: 23
Capacity: 40
Deficiencies: 5
Date: Jul 11, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted on July 5, 6, 7, 10 and 11, 2023.
Findings
The facility was found deficient in multiple areas including failure to thoroughly investigate an abuse allegation, incomplete significant change assessments, insufficient RN coverage, and improper medication disposal and storage practices.
Deficiencies (5)
Failed to thoroughly investigate an allegation and immediately take action to prevent further abuse or mistreatment while the investigation was in progress for 1 resident (Resident 10).
Failed to ensure a significant change Minimum Data Set (MDS) assessment was completed for a resident with a fall resulting in injury and increased behavioral issues (Resident 7).
Failed to ensure a Registered Nurse was in the facility for 8 hours during a 24-hour period for 9 days in the first quarter of 2023.
Failed to ensure medications were disposed of according to regulations and standards of practice for 1 resident (Resident 21).
Failed to destroy controlled substances after medication discontinuation and to dispose of compromised controlled substances properly in medication storage (West cart).
Report Facts
Survey dates: 5
Residents present (census): 23
Total licensed capacity: 40
Residents reviewed for MDS assessments: 3
Days without 8 hours RN coverage: 9
Residents reviewed for medication observation: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Steven M. Still | Administrator | Signed the report and involved in facility administration |
| CNA 13 | Named in abuse allegation involving Resident 10; resigned on 02/23/2023 | |
| Clinical Nurse 12 | Provided working hours of CNA 13 and interviewed regarding abuse investigation | |
| Human Resources Director | Provided information on CNA 13 and RN staffing issues | |
| LPN 10 | Observed disposing medications improperly | |
| Clinical Nurse 3 | Provided medication disposal policies and interviewed about medication storage | |
| Director of Nursing | Interviewed regarding medication disposal policy and RN staffing |
Inspection Report
Renewal
Deficiencies: 0
Date: Jul 11, 2023
Visit Reason
The visit was a paper compliance review related to the Recertification and State Licensure Survey completed on July 11, 2023.
Findings
St. Augustine Home for the Aged 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 for the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jul 11, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding alleged abuse or mistreatment of Resident 10 and to assess compliance with regulatory requirements related to resident care, staffing, assessments, and medication management.
Complaint Details
The complaint involved an allegation by Resident 10 that a staff member (CNA 13) was rough and caused wrist pain. The facility failed to thoroughly investigate the allegation and allowed the staff member to return to work pending investigation. CNA 13 was sent home and resigned shortly after. The investigation lacked documentation and interviews with other residents. The allegation was substantiated as the facility acknowledged the failure to protect the resident and properly investigate.
Findings
The facility failed to thoroughly investigate an abuse allegation involving Resident 10, allowed a staff member under investigation to return to work, failed to complete a significant change Minimum Data Set assessment for Resident 7 after a fall with injury, lacked sufficient Registered Nurse coverage for multiple days in early 2023, and failed to properly dispose of medications for Resident 21 according to regulations.
Deficiencies (4)
Failed to thoroughly investigate an allegation and immediately take action to prevent further abuse or mistreatment for Resident 10.
Failed to ensure a significant change Minimum Data Set (MDS) assessment was completed for Resident 7 after a fall resulting in injury and increased behavioral issues.
Failed to ensure Registered Nurse coverage for 8 hours during a 24-hour period for 9 days in the first quarter of 2023.
Failed to ensure medications were disposed of according to regulations and standards of practice for Resident 21.
