Inspection Reports for
Aperion Care Greenfield
5430 W US 40, GREENFIELD, IN, 46140
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
12.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
198% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
36
27
18
9
0
Occupancy
Latest occupancy rate
85% occupied
Based on a February 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 0
Date: Feb 28, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00448395 and IN00453833 at the facility.
Complaint Details
Complaint IN00448395 and Complaint IN00453833 were investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies related to the allegations in complaints IN00448395 and IN00453833 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 51
Medicare residents: 2
Medicaid residents: 49
Inspection Report
Re-Inspection
Census: 52
Capacity: 60
Deficiencies: 0
Date: Nov 13, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and Life Safety Recertification and State Licensure Survey originally conducted on 09/17/2024.
Findings
At this PSR Emergency Preparedness survey and Life Safety Code survey, Aperion Care Greenfield was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility was fully sprinkled and had appropriate fire alarm and smoke detection systems.
Report Facts
Certified beds: 60
Census: 52
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 7, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00444277 completed on October 15, 2024.
Complaint Details
Complaint IN00444277 was investigated and found to be corrected.
Findings
Aperion Care Greenfield was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 52
Capacity: 52
Deficiencies: 1
Date: Oct 15, 2024
Visit Reason
This visit was for the investigation of complaints IN00444277, IN00444280, IN00444012, and IN00442831, in conjunction with a Post Survey Revisit to the Recertification and State Licensure Survey completed on August 30, 2024.
Complaint Details
Complaint IN00444277 was substantiated with federal/state deficiencies cited at F609 related to failure to timely report abuse. Complaints IN00444280, IN00444012, and IN00442831 had no deficiencies related to the allegations.
Findings
The facility failed to report an allegation of abuse timely to the Indiana Department of Health for one resident (Resident B). Other complaints investigated did not result in deficiencies. The facility implemented corrective actions including staff re-education and monitoring to prevent recurrence.
Deficiencies (1)
Failed to report an allegation of abuse to the Indiana Department of Health timely for 1 of 3 residents reviewed for abuse (Resident B).
Report Facts
Census: 52
Total Capacity: 52
Medicare Census: 4
Medicaid Census: 45
Other Payor Census: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Adams | HFA | Signed as Laboratory Director's or Provider/Supplier Representative |
| Business Office Manager | Named in abuse reporting failure and investigation | |
| Assistant Director of Nursing | Responsible for reporting abuse in Administrator's absence | |
| Administrator | Interviewed regarding abuse reporting responsibility | |
| Regional Nurse Consultant | Provided reportable regarding abuse allegations |
Inspection Report
Follow-Up
Census: 52
Capacity: 52
Deficiencies: 0
Date: Oct 15, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on August 30, 2024, conducted in conjunction with the Investigation of Complaints IN00444277, IN00444280, IN00444012, and IN00442831.
Complaint Details
The visit was conducted in conjunction with the investigation of multiple complaints identified by numbers IN00444277, IN00444280, IN00444012, and IN00442831.
Findings
Aperion Care Greenfield was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regards to the PSR to the Recertification and State Licensure Survey.
Report Facts
Census SNF/NF beds: 52
Census total residents: 52
Census Medicare residents: 4
Census Medicaid residents: 45
Census other payor residents: 3
Inspection Report
Routine
Census: 50
Capacity: 60
Deficiencies: 15
Date: Sep 17, 2024
Visit Reason
A Life Safety Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a). The survey included an Emergency Preparedness Survey and Life Safety Code inspection.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code standards including deficiencies in emergency preparedness plan updates, fire alarm and sprinkler system policies, corridor door integrity, smoke barrier penetrations, electrical safety, HVAC return air system use, and annual fuel quality testing for the diesel generator.
Deficiencies (15)
Failed to review and update the Emergency Preparedness Plan (EPP) at least annually.
Failed to maintain an Emergency Preparedness Plan based on a documented facility-based and community-based risk assessment using an all-hazards approach.
