Inspection Reports for Arbor Grove Village
1021 E Central Ave, Greensburg, IN 47240, United States, IN, 47240
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Inspection Report
Annual Inspection
Deficiencies: 0
Jun 19, 2025
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure survey conducted on April 28, 2025.
Findings
Arbor Grove Village 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 for the Recertification and State Licensure survey.
Inspection Report
Re-Inspection
Census: 75
Capacity: 83
Deficiencies: 0
Jun 13, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Certification and State Licensure Survey conducted on 05/12/25 was performed to verify compliance with previous deficiencies.
Findings
At this PSR Life Safety Code survey, Arbor Grove Village was found in compliance with Medicare/Medicaid participation requirements, the Life Safety Code, and state regulations. The facility was fully sprinklered with appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 83
Census: 75
Inspection Report
Life Safety
Census: 74
Capacity: 83
Deficiencies: 7
May 12, 2025
Visit Reason
A Life Safety Code Certification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 standards.
Findings
The facility was found not in compliance with Life Safety Code requirements due to multiple deficiencies including lint accumulation in laundry dryer rooms, hazardous area doors lacking self-closing devices, sprinkler system installation issues, corridor doors failing to close and latch properly, smoking policy violations, improper use of multi-plug adapters, and incomplete testing and maintenance documentation for electrical equipment.
Severity Breakdown
SS=E: 6
SS=F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Laundry area dryer room was not free of lint and other debris, posing a fire hazard. | SS=E |
| Two hazardous area doors lacked properly working self-closing devices. | SS=E |
| Ceiling construction in 2 rooms did not comply with NFPA 13 sprinkler system installation standards. | SS=E |
| Four corridor doors failed to close and latch properly, impeding smoke passage resistance. | SS=E |
| Facility failed to enforce smoking policy; employees observed smoking outside designated area. | SS=E |
| Use of multi-plug adapters in resident room as substitute for fixed wiring. | SS=E |
| Facility failed to conduct required maintenance and maintain complete documentation for Patient Care Related Electrical Equipment testing. | SS=F |
Report Facts
Certified beds: 83
Census: 74
Hazardous area doors without self-closing devices: 2
Rooms with sprinkler ceiling construction issues: 2
Corridor doors failing to close and latch: 4
Employees observed smoking outside designated area: 3
Resident rooms using multi-plug adapters: 1
Residents affected by multi-plug adapter use: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Debra McKinley | Maintenance Director | Acknowledged all findings during observations and exit conference |
| Executive Director | Present at exit conference and involved in corrective action planning |
Inspection Report
Renewal
Census: 77
Capacity: 77
Deficiencies: 5
Apr 28, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from April 22 to April 28, 2025.
Findings
The facility was found deficient in multiple areas including failure to prevent pressure ulcers, failure to ensure availability of physician-prescribed medications, failure to follow physician orders related to medication dose reduction, improper storage in resident snack refrigerators, and incomplete documentation and monitoring after a resident fall.
Severity Breakdown
SS=D: 4
SS=E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to prevent pressure ulcers and implement Care Plan interventions for a resident at risk for pressure ulcers. | SS=D |
| Failed to ensure physician prescribed medications were available for residents. | SS=D |
| Failed to follow physician's orders related to Gradual Dose Reduction of medication. | SS=D |
| Failed to maintain resident snack refrigerators appropriately related to storage of staff food items, incomplete labeling, and storage of non-food items. | SS=E |
| Failed to completely and accurately document assessment and monitoring of a resident after a fall. | SS=D |
Report Facts
Survey dates: 5
Census: 77
Total capacity: 77
Medication missed doses: 9
Medication missed doses: 9
Audit frequency: 4
Audit frequency: 6
Audit frequency: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Debra McKinley | HFA | Signed the report |
| Licensed Practical Nurse 2 | Observed wound treatments for Resident 23 | |
| Certified Nurse Aide 5 | Interviewed regarding Resident 23's care needs | |
| Certified Nurse Aide 6 | Interviewed regarding Resident 23's care needs and provided Approaches on Profile | |
| Director of Nursing | DON | Provided information on Resident 23's pressure ulcer development and medication procedures |
| Assistant Director of Nursing | ADON | Provided information on Resident 23 and Resident 35 medication and care |
| Regional Director of Clinical Services | RDCS | Provided information on Resident 23 and Resident 35 medication and facility policies |
| Licensed Practical Nurse 7 | Observed and described contents of 100/200 Hall Resident Snack Refrigerator | |
| Licensed Practical Nurse 8 | Interviewed about 400 Hall Resident Snack Refrigerator contents | |
| Licensed Practical Nurse 9 | Described fall assessment and notification procedures | |
| Physical Therapist | PT | Provided information on Resident 58 and fall report review |
| Social Services Director | Documented psychiatric nurse practitioner orders for Resident 47 |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 76
Deficiencies: 0
Apr 7, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00454282.