Report Facts
Days without RN coverage: 9
MDS assessment date: May 30, 2023
MDS assessment date: 201808
Medication observation date: Jul 7, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 13 | Certified Nursing Assistant | Named in abuse allegation involving Resident 10; sent home pending investigation and resigned shortly after. |
| Human Resources Director | Provided information about CNA 13 and RN staffing issues. | |
| Clinical Nurse 12 | Provided timesheets for CNA 13 and interview information. | |
| LPN 4 | Licensed Practical Nurse | Authored unidentified statement in investigation and disposed of refused medications in biohazard container. |
| Sister 1 | Documented late entry regarding abuse allegation and interviewed about investigation. | |
| LPN 10 | Licensed Practical Nurse | Observed disposing medications improperly during medication observation. |
| Director of Nursing | Director of Nursing | Interviewed about medication disposal policy and staffing. |
| Clinical Nurse 3 | Provided medication disposal policies and procedures. |
Inspection Report
Re-Inspection
Census: 27
Capacity: 42
Deficiencies: 0
Date: Oct 20, 2022
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey following prior surveys conducted between 08/02/22 - 08/03/22.
Findings
At this PSR Emergency Preparedness survey, the facility was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. At the PSR Life Safety Code survey, the facility was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code.
Report Facts
Certified beds: 42
Census: 27
Walk-in coolers not sprinklered: 2
Total walk-in coolers: 5
Inspection Report
Complaint Investigation
Census: 27
Capacity: 27
Deficiencies: 0
Date: Oct 7, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00389592.
Complaint Details
Complaint IN00389592 was investigated and found unsubstantiated due to lack of evidence.
Findings
The complaint IN00389592 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 27
Medicare Census: 2
Medicaid Census: 24
Other Payor Census: 1
Inspection Report
Re-Inspection
Census: 46
Deficiencies: 0
Date: Sep 28, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on July 1, 2022, including a PSR to the State Residential Licensure Survey completed on July 1, 2022.
Findings
St Augustine Home For The Aged 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: 26
Census Residential: 20
Census Payor Medicare: 1
Census Payor Medicaid: 24
Census Payor Other: 1
Census Payor Total: 26
Inspection Report
Life Safety
Census: 25
Capacity: 42
Deficiencies: 13
Date: Aug 2, 2022
Visit Reason
The survey 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).
Findings
The facility was found not in compliance with Life Safety Code requirements including issues with fire doors not latching, exit discharge unevenness, hazardous area doors lacking self-closing devices, sprinkler system obstructions, corridor doors not closing properly, unsealed smoke barrier penetrations, unsecured electrical panels, lack of GFCI protection in wet locations, improper use of power strips, and inadequate mechanical ventilation in oxygen storage rooms.
Deficiencies (13)
Emergency Preparedness plan lacked a method for sharing information with residents and families.
Four separation fire doors did not positively latch to limit fire and smoke spread.
Means of egress through 2nd floor stairwell exit was not readily accessible due to locked door without posted code.
Exit discharge from East Stairwell Exit had a 4-5 inch elevation change causing uneven surface.
Five hazardous area doors lacked properly working self-closing devices.
HVAC closet near 2nd Floor East Food Prep Area lacked sprinkler protection and 3rd Floor Supply Closet sprinkler head was obstructed.
Three corridor doors failed to close and latch properly to resist passage of smoke.
Unsealed penetrations in smoke barrier wall above drop ceiling near West Hall Dining area.
Electrical panels in corridors were unsecured and unlocked.
Two wet locations lacked ground fault circuit interrupter (GFCI) protection.
Power strips in patient care vicinity lacked required UL rating and were improperly used as substitute for fixed wiring.
Oxygen storage room lacked properly working mechanical ventilation to maintain negative pressure.
Chapel contained combustible decorations including lit candles without proper controls.
Report Facts
Certified beds: 42
Census: 25
Fire doors not latching: 4
Hazardous area doors lacking self-closing devices: 5
Corridor doors failing to close and latch: 3
Unsealed penetrations: 1
Electrical panels unlocked: 2
Wet locations lacking GFCI: 2
Power strips lacking UL rating: 4
Power strips daisy chained: 2
Oxygen storage rooms lacking ventilation: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Steven M Still | Administrator | Signed report and present at exit conference |
| Facilities Operations Manager | Interviewed and acknowledged multiple findings | |
| Assistant Maintenance Supervisor | Interviewed and acknowledged multiple findings |
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