Failed to ensure the emergency preparedness plan included a process for cooperation and collaboration with local, tribal, regional, State, or Federal emergency preparedness officials.
Failed to review and update the Emergency Preparedness Plan's Policies and Procedures at least annually.
Failed to review and update the Emergency Preparedness Plan's Communication Plan at least annually.
Failed to ensure the emergency preparedness communication plan included names and contact information for staff and resident physicians.
Failed to review and update the Emergency Preparedness Plan's Training and Testing Plan at least annually.
Failed to implement the emergency power system inspection, testing, and maintenance requirements including annual fuel quality testing for the diesel generator.
Failed to provide a complete written policy for fire alarm system out of service procedures including notification to Indiana State Department of Health (ISDH).
Failed to provide correct written policies for sprinkler system out of service procedures including notification to ISDH.
Business office pass-through window greater than 20 square inches was not protected by electrically supervised automatic smoke detection.
Corridor door to employee breakroom was broken and not solid core, failing to resist passage of smoke.
Penetrations through smoke barrier walls were not protected to maintain smoke resistance.
Electrical junction box in laundry room was missing cover leaving exposed wiring; electrical outlet cover missing in DON office.
Egress corridors were used as return air system for adjoining resident rooms without a current waiver.
Report Facts
Certified beds: 60
Census: 50
Deficiencies cited: 17
Fuel quality test date: Sep 19, 2024
Fuel quality test result date: Sep 26, 2024
Fire alarm out of service notification threshold: 4
Sprinkler system out of service notification threshold: 10
Corridor door monitoring frequency: 5
Corridor door monitoring duration: 4
Corridor door monitoring duration: 8
Ceiling tile monitoring duration: 4
Ceiling tile monitoring duration: 8
Outlet and junction box monitoring duration: 4
Outlet and junction box monitoring duration: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and involved in findings and corrective actions throughout the report |
Inspection Report
Recertification
Census: 52
Capacity: 52
Deficiencies: 18
Date: Aug 30, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey including investigation of three complaints.
Complaint Details
This visit included investigation of Complaints IN00439061, IN00439795, and IN00440705. No deficiencies related to the allegations were cited for any of the complaints.
Findings
The facility was cited for multiple deficiencies including failure to ensure fluids were available at bedside, failure to provide a homelike environment, failure to prevent resident abuse, failure to provide bed hold policy documentation, inaccurate MDS assessments, incomplete PASARR screening, failure to hold scheduled care plan meetings, inadequate activities programming, quality of care issues including undated dressings and incomplete skin assessments, delayed optometry and dental services, incomplete smoking assessments, failure to supervise aerosol treatments, expired medical supplies in medication rooms, improper disposal of trash and soiled linen, and inappropriate antibiotic use.
Deficiencies (18)
Failed to ensure fluids were available at bedside for 7 of 7 residents reviewed.
Failed to provide a homelike environment for 2 of 12 residents reviewed.
Failed to ensure residents were free from physical abuse for 5 of 5 residents reviewed.
Failed to maintain documentation of bed hold policy for 1 of 1 resident reviewed.
Failed to accurately encode MDS information for 2 of 19 residents reviewed.
Failed to ensure PASARR Level II screening was completed for 1 of 3 residents reviewed.
Failed to hold regularly scheduled care plan meetings for 1 of 2 residents reviewed.
Failed to follow scheduled activities calendar or provide outside activities for 3 of 3 residents reviewed.
Failed to date dry dressing and complete skin assessments as care planned for 2 of 2 residents reviewed.
Failed to ensure timely optometry services for 1 of 3 residents reviewed.
Failed to complete quarterly smoking assessments for 1 of 1 resident reviewed.
Failed to supervise dependent resident during aerosol treatment for 1 of 1 resident reviewed.
Failed to ensure medication storage rooms did not contain expired supplies for 2 medication rooms observed.
Failed to ensure routine lab was drawn per physician order for 1 of 1 resident reviewed.
Failed to ensure timely dental services for 1 of 2 residents reviewed.
