Inspection Reports for Westside Garden Plaza
8616 W 10th St, Indianapolis, IN 46234, United States, IN, 46234
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 7, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a pattern of deficiencies primarily related to medication administration, staff training on dementia care, resident safety including bedrail use, and investigation/documentation of abuse allegations. Complaint investigations were mostly unsubstantiated or found no deficiencies, except for one substantiated complaint involving medication administration and self-medication safety issues. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows some improvement over time, with recent complaint investigations and follow-up visits indicating compliance.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
38% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
71 residents
Based on a March 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 0
Mar 7, 2025
Visit Reason
This visit was for the investigation of Complaint IN00449429.
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 IN00449429 - No deficiencies related to the allegations are cited.
Report Facts
Residential Census: 71
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 0
Oct 16, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00443840 at Bridge At Garden Plaza.
Findings
No deficiencies related to the allegations in Complaint IN00443840 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Complaint Details
Complaint IN00443840 was investigated and found to have no deficiencies related to the allegations.
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 1
Sep 17, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00441636 and IN00441104, specifically related to allegations of sexual abuse at the facility.
Findings
The facility failed to ensure an allegation of sexual abuse was reported to the Indiana Department of Health and did not conduct a thorough investigation for one of three residents reviewed. The investigation concluded the allegations were unsubstantiated and likely due to worsening dementia and a urinary tract infection. Several required investigation documents and interviews were incomplete or missing.
Complaint Details
Complaint IN00441636 had state deficiencies related to the allegations cited at R0090. Complaint IN00441104 had no deficiencies related to the allegations. The facility's investigation was completed and unsubstantiated. The resident had baseline dementia and a UTI at the time of the allegation. The Police and Adult Protective Services were notified, but documentation of state notification and follow-up was lacking. The local police Sex Crimes Division did not assign the case and inactivated the allegation relying on the facility's investigation.
Deficiencies (1)
| Description |
|---|
| Failed to ensure an allegation of sexual abuse was reported to the Indiana Department of Health and failed to ensure a thorough investigation of the allegations was conducted for 1 of 3 residents reviewed for abuse. |
Report Facts
Residential Census: 73
Brief Interview for Mental Status (BIMS) score: 9
Survey date: Sep 17, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andy Black | Regional Director of Operations | Signed the report and involved in monitoring corrective actions |
| Director of Nursing (DON) | Interviewed regarding abuse investigation, provided investigation packet, and facility policy | |
| Resident Care Director (RCD) | Received education on investigation process and timely completion |
Inspection Report
Census: 72
Deficiencies: 4
Aug 14, 2024
Visit Reason
This visit was for a State Residential Licensure Survey conducted on August 13 and 14, 2024.
Findings
The facility was found deficient in multiple areas including failure to ensure staff received required dementia-specific training, failure to ensure residents' environments were free from accident potential related to bedrails without physician orders and proper assessments, failure to ensure service plans were properly signed, and failure to ensure kitchen staff wore hair restraints according to policy.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure staff received the minimum dementia-specific training upon hire and annually for 6 of 6 employees reviewed. |
| Facility failed to ensure residents' environments were free from accident potential and failed to follow policy for bedrails without physician orders and lacking routine assessments for 2 residents. |
| Facility failed to ensure service plans were signed according to policy for 2 closed resident records. |
| Facility failed to ensure kitchen staff wore hair restraints according to policy for 3 kitchen observations. |
Report Facts
Residential Census: 72
Employees reviewed for dementia training: 6
Residents affected by dementia training deficiency: 16
Residents reviewed for bedrails: 2
Closed resident records reviewed for service plan signatures: 2
Kitchen staff observations: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marque McKinnor | Executive Director | Named as Executive Director in the report |
| Dietary Manager | Interviewed regarding kitchen staff hair restraint compliance | |
| Director of Nursing | DON | Interviewed regarding service plan signatures and bedrail assessments |
| Maintenance Director | Interviewed regarding bedrail safety checks | |
| Business Office Assistant | BOA | Interviewed regarding dementia training hours |
| Regional Nurse Consultant | RNC | Interviewed regarding facility policies and training |
Inspection Report
Follow-Up
Census: 74
Deficiencies: 0
Dec 8, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00417988 completed on October 2, 2023.
