Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 0
Jul 10, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00460871.
Findings
No deficiencies related to the allegations in Complaint IN00460871 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00460871 was investigated and found to have no related deficiencies; the complaint was not substantiated.
Report Facts
Residential Census: 99
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 1
Apr 28, 2025
Visit Reason
This visit was for the investigation of complaints IN00457930, IN00455654, and IN00454049. The investigation focused on allegations related to resident care and safety.
Findings
The facility failed to provide adequate supervision to prevent the elopement of a cognitively impaired resident (Resident B) from the secured memory care unit. The resident was found outside the facility without supervision for approximately 4 minutes due to staff holding the secured door open.
Complaint Details
Complaint IN00457930 was substantiated with state deficiencies cited related to the allegations. Complaints IN00455654 and IN00454049 had no state residential findings related to the allegations.
Deficiencies (1)
| Description |
|---|
| Failure to provide adequate supervision to prevent elopement of a cognitively impaired resident from the secured unit. |
Report Facts
Residential Census: 101
Survey Dates: April 28, 29, and 30, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Named in the finding related to holding the secured door open leading to resident elopement; received written disciplinary action on 4/23/2025. | |
| CNA 2 | Named in the finding related to holding the secured door open leading to resident elopement; received written disciplinary action on 4/23/2025. | |
| Lorena Glover | Executive Director | Signed the report. |
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 1
Jan 27, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00450661 regarding allegations of abuse involving cognitively impaired residents.
Findings
The facility failed to conduct a thorough investigation of an allegation of abuse involving two residents with cognitive impairments. Documentation and assessments related to the abuse allegations were incomplete, and staff education and interventions were insufficient.
Complaint Details
Complaint IN00450661 was substantiated with state deficiencies cited related to the allegations. The investigation lacked staff interviews, resident assessments, and injury assessments. Staff education on abuse and neglect was provided but not timely or comprehensive.
Deficiencies (1)
| Description |
|---|
| Failed to conduct a thorough investigation of an allegation of abuse involving cognitively impaired residents (Residents B and C). |
Report Facts
Residential Census: 104
Dates of survey: Survey conducted on January 27 and 28, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lorena Glover | Executive Director | Signed the report and mentioned as facility representative |
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 1
Nov 13, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00445979 regarding a resident-to-resident sexual incident.
Findings
The facility failed to notify Resident B's family about the resident-to-resident sexual incident. Interviews and record reviews confirmed the lack of family notification despite notification of the Administrator and Director of Nursing.
Complaint Details
Complaint IN00445979 was substantiated with a state deficiency cited at R0036 related to failure to notify Resident B's family of the incident.
Deficiencies (1)
| Description |
|---|
| Facility failed to notify a resident's family regarding a resident-to-resident sexual incident for 1 of 2 reviewed for abuse. |
Report Facts
Residential Census: 97
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lorena Glover | Executive Director | Signed as Laboratory Director's or Provider/Supplier Representative's Signature |
| QMA 1 | Completed progress note and was unaware of family notification requirement | |
| DON | Director of Nursing | Interviewed regarding failure to notify family and provided facility policy |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 1
Oct 16, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00445005 regarding staff scope of practice violations.
Findings
The facility failed to ensure that a Qualified Medication Aide (QMA) was working within their scope of practice by performing intradermal tuberculosis skin testing on residents, which is outside the allowed scope for QMAs.
Complaint Details
Complaint IN00445005 was substantiated with a state deficiency cited at R0117 related to the allegation of improper scope of practice by a QMA.
Deficiencies (1)
| Description |
|---|
| Qualified Medication Aide (QMA) performed intradermal tuberculosis skin testing on residents, which is outside the QMA scope of practice. |
Report Facts
Residential Census: 92
Survey Completion Date: Oct 17, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lorena Glover | Executive Director | Signed the report |
| QMA 1 | Qualified Medication Aide | Performed tuberculosis skin testing outside scope of practice |
| LPN 2 | Licensed Practical Nurse | Certified to give and read tuberculosis skin tests; aware of QMA 1's actions |
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 6
Sep 18, 2024
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaint IN00441028 related to allegations of misappropriation and other regulatory compliance issues.
Findings
The facility was found noncompliant for failing to protect a cognitively impaired resident from misappropriation, failing to complete medication self-administration assessments prior to resident self-administration, failing to reconcile narcotics per policy, failing to act on pharmacy recommendations, failing to secure medication carts when unattended, and failing to accurately reflect a resident's code status in clinical records.