Findings
No deficiencies related to the allegations in Complaint IN00454282 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00454282 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare residents: 4
Medicaid residents: 53
Other residents: 19
Inspection Report
Complaint Investigation
Census: 75
Capacity: 75
Deficiencies: 0
Jan 23, 2025
Visit Reason
This visit was for the investigation of complaints IN00451376 and IN00450776.
Findings
No deficiencies related to the allegations in complaints IN00451376 and IN00450776 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00451376 - No deficiencies related to the allegations were cited. Complaint IN00450776 - No deficiencies related to the allegations were cited.
Report Facts
Medicare census: 4
Medicaid census: 61
Other payor census: 10
Inspection Report
Complaint Investigation
Census: 73
Capacity: 73
Deficiencies: 0
Sep 17, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00440628.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable federal and state regulations.
Complaint Details
Complaint IN00440628 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare residents: 2
Medicaid residents: 62
Private pay residents: 4
Other pay residents: 5
Inspection Report
Follow-Up
Census: 72
Capacity: 83
Deficiencies: 0
Sep 5, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to the previous Life Safety Code Certification and State Licensure Survey to verify compliance with regulatory requirements.
Findings
At this PSR Life Safety Code survey, Arbor Grove Village was found in compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered with appropriate fire alarm and smoke detection systems.
Inspection Report
Re-Inspection
Census: 69
Capacity: 83
Deficiencies: 1
Jul 10, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Certification and State Licensure Survey conducted on 06/06/24 was conducted to verify compliance with fire safety regulations.
Findings
The facility was found not in compliance with fire safety requirements due to one corridor door lacking latching hardware, which could affect residents and staff. The deficiency was previously cited and the facility failed to implement a systemic plan of correction to prevent recurrence.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure 1 of over 30 corridor doors had no impediment to closing and latching into the door frame and would resist the passage of smoke. | SS=E |
Report Facts
Facility capacity: 83
Census: 69
Number of corridor doors: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Debra Dee McKinley | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Maintenance Director | Named in deficiency finding and plan of correction related to door hardware |
Inspection Report
Re-Inspection
Census: 74
Capacity: 74
Deficiencies: 0
Jun 24, 2024
Visit Reason
This visit was for a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 2024-05-17.
Findings
Arbor Grove Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey.
Report Facts
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 61
Census Payor Type - Other: 10
Inspection Report
Life Safety
Census: 78
Capacity: 83
Deficiencies: 7
Jun 6, 2024
Visit Reason
The survey was conducted as a Life Safety Code Certification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and related NFPA standards.
Findings
The facility was found not in compliance with Life Safety Code requirements including obstructions in means of egress, incomplete maintenance documentation for battery operated smoke alarms, missing or malfunctioning self-closing devices on hazardous area doors, missing drip tray on kitchen hood, missing sprinkler escutcheon, corridor doors not latching properly, and an oxygen trans-filling room door failing to latch properly.
Severity Breakdown
SS=E: 6
SS=F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 6 means of egress was continuously maintained free of obstructions, including chairs blocking an exit door and a trash can stored in corridor without wheels. | SS=E |
| Failed to ensure documentation for preventative maintenance of battery operated smoke alarms in resident rooms was complete. | SS=F |
| Failed to ensure 2 hazardous area doors were provided with properly working self-closing devices. | SS=E |
| Failed to install kitchen range hood system with required drip trays on both sides. | SS=E |
| Failed to maintain sprinkler system escutcheon on sprinkler head in resident room #107. | SS=E |
| Failed to ensure 4 corridor doors had no impediment to closing and latching into the door frame and would resist passage of smoke. | SS=E |
| Failed to ensure oxygen trans-filling room door latched completely as part of fire-resistive enclosure. | SS=E |
Report Facts
Certified beds: 83
Census: 78
Deficiencies cited: 7
Residents potentially affected: 15
Residents potentially affected: 10
Residents potentially affected: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Debra McKinley | Laboratory Director or Provider/Supplier Representative | Signed the report |
| Maintenance Director | Interviewed and acknowledged multiple deficiencies related to maintenance and fire safety | |
| Executive Director | Present at exit conference acknowledging findings | |
| Activity Director | In-serviced staff on exit door access and equipment storage |
Inspection Report
Annual Inspection
Census: 74
Capacity: 74
Deficiencies: 3
May 17, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00433744. No deficiencies related to the complaint allegations were cited.
