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)
23.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
455% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
71 residents
Based on a March 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jul 22, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to concerns about quality of care, neglect, and infection control at Westside Retirement Village.
Complaint Details
The deficiencies relate to Complaint numbers 1669976.3.1-37(a), 1669976.3.1-47(a)(6), and 1669993.3.1-18(b).
Findings
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.
Deficiencies (3)
Failed to complete a physician's order by documenting fluid intakes for a resident on restricted fluid intake.
Failed to keep a resident's call light in reach and to apply ordered oxygen for a resident.
Failed to maintain a clean, orderly shower room for resident use; floor had feces, used plastic bag, wet paper towels, used nicotine patch, and black substance between tiles.
Report Facts
Residents reviewed for quality of care: 4
Residents reviewed for neglect: 4
Shower rooms observed for cleanliness: 3
Fluid restriction amount: 1500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing (ADON) | Interviewed regarding fluid restriction and shower room cleanliness. | |
| Administrator | Observed oxygen administration and call light placement; provided facility policies. | |
| Lead Housekeeper | Interviewed regarding shower room cleanliness. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: May 21, 2025
Visit Reason
The inspection was conducted in response to a complaint (IN00459628) regarding concerns about resident care, grievances, food temperature and quality, and housekeeping conditions at Westside Retirement Village.
Complaint Details
The complaint IN00459628 involved issues with bathing accommodations, grievance follow-up and resolution, food temperature and quality, and housekeeping cleanliness.
Findings
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.
Deficiencies (4)
Failed to provide or document showers for 1 of 3 residents reviewed for bathing preferences (Resident D).
Failed to ensure grievances were followed up, investigated, and resolved for 3 of 3 residents reviewed for grievances and 3 months of Resident Council.
Failed to ensure the temperature and palatability of food served for 5 of 6 residents reviewed for food temperature.
Failed to maintain a safe, clean, and sanitary environment on 1 of 2 units (100) observed for cleanliness.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 5
Residents affected: 89
Units observed: 2
Rooms observed: 9
Housekeeping schedules: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding Tegaderm dressings and shower accommodations for Resident D |
| Administrator | Administrator (ADM) | Provided policies and information on grievance program, food temperature control, and housekeeping services |
| Dietary Manager | Dietary Manager (DM) | Interviewed regarding food temperature complaints and kitchen operations |
| Housekeeper 19 | Housekeeper | Observed cleaning and interviewed about housekeeping assignments and workload |
| Housekeeper 20 | Housekeeper | Assigned to 300 unit, involved in cleaning Resident C's room |
| Housekeeper 21 | Housekeeper | Assigned to resident rooms 116 through 130 and nurse's station, not observed working during survey |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed about housekeeping schedules, staffing, and Resident C's room cleaning issues |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 0
Date: Mar 7, 2025
Visit Reason
This visit was for the investigation of Complaint IN00449429.
Complaint Details
Complaint IN00449429 - No deficiencies related to the allegations are cited.
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.
Report Facts
Residential Census: 71
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jan 15, 2025
Visit Reason
The inspection was conducted based on complaint IN00449427 to investigate allegations related to care plan revisions, assistance with activities of daily living, and respiratory care.
Complaint Details
Complaint IN00449427 related to care plan revisions, activities of daily living assistance, and respiratory care deficiencies.
Findings
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.
Deficiencies (3)
Failed to ensure comprehensive care plans were reviewed and revised as needed with resident's updated interventions for 1 of 18 residents (Resident 14).
Failed to ensure a resident's activities of daily living were completed for 1 of 8 residents reviewed (Resident B).
Failed to ensure oxygen levels were set correctly for 2 of 2 residents using nasal cannulas and failed to ensure humidifier bottles were changed at 7 day intervals; bipap mask and tubing were not protected from contamination for 1 of 2 residents (Resident B).
