Inspection Reports for Asbury Towers Retirement Community
102 W Poplar St, Greencastle, IN 46135, United States, IN, 46135
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 5, 2025, found the facility in compliance with Medicare/Medicaid participation requirements and Life Safety Code standards, with no deficiencies cited. Earlier inspections showed a pattern of deficiencies primarily related to emergency preparedness, fire safety, and documentation of safety system maintenance, including issues with sprinkler system testing, fire door ratings, and generator inspections. Prior reports also noted concerns with resident care documentation, food service practices, and supervision following substantiated complaints of resident neglect and abuse. Complaint investigations were mostly unsubstantiated except for a substantiated case involving inadequate supervision and investigation of resident-to-resident verbal abuse, and prior substantiated neglect related to supervision on the dementia unit. The recent clean inspection suggests improvement in addressing earlier safety and compliance issues.
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/year
Deficiencies per year
28
21
14
7
0
Census
Latest occupancy rate
50% occupied
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Census: 24
Capacity: 48
Deficiencies: 0
Jun 5, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 04/23/25 was performed to verify compliance with fire safety and licensure requirements.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The building is fully sprinklered except for the Electrical room on the North wing hall on the ground floor.
Report Facts
Facility capacity: 48
Census: 24
Inspection Report
Life Safety
Census: 20
Capacity: 48
Deficiencies: 5
Apr 23, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 04/23/2025.
Findings
The Emergency Preparedness Survey found the facility in compliance with requirements. The Life Safety Code survey found the facility not in compliance with several NFPA 101 Life Safety Code requirements, including means of egress obstructions, sprinkler system maintenance and testing deficiencies, improperly installed fire extinguishers, corridor door latches not closing properly, and electrical receptacle testing deficiencies.
Severity Breakdown
SS=E: 3
SS=F: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to maintain means of egress free from obstructions; a non-wheeled plastic chest was stored in a corridor reducing clear width. | SS=E |
| Facility failed to provide written documentation for sprinkler system inspection and testing for 1 of 4 quarters and failed to ensure annual testing of backflow prevention device. | SS=F |
| One portable fire extinguisher was installed too high (5 feet 2 inches above floor) violating NFPA 10. | SS=E |
| Three resident room corridor doors failed to close completely and latch into the door frame. | SS=E |
| Facility failed to ensure all nonhospital-grade electrical receptacles at resident room locations were tested at least annually as required by NFPA 99. | SS=F |
Report Facts
Certified beds: 48
Census: 20
Deficient corridor doors: 3
Portable fire extinguishers: 12
Affected residents: 6
Affected staff: 2
Affected visitors: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eric P Ahlbrand | Executive Director | Named as facility representative during survey |
| Maintenance Director | Interviewed regarding deficiencies and corrective actions | |
| Plant Operations Support Director | Participated in discussion of deficiencies |
Inspection Report
Annual Inspection
Census: 47
Capacity: 66
Deficiencies: 5
Mar 28, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted from March 24 to 28, 2025.
Findings
The facility was found deficient in several areas including failure to communicate and document hospital transfer communications for residents, inaccurate Minimum Data Set (MDS) assessments, failure to serve food at palatable temperatures, failure to wear hair and beard nets in food service areas, and failure to obtain physician orders for hospital transfers. Corrective actions and monitoring plans were implemented for each deficiency.
Severity Breakdown
SS=D: 4
SS=A: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure communication and documentation with receiving hospital when residents were transferred to the emergency room for 3 of 4 residents reviewed. | SS=D |
| Failed to ensure Minimum Data Set (MDS) assessment was coded accurately for 1 of 16 residents reviewed. | SS=A |
| Failed to ensure food was served at a palatable temperature for 3 of 15 residents reviewed. | SS=D |
| Failed to ensure hair and beard nets were worn in the food service area during meal service during 1 of 4 dining observations. | SS=D |
| Failed to ensure a Physician's Order was obtained and documented for hospital transfers for 3 of 4 residents reviewed. | SS=D |
Report Facts
Survey dates: 5
Census: 47
Total capacity: 66
Residents reviewed for hospitalization: 4
Residents reviewed for MDS accuracy: 16
Residents reviewed for food temperature: 15
Dining observations: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eric P Ahlbrand | Executive Director | Signed the inspection report |
| Director of Nursing | Director of Nursing | Interviewed regarding lack of documentation of communication with receiving hospital and physician orders for transfers |
| MDS Coordinator | MDS Coordinator | Provided information on MDS assessment coding and audits |
| Dietary Manager | Dietary Manager | Provided education to dietary staff on food temperature and hair/beard net compliance |
| Cook 5 | Cook | Observed serving food without beard net |
| Dietary Aide 10 | Dietary Aide | Observed checking food temperatures during meal service |
Inspection Report
Renewal
Deficiencies: 0
Mar 28, 2025
Visit Reason
The inspection was a paper compliance review related to the Recertification and State Licensure Survey completed on March 28, 2025.
