Inspection Reports for Tanglewood Trace
530 Tanglewood Ln, Mishawaka, IN 46545, IN, 46545
Back to Facility ProfileInspection Report Summary
The most recent inspection on August 20, 2024, identified deficiencies related to medication assessments, nurse authorization for PRN medications, food storage, and emergency information documentation. Earlier inspections showed a pattern of issues including resident care after falls, medication documentation, sanitation, safety standards, and service plan evaluations. Complaint investigations were mostly unsubstantiated or substantiated without related deficiencies, with one substantiated complaint noting no cited issues. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. The facility’s inspection history reflects ongoing challenges in medication management, documentation, and sanitation, with no clear trend of improvement or worsening over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
29% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
64 residents
Based on a August 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 64
Deficiencies: 4
Date: Aug 20, 2024
Visit Reason
This visit was for a State Residential Licensure Survey conducted on August 20, 21 and 22, 2024.
Findings
The facility was found deficient in several areas including failure to complete self-administration of medication assessments for residents, lack of prior nurse authorization for PRN medications administered by QMA, improper food storage with unlabeled and undated food items, and incomplete emergency information binders missing hospital preferences for multiple residents.
Deficiencies (4)
Failed to ensure Self Administration of Medication assessments were completed for 2 of 2 residents reviewed for self-administration of medications.
Failed to ensure PRN medications administered by qualified medication aides were authorized by a licensed nurse prior to administration for 3 of 10 residents reviewed.
Failed to store food under sanitary conditions related to undated and unlabeled food in the kitchen.
Failed to ensure an emergency information binder was accurate and complete with all required resident information for 11 of 64 residents.
Report Facts
Residents reviewed for self-administration: 2
Residents reviewed for PRN medication administration: 10
Residents affected by emergency binder deficiencies: 11
Residential Census: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barbara Gawel | Executive Director | Signed the report |
| Director of Nursing | Named in relation to findings on medication assessments, PRN medication authorization, and emergency binder deficiencies |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 2
Date: Mar 14, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00427872 and IN00430496 regarding resident care and medication documentation.
Complaint Details
Complaint IN00427872 related to fall care deficiencies; Complaint IN00430496 related to medication documentation deficiencies.
Findings
The facility failed to ensure proper care was provided after a resident's fall, including lack of licensed staff assessment and delayed incident reporting. Additionally, the facility failed to maintain complete and accurate clinical records related to medication administration for a resident.
Deficiencies (2)
Failure to ensure proper care was provided related to a resident not being assessed by licensed staff after a fall (Resident C).
Failure to ensure a resident's record was complete and accurately documented related to medication (Resident B).
Report Facts
Residential Census: 66
Incident number: 264
Medication doses: 12.5
Medication doses: 10
Deficiency correction completion date: Mar 29, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barbara Gawel | Executive Director | Signed the report |
| Director of Nursing | Interviewed regarding fall assessments and medication administration policies; responsible for corrective actions and audits | |
| Qualified Medication Aide 2 | QMA | Interviewed about fall reporting and medication administration |
| Certified Nursing Assistant 3 | CNA | Interviewed about fall procedures |
| Certified Nursing Assistant 4 | CNA | Interviewed about resident fall incident |
| Qualified Medication Aide 5 | QMA | Interviewed about medication availability and reporting |
| Licensed Practical Nurse 6 | LPN | Interviewed about medication administration and pharmacy communication |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 0
Date: Jan 4, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00422963.
Complaint Details
Complaint IN00422963 was investigated and found to have no related deficiencies; the complaint was not substantiated.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations regarding the complaint.
Report Facts
Residential Census: 69
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 3
Date: Aug 2, 2023
Visit Reason
This visit was for a State Residential Licensure Survey which included the investigation of Complaint IN00409743.
Complaint Details
Complaint IN00409743 was investigated and no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the complaint allegations were cited. However, deficiencies were found related to sanitation and safety standards, evaluation service plans, and food and nutritional services.
Deficiencies (3)
Facility failed to ensure hot water temperatures were maintained at a safe level on 3 of 3 halls (Rooms 425, 521, 602, and 622).
Facility failed to ensure a service plan was completed for 1 out of 7 clinical records reviewed (Resident D).
Facility failed to ensure 1 of 1 kitchens was maintained in a sanitary manner and failed to ensure there was an adequate air gap between the ice machine drainage pipe and the floor drain, potentially affecting all 67 residents.
Report Facts
Residential Census: 67
Hot water temperature readings: 124.3
Hot water temperature readings: 120.4
Hot water temperature readings: 121.6
Hot water temperature readings: 120.4
Temperature log over 120 degrees: 2
Clinical records reviewed: 7
Deficient clinical records: 1
Residents potentially affected: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barbara Gawel | Executive Director | Signed the report. |
| Maintenance Supervisor | Interviewed regarding hot water heaters and mixing valves. | |
| Director of Maintenance | Tested water temperatures and was in-serviced on hot water policy; responsible for monitoring water heaters and mixing valves. | |
| Director of Nursing | Indicated Resident D did not have a service plan; in-serviced on assessment and care plans policy; responsible for monitoring assessments and care plans. | |
| Administrator | Provided policy titled 'Assistance/Service Plan' and responsible for reporting audit results to Quality Assurance committee. | |
| Food Service Supervisor | Interviewed regarding kitchen sanitation and confirmed maintenance repairs. | |
| Director of Food Services | In-serviced kitchen staff on sanitation policy; responsible for weekly audits of kitchen areas. |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 0
Date: Nov 22, 2022
Visit Reason
This visit was for a State Residential Licensure Survey which included the investigation of three complaints: IN00389168, IN00384825, and IN00391838.
Complaint Details
Complaint IN00389168 - Substantiated with no deficiencies cited. Complaint IN00384825 - Unsubstantiated due to lack of evidence. Complaint IN00391838 - Substantiated with no deficiencies cited.
Findings
Complaints IN00389168 and IN00391838 were substantiated but no deficiencies related to the allegations were cited. Complaint IN00384825 was unsubstantiated due to lack of evidence. The facility was found to be in compliance with applicable state licensure requirements.
Report Facts
Complaint investigations: 3
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