Inspection Reports for Sugar Grove Senior Living Community
5865 SUGAR LN, PLAINFIELD, IN, 46168
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 20, 2024, found no deficiencies related to the complaint investigated. Earlier inspections showed a pattern of deficiencies mainly involving food safety and sanitation issues, medication management, and staff training or monitoring, with some substantiated complaints related to these areas. Notable findings included inadequate dishwasher rinse temperatures, incomplete medication assessments, and lapses in kitchen sanitation and hand hygiene. One substantiated complaint involved neglect related to a resident’s medical emergency resulting in death, but no fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s inspection history shows some recurring issues but also periods of compliance and correction, with recent investigations mostly finding no deficiencies.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
21% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
123 residents
Based on a December 2024 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 123
Deficiencies: 0
Date: Dec 20, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00448897.
Complaint Details
Complaint IN00448897 was investigated and found to have no deficiencies related to the allegations.
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.
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 0
Date: Oct 1, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00442895 at Sugar Grove Senior Living Community.
Complaint Details
Investigation of Complaint IN00442895 found no deficiencies related to the allegations; complaint was not substantiated.
Findings
No deficiencies related to the allegations in Complaint IN00442895 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Report Facts
Residential Census: 114
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 1
Date: Jul 23, 2024
Visit Reason
This visit was for the investigation of complaints IN00438215, IN00438357, IN00437915, and IN00438231. Deficiencies related to complaint IN00438231 were cited.
Complaint Details
Complaint IN00438231 was substantiated with state deficiencies cited at R0154. Complaints IN00438215, IN00438357, and IN00437915 had no deficiencies related to the allegations.
Findings
The facility failed to maintain adequate rinse temperatures for the dishwasher, which had the potential to affect all 116 residents. Observations showed rinse cycle temperatures below the required 180 degrees Fahrenheit on multiple occasions.
Deficiencies (1)
Failed to maintain adequate rinse temperatures for the dishwasher, with rinse cycles below the required 180 degrees Fahrenheit.
Report Facts
Residential Census: 116
Dishwasher wash cycle temperature: 154
Dishwasher rinse cycle temperature: 167
Dishwasher wash cycle temperature: 162
Dishwasher rinse cycle temperature: 172
Dishwasher wash cycle temperature: 158
Dishwasher rinse cycle temperature: 165
Days with AM temperature at or above 180°F: 3
PM temperatures below 180°F: 30
PM temperatures above 180°F: All except 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline Mullins | Executive Director | Signed the report and provided the policy titled 'Dish Machine Operation' |
| Dietary Manager | Interviewed regarding dishwasher temperatures; indicated machine rarely reached 180 degrees Fahrenheit |
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 5
Date: Jun 27, 2024
Visit Reason
This visit was for a State Residential Licensure Survey which included the Investigation of Complaint IN00434118. The complaint investigation found no deficiencies related to the allegations.
Complaint Details
Complaint IN00434118 was investigated with no deficiencies related to the allegations cited.
Findings
The facility was found deficient in several areas including staff first aid certification coverage for 7 of 21 shifts, unsafe bed rail use without proper assessment and monitoring, incomplete medication self-administration assessments for 6 residents, food safety violations including unlabeled and undated foods and improper thermometer sanitation, and medication cart issues with undated eye drops, insulin, and unlabeled over-the-counter medications.
Deficiencies (5)
Failed to ensure at least one staff member was first aid certified on 7 of 21 shifts reviewed.
Failed to ensure resident's environment was free from hazards related to bedrails not assessed or monitored for safety.
Failed to complete medication self-administration assessments for 6 residents reviewed.
Failed to ensure all foods were labeled and dated, hair restraints worn by kitchen staff, thermometers sanitized properly, and frozen meats thawed appropriately.
Failed to date eye drops, insulin, and label over-the-counter medications on 2 of 5 medication carts reviewed.
Report Facts
Shifts without first aid certified staff: 7
Residents reviewed for bed rails: 2
Residents reviewed for medication self-administration: 6
Residents census: 116
Medication carts reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline Mullins | Executive Director | Provided facility policies and interview responses related to staffing and bed rail policies |
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 0
Date: Nov 13, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00417447 and IN00420647 at Sugar Grove Senior Living Community.
Complaint Details
Investigation of Complaints IN00417447 and IN00420647 found no deficiencies related to the allegations; facility was compliant.
Findings
No deficiencies related to the allegations in complaints IN00417447 and IN00420647 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 0
Date: Aug 3, 2023
Visit Reason
This visit was conducted for the Investigation of Complaint IN00414226.
Complaint Details
Investigation of Complaint IN00414226 found no deficiencies related to the allegations.
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.
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 2
Date: Jun 26, 2023
Visit Reason
This visit was for the investigation of complaints IN00410938 and IN00411080. Complaint IN00410938 resulted in state deficiencies related to the allegations, while Complaint IN00411080 had no deficiencies cited.
Complaint Details
Complaint IN00410938 was substantiated with state deficiencies cited. Complaint IN00411080 had no deficiencies related to the allegations.
Findings
The facility failed to ensure an organized and sanitary kitchen, food storage, and dining environment, and failed to ensure adequate hand washing for staff during observed days. Multiple sanitation issues were observed including food debris, improper food storage, contaminated serving practices, and inadequate cleaning and pest control measures, potentially affecting all 114 residents.
Deficiencies (2)
Failed to ensure an organized and sanitary kitchen, food storage, and dining environment.
Failed to ensure adequate hand washing for staff during observed days.
