Inspection Reports for StoryPoint Granger
6330 N Fir Rd, Granger, IN 46530, United States, IN, 46530
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Inspection Report
Complaint Investigation
Census: 126
Deficiencies: 1
Feb 17, 2025
Visit Reason
This visit was conducted as an investigation of Complaint IN00452241 regarding allegations of abuse at StoryPoint Granger.
Findings
The facility failed to implement their policy related to investigating and reporting allegations of abuse for one resident (Resident B). The investigation found that a Certified Nurse Aide (CNA 3) allegedly acted abusively toward Resident B, but the facility did not immediately report the allegation to the Director of Nursing, Administrator, or State Authorities, and did not suspend the CNA pending investigation.
Complaint Details
Complaint IN00452241 involved allegations of abuse by CNA 3 toward Resident B. The Adult Protective Services (APS) investigation did not substantiate the abuse but was concerned the facility failed to report the allegation to State Authorities. The facility delayed reporting the allegation internally and did not suspend the CNA immediately. The allegation was reported late to the Director of Nursing and Administrator, and the Administrator did not report to the State Agency due to the allegation being unsubstantiated.
Deficiencies (1)
| Description |
|---|
| Failure to implement policy related to investigating and reporting allegations of abuse for 1 of 3 residents reviewed. |
Report Facts
Residential Census: 126
Survey Date: Feb 17, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Martin Lebbin | Executive Director | Signed the plan of correction and correspondence related to the complaint investigation |
| CNA 2 | Certified Nurse Aide | Reported the incident and made referral to Adult Protective Services |
| CNA 3 | Certified Nurse Aide | Alleged to have acted abusively toward Resident B |
| Director of Nursing | Interviewed regarding the incident and reporting failures | |
| Assistant Director of Nursing | Received report from CNA 2 and delayed reporting to Director of Nursing and Administrator | |
| Administrator | Was on vacation during incident and delayed reporting to State Agency |
Inspection Report
Annual Inspection
Census: 122
Deficiencies: 4
Nov 14, 2024
Visit Reason
This visit was for a State Residential Licensure Survey including the investigation of three complaints (IN00446324, IN00445359, IN00445068).
Findings
No deficiencies were cited related to the complaints investigated. The survey identified deficiencies in evaluation documentation, food and nutritional services, infection control program, and tuberculosis skin testing compliance.
Complaint Details
Complaint IN00446324, IN00445359, and IN00445068 were investigated with no deficiencies related to the allegations cited.
Deficiencies (4)
| Description |
|---|
| Failed to obtain a signature from the resident or resident's representative on the service plan for 1 of 7 residents reviewed. |
| Failed to ensure food was stored in a sanitary manner in the kitchen, including undated opened food items and improper storage of measuring cups. |
| Failed to establish an infection control program that included ongoing analysis and surveillance data review for March to September 2024. |
| Failed to complete a second step tuberculosis skin test after admission for 1 of 7 residents reviewed. |
Report Facts
Residents reviewed for evaluation documentation: 7
Residents affected by food storage deficiency: 122
Residents affected by infection control deficiency: 122
Residents reviewed for tuberculosis skin testing: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Martin Lebbin | Executive Director | Signed the report and plan of correction; mentioned in relation to survey and follow-up. |
| Director of Nursing (DON) | Interviewed regarding service plan signatures and tuberculosis skin testing; name not fully provided. | |
| Executive Chef | Interviewed regarding food storage deficiencies and re-education of dietary staff; name not fully provided. | |
| Wellness Director | Interviewed regarding infection control logbook and surveillance; name not fully provided. |
Inspection Report
Follow-Up
Census: 122
Deficiencies: 0
Nov 8, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to investigate complaints IN00444050, IN00435195, IN00435202, and IN00435204 completed on 10/4/24.
Findings
The facility was found to be in compliance with 410 IAC 16.2-5 regarding the PSR to the investigation of the listed complaints, all of which were corrected.
Complaint Details
Complaints IN00444050, IN00435195, IN00435202, and IN00435204 were investigated and found to be corrected.
