Inspection Report
Renewal
Census: 91
Deficiencies: 5
Jul 2, 2025
Visit Reason
This visit was for a State Residential Licensure Survey conducted on July 1 and 2, 2025, to assess compliance with state regulations.
Findings
The facility was found deficient in multiple areas including failure to ensure staff with current CPR and first aid certification on all shifts, expired certification of a Home Health Aide, incomplete annual and new hire training for some employees, missing health screenings and TB tests for newly hired employees, and unsafe food handling practices in the kitchen.
Deficiencies (5)
| Description |
|---|
| Failed to ensure a staff member with first aid and CPR certification was scheduled for 8 of 21 shifts reviewed. |
| Failed to ensure a Home Health Aide provided care with an expired certification. |
| Failed to ensure employees employed over one year had required annual dementia, resident rights, and abuse training, and newly hired employees had required training within 6 months. |
| Failed to ensure employees were screened for tuberculosis and/or had completed health screenings upon hire for 2 of 3 newly hired employees. |
| Failed to ensure food was prepared and served under safe sanitary conditions, including improper glove use and cross-contamination during meal preparation. |
Report Facts
Shifts lacking certified staff: 8
Employees reviewed for certification: 24
Residents potentially affected: 91
Audit duration: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vernatene Banks | Executive Director | Signed report and responsible for oversight |
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 0
Jun 5, 2025
Visit Reason
This visit was conducted for the investigation of four complaints: IN00460653, IN00460132, IN00459980, and IN00459714.
Findings
No deficiencies related to the allegations in any of the four complaints were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the investigation of these complaints.
Complaint Details
Complaints IN00460653, IN00460132, IN00459980, and IN00459714 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Residential Census: 94
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 0
Mar 27, 2025
Visit Reason
This visit was conducted to investigate complaints IN00455974, IN00456119, and IN00455985 at Sweet Galilee at the Wigwam.
Findings
No deficiencies related to the allegations in complaints IN00455974, IN00456119, and IN00455985 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Complaint Details
Investigation of complaints IN00455974, IN00456119, and IN00455985 found no deficiencies related to the allegations; all complaints were not substantiated.
Report Facts
Residential Census: 92
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 1
Mar 13, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00454065 regarding allegations of staff entering resident rooms without permission.
Findings
The facility failed to protect resident privacy by allowing a night shift staff member to enter resident rooms without permission for 3 of 6 residents reviewed (Residents C, E, and F). The night guard entered rooms at night without knocking or valid reason, causing distress to residents.
Complaint Details
Complaint IN00454065 was substantiated with state deficiencies cited related to the allegations. The deficiency had the potential to affect all residents but no adverse effect was noted to residents C, E, and F.
Deficiencies (1)
| Description |
|---|
| Facility failed to protect resident privacy by allowing a night shift staff member to enter resident rooms without permission for 3 of 6 residents reviewed. |
Report Facts
Residential Census: 93
Completion date for plan of correction: 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vernatene Banks | Executive Director | Named as Executive Director who provided interviews and plan of correction |
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 0
Feb 17, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00452698.
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 IN00452698 was investigated and found to have no deficiencies related to the allegations.
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 2
Jan 14, 2025
Visit Reason
This visit was for the investigation of Complaint IN00450055, which involved allegations related to resident verbal abuse and inaccurate resident needs assessment.
Findings
The facility failed to protect a resident's right to be free from verbal abuse by another resident and failed to accurately complete a resident's needs assessment to include negative behaviors, preventing appropriate interventions.
Complaint Details
Complaint IN00450055 was substantiated with state deficiencies cited related to verbal abuse and needs assessment inaccuracies.
Deficiencies (2)
| Description |
|---|
| Failed to protect a resident's right to be free of verbal abuse from another resident for 1 of 6 residents reviewed. |
| Failed to accurately complete a resident's needs assessment to include negative behaviors for 1 of 6 residents reviewed. |
Report Facts
Residential Census: 98
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Verna Banks | Executive Director | Named in relation to findings and responsible for compliance and corrective actions |
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 2
Dec 26, 2024
Visit Reason
This visit was for the investigation of multiple complaints (IN00449942, IN00449881, IN00448676, IN00448579, IN00448370, and IN00448394) regarding the facility's care and compliance.