Report Facts
Residential Census: 114
Consultant Dietician Report Score: 76
Number of complaints investigated: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline Mullins | Executive Director | Signed the inspection report |
| Dietary Aide 8 | Observed frequently wiping hands on pants, not wearing gloves or hair net, and not washing hands during food service | |
| Morning Cook 9 | Observed placing bacon on cooking sheets without beard restraint | |
| Afternoon Cook 10 | Observed serving food covered by contaminated lids | |
| Dietary Manager | Recently appointed, responsible for kitchen cleanliness and food safety | |
| Administrator (ADM) | Administrator | Provided policies and acknowledged kitchen condition and cleaning responsibilities |
Inspection Report
Re-Inspection
Census: 119
Deficiencies: 0
Date: Apr 17, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00402850 completed on March 7, 2023.
Complaint Details
Complaint IN00402850 - Corrected
Findings
Sugar Grove Assisted Living was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of Complaint IN00402850.
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 1
Date: Mar 7, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00402850 and IN00402509. Complaint IN00402850 resulted in state deficiencies related to allegations of neglect, while complaint IN00402509 had no deficiencies cited.
Complaint Details
Complaint IN00402850 was substantiated with deficiencies cited related to neglect of Resident B, who experienced an acute medical emergency on 11/26/22 and was found unresponsive. Staff failed to perform CPR or adequate assessment, and the resident later died. Complaint IN00402509 had no deficiencies cited.
Findings
The facility failed to ensure a resident was free from neglect when staff did not perform a thorough assessment or continued monitoring of a resident with a change of condition, and failed to provide rescue efforts after the resident stopped breathing before EMS arrival, resulting in the resident's death due to multisystem organ failure and anoxic encephalopathy following cardiac arrest.
Deficiencies (1)
Facility failed to ensure a resident was free from neglect when the staff failed to ensure a thorough assessment of a resident with a change of condition, failed to ensure continued monitoring of and assessment for worsening symptoms, and failed to provide rescue efforts after the resident was noted to have stopped breathing before EMS arrived.
Report Facts
Resident census: 109
Date of incident: Nov 26, 2022
CPR duration: 30
Epinephrine doses: 5
Date of survey: Mar 7, 2023
Completion date for plan of correction: Apr 7, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 10 | Licensed Practical Nurse | Nurse on duty during incident who left resident to call 911 and failed to perform full assessment or CPR |
| QMA 9 | Qualified Medication Aide | Staff who found resident unresponsive and attempted to get vital signs but did not check pulse |
| DON | Director of Nursing | Provided interviews and facility policies; indicated no AED on site and described nursing expectations |
| OTR | Registered Occupational Therapist | CPR certified staff who described appropriate emergency response |
| Plainfield Fire & Rescue EMS Captain | EMS Captain | Responded to 911 call, observed resident unresponsive and staff not performing CPR |
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 0
Date: Jan 17, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00399291.
Complaint Details
Complaint IN00399291 - Substantiated. No deficiencies related to the allegations are cited.
Findings
Complaint IN00399291 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.
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 1
Date: Nov 22, 2022
Visit Reason
This visit was for the investigation of Complaint IN00389430. The complaint was unsubstantiated due to lack of evidence.
Complaint Details
Complaint IN00389430 was unsubstantiated due to lack of evidence.
Findings
The facility failed to ensure that service plans had been signed and dated by the resident for 3 of 3 residents reviewed (Residents B, C, and D). The service plans lacked resident signatures despite being signed by nursing staff. The facility did not have a policy to ensure service plans were signed and dated once agreed upon.
Deficiencies (1)
Failed to ensure service plans were signed and dated by residents for 3 of 3 residents reviewed (Residents B, C, and D).
Report Facts
Residents reviewed with unsigned service plans: 3
Residential Census: 109
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Holly Wachtel | Laboratory Director's or Provider/Supplier Representative | Signed the report |
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 0
Date: Sep 1, 2022
Visit Reason
This visit was for the Investigation of Complaints IN00387587, IN00387672, and IN00388913, in conjunction with a Post Survey Revisit (PSR) to Complaint IN00375925 completed on June 10, 2022.
Complaint Details
Complaint IN00387587 - Substantiated with no deficiencies cited. Complaint IN00387672 - Unsubstantiated due to lack of evidence. Complaint IN00388913 - Substantiated with no deficiencies cited. Complaint IN00375925 - Corrected.
Findings
Complaint IN00387587 was substantiated with no deficiencies cited. Complaint IN00387672 was unsubstantiated due to lack of evidence. Complaint IN00388913 was substantiated with no deficiencies cited. Complaint IN00375925 was corrected. The facility was found to be in compliance with relevant regulations regarding these complaints.
Report Facts
Residential Census: 99
Inspection Report
Follow-Up
Census: 99
Deficiencies: 0
Date: Sep 1, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to a PSR for Investigation of Complaint IN00375925 completed on June 10, 2022, conducted in conjunction with investigations of Complaints IN00387587, IN00387672, and IN00388913.
Complaint Details
Complaint IN00375925 was corrected. Complaint IN00387587 was substantiated with no deficiencies cited. Complaint IN00387672 was unsubstantiated due to lack of evidence. Complaint IN00388913 was substantiated with no deficiencies cited.
Findings
Complaint IN00375925 was corrected. Complaints IN00387587 and IN00388913 were substantiated but no deficiencies related to the allegations were cited. Complaint IN00387672 was unsubstantiated due to lack of evidence. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the PSR to Complaint IN00375925.
Report Facts
Residential census: 99
Viewing
Loading inspection reports...
