Inspection Reports for
Sugar Grove Senior Living Community

Complaint IN00438231 was substantiated with state deficiencies cited at R0154. Complaints IN00438215, IN00438357, and IN00437915 had no deficiencies related to the allegations.

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.

Complaint IN00434118 was investigated with no deficiencies related to the allegations cited.

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.

Complaint IN00410938 was substantiated with state deficiencies cited. Complaint IN00411080 had no deficiencies related to the allegations.

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.

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.

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.

Complaint IN00389430 was unsubstantiated due to lack of evidence.

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.