Complaint Details
Complaint IN00441028 involved allegations of misappropriation by a former employee using a resident's online retailer account. The facility conducted an investigation, notified law enforcement, and took corrective actions including staff education and fraud claims.
Deficiencies (6)
| Description |
|---|
| Failed to ensure a cognitively impaired resident was free from misappropriation. |
| Failed to ensure medication self-administration assessment was completed prior to resident self-administering medications. |
| Failed to ensure narcotics were reconciled per facility policy for medication carts. |
| Failed to act upon pharmacy recommendations for residents reviewed. |
| Failed to ensure medication carts were appropriately locked when authorized personnel were not present. |
| Failed to ensure a resident's desired code status was accurately reflected in the clinical record. |
Report Facts
Residential Census: 94
Medication Cart Narcotics Reconciliation Deficiency Dates: 50
Pharmacy Recommendations Follow-up: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lorena Glover | Executive Director | Signed the report and involved in oversight |
| CNA 6 | Reported misappropriation incident and provided statements | |
| HHA 7 | Reported misappropriation incident and provided statements | |
| CNA 8 | Former employee involved in misappropriation, terminated for No Call/No Show | |
| LPN 5 | Licensed Practical Nurse | Interviewed regarding resident code status and narcotics reconciliation |
| QMA 3 | Observed medication cart and narcotics reconciliation | |
| QMA 4 | Observed medication cart and narcotics reconciliation |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 1
Jul 19, 2024
Visit Reason
This visit was for the investigation of Complaints IN00433195 and IN00433785. Complaint IN00433195 had no deficiencies related to the allegations, while Complaint IN00433785 resulted in state deficiencies being cited.
Findings
The facility failed to ensure service plans were signed by the resident or resident representative for 2 of 3 residents reviewed (Residents B and D). Resident B had moved out prior to the survey. The Health and Wellness Director and Memory Care Director were re-educated and corrective actions were planned to ensure compliance.
Complaint Details
Complaint IN00433195 - No deficiencies related to the allegations are cited. Complaint IN00433785 - State deficiencies related to the allegations are cited at R0217.
Deficiencies (1)
| Description |
|---|
| Failed to ensure service plans were signed by the resident or resident representative for 2 of 3 residents reviewed (Residents B and D). |
Report Facts
Residential Census: 92
Residents reviewed for service plans: 3
Residents with unsigned service plans: 2
Survey dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed and indicated inability to locate signed service plans for Residents B and D | |
| Health and Wellness Director | Involved in auditing resident files and re-education on service plan policy | |
| Memory Care Director | Involved in auditing resident files and re-education on service plan policy |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 1
Jan 31, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00427002 and IN00424212. Complaint IN00427002 resulted in state deficiencies related to the allegations, while Complaint IN00424212 had no state residential findings.
Findings
The facility failed to notify a cognitively impaired resident's family representative of a fall for 1 of 3 residents reviewed for falls. The resident was found on the floor next to the bed, and although the facility notified the on-call manager, physician, and hospice agency, family notification was not documented. The facility lacked a policy related to notification of responsible parties or family members.
Complaint Details
Complaint IN00427002 was substantiated with state deficiencies cited at R0036. Complaint IN00424212 had no state residential findings related to the allegations.
Deficiencies (1)
| Description |
|---|
| Failed to notify a cognitively impaired resident's family representative of a fall for 1 of 3 residents reviewed for falls. |
Report Facts
Residential Census: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Meredith McWade Peterson | Administrator of Record | Signed as Administrator of Record on the report |
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 2
Dec 12, 2023
Visit Reason
This visit was for the investigation of complaints IN00423437, IN00423379, and IN00422337 at Sugar Fork Crossing.
Findings
The facility failed to provide semi-annual and change in condition assessments for one resident, and failed to ensure appropriate infection control protocols for four residents in isolation, specifically related to PPE disposal and signage.
Complaint Details
Complaint IN00423437 cited deficiencies related to infection control protocols. Complaint IN00422337 cited deficiencies related to resident assessments. Complaint IN00423379 had no state residential findings related to the allegations.