Findings
Bridge At Garden Plaza was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of Complaint IN00417988.
Complaint Details
Complaint IN00417988 was corrected.
Report Facts
Residential Census: 74
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 2
Oct 2, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00417988, which alleged deficiencies related to medication administration and self-medication practices at the facility.
Findings
The facility failed to ensure proper medication administration by staff, including administering medications from correctly labeled pharmacy packets without contamination and in the correct form for 3 of 5 residents reviewed. Additionally, the facility failed to ensure a resident who self-administered medications was able to do so safely, had a current self-medication assessment, and that medications were secure.
Complaint Details
Complaint IN00417988 was substantiated with state deficiencies cited at R241 and R295 related to medication administration and self-medication safety.
Deficiencies (2)
| Description |
|---|
| Failed to ensure staff administered medications from pharmacy packets with labels matching physician orders, without contamination, and in correct medication form for 3 of 5 residents. |
| Failed to ensure a resident who self-administered medications was able to do so safely, did not have additional unsecured medications in her room, had a current self-medication administration assessment, and ensured medications were secure. |
Report Facts
Residents reviewed for medication administration: 5
Residential Census: 75
Medication administration audits: 5
Self-administration evaluations: 4
Medication doses missed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marque McKinnor | Executive Director | Signed the report and provided policies. |
| Qualified Medication Aide (QMA) 5 | Observed administering medications incorrectly to Residents E and F. | |
| Qualified Medication Aide (QMA) 6 | Observed administering medications to Resident D without proper crush order. | |
| Director of Nursing (DON) | Provided statements regarding medication administration policies and corrective actions. | |
| Certified Nursing Aide (CNA) 4 | Observed assisting Resident B and found misplaced medications. | |
| Resident Care Director (RCD) | Conducted medication administration audits and in-service education. |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 3
Jun 12, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00409956 related to state residential deficiencies concerning medication administration and diabetes management.
Findings
The facility failed to ensure a medication error rate of less than 5%, with an observed error rate of 83.3% for 3 of 7 residents and 100% error rate for 15 residents during the 8:00 a.m. medication pass. Additionally, the facility failed to manage residents with diabetes by administering insulin injections timely and documenting interventions for high blood sugar readings for 4 residents. There was also a failure to process physician orders timely and administer anticoagulant medication doses correctly for one resident.
Complaint Details
Complaint IN00409956 - State Residential deficiencies related to medication administration errors and diabetes management.
Deficiencies (3)
| Description |
|---|
| Failed to ensure a medication error rate of less than 5%, with 30 errors out of 36 opportunities observed during medication administration. |
| Failed to manage residents with diabetes by administering insulin injections timely and documenting interventions for blood sugar readings over 130 for 4 residents. |
| Failed to ensure physician's orders were processed timely and anticoagulant medication doses were administered correctly for 1 resident. |
Report Facts
Medication errors observed: 30
Residents observed with medication errors: 3
Residents with late medication administration: 15
Insulin doses administered late: 13
Insulin doses administered late: 29
Insulin doses administered late: 14
Insulin doses administered late: 6
Blood sugar readings high: 38
Blood sugar readings high: 50
Blood sugar readings high: 31
Blood sugar readings high: 12
Medication errors caught: 12
PT/INR test result: 4.09
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marque McKinnor | Administrator | Signed the report. |
| QMA 5 | Qualified Medication Aide | Observed administering medications late and acknowledged medication pass delays. |
| LPN 7 | Licensed Practical Nurse | Provided information about medication administration timing and responsibilities. |
| QMA 4 | Qualified Medication Aide | Provided information about insulin administration and order processing. |
| QMA 6 | Qualified Medication Aide | Provided information about residents with insulin orders. |
| Executive Director | Executive Director | Provided medication assistance policy and confirmed nurse responsibilities. |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 0
May 17, 2023
Visit Reason
This visit was for the investigation of Complaint IN00408419.