Findings
The facility was found deficient in following physician's orders for holding blood pressure medication for one resident, ensuring medication availability and documentation for another resident, and proper labeling and storage of medications in the medication storage refrigerator. Corrective actions and systemic changes were planned and implemented to address these issues.
Complaint Details
Complaint IN00433744 was investigated during this visit. No deficiencies related to the allegations were cited.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to follow physician's orders related to hold parameters for a resident's blood pressure medication (Resident 34). | SS=D |
| Failed to ensure medications were available and document medication administration for a resident (Resident 1). | SS=D |
| Failed to label and store medications appropriately for one of two medication storage refrigerators observed (100/200 Hall Medication Storage Refrigerator). | SS=D |
Report Facts
Survey dates: 5
Residents reviewed for quality of care: 18
Residents reviewed for pharmacy services: 14
Medication storage refrigerators observed: 2
Residents census: 74
Total licensed capacity: 74
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Debra Dee McKinley | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| LPN 3 | Licensed Practical Nurse | Interviewed regarding blood pressure medication hold parameters |
| DON | Director of Nursing | Interviewed regarding facility policies and corrective actions related to medication administration and storage |
| RN 2 | Registered Nurse | Interviewed regarding medication availability and documentation |
| LPN 4 | Licensed Practical Nurse | Interviewed regarding medication documentation in EMAR |
| RN 3 | Registered Nurse | Interviewed regarding medication storage refrigerator and TB serum labeling |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 74
Deficiencies: 0
Oct 23, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00417623.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00417623 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 74
Total Capacity: 74
Medicaid Census: 60
Other Payor Census: 14
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 13, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00409588 completed on June 7, 2023.
Findings
Arbor Grove Village 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.
Complaint Details
Investigation of Complaint IN00409588 completed on June 7, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 74
Capacity: 74
Deficiencies: 1
Jun 6, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00408115 and IN00409588. Complaint IN00408115 had no deficiencies related to the allegations, while Complaint IN00409588 resulted in a federal/state deficiency citation.
Findings
The facility failed to implement a person-centered dementia care plan related to a female resident seeking male companionship. An incident was observed where a male resident touched the female resident inappropriately. The facility had care plans for both residents but lacked a specific plan addressing behaviors related to seeking male attention. The facility updated care plans and implemented interventions to prevent recurrence.
Complaint Details
Complaint IN00408115 - No deficiencies related to the allegations are cited. Complaint IN00409588 - Federal/State deficiency related to the allegation is cited at F740.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to implement a person-centered dementia care plan related to a female resident seeking male companionship. | SS=D |
Report Facts
Census: 74
Total Capacity: 74
Medicare residents: 2
Medicaid residents: 57
Other residents: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kim Bowling | RN DNS | Signed the report as Laboratory Director or Provider/Supplier Representative |
| Memory Care Coordinator | Interviewed regarding the incident and care plans | |
| QMA 3 | Qualified Medication Aide | Reported the incident and assisted with resident supervision |
| DON | Director of Nursing | Provided information about residents and facility policies |
| Psychiatric Nurse Practitioner | NP | Evaluated residents and provided clinical opinions on the incident |
| Regional Clinical Support Nurse | Provided information on post-incident monitoring and observations |
Inspection Report
Re-Inspection
Census: 71
Capacity: 71
Deficiencies: 0
May 3, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 2023-03-16.
Findings
Arbor Grove Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey.
Report Facts
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 50
Census Payor Type - Other: 18
Inspection Report
Re-Inspection
Census: 73
Capacity: 83
Deficiencies: 0
Apr 25, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Certification and State Licensure Survey conducted on 03/30/23 was performed by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR Life Safety Code survey, Arbor Grove Village was found in compliance with Requirements for Participation Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety From Fire and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinklered with appropriate fire alarm and smoke detection systems.
Inspection Report
Life Safety
Census: 76
Capacity: 83
Deficiencies: 8
Mar 30, 2023
Visit Reason
A Life Safety Code Certification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 standards.
Findings
The facility was found not in compliance with Life Safety Code requirements, with deficiencies including improperly secured egress doors, corridor obstructions reducing aisle width, hazardous area doors lacking self-closing devices, sprinkler heads loaded with dust, corridor doors not latching properly, smoke barrier penetrations, improperly maintained GFCI receptacles, and misuse of power strips and extension cords.