Failed to ensure trash was contained within dumpsters and lids were closed for 52 residents.
Failed to place soiled linen in bags during transport, contain soiled linen in bins, and properly discard PPE for residents in enhanced barrier precautions.
Failed to ensure antibiotic was appropriate for treatment of UTI for 1 of 2 residents reviewed.
Report Facts
Residents reviewed for fluids availability: 7
Residents reviewed for homelike environment: 12
Residents reviewed for abuse: 5
Residents reviewed for bed hold policy: 1
Residents reviewed for MDS accuracy: 19
Residents reviewed for PASARR screening: 3
Residents reviewed for care planning: 2
Residents reviewed for activities: 3
Residents reviewed for skin impairments: 2
Residents reviewed for vision/hearing services: 3
Residents reviewed for smoking safety: 1
Residents reviewed for respiratory care: 1
Medication storage rooms observed: 2
Residents reviewed for laboratory services: 1
Residents reviewed for dental services: 2
Residents in facility: 52
Residents reviewed for infection control: 7
Residents reviewed for antibiotic therapy: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Adams | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| LPN 13 | Nurse who observed and corrected aerosol treatment for Resident 30 | |
| CNA 10 | Certified Nursing Assistant | Interviewed regarding soiled linen handling |
| CNA 11 | Certified Nursing Assistant | Observed transporting soiled linen |
| LPN 6 | Licensed Practical Nurse | Observed cleaning brown substance from floor |
| Social Services Director | Provided multiple policies and interviewed regarding ancillary services | |
| Executive Director | Interviewed regarding multiple findings including fluids, activities, labs, and dental services | |
| Director of Nursing | Interviewed regarding skin assessments and nebulizer policy | |
| Dietary Manager | Interviewed regarding dumpster lids and trash |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 48
Deficiencies: 0
Date: Jul 9, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00435119 and IN00437549 at Aperion Care Greenfield.
Complaint Details
Investigation of Complaints IN00435119 and IN00437549 found no deficiencies related to the allegations; both complaints were not substantiated.
Findings
No deficiencies related to the allegations in complaints IN00435119 and IN00437549 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 48
Total Capacity: 48
Medicare Census: 3
Medicaid Census: 42
Other Payor Census: 3
Inspection Report
Complaint Investigation
Census: 48
Capacity: 48
Deficiencies: 0
Date: Apr 4, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00426903.
Complaint Details
Complaint IN00426903 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 48
Total Capacity: 48
Medicare Census: 1
Medicaid Census: 44
Other Payor Census: 3
Inspection Report
Re-Inspection
Census: 43
Capacity: 60
Deficiencies: 0
Date: Sep 1, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Recertification and State Licensure Survey conducted on 07/28/23 was performed to verify compliance with Life Safety Code requirements.
Findings
At this PSR Life Safety Code survey, Sugar Creek Rehabilitation and Convalescent Center was found in compliance with Requirements for Participation in Medicare/Medicaid and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Report Facts
Facility capacity: 60
Census: 43
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 10, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure completed on June 27, 2023.
Findings
Sugar Creek Rehabilitation and Convalescent Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Recertification and State Licensure.
Inspection Report
Life Safety
Census: 40
Capacity: 60
Deficiencies: 9
Date: Jul 28, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements, including issues with egress door locking, hazardous area door self-closing devices, fire alarm system maintenance, electrical outlet protection, HVAC return air system use of egress corridors, fire drill scheduling, fire door assembly inspection, electrical outlet receptacle testing, and improper use of power strips.
Deficiencies (9)
Exit doors were magnetically locked with posted inactive codes, which could affect egress accessibility.
Corridor doors to hazardous areas lacked proper self-closing devices or did not self-close and latch properly.
Fire alarm system lacked documentation of semi-annual visual inspection.
Electrical outlets were not properly protected; covers missing or outlets loose.
Egress corridors were used as return air systems serving adjoining resident rooms without an approved waiver.
