Inspection Reports for
Westside Garden Plaza

The deficiencies relate to Complaint numbers 1669976.3.1-37(a), 1669976.3.1-47(a)(6), and 1669993.3.1-18(b).

The facility failed to document fluid intake for a resident on fluid restriction, failed to keep a resident's call light within reach and to apply ordered oxygen, and failed to maintain a clean and orderly shower room for resident use.

The complaint IN00459628 involved issues with bathing accommodations, grievance follow-up and resolution, food temperature and quality, and housekeeping cleanliness.

The facility failed to provide or document showers for a resident with bathing preferences, did not adequately follow up on grievances or resolve them, served food that was often cold and unpalatable to multiple residents, and failed to maintain a safe, clean, and sanitary environment on one unit with issues such as unclean resident rooms and common areas.

Complaint IN00449427 related to care plan revisions, activities of daily living assistance, and respiratory care deficiencies.

The facility failed to revise comprehensive care plans as needed for residents, ensure completion of activities of daily living for dependent residents, and provide safe and appropriate respiratory care including correct oxygen settings and proper maintenance of respiratory equipment.

The inspection was complaint-driven based on multiple complaints including IN00447172, IN00449427, and IN00451144.

The facility was found deficient in multiple areas including failure to treat residents with dignity, failure to ensure voting rights, inadequate response to call lights, incomplete advance directive documentation, unclean environment with fecal contamination, inaccurate MDS assessments, inadequate accident prevention and supervision, improper respiratory care including oxygen management and bipap mask contamination, medication errors including expired drugs and lack of blood pressure monitoring, failure to follow infection control protocols during medication administration, and unsafe wheelchair conditions.

The complaint involved multiple aggressive incidents by Resident BB against other residents on the memory care unit, with investigations documenting physical altercations, safety monitoring, and involvement of police, physicians, and families. The facility's response and care planning were inadequate to prevent recurrence.

The facility failed to ensure adequate supervision, monitoring, and individualized interventions for Resident BB, leading to multiple incidents of aggression and resident-to-resident altercations. The care plan lacked resident-specific interventions and did not address each incident. Additionally, medication storage and labeling deficiencies were found on multiple medication carts.

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.

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.

The citation related to Complaint IN00439467. The complaint involved failure to honor resident rights regarding shower preferences and failure to follow infection prevention and control protocols during catheter care.

The facility failed to ensure a resident was provided showers per their choice and failed to follow proper infection control practices during catheter care for two residents. Documentation of shower refusals was inadequate, and staff did not sanitize catheter tubing or perform hand hygiene properly during catheter bag changes.

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.

This citation relates to complaint IN00437197. The complaint involved unresolved grievances about residents not receiving scheduled showers, call lights taking too long to be answered, missing laundry items, and lack of accountability for staff duties. Residents E, K, Q, and R and a family member reported submitting grievance cards without receiving responses.

The facility failed to address grievances in a manner that allowed tracking or resolution for multiple months and residents. Resident concerns about not receiving scheduled showers, delayed call light responses, and missing laundry items were documented but not responded to by the facility. Several residents and a family member confirmed submitting grievance cards without receiving any responses.

The facility failed to develop complete care plans within 7 days of comprehensive assessments and failed to revise care plans for residents with wounds. Additionally, the facility did not ensure effective wound management for a resident with a worsening stage 3 pressure ulcer, including delayed wound tracking and inadequate documentation.

The citation relates to Complaints IN00422417 and IN00422535. Complaints included insufficient staffing, delayed resident care, call lights not answered timely, and poor food service quality.

The facility failed to provide adequate nursing staff to meet resident care needs, resulting in delayed assistance and unmet care tasks. Additionally, the facility failed to ensure timely meal service, maintain proper food temperatures, and provide appealing meals, leading to widespread resident dissatisfaction.

The complaint investigation included allegations of inadequate staffing, poor resident care, dignity violations, food service issues, and unsafe environment conditions.

The facility failed to ensure residents' rights to dignity, adequate staffing, proper care, safe environment, accurate assessments, appropriate care planning, pain management, medication management, infection control, and food service standards. Multiple deficiencies were observed including failure to respond to resident needs, inadequate supervision, poor food quality and temperature, unsanitary kitchen conditions, improper medication handling, and unsafe environment conditions.

The complaint investigation was triggered by allegations of abuse, neglect, elopement, and failure to provide adequate care and supervision for residents, specifically Resident B, Resident D, and Resident F. The investigation included review of video evidence, interviews with staff and family, and record reviews. The complaint numbers referenced are IN00410616, IN00418979, and IN00419005.

The facility was found to have failed to protect a resident from abuse resulting in actual harm, failed to timely report allegations of abuse, failed to revise and follow care plans, failed to prevent elopement due to inadequate monitoring of secured doors, and failed to ensure a resident had their call light within reach.

Complaint IN00417988 was substantiated with state deficiencies cited at R241 and R295 related to medication administration and self-medication safety.

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 IN00409956 - State Residential deficiencies related to medication administration errors and diabetes management.

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.

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.

This Federal tag relates to Complaint IN00405336. The complaint involved Resident B's dissatisfaction with care related to urinary incontinence, including untimely response to call lights and lack of appropriate continence care.

The facility failed to ensure that Resident B, who had a history of urinary continence, received appropriate services and assistance to maintain continence. Resident B experienced frequent urinary incontinence during the stay, with no toileting program initiated or implemented, and staff did not provide timely assistance. Resident B and family expressed dissatisfaction with care, and no documentation of continence care was provided by the Director of Nursing.

The facility was found deficient in multiple areas including failure to provide adaptive equipment for a resident, failure to notify physicians of elevated blood sugars, incomplete discharge notifications, inaccurate Minimum Data Set (MDS) assessments, failure to obtain required PASRR screenings, incomplete care plans, medication administration errors including late and inappropriate administration, improper medication storage and labeling, failure to provide oxygen humidification, inadequate infection control practices, and failure to follow food preparation recipes.