Findings
The facility was found deficient in failing to obtain physician orders before removing a urinary catheter, which resulted in a resident being sent to the hospital due to inability to urinate for approximately 8 hours. Additionally, the facility failed to administer and document medications properly for one resident. Some complaints had no deficiencies cited, while others had state deficiencies related to catheter care and medication administration.
Complaint Details
The investigation involved complaints IN00449942, IN00449881, IN00448676, IN00448579, IN00448370, and IN00448394. Deficiencies were cited related to complaints IN00448676 and IN00448370. Some complaints had no deficiencies related to the allegations. The facility failed to follow proper catheter care policies and medication administration documentation.
Deficiencies (2)
| Description |
|---|
| Failed to ensure physician orders were obtained for removal of urinary catheter, resulting in resident being sent to hospital for inability to urinate for approximately 8 hours. |
| Failed to administer and document medication administration for one resident. |
Report Facts
Survey dates: December 26, 27, and 30, 2024
Resident census: 95
Missed medication administration dates: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Mentioned as no longer employed at time of survey and involved in catheter care deficiency | |
| Administrator | Provided information about facility policies and admission of residents with catheters | |
| Nursing Home DON | Interviewed regarding Resident B's catheter care and orders | |
| Operational Specialist | Interviewed regarding catheter care policies and procedures | |
| Nurse Practitioner | Interviewed regarding communication about catheter removal | |
| LPN 1 | Interviewed about medication documentation and use of agency staff | |
| LPN 2 | Interviewed about medication documentation procedures |
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 4
Nov 26, 2024
Visit Reason
This visit was for the Investigation of Complaints IN00445789, IN00447154, and IN00445885.
Findings
The facility was found deficient in multiple areas including failure to prevent smoking violations inside the facility, inadequate preparation of apartments for bedbug extermination, failure to provide gluten-free diet information for a resident with celiac disease, and unsafe food handling and sanitation practices in the kitchen.
Complaint Details
Complaints IN00445789, IN00447154, and IN00445885 were investigated. Deficiencies related to smoking violations, bedbug infestation, dietary accommodations, and food safety were substantiated.
Deficiencies (4)
| Description |
|---|
| Failed to ensure residents were free from potential safety hazards related to smoking within the facility. |
| Failed to ensure residents prepared their apartments for extermination to manage and eliminate bedbug infestation. |
| Failed to provide resources to a resident with the need for a gluten-free diet to make meal selections to meet dietary requirements. |
| Failed to prepare, store, and serve foods under safe sanitary conditions regarding kitchen cleanliness, food labeling, food handling, hand washing, glove use, and temperature logging. |
Report Facts
Residents present: 94
Complaints investigated: 3
Dates of survey: 2
30-day notice: 30
Audit frequency: 4
Audit frequency: 3
Training completion date: Dec 18, 2024
Training completion date: Dec 17, 2024
Audit frequency: 30
Audit frequency: 90
Training completion date: Dec 18, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vernatene Banks | Executive Director | Named in relation to smoking policy enforcement and overall compliance responsibility |
| Cook 2 | Named in relation to food handling violations during meal service | |
| Director of Nursing | DON | Interviewed regarding smoking violations and bedbug infestation |
| Dietary Manager | Interviewed regarding gluten-free diet and kitchen sanitation deficiencies | |
| Regional Operations Specialist | Interviewed regarding documentation of memos for bedbug extermination preparation |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 0
Oct 15, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00444717 and IN00444075.
Findings
No deficiencies related to the allegations in complaints IN00444717 and IN00444075 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Complaint Details
Investigation of Complaints IN00444717 and IN00444075 found no deficiencies related to the allegations; both complaints were not substantiated.