Report Facts
Residents reviewed for care plan revisions: 18
Residents reviewed for completed ADLs: 8
Residents reviewed for respiratory care: 2
Oxygen liters per minute: 2
Oxygen liters per minute observed: 1
Recall list interval: 60
Humidifier bottle replacement interval (days): 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Therapy | Director of Therapy (DOT) | Indicated Resident 14's brace was no longer needed and care plan should have been revised. |
| Executive Director | Executive Director (ED) | Provided documentation and information regarding Resident B's podiatry visits and facility policies. |
| Director of Nursing | Director of Nursing (DON) | Indicated residents should be seen routinely by podiatrist and bipap mask should be covered when not in use. |
| Licensed Practical Nurse 8 | Licensed Practical Nurse (LPN) 8 | Provided care and oxygen adjustments for Resident Z. |
| Licensed Practical Nurse 37 | Licensed Practical Nurse (LPN) 37 | Provided care and observations for Resident Z and Resident B, including oxygen saturation and nebulizer treatments. |
| Physician's Assistant | Physician's Assistant (PA) 9 | Assessed Resident Z and ordered treatments. |
| Regional Director of Clinical Services | Regional Director of Clinical Services (RDCS) | Provided current policy on oxygen administration. |
Inspection Report
Complaint Investigation
Deficiencies: 12
Date: Jan 15, 2025
Visit Reason
The inspection was conducted based on complaints alleging issues with resident dignity, voting rights, call light response times, advance directives, environmental cleanliness, assessment accuracy, accident prevention, respiratory care, medication management, infection control, and wheelchair maintenance.
Complaint Details
The inspection was complaint-driven based on multiple complaints including IN00447172, IN00449427, and IN00451144.
Findings
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.
Deficiencies (12)
Failure to treat residents with dignity including harsh communication and inappropriate posting of photographs.
Failure to ensure residents who wanted to vote were registered and able to vote.
Failure to respond timely to call lights despite repeated grievances and resident council complaints.
Failure to ensure residents had advance directives or code statuses documented and updated.
Failure to maintain a clean and homelike environment with fecal contamination in dining room and stained floors in resident rooms.
Failure to code MDS assessments accurately for wandering behaviors and mental health diagnoses.
Failure to prevent accidents including inadequate supervision of wandering residents, incomplete elopement binder, and medications left at bedside without orders.
Failure to provide appropriate respiratory care including incorrect oxygen settings, contaminated bipap mask and tubing, and delayed bipap application.
Failure to obtain blood pressure prior to administration of blood pressure medication as ordered.
Failure to remove expired drugs from medication rooms.
Failure to provide hand hygiene and wear gloves when administering ear drops.
Failure to maintain wheelchairs in safe operating condition with broken brake handles and loose wheelchair armrests.
Report Facts
Residents affected: 22
Residents affected: 11
Residents affected: 5
Residents affected: 4
Residents affected: 2
Residents affected: 8
Residents affected: 2
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 6 | Registered Nurse | Named in medication error and resident dignity findings |
| CNA 7 | Certified Nursing Assistant | Named in resident dignity findings |
| RN 35 | Registered Nurse | Named in resident dignity findings |
| Executive Director | Interviewed regarding resident dignity, voting rights, call light response, and wheelchair maintenance | |
| Director of Nursing | Interviewed regarding resident dignity, voting rights, call light response, advance directives, respiratory care, medication management, infection control, and wheelchair maintenance | |
| Activity Assistant 29 | Named in call light response and wandering resident findings | |
| LPN 28 | Licensed Practical Nurse | Named in call light response and wheelchair maintenance findings |
| CNA 26 | Certified Nursing Assistant | Named in call light response and wandering resident findings |
| LPN 15 | Licensed Practical Nurse | Named in fall and respiratory care findings |
| Floor Tech | Named in environmental cleanliness findings | |
| Social Service Director | Named in MDS and PASRR findings | |
| Social Service Assistant | Named in PASRR findings | |
| Licensed Practical Nurse 8 | Licensed Practical Nurse | Named in respiratory care findings |
| LPN 37 | Licensed Practical Nurse | Named in respiratory care findings |
| PA 9 | Physician's Assistant | Named in respiratory care findings |
| QMA 21 | Qualified Medication Aide | Named in infection control deficiency |
| Certified Occupational Therapy Assistant 38 | COTA | Named in wheelchair maintenance findings |
| Maintenance Director | Named in wheelchair maintenance findings |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 7, 2024
Visit Reason
The inspection was conducted due to multiple incidents involving Resident BB, a resident with dementia and aggressive behaviors, resulting in verbal and physical altercations with other residents on the memory care unit.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failed to provide appropriate treatment and services to a resident diagnosed with dementia, resulting in multiple aggressive incidents and inadequate individualized care planning.