Report Facts
Complaint investigations: 4
Inspection Report
Complaint Investigation
Census: 118
Deficiencies: 4
Oct 4, 2024
Visit Reason
This visit was for the investigation of complaints IN00444050, IN00435195, IN00435202, and IN00435204 at StoryPoint Granger.
Findings
The facility was found deficient in multiple areas including improper use of chemical restraints without supporting diagnosis or physician order, failure to provide nursing assessments after an unwitnessed fall resulting in resident death, failure to report an incident to the state, and failure to provide physician-ordered colostomy/ileostomy care and assistance.
Complaint Details
Complaints investigated included IN00444050, IN00435195, IN00435202, and IN00435204. Deficiencies were substantiated related to chemical restraint use, fall assessment and reporting, and ostomy care.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure residents were free from chemical restraints related to the use of antipsychotic medications for Resident B without a supporting diagnosis and a physician's order. |
| Facility neglected to provide nursing assessments after an unwitnessed fall for Resident D, resulting in the resident becoming nonresponsive and later dying from brain hemorrhage. |
| Facility failed to inform the Indiana Department of Health of an incident involving Resident D's unwitnessed fall resulting in hospitalization and death. |
| Facility failed to provide physician ordered colostomy/ileostomy care and assistance for Resident C, with some staff refusing to provide care. |
Report Facts
Residents present: 118
Survey dates: 4
Compliance dates: Nov 5, 2024
Compliance date: Nov 15, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Martin Lebbin | Executive Director | Signed plan of correction letter |
| RN 6 | Triage Nurse | Provided telephone triage during Resident D's fall incident |
| LPN 3 | Licensed Practical Nurse | Documented Resident D's transport to ER after fall |
| QMA 2 | Qualified Medication Aide | Reported Resident D's fall and contacted triage nurse |
| Assistant Director of Nursing | ADON | Provided interviews and information on medication and ostomy care |
| Director of Nursing | DON | Provided interviews and policy information regarding falls and incident reporting |
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 0
Mar 27, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00428642, IN00429080, and IN00430956.
Findings
No deficiencies related to the allegations in complaints IN00428642, IN00429080, and IN00430956 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Complaint Details
Complaints IN00428642, IN00429080, and IN00430956 were investigated and found to have no deficiencies related to the allegations.
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 0
Jan 23, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00426181.
Findings
No deficiencies related to the allegations in Complaint IN00426181 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Complaint Details
Complaint IN00426181 was investigated and found to have no deficiencies related to the allegations.
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 13
Jan 4, 2024
Visit Reason
This visit was for a State Residential Licensure Survey which included the Investigation of Complaint IN00423080.
Findings
The facility was found deficient in multiple areas including misappropriation of resident property, failure to conduct quarterly fire drills, incomplete health screenings for employees, incomplete resident evaluations, medication administration issues, expired medications not removed, incomplete clinical records, missing emergency information, incomplete infection control practices including TB testing and hand hygiene.
Complaint Details
Complaint IN00423080 was investigated and a state deficiency related to the allegations was cited at R0064 for misappropriation of resident property involving a check cashed fraudulently by a CNA who was terminated.