Deficiencies (2)
| Description |
|---|
| Failed to provide semi-annual assessments and change in condition assessments for 1 out of 5 residents reviewed. |
| Failed to ensure staff practiced appropriate infection control protocols for 4 of 5 residents reviewed for isolation. |
Report Facts
Residents reviewed for assessments: 5
Residents with infection control issues: 4
Residential Census: 82
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Waymire | Executive Director | Signed the report |
| Director of Nursing | Interviewed regarding resident assessments and infection control practices | |
| Memory Care Director | Completed change in condition assessment for Resident B and re-educated staff | |
| Health and Wellness Director | Re-educated staff on resident assessments and infection control protocols | |
| QMA 1 | Interviewed about PPE removal practices | |
| CNA 2 | Interviewed about PPE removal practices | |
| CNA 3 | Interviewed about PPE removal practices | |
| CNA 4 | Interviewed about PPE removal practices |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 1
Sep 20, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00416961 regarding allegations of failure to provide assessment by a licensed nurse after resident-to-resident physical altercations.
Findings
The facility failed to provide timely physical assessments by a licensed nurse for two cognitively impaired residents (Resident C and Resident D) following physical altercations with other residents. Documentation and incident reports were lacking, and no nurse was present to assess Resident D at the time of the incident.
Complaint Details
Complaint IN00416961 was substantiated with state deficiencies cited related to failure to assess residents after incidents of abuse. The Director of Nursing and other staff interviews confirmed lack of incident reports and assessments.
Deficiencies (1)
| Description |
|---|
| Failure to provide assessment by a licensed nurse for cognitively impaired residents after resident-to-resident physical altercations. |
Report Facts
Residential Census: 89
Date of Incident: Sep 6, 2023
Date of Incident: Sep 17, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Waymire | Executive Director | Signed the report |
| QMA 1 | Charge person who did not initiate incident report or ensure nurse assessment | |
| Director of Nursing | DON | Interviewed regarding lack of incident reports and assessments |
| LPN 2 | Licensed Practical Nurse | Called to assess another resident but did not assess Resident C |
| Hospice RN | Registered Nurse | Interviewed and indicated Resident C was not her resident and she did not assess her |
| CNA 3 | Certified Nursing Assistant | Observed Resident D being struck and reported incident |
| QMA 4 | Charge person who did not call nurse to assess Resident D and followed administrator instructions |
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 6
Sep 6, 2023
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaints IN00415480 and IN00415903.
Findings
The facility was found noncompliant for failing to complete medication self-administration assessments, follow-up on pharmacy recommendations, ensure service plans were reviewed and acknowledged, label over-the-counter medications properly, and complete required tuberculosis (TB) testing and policies.
Complaint Details
Complaint IN00415480 resulted in state deficiencies related to medication self-administration assessment. Complaint IN00415903 had no deficiencies related to the allegations.
Deficiencies (6)
| Description |
|---|
| Failed to complete a medication self-administration assessment for a resident who self-administered medications stored in his room. |
| Failed to ensure a service plan was reviewed and acknowledged by the resident or representative for one resident. |
| Failed to follow-up on pharmacy recommendations for 5 of 7 residents reviewed. |
| Failed to label over-the-counter medications brought into the facility by resident families for 4 of 49 residents. |
| Failed to ensure an admission tuberculin (TB) skin test was completed for 1 of 7 residents reviewed for admission TB testing. |
| Failed to develop and implement policies and procedures for prevention of tuberculosis for 3 of 7 residents reviewed. |
Report Facts
Residential Census: 88
Residents reviewed for self-administration: 7
Residents reviewed for service plans: 5
Residents reviewed for pharmacy recommendations: 7
Residents reviewed for TB testing: 7
Residents affected by TB policy deficiency: 88
Residents with unlabeled OTC medications: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| QMA 4 | Qualified Medication Aide | Interviewed regarding medication self-administration and medication cart observations |
| DON | Director of Nursing | Interviewed regarding medication self-administration assessments, pharmacy recommendations, TB testing, and facility policies |
| LPN 3 | Licensed Practical Nurse | Interviewed regarding residents storing medications for self-administration |
| Administrator | Facility Administrator | Interviewed regarding service plan signatures, pharmacy recommendations, and TB policies |
| Health and Wellness Director | Responsible for re-education, audits, and follow-up on medication assessments, service plans, pharmacy recommendations, OTC medication labeling, and TB screening | |
| Memory Care Director | Re-educated on facility service plan policy and Indiana regulations |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 2
Aug 3, 2023
Visit Reason
This visit was conducted for the investigation of complaint IN00411689 concerning resident safety and abuse allegations.
Findings
The facility failed to prevent the elopement of a cognitively impaired resident during a move-in due to inadequate visitor monitoring and lack of policy. Additionally, the facility failed to report a resident-to-resident abuse incident to the Indiana State Board of Health.
Complaint Details
Complaint IN00411689 was substantiated with state deficiencies cited related to the allegations of elopement and failure to report abuse.