Severity Breakdown
SS=F: 1
SS=E: 7
Deficiencies (8)
| Description | Severity |
|---|---|
| Front exit door equipped with a magnetically controlled lock but the code to release the lock was not posted. | SS=F |
| Corridors contained unsecured furniture and motorized scooter reducing corridor width below required minimum. | SS=E |
| Four hazardous area doors lacked properly working self-closing devices. | SS=E |
| One sprinkler head in laundry area was loaded with dust. | SS=E |
| One corridor door (Resident Room 304) failed to close and latch positively. | SS=E |
| Hole in ceiling in Sprinkler Riser Room compromised smoke barrier integrity. | SS=E |
| Ground fault circuit interrupter (GFCI) receptacles in Therapy area failed to trip and showed open ground condition. | SS=E |
| Power strip used to power dorm style refrigerator in Medical Records Office, and extension cord used in lobby for temperature scanner and check-in station. | SS=E |
Report Facts
Certified beds: 83
Census: 76
Corridors with width deficiency: 3
Hazardous area doors lacking self-closing devices: 4
Sprinkler heads loaded with dust: 1
Corridor doors failing to latch: 1
Hole size in ceiling: 7
Staff affected by GFCI deficiency: 2
Residents affected by GFCI deficiency: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Debra McKinley | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Maintenance Supervisor | Acknowledged multiple findings during observations and exit conference | |
| Executive Director | Present at exit conference acknowledging findings | |
| Maintenance Director | Named in Plan of Correction for corrective actions and monitoring |
Inspection Report
Annual Inspection
Census: 72
Capacity: 72
Deficiencies: 6
Mar 16, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from March 12 to March 16, 2023.
Findings
The facility was found deficient in multiple areas including failure to prevent abuse and neglect of a cognitively impaired resident, failure to timely report abuse allegations, inadequate implementation of fall prevention interventions, failure to provide competent staff for dementia care, and improper storage and labeling of insulin pens.
Severity Breakdown
SS=G: 2
SS=D: 4
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to ensure a cognitively impaired resident was free from mental and physical abuse, resulting in psychological harm. | SS=G |
| Failure to ensure staff reported an allegation of abuse in a timely manner. | SS=D |
| Failure to ensure residents' safety related to following fall care plan interventions for 2 residents. | SS=D |
| Failure to ensure competent staff were available to provide care for a resident with dementia and behavioral disturbances. | SS=D |
| Failure to adequately implement care planned interventions and strategies for a resident with anxiety, combative behaviors, and dementia. | SS=G |
| Failure to store medications appropriately related to insulin pens on the 200 Hall medication cart. | SS=D |
Report Facts
Survey dates: 5
Residents reviewed for abuse: 24
Residents reviewed for accidents: 5
Insulin pen expiration days: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Debra McKinley | HFA | Named in relation to staff education on abuse, neglect, and exploitation |
| QMA 9 | Named in abuse and behavior management findings; employment terminated | |
| CNA 10 | Named in abuse and behavior management findings; employment terminated | |
| CNA 11 | Witnessed abuse incident but failed to report timely | |
| Administrator | Provided interviews and facility policy information | |
| DON | Director of Nursing | Provided interviews and facility policy information |
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 30, 2022
Visit Reason
Paper compliance review to the Investigation of Complaint IN00389819 and IN00392920 unrelated deficiency cited on November 1, 2022.
Findings
Arbor Grove Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the unrelated deficiency cited.
Inspection Report
Complaint Investigation
Census: 72
Capacity: 72
Deficiencies: 1
Nov 1, 2022
Visit Reason
This visit was conducted for the investigation of two complaints, IN00389819 and IN00392920, both of which were found unsubstantiated due to lack of evidence.
Findings
The facility failed to ensure a resident's safe transport when the transportation vehicle made an unscheduled stop at the resident's home, resulting in the resident being out of staff's sight and police being called. The bus driver was educated on preapproved stops and corrective actions were implemented to prevent recurrence.
Complaint Details
Complaint IN00389819 and Complaint IN00392920 were both unsubstantiated due to lack of evidence. The investigation revealed an unrelated deficiency regarding transportation safety.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure a resident's safe transport when the transportation vehicle stopped unscheduled at the resident's home, resulting in the resident being out of staff's sight and police involvement. | SS=D |
Report Facts
Census: 72
Total Capacity: 72
Medicare Residents: 5
Medicaid Residents: 47
Other Payor Residents: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kim Bowling | RN DNS (Director of Nursing Services) | Interviewed regarding the transportation incident and facility policies |
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