Report Facts
Residential Census: 91
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 2
Sep 17, 2024
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00441299, IN00441690, IN00442355, IN00443189, IN00443307, and IN00443304) regarding medication administration and resident care at Sweet Galilee at the Wigwam.
Findings
The facility failed to ensure proper medication administration for several residents, including allowing a resident not assessed for self-administration to self-administer insulin and blood sugar checks, and failing to administer prescribed medications timely or at all for 4 of 5 residents reviewed. The facility implemented corrective actions including medication audits, staff retraining, and ongoing monitoring.
Complaint Details
Complaints IN00443189 and IN00443304 were substantiated with state deficiencies cited at tags R0217 and R0241. Other complaints had no deficiencies related to allegations.
Deficiencies (2)
| Description |
|---|
| Failed to ensure a resident assessed as unable to self-administer insulin and blood sugar checks did not self-administer medications (Resident J). |
| Failed to ensure residents received prescribed medications as ordered by a physician for 4 of 5 residents reviewed (Residents E, G, H, and J). |
Report Facts
Residential Census: 90
Residents reviewed for medication administration: 6
Residents with medication administration deficiencies: 4
Dates of missed medication administration: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Verna Banks | Executive Director | Signed the report and responsible for compliance |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 4
Aug 9, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00439676, IN00440693, and IN00441033.
Findings
The facility was found deficient in ensuring residents were free from verbal abuse, conducting thorough investigations of alleged abuse, securing medications properly, and ensuring service plans were signed by residents or representatives. Specific incidents involved verbal abuse of Resident D by staff, incomplete abuse investigations for Residents B and D, missing narcotic medications for Residents C, E, and F, and unsigned service plans for Residents B, C, and D.
Complaint Details
The investigation was triggered by complaints IN00439676, IN00440693, and IN00441033. Complaint IN00439676 and IN00440693 involved allegations of verbal abuse and inadequate abuse investigations. Complaint IN00441033 involved medication storage deficiencies.
Deficiencies (4)
| Description |
|---|
| Failed to ensure residents remained free from verbal abuse for 1 of 3 residents reviewed (Resident D). |
| Failed to complete thorough investigations of alleged abuse for 2 of 3 residents reviewed (Residents B and D). |
| Failed to ensure service plans were signed by residents or representatives for 3 of 3 residents reviewed (Residents B, C, and D). |
| Failed to ensure secure storage and reconciliation of resident medications for 3 of 3 residents reviewed (Residents C, E, and F). |
Report Facts
Residents present: 80
Missing medication pills: 54
Employee signatures: 21
Medication checks frequency: 15
Medication checks duration: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Erin Tuttle | Regional Director of Operations | Signed report and involved in oversight |
| HHA 3 | Staff member terminated for verbally abusing Resident D | |
| Administrator | Conducted investigations and interviews related to abuse incidents | |
| RN 4 | Registered Nurse | Conducted medication audits and provided statements regarding medication delivery |
| LPN 6 | Licensed Practical Nurse | Handled medication delivery and provided statements about narcotic bag |
| QMA 5 | Qualified Medication Aide | Provided statement about awareness of pharmacy delivery and medication count |
| QMA 7 | Qualified Medication Aide | Accepted pharmacy delivery, counted narcotics, and reported missing medications |
| DON | Director of Nursing | Provided interviews regarding medication checks and service plan signatures |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 2
Apr 29, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00432313, IN00432974, and IN00432987 at Sweet Galilee at the Wigwam.
Findings
The facility was found to have deficiencies related to resident-to-resident abuse involving Resident C and Resident E, and failure to report such abuse to the Indiana Department of Health. Resident C exhibited aggressive and threatening behaviors, including spitting on Resident E and making threats involving a gun. The facility failed to effectively monitor Resident C and failed to notify the state agency within 24 hours of an unusual occurrence threatening resident safety.
Complaint Details
Complaint IN00432974 was substantiated with state deficiencies cited. Complaints IN00432313 and IN00432987 had no deficiencies related to the allegations cited.