Findings
Asbury Towers Health Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper compliance review.
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 0
Feb 10, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00451349 at Asbury Towers Health Care Center.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00451349 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 23
Census Residential: 47
Total Census: 70
Medicaid Census: 13
Other Payor Census: 57
Inspection Report
Follow-Up
Census: 20
Capacity: 48
Deficiencies: 0
May 23, 2024
Visit Reason
A 2nd Post Survey Revisit (PSR) to the Post Survey Revisit on 04/23/24 to the Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey conducted on 03/04/24.
Findings
At this PSR survey, Asbury Towers Health Care Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements for Medicare and Medicaid Participating Providers and Suppliers.
Inspection Report
Re-Inspection
Census: 17
Capacity: 48
Deficiencies: 6
Apr 23, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on previous deficiencies related to Emergency Preparedness and Life Safety Code compliance identified during the initial survey on 03/04/2024.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code standards, including deficiencies in emergency power system inspection, testing, and maintenance, fire door ratings on stairwells, and generator testing documentation. The facility failed to implement systemic plans of correction to prevent recurrence of these deficiencies.
Severity Breakdown
SS=F: 5
SS=E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to implement emergency power system inspection, testing, and maintenance requirements; monthly generator inspection sheets for 03/07/24 and 04/04/24 were missing transfer time, load percentage, and cool down time. | SS=F |
| Failed to ensure protection of 1 of 3 stairwells with proper fire resistance rating; door lacked fire resistive rating tag and was replaced with a 90-minute fire rated door. | SS=E |
| Failed to document transfer time to alternate power source on monthly load tests for 2 of 12 months. | SS=F |
| Failed to exercise the generator for 2 of 12 months to meet NFPA 110 requirements for monthly testing and load conditions. | SS=F |
| Failed to document load percentage on monthly generator inspection sheets for 03/07/24 and 04/04/24. | SS=F |
| Failed to allow a 5 minute cool down period after generator load test as required by NFPA 110. | SS=F |
Report Facts
Certified beds: 48
Census: 17
Deficiencies cited: 6
Generator exercise frequency: 12
Generator exercise duration: 30
Fire door replacement date: Apr 26, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Audra Rose | RN, DON | Named as Laboratory Director's or Provider/Supplier Representative's signature on report |
Inspection Report
Routine
Census: 18
Capacity: 48
Deficiencies: 25
Mar 4, 2024
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with federal and state regulations including emergency preparedness, fire safety, and facility maintenance.
Findings
The facility was found not in compliance with multiple emergency preparedness requirements including failure to annually review and update emergency plans, policies, communication plans, and training/testing programs. Deficiencies were also found in life safety code compliance including fire safety plan inadequacies, maintenance issues with fire doors, sprinkler systems, fire alarm systems, emergency power systems, and electrical safety. Several physical deficiencies such as heat damage to shower room heater, obstructed egress by wheeled equipment, unsealed smoke barrier penetrations, and unlocked electrical panels were noted.
Severity Breakdown
SS=C: 6
SS=D: 4
SS=E: 3
SS=F: 13
Deficiencies (25)
| Description | Severity |
|---|---|
| Failed to annually review and update emergency preparedness plan, policies, communication plan, and training/testing programs. | SS=C |
| Failed to maintain after action reports for emergency preparedness exercises. | SS=C |
| Monthly generator inspection sheets missing key data such as transfer time, load percentage, and cool down time; weekly visual generator inspection sheets incomplete. | SS=F |
| Combination ceiling mounted light and heater unit in shower room showed signs of heat damage. | SS=E |
| One means of egress was obstructed by wheeled equipment not addressed in fire safety plan. | SS=F |
| Boiler room door was propped open, compromising smoke barrier integrity. | SS=D |
| Items stored in interior fire escape stairwell could interfere with egress. | SS=F |
| Benches near first floor nurse station were not affixed to wall or floor, reducing corridor width. | SS=E |
| Ground floor center stairwell door lacked required fire resistive rating tag. | SS=E |
| Old copier room door lacked self-closing device and was used to store combustible supplies. | SS=C |
| Plastic paneling used as interior wall finish lacked flame spread documentation. | SS=F |
| Fire alarm control panel door was unlocked with key left in lock. | SS=F |
| Fire alarm system inspection documentation incomplete; semi-annual visual inspections not documented; smoke detectors outside sensitivity range without recalibration or replacement documentation. | SS=F |
| Ground floor mechanical room lacked sprinkler protection; canopy attached to building was not sprinklered and lacked flame retardant documentation. | SS=F |
| Portable fire extinguisher in basement was not mounted. | SS=D |
| Fourteen Dutch doors to resident rooms on ground floor lacked latching mechanism on top half. | SS=F |
| Weight room door was propped open, preventing proper closing and smoke resistance. | SS=F |
| Unsealed penetrations in smoke barrier walls compromised smoke resistance. | SS=F |
