Inspection Report Summary
The most recent inspection on April 16, 2025, identified multiple deficiencies related to medication administration, service plan documentation, food and medication storage, mental health assessments, and infection control practices. Earlier inspections showed a pattern of medication administration issues, including unauthorized PRN medication use by Qualified Medication Aides and medication errors, as well as recurring problems with food and medication storage. Complaint investigations were mostly unsubstantiated, except for a few substantiated complaints involving medication errors and failure to obtain proper authorization for PRN medications. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s deficiencies have persisted over time with similar themes, indicating ongoing challenges in medication management and related care processes.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
19% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
90 residents
Based on a April 2025 inspection.
Census over time
Inspection Report
Renewal
Census: 90
Deficiencies: 9
Date: Apr 16, 2025
Visit Reason
This visit was for a State Residential Licensure Survey conducted on April 15 and 16, 2025, to assess compliance with state regulations for the facility.
Findings
The facility was found deficient in multiple areas including failure to ensure service plans were signed, unauthorized administration of PRN medications by QMAs, medication errors, improper food storage, medication storage and labeling issues, lack of mental health assessments and service plans for residents with major mental illness, and failure to perform proper hand hygiene during medication administration.
Deficiencies (9)
Failed to ensure service plans were signed for 2 of 7 residents who received services in the facility.
Failed to ensure PRN medications administered by a Qualified Medication Aide (QMA) were preauthorized by a licensed nurse for 3 of 7 resident records reviewed.
Failed to ensure that a medication error was documented in the resident's record; resident received a medication not ordered.
Failed to store and prepare food under sanitary conditions; food past use-by dates was not discarded, food was not labeled or dated, and air conditioning unit blew air toward food preparation area.
Failed to properly store medication; an unopened, unrefrigerated box of Ozempic was found in a medication cart.
Failed to properly store and label medications in medication and treatment carts; loose pills and improperly labeled over-the-counter medications were observed.
Failed to ensure a resident requiring mental health assessment was assessed and offered mental health consultation.
Failed to ensure a service plan of care related to major mental illness diagnoses was developed for a resident.
Failed to ensure infection control practices; staff observed not performing hand hygiene during medication passes.
Report Facts
Residential Census: 90
Deficiencies cited: 9
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 0
Date: Oct 17, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00444184.
Complaint Details
Complaint IN00444184 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00444184 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 0
Date: Sep 18, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00440670.
Complaint Details
Complaint IN00440670 was investigated and found to have no related deficiencies; the complaint was not substantiated.
Findings
No deficiencies related to the allegations in Complaint IN00440670 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 2
Date: Apr 2, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00431356 regarding medication administration and PRN medication authorization issues at Wyndmoor of Evansville LLC.
Complaint Details
Complaint IN00431356 was substantiated with state deficiencies cited related to medication administration errors and failure to obtain authorization for PRN medications.
Findings
The facility failed to ensure medications were administered as ordered, including giving a discontinued medication to Resident E without physician order or documentation. Additionally, PRN medications were administered to Residents B and C without prior authorization from a licensed nurse or physician.
Deficiencies (2)
Medication was given without a physician order and was not documented as given for Resident E; discontinued medication was administered.
PRN medications were administered without authorization by a licensed nurse or physician for Residents B and C.
Report Facts
Residents observed for medication pass: 5
Discontinued medication doses missing: 26
Medication doses delivered: 30
Residents observed for PRN medication: 2
Residents in sample for medication observation: 5
Residential Census: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessie Hawkins | Executive Director | Signed as facility representative on the inspection report. |
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 0
Date: Feb 7, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00425413 and IN00427825.
Complaint Details
Investigation of Complaint IN00425413 and IN00427825 found no deficiencies related to the allegations; facility was compliant.
Findings
No deficiencies related to the allegations in complaints IN00425413 and IN00427825 were cited. The facility was found to be in compliance with applicable regulations.
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 0
Date: Jul 27, 2023
Visit Reason
This visit was for the investigation of complaints IN00413430 and IN00412113.
Complaint Details
Investigation of Complaint IN00413430 and IN00412113 found no deficiencies related to the allegations; facility was in compliance.
Findings
No deficiencies related to the allegations in complaints IN00413430 and IN00412113 were cited. The facility was found to be in compliance with applicable regulations.
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 2
Date: Jun 29, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00411492, which triggered a review of state deficiencies related to the allegations cited at R0246 and R0349.
Complaint Details
Complaint IN00411492 was investigated. State deficiencies related to the allegations were cited at R0246 and R0349. The complaint was substantiated by findings of noncompliance in medication administration and clinical record accuracy.
Findings
The facility failed to ensure that Qualified Medication Aides (QMAs) obtained proper authorization from a licensed nurse before administering PRN medications to one resident, and failed to correctly transcribe medication orders from the physician to the electronic Medication Administration Record (eMAR) for another resident.
Deficiencies (2)
Failed to ensure QMAs obtained authorization by a licensed nurse for administration of PRN medication for 1 of 6 residents reviewed (Resident W).
Failed to ensure medication orders were correctly transcribed from the physician's order to the resident's eMAR for 1 of 6 residents (Resident K).
Report Facts
Residents reviewed for medication administration: 6
Residents reviewed for medication transcription: 6
Dates of survey: June 27, 28, and 29, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessie Maelee Hawkins | Admin Assistant | Signed the report |
| Director of Nursing | Interviewed regarding QMA medication administration policies | |
| Assistant Director of Nursing | Provided physician office After-Visit Summary for Resident K |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 2
Date: Apr 25, 2023
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaints IN00403906 and IN00401348.
Complaint Details
Complaint IN00403906 and Complaint IN00401348 were investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies were cited related to the complaints. Deficiencies were found related to food storage practices and medication storage and labeling, including undated and uncovered food items and improperly labeled medications on multiple medication carts and treatment carts.
Deficiencies (2)
Food was not stored appropriately in the kitchen; open food containers were not dated or covered, and boxes were stored on the floor.
Facility failed to provide proper storage of medications on 4 medication carts and 1 treatment cart; multiple medications lacked complete and/or accurate labels.
Report Facts
Residential Census: 86
Unidentified pills: 18
Medications lacking complete labels: 28
Survey dates: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessie Hawkins | Laboratory Director or Provider/Supplier Representative | Signed the report. |
| Dietary Manager | Interviewed regarding food storage and sanitation practices. | |
| QMA 10 (Qualified Medication Aide) | Observed handling loose medications and interviewed regarding medication storage. | |
| Assistant Director of Nursing (ADON) | Provided current medication storage policy. |
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