Deficiencies (2)
| Description |
|---|
| Failed to prevent elopement of a cognitively impaired resident by not monitoring visitors during a resident move-in. |
| Failed to report resident-to-resident abuse to the Indiana State Board of Health. |
Report Facts
Residential Census: 87
Elopement duration (minutes): 24
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Waymire | Executive Director | Signed the report and was interviewed regarding the abuse reporting deficiency |
Inspection Report
Follow-Up
Census: 87
Deficiencies: 0
May 15, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00402597 completed on April 11, 2023.
Findings
Sugar Fork Crossing was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of Complaint IN00402597.
Complaint Details
Complaint IN00402597 was corrected.
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 3
Apr 10, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00405033 and IN00402597. Complaint IN00405033 had no state residential findings, while complaint IN00402597 resulted in state deficiencies related to resident abuse and verbal abuse allegations.
Findings
The facility failed to prevent resident-to-resident abuse involving cognitively impaired residents found inappropriately together, and failed to prevent verbal abuse and intimidation of a resident by staff members. The facility also failed to report these incidents timely to the appropriate state agency and responsible parties, and delayed initiating investigations. Staff failed to notify the Administrator of abuse allegations, and the facility did not implement interventions to prevent recurrence.
Complaint Details
Complaint IN00405033 had no state residential findings related to the allegations. Complaint IN00402597 was substantiated with state deficiencies cited for failure to prevent resident abuse, verbal abuse by staff, and failure to report incidents to the state agency and responsible parties.
Deficiencies (3)
| Description |
|---|
| Failed to prevent resident to resident abuse when cognitively impaired residents were found in bed together without interventions to prevent recurrence. |
| Failed to prevent verbal abuse and intimidation of a cognitively impaired resident by staff members. |
| Failed to report inappropriate resident to resident interactions and verbal abuse allegations to the appropriate state agency and responsible parties in a timely manner. |
Report Facts
Residential Census: 95
Survey Dates: April 10 and 11, 2023
Plan of Correction Completion Date: May 1, 2023
Number of Monthly Interviews: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Waymire | Executive Director | Named as the Executive Director responsible for reporting and corrective actions. |
| LPN 2 | Staff member who witnessed resident abuse, failed to notify Administrator, and was involved in verbal abuse allegations. | |
| Agency CNA 4 | Agency staff member involved in verbal abuse and intimidation of a resident. | |
| Employee 1 | Witnessed resident disrobing incident and attempted to redirect resident. | |
| Employee 3 | Reported verbal abuse incident but did not recognize it as abuse or report to Administrator. | |
| Employee 5 | Attempted to intervene in verbal abuse incident. | |
| Director of Nursing | Director of Nursing | Informed of incidents and responsible for staff education and reporting. |
| Assistant Director of Nursing | Assistant Director of Nursing | Involved in notification and placing resident on 15-minute checks. |
| Administrator | Administrator | Responsible for reporting incidents to state agency and overseeing facility compliance. |
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 0
Jan 9, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00398724 and IN00397913.
Findings
Both complaints were substantiated; however, no State Residential Findings related to the allegations were cited. The facility was found to be in compliance with applicable regulations regarding these complaints.
Complaint Details
Complaint IN00398724 - Substantiated with no state findings cited. Complaint IN00397913 - Substantiated with no state findings cited.
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 3
Nov 29, 2022
Visit Reason
This visit was for a State Residential Licensure Survey, which included the Investigation of Complaint IN00394818.
Findings
Complaint IN00394818 was substantiated but no deficiencies related to the allegations were cited. Deficiencies were found related to staff CPR certification, licensed practical nurse licensure, and proper insulin administration training.
Complaint Details
Complaint IN00394818 was substantiated; however, no deficiencies related to the allegations were cited.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure a staff member was certified in CPR on 4 of 7 night shifts for the week reviewed. |
| Facility failed to ensure a Licensed Practical Nurse had an active license to administer care for 1 of 37 employees reviewed. |
| Facility failed to assure an employee was properly trained to administer insulin and to prime the insulin pen's needle per manufacturer's guidelines for 1 resident observed. |
Report Facts
Residential Census: 91
Staff CPR certification missing shifts: 4
Employees reviewed for licensure: 37
Licensed Practical Nurse license expiration date: Oct 31, 2022
Insulin dose administered: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 2 | Licensed Practical Nurse and Director of Nursing | Named in findings for expired nursing license and improper insulin administration. |
| Susan Waymire | Executive Director | Named as Executive Director and involved in re-education and audits related to deficiencies. |
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