Deficiencies (2)
| Description |
|---|
| Failed to ensure Resident E was free from resident-to-resident abuse perpetrated by Resident C, failed to ensure Resident C was effectively monitored to prevent further events of abuse, and failed to thoroughly investigate allegations of abuse. |
| Failed to inform the division within twenty-four hours of becoming aware of an unusual occurrence that directly threatened the welfare, safety, or health of a resident as required by 410 IAC 16.2-5-1.3(g)(1-6). |
Report Facts
Survey dates: April 29 and 30, 2024
Residential Census: 85
Compliance date: 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joan Cook | Executive Director | Named as Executive Director and involved in abuse reporting and corrective actions |
Inspection Report
Renewal
Census: 90
Deficiencies: 8
Mar 27, 2024
Visit Reason
This visit was for a State Residential Licensure Survey conducted on March 26 and 27, 2024, to assess compliance with state regulations for the facility.
Findings
The facility was found deficient in multiple areas including failure to conduct required quarterly fire drills on all shifts, insufficient staff certified in First Aid, incomplete employee orientation and health screenings, unsafe food handling practices, lack of coordination with mental health providers for resident care plans, and inadequate infection control program implementation.
Deficiencies (8)
| Description |
|---|
| Failure to ensure fire drills were performed quarterly on each shift resulting in less than twelve drills per year. |
| Failure to ensure an available staff member was First Aid certified for 15 of 21 shifts scheduled. |
| Failure to ensure newly hired employees had general facility orientation for 2 of 6 employees reviewed. |
| Failure to ensure newly hired employees had health screens completed and tuberculin skin tests or risk assessments for 2 of 6 employees reviewed. |
| Failure to ensure newly hired employees had job specific orientation for 1 of 6 employees and signed job descriptions for 1 of 6 employees reviewed. |
| Failure to store, prepare, handle, and serve food in a safe, sanitary manner including uncovered food in freezer and refrigerator, lack of thermometer and temperature logs, unclean can opener, and improper glove use by food service staff. |
| Failure to coordinate mental health service plans with the resident's mental health care provider for 1 of 1 residents reviewed. |
| Failure to establish and implement an infection control program that tracks and trends infections for the facility. |
Report Facts
Fire drills completed: 12
Residents present: 90
Shifts lacking First Aid certified staff: 15
Employees reviewed for orientation: 6
Employees lacking general orientation: 2
Employees lacking health screens: 2
Employees lacking tuberculin screening: 2
Employees lacking job specific orientation: 1
Employees lacking signed job descriptions: 1
Days without all three meal temperatures recorded: 23
Days with zero meals recorded for temperature: 5
Residents reviewed for mental health services: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James Combs | Executive Director | Signed the report and involved in corrective action plans |
| Cook 6 | Observed improperly handling food during meal service | |
| Director of Environmental Services | Provided information about fire drill scheduling and documentation | |
| DON | Director of Nursing | Interviewed regarding staff certifications, employee orientation, and mental health service coordination |
| Dietary Manager | Interviewed and observed regarding food safety and sanitation practices | |
| LPN 4 | Provided infection control documentation and interview |
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 0
Dec 21, 2023
Visit Reason
This visit was for the investigation of complaints IN00424109 and IN00424546.
Findings
No deficiencies related to the allegations in complaints IN00424109 and IN00424546 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Complaint Details
Complaint IN00424109 and Complaint IN00424546 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Residential Census: 83
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 5
Nov 14, 2023
Visit Reason
This visit was for the investigation of complaints IN00419644 and IN00421234 regarding alleged deficiencies at the facility.
Findings
The facility was found deficient in multiple areas including failure to complete reference checks for new employees, employing a CNA without an active certification, incomplete employee orientation, inadequate inservice training documentation, and failure to properly administer and document medications for three residents.
Complaint Details
Complaint IN00419644 related to medication administration deficiencies. Complaint IN00421234 related to personnel issues including reference checks, certification, orientation, and training.