Deficiencies (13)
| Description |
|---|
| Failed to ensure a resident was free of misappropriation of property. |
| Failed to ensure quarterly fire drills were completed for January through May 2023. |
| Failed to ensure new employees had a health screen prior to resident contact for 4 of 5 employee files reviewed. |
| Failed to ensure a Self-Medication Administration Evaluation was completed for a resident who self-administers breathing treatments and failed to ensure semi-annual weights were completed for residents. |
| Failed to include resident's signature, date, and needed service in the service plan for 1 of 6 residents. |
| Failed to ensure PRN medication administered by QMA was approved by a licensed nurse for 1 of 7 residents. |
| Failed to ensure over-the-counter medications were labeled in 3 of 6 medication carts observed. |
| Failed to ensure expired medications were removed from medication carts and destroyed in 3 of 3 medication carts observed. |
| Failed to have Physician's Orders signed timely by a Physician for 3 of 8 residents reviewed. |
| Failed to ensure accurate and current emergency information was located in the Resident Emergency binder for 4 of 7 residents reviewed. |
| Failed to ensure an annual health statement from the physician was obtained on admission for 2 of 7 residents reviewed. |
| Failed to ensure a resident was tested for TB and/or had a risk assessment completed for 2023 and failed to read an admission TB timely for 1 of 6 residents reviewed. |
| Failed to ensure staff washed hands after direct resident contact during blood glucose testing and insulin injection for 2 of 3 medication administration observations. |
Report Facts
Residents present: 113
Check amount: 3500
Fire drills missing: 5
Employees without health screen: 4
Residents with unsigned physician orders: 3
Residents missing emergency info: 4
Residents missing annual health statement: 2
Residents missing TB testing or risk assessment: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Martin Lebbin | Executive Director | Named in relation to plan of correction and notification of misappropriation incident |
| CNA 13 | Employee terminated for misappropriation of resident property | |
| Wellness Director | Provided policies and interviews related to multiple deficiencies | |
| Maintenance Director | Re-educated and responsible for fire drill compliance | |
| LPN 10 | Employee file reviewed for health screening | |
| HK 11 | Employee file reviewed for health screening | |
| DA 12 | Employee file reviewed for health screening | |
| CNA 14 | Employee file reviewed for health screening | |
| QMA 7 | Observed medication administration and interviewed | |
| QMA 2 | Observed medication administration and interviewed | |
| QMA 8 | Observed medication cart and interviewed | |
| QMA 15 | Observed medication cart and interviewed | |
| ADON | Assistant Director of Nursing | Interviewed regarding emergency binder and physician orders |
| DNS | Director of Nursing Services | Responsible for education and monitoring of corrective actions |
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 0
Nov 3, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00419844.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Complaint Details
Complaint IN00419844 was investigated and found to have no deficiencies related to the allegations.
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 1
Aug 1, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00414012, IN00413416, and IN00412030 at StoryPoint Granger.
Findings
No deficiencies were cited related to complaints IN00414012 and IN00412030. A state deficiency related to complaint IN00413416 was cited for failure to ensure a Qualified Medication Aide (QMA) did not administer insulin to a resident without proper certification.
Complaint Details
Complaint IN00414012 - No deficiencies related to the allegations are cited. Complaint IN00413416 - State deficiency related to the allegations is cited at R0245. Complaint IN00412030 - No deficiencies related to the allegations are cited.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure a Qualified Medication Aide (QMA) did not administer insulin in 1 of 5 residents who received injectable insulin (Resident C). |
Report Facts
Resident count: 119
Incident number: 257
Units of insulin: 6
Dates: Jul 13, 2023
Dates: Jul 19, 2023
Dates: Jul 20, 2023
Compliance date: Aug 3, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Martin Lebbin | Executive Director | Signed Plan of Correction and correspondence regarding the complaint survey |
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 0
Jun 27, 2023
Visit Reason
This visit was for the investigation of complaints IN00410972 and IN00410392, conducted in conjunction with a previous complaint investigation completed on May 25, 2023.
Findings
No deficiencies related to the allegations in complaints IN00410972 and IN00410392 were cited. Previous complaints IN00409063, IN00408412, and IN00408053 were corrected. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00410972 - No deficiencies related to the allegations are cited. Complaint IN00410392 - No deficiencies related to the allegations are cited. Complaint IN00409063 - Corrected. Complaint IN00408412 - Corrected. Complaint IN00408053 - Corrected.
Report Facts
Residential Census: 119
Inspection Report
Follow-Up
Census: 119
Deficiencies: 0
Jun 27, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to Investigation of Complaints IN00409063, IN00408412, and IN00408053 completed on May 25, 2023, conducted in conjunction with the Investigation of Complaints IN00410972 and IN00410392.
Findings
The facility was found to be in compliance with 410 IAC 16.2-5 regarding the PSR to Investigation of Complaints IN00409063, IN00408412, and IN00408053. Complaints IN00409063, IN00408412, and IN00408053 were corrected, while complaints IN00410972 and IN00410392 had no deficiencies related to the allegations.