Failed to ensure medications and biologicals were labeled, stored, and destroyed properly for 4 of 5 medication carts, including unlabeled ointments and improperly stored nebulizer vials.
Report Facts
Number of incidents involving Resident BB: 6
Medication carts with deficiencies: 4
Medication bottles without opened dates: 10
Tablets counted in over-the-counter bottles: 12
Tablets counted in over-the-counter bottles: 48
Tablets counted in over-the-counter bottles: 36
Tablets counted in over-the-counter bottles: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided information on Resident BB's aggressive behaviors and medication cart deficiencies |
| Administrator | Administrator (ADM) | Provided reportable incidents and facility policies related to dementia care and incident investigations |
| RN 10 | Registered Nurse | Observed medication cart deficiencies and explained medication storage practices |
| RN 5 | Registered Nurse | Observed medication cart and explained eye medication expiration |
| RN 15 | Registered Nurse | Observed medication cart and medication labeling issues |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 0
Date: Oct 16, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00443840 at Bridge At Garden Plaza.
Complaint Details
Complaint IN00443840 was investigated and found to have no deficiencies related to the allegations.
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.
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
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
Complaint Investigation
Deficiencies: 2
Date: Aug 15, 2024
Visit Reason
The inspection was conducted in response to Complaint IN00439467, focusing on allegations related to resident rights and infection control practices.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failed to ensure a resident was provided showers per the resident's choice for 1 of 3 residents reviewed.
Failed to ensure infection control practices were followed when providing catheter care to 1 of 2 residents reviewed.
Report Facts
Showers administered: 1
Showers administered: 6
Showers administered: 3
Residents reviewed for activities of daily living and showers: 3
Residents reviewed for catheter care: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 6 | Interviewed regarding shower refusals and scheduling | |
| Director of Nursing (DON) | Interviewed regarding documentation of shower refusals | |
| Qualified Medication Aide (QMA) 3 | Observed and interviewed regarding catheter care and bag changes | |
| Registered Nurse (RN) 7 | Interviewed regarding proper catheter bag change procedures | |
| Licensed Practical Nurse (LPN) 9 | Interviewed regarding catheter bag change procedures | |
| Administrator | Provided facility policies and documentation |
Inspection Report
Census: 72
Deficiencies: 4
Date: 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)
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
Complaint Investigation
Deficiencies: 1
Date: Jun 28, 2024
Visit Reason
The inspection was conducted in response to a complaint regarding the facility's failure to address resident grievances, specifically concerning unresolved concerns raised during Resident Council meetings and individual grievance cards.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to address grievances in a manner which could be tracked for 5 of 5 months reviewed for grievance resolutions for the Resident Council meetings and the facility's grievance log for 4 of 4 residents reviewed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided Resident Council minutes and described grievance process. |
| Activity Director | Activity Director/Life Enrichment Director (AD) | Took minutes for Resident Council meetings and completed grievance cards. |
| Executive Director | Executive Director (ED) | Facility's grievance official who had just started working on 6/20/24. |
Inspection Report
Routine
Deficiencies: 2
Date: Apr 17, 2024
Visit Reason
The inspection was conducted to evaluate compliance with care plan development and wound management standards at Westside Retirement Village.
Findings
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.
Deficiencies (2)
Failed to develop complete care plans within 7 days of comprehensive assessment and failed to revise care plans for residents with wounds.
Failed to ensure effective wound management for a resident admitted with an open area on the coccyx that worsened to a stage 3 pressure ulcer.
Report Facts
Wound measurement: 1.1
Wound measurement: 1.5
Mini Nutritional Assessment score: 10
BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 6 | Registered Nurse | Signed wound observation tools and responsible for wound documentation and staging |
| LPN 5 | Licensed Practical Nurse | Provided observations and interviews regarding wound care and documentation responsibilities |
| DON | Director of Nursing | Provided wound tracking logs, policies, and interviews regarding wound care procedures |
| Wound MD | Wound Physician | Responsible for wound assessment and treatment; interviewed regarding wound rounds and documentation |
Inspection Report
Follow-Up
Census: 74
Deficiencies: 0
Date: Dec 8, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00417988 completed on October 2, 2023.