Deficiencies (5)
| Description |
|---|
| Failed to complete reference requests for 3 newly hired employees. |
| Employed a CNA without an active certification for 33 days. |
| Failed to ensure general and specific orientations were completed for 2 employees. |
| Failed to ensure inservice education was offered and properly documented for safe physical transfers. |
| Failed to ensure medications were administered and documented in the resident medication administration record for 3 residents. |
Report Facts
Residents affected: 82
Employees reviewed: 5
Direct care staff employed: 17
Medications not administered/documented: 3
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 0
Oct 6, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00414921 and IN00413838.
Findings
No deficiencies related to the allegations in complaints IN00414921 and IN00413838 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Complaint Details
Complaint IN00414921 and IN00413838 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Residential Census: 82
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 0
Jun 5, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00409766.
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 IN00409766 was investigated and found to have no deficiencies related to the allegations.
Inspection Report
Renewal
Census: 70
Deficiencies: 4
May 11, 2023
Visit Reason
This visit was for a State Residential Licensure Survey conducted on May 11 and 12, 2023, to assess compliance with state regulations for Sweet Galilee at the Wigwam.
Findings
The facility was found deficient in posting required contact information for advocacy and regulatory agencies, providing access to the most recent annual survey results and plan of correction, ensuring sufficient staff with First Aid certification on duty, and coordinating mental health service plans with residents' mental health providers.
Deficiencies (4)
| Description |
|---|
| Failed to post contact information for advocacy and regulatory agencies accessible to residents. |
| Failed to ensure residents had access to examine the results of the most recent annual survey and plan of correction. |
| Failed to ensure one employee with First Aid Certification was on duty each shift for 18 of 21 shifts reviewed. |
| Failed to coordinate service plans related to mental health needs with residents' mental health care providers for 2 of 2 residents reviewed. |
Report Facts
Residential Census: 70
Shifts without First Aid Certified Staff: 18
Residents with mental health needs: 13
Residents reviewed for mental health service plans: 2
Inspection Report
Follow-Up
Census: 67
Deficiencies: 0
May 3, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00404895 completed on March 29, 2023.
Findings
Sweet Galilee At The Wigwam was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of Complaint IN00404895.
Complaint Details
Complaint IN00404895 was corrected.
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 2
Mar 28, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00404895 related to state residential findings.
Findings
The facility failed to ensure a resident received her mail promptly and failed to ensure chicken was cooked thoroughly to proper temperature prior to being served, potentially affecting all residents.
Complaint Details
Complaint IN00404895 was substantiated with findings related to mail delivery and food safety.
Deficiencies (2)
| Description |
|---|
| Failed to ensure a resident received her mail promptly for 1 of 1 resident reviewed for mail delivery (Resident D). |
| Failed to ensure chicken was cooked thoroughly to proper temperature prior to being served to residents, potentially affecting 76 residents. |
Report Facts
Residential Census: 76
Undercooked chicken pieces: 14
Undercooked breast meat pieces: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daphne New | Administrator | Named in relation to mail delivery and food safety findings. |
| Cook 4 | Named in relation to serving undercooked chicken. | |
| Cook 6 | Named in relation to cooking and miscommunication about chicken preparation. | |
| Dietary Manager | Named in relation to food safety and corrective actions. |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 0
Mar 24, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00404403.
Findings
No deficiencies related to the allegations in Complaint IN00404403 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Complaint Details
Complaint IN00404403 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Residential Census: 78
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 2
Mar 10, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00402565 and IN00400751. Complaint IN00402565 had no state residential findings, while Complaint IN00400751 resulted in a state deficiency related to the allegations.
Findings
The facility failed to ensure appropriate care and response to falls for Resident C and failed to protect Resident B from verbal abuse by a staff member. No other residents were found to be affected, and the implicated staff member (HHA 1) was no longer employed. The facility implemented re-education and auditing measures to prevent recurrence.
Complaint Details
Complaint IN00402565 had no state residential findings related to the allegations. Complaint IN00400751 was substantiated with state deficiencies cited related to Resident C's fall care and Resident B's verbal abuse. Resident C had no lasting effects, and Resident B showed no adverse effects and feels safe with corrective actions taken.