Complaint Details
Complaint IN00409063 - Corrected; Complaint IN00408412 - Corrected; Complaint IN00408053 - Corrected; Complaint IN00410972 - No deficiencies related to the allegations; Complaint IN00410392 - No deficiencies related to the allegations.
Report Facts
Residential Census: 119
Inspection Report
Complaint Investigation
Census: 121
Deficiencies: 2
May 23, 2023
Visit Reason
This visit was conducted as an investigation of complaints IN00409063, IN00408412, IN00408053, and IN00407097 at StoryPoint Granger.
Findings
The facility failed to ensure that a staff member with only a Home Health Aide (HHA) license worked as a Qualified Medication Aide (QMA) and administered medications to residents. Additionally, a QMA without certification to administer insulin gave insulin injections to residents. Corrective actions included removal of unqualified staff from medication and insulin administration duties and review of residents' medication administration records, with no negative outcomes reported.
Complaint Details
Complaints IN00409063, IN00408412, and IN00408053 resulted in state deficiencies related to medication administration and insulin administration. Complaint IN00407097 had no deficiencies related to the allegations.
Deficiencies (2)
| Description |
|---|
| Staff member with only a Home Health Aide (HHA) license worked as a Qualified Medication Aide (QMA) and administered medications to residents. |
| Qualified Medication Aide (QMA) administered insulin without having certification for insulin administration. |
Report Facts
Residents affected by unqualified medication administration: 3
Residents affected by unqualified insulin administration: 3
Residential Census: 121
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 0
Apr 17, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00405429.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Complaint Details
Complaint IN00405429 was investigated and found to have no deficiencies related to the allegations.
Inspection Report
Complaint Investigation
Census: 122
Deficiencies: 0
Dec 14, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00396231.
Findings
Complaint IN00396231 was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Complaint Details
Complaint IN00396231 - Substantiated. No deficiencies related to the allegations are cited.
Report Facts
Residential Census: 122
Inspection Report
Complaint Investigation
Census: 127
Deficiencies: 4
Nov 1, 2022
Visit Reason
This visit was for a State Residential Licensure Survey including the investigation of five complaints (IN00392801, IN00383405, IN00382475, IN00381401, and IN00377538).
Findings
The survey found multiple deficiencies including failure to obtain admission and semi-annual weights for some residents, lack of physician signatures on medication orders, improper labeling and disposal of outdated food in the kitchen, failure to provide annual health assessments stating infectious disease history for several residents, and failure to complete two-step Mantoux testing for newly admitted residents.
Complaint Details
Complaints IN00392801, IN00382475, IN00381401, and IN00377538 were substantiated but no state residential findings related to the allegations were cited. Complaint IN00383405 was unsubstantiated due to lack of evidence.
Deficiencies (4)
| Description |
|---|
| Failed to obtain weights for 1 of 8 residents for admission weights and 2 of 8 residents for semi-annual weights; failed to have physician sign medication orders for 2 of 8 residents. |
| Failed to properly label and dispose of outdated food in the walk-in cooler. |
| Failed to provide annual health assessment stating history of or present infectious disease for 5 of 8 residents reviewed. |
| Failed to provide two-step Mantoux testing for newly admitted residents for 2 of 8 residents reviewed. |
Report Facts
Number of complaints investigated: 5
Residential census: 127
Survey dates: 6
Residents reviewed for weights: 8
Residents with missing admission or semi-annual weights: 3
Residents with missing physician signatures on medication orders: 2
Residents missing annual health assessment: 5
Residents missing two-step Mantoux testing: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natalie Palmer | Director of Nursing Services | Signed plan of correction and referenced in interviews |
| Natalie Palmer | Wellness Director | Interviewed regarding missing weights, medication orders, and Mantoux testing documentation |
| Cook 1 | Interviewed regarding food labeling and disposal practices | |
| Dietary Manager | Responsible for re-education and monitoring of food labeling and disposal |
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