Complaint Details
Complaint IN00417988 was corrected.
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.
Report Facts
Residential Census: 74
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 4, 2023
Visit Reason
The inspection was conducted in response to complaints regarding insufficient nursing staff to meet resident needs, delayed call light responses, and poor food service quality.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failed to ensure sufficient nursing staff were available to meet resident needs and timely answer call lights over multiple days and residents.
Failed to ensure timely meal service, maintain food temperatures before serving, and provide appealing meals per resident preference and repeated complaints.
Report Facts
PPD (nursing hours allotted per day per resident): 2.7
PPD (nursing hours allotted per day per resident): 2.9
PPD (nursing hours allotted per day per resident): 3.4
PPD (nursing hours allotted per day per resident): 2.4
PPD (nursing hours allotted per day per resident): 3.2
PPD (nursing hours allotted per day per resident): 2.7
Average PPD: 2.8
Residents served: 102
Residents interviewed: 14
Days of observation: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 50 | Licensed Practical Nurse | Mentioned in relation to staffing shortages and meal assistance delays |
| CNA 9 | Certified Nursing Assistant | Mentioned for not providing resident care due to required online training |
| Director of Rehabilitation | Director of Rehabilitation | Observed interacting with Resident OO regarding call light needs |
| Director of Nursing | Director of Nursing | Observed ignoring call light for over 5 minutes |
| Staffing Coordinator | Staffing Coordinator | Provided staffing data and discussed open positions and turnover |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided nursing schedules and staffing postings |
| Business Office Manager | Business Office Manager | Observed holding door during meal service and provided dining policies |
| Licensed Practical Nurse 5 | Licensed Practical Nurse | Observed not answering call light while on medication cart |
| Wound Nurse | Wound Nurse | Commented on CNA 9's lack of resident care due to training |
| Activity Director | Activity Director | Observed pulled from activities to help housekeeping and meal service |
| [NAME] 4 | Observed food temperatures and discussed meal service issues | |
| [NAME] 55 | Dishwasher staff commenting on staffing shortages in kitchen |
Inspection Report
Complaint Investigation
Census: 16
Deficiencies: 19
Date: Nov 27, 2023
Visit Reason
The inspection was conducted based on complaints regarding resident care, dignity, staffing, food service, and facility conditions.
Complaint Details
The complaint investigation included allegations of inadequate staffing, poor resident care, dignity violations, food service issues, and unsafe environment conditions.
Findings
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.
Deficiencies (19)
Failed to honor residents' rights to a dignified existence, self-determination, communication, and to exercise rights.
Failed to ensure Resident Council grievances were followed up on and effective resolutions achieved.
Failed to maintain Memory Care resident rooms and bathrooms clean and safe, and failed to maintain shower areas in good condition.
Failed to ensure accurate Minimum Data Set (MDS) assessments and coding.
Failed to develop and implement complete care plans addressing advance directives, end of life care, and unnecessary medications.
Failed to provide a resident shower twice a week as requested.
Failed to provide appropriate care and interventions for residents' range of motion and mobility needs.
Failed to ensure resident safety by preventing accidents, including medication storage and supervision.
Failed to provide appropriate care for bowel and bladder management, including catheter care and constipation prevention.
Failed to date PICC dressing and IV tubing as ordered.
Failed to provide safe, appropriate pain management for residents after falls.
Failed to ensure sufficient nursing staff to meet resident needs and timely response to call lights.
Failed to ensure accurate blood glucose monitoring and medication indication for use.
Failed to ensure timely meal service, maintain food temperatures, and provide appealing meals per resident preference.
Failed to maintain kitchen cleanliness, proper food labeling, removal of expired items, use of hair restraints, and food coverage during preparation; failed to ensure hand hygiene during meal service.
Failed to ensure essential kitchen equipment was maintained in good working condition.
Failed to ensure glucometers were cleaned between residents and disinfected properly.
Failed to ensure residents had opportunity to receive influenza, pneumonia, and COVID-19 vaccinations.