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 investigation of the complaint.
Complaint Details
Complaint IN00408419 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Residential Census: 80
Inspection Report
Routine
Census: 71
Deficiencies: 13
Apr 20, 2023
Visit Reason
This visit was for a State Residential Licensure Survey conducted on April 18, 19, and 20, 2023 to assess compliance with state regulations.
Findings
The facility was found deficient in multiple areas including failure to prevent neglect resulting in a resident's death, failure to assess and monitor residents after falls, failure to ensure proper medication administration and monitoring, failure to maintain safe bedrails, failure to ensure secure medication storage, and failure to follow proper handwashing protocols.
Deficiencies (13)
| Description |
|---|
| Failure to ensure a resident was free from neglect resulting in delay of CPR and death (Resident 74). |
| Failure to identify and assess a resident after a fall resulting in a burst fracture (Resident 59). |
| Failure to report injury of unknown origin to the Department of Health (Resident 14). |
| Failure to provide required dementia training for employees (9 employees). |
| Failure to maintain bedrails in a safe operating condition and lack of physician orders for bedrail use (Residents 14, 13, 30, 42). |
| Failure to ensure emergency call light systems were accessible and functioning properly (Residents 56 and 14). |
| Failure to monitor resident weights as ordered resulting in weight loss (Resident 70). |
| Failure to ensure fall neurological assessments and interventions were completed and documented (Resident 14). |
| Failure to ensure supervised self-administration of medications and monitoring of medication effects (Resident 70). |
| Failure to safely administer medications one resident at a time and ensure residents took medications administered (Resident 20). |
| Failure to ensure medications were secure for resident self-administration (Resident 32). |
| Failure to ensure resident received physician ordered medication (Resident 59). |
| Failure to ensure proper handwashing before administering injection (Resident 59). |
Report Facts
Residents reviewed for quality of care: 7
Residents reviewed for medication monitoring: 2
Residents reviewed for emergency call assistance: 5
Residents reviewed for secure self-administration of medication: 5
Residents reviewed for medication administration: 5
Residents reviewed for bedrails: 11
Resident census: 71
Resident weight: 127.6
Resident weight: 119
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 5 | Licensed Practical Nurse | Observed carrying multiple medication cups and not observing resident take medications |
| QMA 7 | Qualified Medication Aide | Observed administering insulin injection and handwashing |
| QMA 11 | Qualified Medication Aide | Involved in CPR delay incident with Resident 74 |
| QMA 20 | Qualified Medication Aide | Performed CPR on Resident 74 |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple findings including medication administration and fall assessments |
| Executive Director | Executive Director | Interviewed regarding multiple findings and facility policies |
| Director of Assisted Living | Director of Assisted Living | Interviewed regarding medication storage and call light policies |
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 0
Aug 26, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00388707.
Findings
The complaint 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 IN00388707 was substantiated, but no deficiencies related to the allegations were cited.
Report
Jul 22, 2025
File
complaint-inspection_2025-07-22.pdf
Report
May 21, 2025
File
complaint-inspection_2025-05-21.pdf
Report
Jan 15, 2025
File
complaint-inspection_2025-01-15.pdf
Report
Jan 15, 2025
File
health-inspection_2025-01-15.pdf
Report
Nov 7, 2024
File
complaint-inspection_2024-11-07.pdf
Report
Aug 16, 2024
File
complaint-inspection_2024-08-16.pdf
Report
Jun 28, 2024
File
complaint-inspection_2024-06-28.pdf
Report
Apr 17, 2024
File
complaint-inspection_2024-04-17.pdf
Report
Dec 4, 2023
File
complaint-inspection_2023-12-04.pdf
Report
Dec 4, 2023
File
health-inspection_2023-12-04.pdf
Report
Oct 12, 2023
File
complaint-inspection_2023-10-12.pdf
Report
Apr 11, 2023
File
complaint-inspection_2023-04-11.pdf
Report
Apr 11, 2023
File
infection-control-inspection_2023-04-11.pdf
Report
Sep 1, 2022
File
health-inspection_2022-09-01.pdf
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