Deficiencies (2)
| Description |
|---|
| Failed to ensure Resident C received appropriate care and response to falls from a staff member. |
| Failed to ensure Resident B was free from verbal abuse by a staff member. |
Report Facts
Residential Census: 75
Survey Dates: March 8 and 10, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daphne New | Administrator | Signed as Laboratory Director's or Provider/Supplier Representative |
| LPN 3 | Nurse who assessed Resident C and stayed with resident until ambulance arrived | |
| HHA 1 | Home Health Aide | Staff member involved in deficient practices related to Resident C's fall and Resident B's verbal abuse; no longer employed |
| CNA 2 | Certified Nursing Aide | Reported verbal abuse of Resident B by HHA 1 and witnessed events |
| Director of Nursing | Director of Nursing | Provided information about staff assignments and facility policies |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 3
Feb 1, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00395485, IN00396376, and IN00395977 at Sweet Galilee at the Wigwam.
Findings
The facility failed to investigate and provide responses to 9 of 18 resident grievances reviewed, lacked completed job-specific orientation for 3 of 5 employee records, and failed to complete required tuberculosis health screenings for 5 newly hired employees.
Complaint Details
Complaint IN00395485 and IN00396376 were substantiated with state deficiencies cited. Complaint IN00395977 was unsubstantiated due to lack of evidence.
Deficiencies (3)
| Description |
|---|
| Failed to investigate and provide a response to the resident for grievances filed for 9 of 18 resident grievances reviewed. |
| Failed to ensure newly hired employees had a completed and signed job-specific orientation for 3 of 5 employee records reviewed. |
| Failed to complete health screenings for tuberculosis (TB) upon hire for 5 of 5 newly hired employees, lacking a required second step TB test. |
Report Facts
Resident grievances reviewed: 18
Resident grievances not investigated: 9
Employee records reviewed: 5
Employee records missing job-specific orientation: 3
Newly hired employees missing second step TB test: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daphne New | Administrator | Interviewed regarding grievances and provided facility policies. |
| Business Office Manager | Interviewed regarding employee records and tuberculosis testing. |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 2
Oct 27, 2022
Visit Reason
This visit was conducted for the investigation of two complaints, IN00391796 and IN00392394, both substantiated with related state residential findings cited.
Findings
The facility failed to ensure Qualified Medication Aides (QMAs) functioned within their scope of practice regarding insulin administration and monitoring equipment for 2 of 3 residents reviewed. Additionally, the facility failed to complete resident assessments and evaluations prior to or at admission for 1 of 3 residents reviewed.
Complaint Details
Complaint IN00392394 was substantiated with findings related to QMA insulin administration and monitoring. Complaint IN00391796 was substantiated with findings related to incomplete resident assessments and evaluations at admission.
Deficiencies (2)
| Description |
|---|
| QMAs administered insulin and maintained insulin monitoring equipment outside their scope of practice for Residents E and F. |
| Resident B's assessments and evaluations were not completed prior to or at admission, lacking required documentation and physician orders. |
Report Facts
Residential Census: 69
Units of insulin administered: 74
Units of insulin administered: 100
Units of insulin administered: 12
Dates of survey: 2022-10-27 to 2022-10-28
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 0
Sep 21, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00390630 and IN00390531.
Findings
Complaint IN00390630 was substantiated but no state residential findings related to the allegations were cited. Complaint IN00390531 was unsubstantiated due to lack of evidence. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Complaint Details
Complaint IN00390630 - Substantiated with no state residential findings cited. Complaint IN00390531 - Unsubstantiated due to lack of evidence.
Report Facts
Residential Census: 61
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 0
Aug 2, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00386839 and IN00386499.
Findings
Complaint IN00386839 was substantiated but no state residential findings related to the allegations were cited. Complaint IN00386499 was unsubstantiated due to lack of evidence. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Complaint Details
Complaint IN00386839 - Substantiated with no state residential findings cited. Complaint IN00386499 - Unsubstantiated due to lack of evidence.
Report Facts
Residential Census: 59
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