Failed to ensure effective supervision and monitoring of residents with dementia and prevent intrusive wandering.
Report Facts
Residents observed in Memory Care dining room: 16
Resident weight loss: 18
Resident weight loss percentage: 13
Resident weight loss: 18.5
Resident weight loss percentage: 12
PPD (nursing hours per resident per day): 2.7
PPD (nursing hours per resident per day): 2.9
PPD (nursing hours per resident per day): 3.4
PPD (nursing hours per resident per day): 2.4
PPD (nursing hours per resident per day): 3.2
PPD (nursing hours per resident per day): 2.7
Average PPD: 2.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 5 | Licensed Practical Nurse | Named in multiple findings related to resident care, pain management, and call light response |
| CNA 7 | Certified Nursing Aide | Named in findings related to resident care and dignity |
| CNA 9 | Certified Nursing Aide | Named in findings related to resident care, call light response, and infection control |
| Director of Nursing | Director of Nursing | Named in multiple findings related to care oversight and policy |
| Executive Director | Executive Director | Named in findings related to policy and facility management |
| Activity Director | Activity Director | Named in findings related to resident council and activities |
| Resident Council President | Named in resident council meeting delay | |
| Housekeeping Aide 22 | Housekeeping Aide | Named in findings related to cleanliness |
| LPN 13 | Licensed Practical Nurse | Named in findings related to resident care and medication |
| QMA 16 | Qualified Medication Aide | Named in infection control findings |
| Cook 4 | Cook | Named in kitchen sanitation findings |
| Director of Rehabilitation | Director of Rehabilitation | Named in staffing and resident care findings |
| Social Service Director | Social Service Director | Named in resident care and dementia care findings |
| Regional Director of Clinical Services | Regional Director of Clinical Services | Named in medication and infection control findings |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Oct 12, 2023
Visit Reason
The inspection was conducted in response to complaints regarding abuse, neglect, elopement, care planning deficiencies, and call light accessibility at Westside Retirement Village.
Complaint Details
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.
Findings
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.
Deficiencies (5)
Failed to ensure 1 of 3 residents reviewed for abuse was free from abuse which resulted in actual harm as Resident B was roughly handled, scolded, and threatened by nursing staff.
Failed to timely report allegations of abuse for 1 of 3 residents reviewed for abuse (Resident B).
Failed to revise and follow care plans for 1 of 2 residents reviewed for care planning (Resident F).
Failed to prevent potential accidents when secured memory care doors were not adequately monitored during a malfunction which unlocked the secured door, allowing Resident D to elope.
Failed to ensure a resident had their call light within reach for 1 of 1 resident reviewed (Resident F).
Report Facts
Residents reviewed for abuse: 3
Residents affected by abuse deficiency: 1
Residents affected by abuse reporting deficiency: 1
Residents reviewed for care planning: 2
Residents affected by care planning deficiency: 1
Residents reviewed for elopement: 3
Residents affected by elopement deficiency: 1
Residents reviewed for call light accessibility: 1
Residents affected by call light deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 6 | Licensed Practical Nurse | Named in abuse and reporting deficiencies related to Resident B. |
| CNA 7 | Certified Nursing Aide | Named in abuse deficiencies related to Resident B. |
| CNA 8 | Certified Nursing Aide | Named in abuse deficiencies related to Resident B. |
| LPN 12 | Licensed Practical Nurse | Named in elopement deficiency related to Resident D. |
| RN 11 | Registered Nurse | Named in care planning deficiency related to Resident F. |
| Executive Director | Executive Director | Involved in interviews and responses related to abuse, elopement, and policies. |
| Director of Nursing | Director of Nursing | Provided grievance logs and policies related to abuse and elopement. |
| Maintenance Director | Maintenance Director | Interviewed regarding door malfunction and elopement incident. |
| IL Maintenance Director | Independent Living Maintenance Director | Interviewed regarding door malfunction and elopement incident. |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 2
Date: 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.
Complaint Details
Complaint IN00417988 was substantiated with state deficiencies cited at R241 and R295 related to medication administration and self-medication safety.
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.
Deficiencies (2)
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
Date: 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.
Complaint Details
Complaint IN00409956 - State Residential deficiencies related to medication administration errors 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.
