Indiana Veterans Home

In the surveyor’s words

From the most serious findings on record at Indiana Veterans Home, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 18, 2025

  Based on observation, interview and record review, the facility failed to ensure a resident was kept safe during a transfer for 1 of 3 residents reviewed for accidents. (Resident B) This deficient practice resulted in Resident B sustaining a 3 cm laceration to his posterior scalp. The deficient practice was corrected on 6/13/25, prior to the start of the survey and was therefore past noncompliance. Findings include: A facility reported incident (FRI), dated 6/8/25, indicated Resident B had a change of plane from a Hoyer lift. Resident B received a 3 cm laceration to the posterior scalp, was sent to the emergency room (ER) for evaluation and returned with 3 staples to his posterior head. The clinical record for Resident B was reviewed on 6/18/25 at 1:10 p.m. […]

• Actual harm, isolatedF689Oct 26, 2023

  Based on interview and record review, the facility failed to ensure a resident in a wheelchair was assisted to get off the facility vehicle safely for 1 of 5 residents reviewed for falls. (Resident O) Resident O sustained a subdural hematoma and was hospitalized for 2 days. The deficient practice was corrected on 8/27/23, prior to the start of the survey and was therefore past noncompliance. Findings include: A Facility Reported Incident (FRI), dated 8/25/23 at 8:33 a.m., indicated Facility Driver 7 reported an accident while he was transporting Resident O. The driver was getting Resident O off the van at the hospital when he lost control of the resident's wheelchair while moving it toward the back of the van. […]

• Actual harm, isolatedF689Nov 4, 2021

  Based on interview and record review, the facility failed to assess and care plan and provide adequate supervision and assistance for the use of an electric scooter during outings away from the facility for 1 of 1 residents reviewed for accidents (Resident C). Resident C sustained a hematoma to his left calf and had to be hospitalized for the removal of the hematoma and to control the bleeding. Finding includes: The record for Resident C was reviewed on 11/4/21 at 3:35 p.m. Diagnoses included, but were not limited to, unspecified left lower leg open wound, a contusion of the left lower leg, [CONDITION(S)], [CONDITION(S)], repeated falls, [CONDITION(S)] and [CONDITION(S)]. […]

• No harm, potential for more than minimal, patternF812Sep 14, 2022

  Based on observation, interview and record review, the facility failed to ensure the dishwasher had reached and maintained the appropriate temperature during the final rinse cycle. This deficient practice had the potential to affect 106 of 106 residents who received food from the kitchen. Finding includes: During an observation, on 9/6/22 at 12:02 p.m., the facility dishwasher final rinse was 120 degrees. The kitchen staff was stacking the dishes and pans which had just run through the dishwasher onto the clean shelves. The final rinse should have reached 180 degrees or above according to the sign on the dishwasher. During an interview, on 9/6/22 at 12:07 p.m., the Dietary Manager had the kitchen staff run the dishes and pans through the dishwasher again. […]

• No harm, potential for more than minimal, patternF880Jan 20, 2021

  Based on observation, interview and record review, the facility failed to ensure staff completed proper hand hygiene after glove removal and when exiting an isolation room and failed to ensure staff wore proper Personal Protective Equipment (PPE) while in isolation rooms for 5 of 5 randomly observed staff members (CNA 1, CNA 2, CNA 3, Housekeeper 4 and Housekeeper 5) Findings include: 1. During a walk through of the(NAME)2 unit, on January 19, 2021 beginning at 12: 19 p.m., with the Infection Preventionist (IP), CNA 1 was observed in Resident C's room, which was clearly marked as a yellow (presumed positive for infection) isolation room and had a sign on the door indicating what PPE was needed to enter the room. […]