Fire drills were not conducted on unexpected days or varying times as required.
Annual inspection and testing of fire door assembly at oxygen transfilling room was not completed.
Documentation of electrical outlet receptacle testing was not available for review.
Power strip was used as a substitute for fixed wiring to power a refrigerator in the Social Services/Dietary office.
Report Facts
Certified beds: 60
Census: 40
Deficiencies cited: 9
Fire drills reviewed: 12
Fire drills non-compliant: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Roger Brannan | Administrator | Signed report and present at exit conference |
| Maintenance Director | Interviewed regarding deficiencies and corrective actions |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 0
Date: Jul 11, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00412094.
Complaint Details
Complaint IN00412094 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00412094 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 39
Medicare residents: 1
Medicaid residents: 38
Inspection Report
Renewal
Census: 40
Capacity: 40
Deficiencies: 5
Date: Jun 27, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted over June 20, 21, 22, 26, and 27, 2023.
Findings
The facility was found deficient in several areas including failure to provide dignity bags for catheter bags, incomplete grievance documentation, failure to implement pressure relieving boots as ordered, failure to maintain Foley catheters off the floor, and inadequate RN coverage on specific dates.
Deficiencies (5)
Failure to provide a dignity bag to cover a catheter for Resident 13.
Failure to complete grievance form including date of notification and disposition for Resident 22.
Failure to implement pressure relieving boots as ordered for Resident 12 with a pressure ulcer.
Failure to maintain Foley catheter off the floor for Resident 12, risking urinary tract infection.
Failure to ensure Registered Nurse coverage for at least 8 consecutive hours on specified dates.
Report Facts
Census: 40
Total Capacity: 40
Survey Dates: 5
RN coverage missing days: 4
RN coverage partial day: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Roger Brannan | Administrator | Named as Administrator and signer of the report |
| Director of Nursing | Referenced multiple times in interviews and corrective action plans but no full name provided |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 7, 2022
Visit Reason
Paper compliance review to the Complaint Investigation with an unrelated deficiency cited, completed on September 1, 2022.
Complaint Details
The visit was related to a complaint investigation; the facility was found in compliance with the complaint investigation with an unrelated deficiency cited.
Findings
Sugar Creek Rehabilitation and Convalescent Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation with an unrelated deficiency cited.
Inspection Report
Complaint Investigation
Census: 47
Capacity: 47
Deficiencies: 0
Date: Sep 20, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00390194.
Complaint Details
Complaint IN00390194 was substantiated, but no deficiencies related to the allegations were cited.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 47
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 46
Inspection Report
Complaint Investigation
Census: 46
Capacity: 46
Deficiencies: 2
Date: Sep 1, 2022
Visit Reason
This visit was conducted for the investigation of two complaints, IN00384434 and IN00388526. Complaint IN00384434 was substantiated with no deficiencies related to the allegations cited, and complaint IN00388526 was unsubstantiated due to lack of evidence.
Complaint Details
Complaint IN00384434 was substantiated with no deficiencies related to the allegations cited. Complaint IN00388526 was unsubstantiated due to lack of evidence.
Findings
The facility failed to identify and investigate potential discrepancies in narcotic and controlled substance records on medication carts and failed to document the date received and signature of recipient for several residents' controlled substance reconciliation records. The discrepancies involved multiple residents and medication carts, with missing or inaccurate documentation noted.
Deficiencies (2)
Failed to identify and investigate potential discrepancies on 4 of 31 narcotic and controlled substance records on 2 medication carts reviewed.
Failed to document the date received and signature of recipient for 5 of 9 residents reviewed for controlled substance reconciliation (Residents C, K, L, M, and N).
Report Facts
Census: 46
Total Capacity: 46
Residents reviewed for controlled substance reconciliation: 9
Narcotic and controlled substance records reviewed: 31
Medication carts reviewed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding discrepancies in narcotic and controlled substance records |
Report
September 30, 2025
Report
October 15, 2024
Report
August 30, 2024
Report
June 27, 2023
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