Deficiencies (3)
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
Date: May 17, 2023
Visit Reason
This visit was for the investigation of Complaint IN00408419.
Complaint Details
Complaint IN00408419 was investigated and found to have no deficiencies related to the allegations.
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.
Report Facts
Residential Census: 80
Inspection Report
Routine
Census: 71
Deficiencies: 13
Date: 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)
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
Deficiencies: 1
Date: Apr 11, 2023
Visit Reason
The inspection was conducted due to a complaint investigation related to concerns about the care provided to Resident B, specifically regarding urinary continence and assistance.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to provide appropriate care to maintain urinary continence for Resident B.
Report Facts
Residents reviewed for urinary continence: 3
Episodes of urinary incontinence: 7
Days Resident B resided at nursing home: 11
Staff assistance required for toileting: 2
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 11, 2023
Visit Reason
The inspection was conducted as an annual survey of the Westside Retirement Village to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 14
Date: Sep 1, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including resident care, medication administration, infection control, and facility safety.
Findings
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.
Deficiencies (14)
Failed to provide adaptive equipment for 1 of 1 resident reviewed for accommodation of needs (Resident E).
Failed to notify the physician for elevated blood sugars for 1 of 5 residents reviewed (Resident 35).
Failed to ensure clinical information was sent to the hospital upon transfer and failed to give a copy of the bed hold policy and notice of transfer/discharge for 1 of 2 residents reviewed (Resident 35).
Failed to ensure Minimum Data Set (MDS) assessments were coded accurately for 3 of 19 residents reviewed (Residents 50, 35, and 1).
Failed to obtain a new Pre-admission Screening and Resident Review (PASRR) Level II for 1 of 3 residents (Resident 53) and failed to ensure a resident with new mental health diagnoses had a new Level 1 screening (Resident 79).
Failed to develop and implement comprehensive care plans for 5 of 19 residents reviewed (Residents 50, 66, 22, 79, and 35).
Failed to provide appropriate treatment and care for skin conditions for 1 of 1 resident reviewed (Resident 57).
Failed to ensure nursing home area was free from accident hazards and provide adequate supervision to prevent accidents; nurse dispensed all morning medications at the same time and left them unattended for 1 of 1 resident observed (Resident E).
Failed to provide oxygen humidification for 1 of 3 residents reviewed for oxygen administration (Resident 53).
Failed to ensure nurses were competent to perform narcotic counts properly for 1 of 1 observation.
Failed to ensure residents were free from significant medication errors; medications were administered late or inappropriately for multiple residents (Residents B, C, D, E, and 31).
Failed to label an over the counter medication for identification in the medication cart for 1 of 3 residents observed (Resident 54).
Failed to ensure food in the kitchen was labeled and had open and expiration dating for 1 of 1 kitchen observation.
Failed to ensure residents in droplet isolation remained in their rooms and staff wore appropriate PPE; failed to clean blood glucose monitoring machine between uses (Residents 40, 13, and 85).
Report Facts
Medication administration late times: 12
Missing pre/post dialysis assessments: 40
Number of medications in cup: 9
Pressure ulcer measurements: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 12 | Licensed Practical Nurse | Named in medication error finding for leaving medications unattended for Resident E |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple findings including medication errors, dialysis assessments, and infection control |
| LPN 13 | Licensed Practical Nurse | Observed and educated on narcotic count and medication administration errors |
| Executive Director | Executive Director | Provided policies and interviewed regarding multiple deficiencies |
| Certified Dietary Manager | Certified Dietary Manager | Interviewed regarding food preparation and kitchen labeling |
| Wound Nurse | Wound Nurse | Interviewed regarding skin tear treatment for Resident 57 |
| Social Service Designee | Social Service Designee | Interviewed regarding PASRR screening for Resident 53 and 79 |
| CNA 15 | Certified Nursing Assistant | Observed assisting Resident 40 without proper PPE |
| CNA 16 | Certified Nursing Assistant | Observed assisting Resident 13 without proper PPE |
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 0
Date: Aug 26, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00388707.
Complaint Details
Complaint IN00388707 was substantiated, but no deficiencies related to the allegations were cited.
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.
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