| Electric receptacle within 3 feet of sink lacked ground fault circuit interrupter protection; two breaker boxes were unlocked; one electrical outlet missing faceplate. | SS=D |
| Boiler room intake louvers for combustion air were closed and could not be opened. | SS=F |
| Emergency generator annunciator panel had low fuel light illuminated due to recent load test and fuel level. | SS=F |
| Weekly generator inspection documentation incomplete for two weeks; monthly load test documentation lacked transfer time and load percentage; generator cool down time not documented; 36-month continuous load test not documented or completed. | SS=F |
| Missing suspended ceiling tile in ground floor dining room near pendant sprinklers. | SS=F |
| Sprinkler system gauge not replaced or calibrated within 5 years. | SS=F |
| Rolling fire door in first floor kitchen lacked annual inspection documentation. | SS=C |
Report Facts
Certified beds: 48
Current census: 18
Deficiencies cited: 26
Generator load test frequency: 12
Generator weekly inspections missing: 2
Generator 36-month test missing: 1
Rolling fire door annual inspection missing: 1
Dutch doors without latch: 14
Sprinkler system gauges not calibrated: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in multiple findings related to emergency preparedness, fire safety, and maintenance deficiencies | |
| Maintenance Supervisor | Acknowledged fire alarm system inspection deficiencies |
Inspection Report
Routine
Census: 18
Capacity: 48
Deficiencies: 28
Mar 4, 2024
Visit Reason
Routine Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health.
Findings
The facility was found not in compliance with multiple Life Safety Code requirements including emergency preparedness plan deficiencies, fire safety issues such as obstructed egress, unmaintained fire doors, sprinkler system deficiencies, electrical safety issues, and generator maintenance and testing deficiencies.
Severity Breakdown
SS=C: 7
SS=D: 3
SS=E: 3
SS=F: 17
Deficiencies (28)
| Description | Severity |
|---|---|
| Failed to develop and maintain an emergency preparedness plan reviewed and updated at least annually. | SS=C |
| Failed to develop and implement emergency preparedness policies and procedures reviewed and updated at least annually. | SS=C |
| Failed to develop and maintain an emergency preparedness communication plan reviewed and updated at least annually. | SS=C |
| Failed to develop and maintain an emergency preparedness training and testing program reviewed and updated at least annually. | SS=C |
| Failed to conduct exercises to test the emergency plan at least twice during the past year and maintain after action reports. | SS=C |
| Failed to implement emergency power system inspection, testing, and maintenance requirements per NFPA 110 and Life Safety Code. | SS=F |
| Combination ceiling mounted light and heater unit in shower room showed signs of heat damage. | SS=E |
| One means of egress was obstructed by wheeled equipment in hallways and stairwells; fire safety plan did not address relocation of wheeled equipment during emergencies. | SS=F |
| Two benches near first floor nurse's station were not affixed to wall or floor, potentially reducing clear corridor width. | SS=E |
| One stairwell door lacked a fire resistive rating tag. | SS=C |
| Boiler room door was propped open, compromising smoke barrier integrity. | SS=D |
| Wheeled equipment stored in a stairwell, potentially interfering with egress. | SS=F |
| Old copier room door used for combustible storage lacked a self-closing device. | SS=F |
| Plastic paneling on corridor walls lacked documentation of flame spread rating. | SS=F |
| Fire alarm control panel door was unlocked with key inside. | SS=F |
| Fire alarm system lacked documentation of semi-annual visual inspections and complete annual testing of all devices including smoke detector sensitivity testing. | SS=F |
| Missing suspended ceiling tile in ground floor dining room near pendant sprinklers. | SS=F |
| One sprinkler system gauge was not replaced or calibrated within 5 years. | SS=F |
| Portable fire extinguisher in basement was not mounted. | SS=D |
| Fourteen Dutch doors to resident rooms lacked latching mechanisms on top half. | SS=F |
| Weight room door was propped open, preventing proper closing and smoke resistance. | SS=F |
| Unsealed penetrations in smoke barrier walls compromising smoke resistance. | SS=F |
| Ground floor mechanical room lacked sprinkler protection; canopy was not sprinklered and lacked flame retardant documentation. | SS=F |
| Generator annunciator panel had low fuel light illuminated due to recent load test and fuel level. | SS=F |
| Generator weekly inspection was incomplete for 2 weeks. | SS=F |
| Generator monthly load test documentation lacked transfer time and load percentage for all months. | SS=F |
| Generator monthly load test did not include required 5 minute cool down period after load test. | SS=F |
| Electric receptacle within 3 feet of sink lacked ground fault circuit interrupter protection; two breaker boxes were unlocked; one electrical outlet missing faceplate. | SS=D |
Report Facts
Certified beds: 48
Current census: 18
Deficiencies with severity SS=C: 7
Deficiencies with severity SS=D: 3
Deficiencies with severity SS=E: 3
Deficiencies with severity SS=F: 17
Missing weekly generator inspections: 2
Missing transfer time documentation: 12
Generator load test duration: 4
Generator exercise frequency: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and acknowledged multiple deficiencies and corrective actions | |
| Maintenance Supervisor | Acknowledged fire alarm system testing deficiencies |
Inspection Report
Renewal
Deficiencies: 0
Feb 9, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on February 9, 2024.
Findings
Asbury Towers Health Care Center 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 Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 1
Jan 25, 2024
Visit Reason
This visit was for the investigation of Residential Complaint IN00426715 related to allegations of resident-to-resident abuse at Asbury Towers Health Care Center.
Findings
The facility failed to ensure increased supervision after an abuse allegation and did not implement their written policy for timely reporting, investigating, and protecting residents for 2 of 2 residents reviewed. Resident C made inappropriate sexual comments to Resident B, leading to increased supervision and psychiatric referral delays. The investigation revealed gaps in monitoring and documentation of behavior and staff interviews.
Complaint Details
Complaint IN00426715 was substantiated with state deficiencies cited related to the allegation of resident-to-resident verbal abuse and inadequate supervision and investigation.
Deficiencies (1)
| Description |
|---|
| Failed to ensure residents had increased supervision after an abuse allegation and failed to implement written policy for timely reporting, investigating, and ensuring protection of residents. |
Report Facts
Residential Census: 54
Survey dates: January 25 and 26, 2024
Psychiatric service order date: Order written on 1/19/24; consent obtained on 2/22/24
Staff interviews: 6
Resident B Service Assessment date: 1/2/24
Resident C Admission Assessment date: 1/23/24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Audra Rose | RN, Director of Nursing | Interviewed and provided policy documents; involved in investigation and findings |
Inspection Report
Complaint Investigation
Census: 20
Capacity: 66
Deficiencies: 0
Sep 13, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00416538.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00416538 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 20
Census Residential: 46
Total Census: 66
Census Payor Medicare: 3
Census Payor Medicaid: 9
Census Payor Other: 8
Inspection Report
Follow-Up
Census: 54
Deficiencies: 0
May 18, 2023
Visit Reason
This visit was for the Post Survey Revisit to the Investigation of Residential Complaints IN00397501 and IN00399574 completed on March 15, 2023.
Findings
Asbury Towers Health Care Center was found to be in compliance with 410 IAC 16.2-5 in regard to the Post Survey Revisit to the Investigation of Residential Complaints IN00397501 and IN00399574.
Complaint Details
Complaint IN00397501 - Corrected. Complaint IN00399574 - Corrected.
Inspection Report
Follow-Up
Census: 41
Capacity: 48
Deficiencies: 0
Mar 23, 2023
Visit Reason
A 2nd Post Survey Revisit (PSR) was conducted to follow up on the Emergency Preparedness Survey and the Life Safety Code Annual Recertification survey that exited on 12/13/22.
Findings
At this PSR survey, Asbury Towers Health Care Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility was fully sprinklered except for the Electrical room on the North wing hall on the ground floor.
Report Facts
Certified beds: 48
Census: 41
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 1
Mar 15, 2023
Visit Reason
This visit was for the investigation of Nursing Home Complaints IN00402998 and IN00403082, and Residential Complaints IN00397501 and IN00399574.
Findings
The facility was found in compliance for complaints IN00402998 and IN00403082 with no deficiencies cited. However, state residential deficiencies related to complaints IN00397501 and IN00399574 were cited due to failure to protect residents from neglect, specifically lack of supervision for cognitively impaired residents leading to physical altercations and injuries among residents on the dementia unit.
Complaint Details
Complaints IN00402998 and IN00403082 had no deficiencies cited. Complaints IN00397501 and IN00399574 were substantiated with state residential deficiencies related to neglect and lack of supervision on the dementia unit.
Deficiencies (1)
| Description |
|---|
| Failure to protect residents' right to be free from neglect due to lack of supervision for cognitively impaired residents who exhibited behaviors, resulting in physical altercations and injury. |
Report Facts
Census: 66
SNF/NF Census: 20
Residential Census: 46
Payor Census: 20
Medicare Census: 3
Medicaid Census: 8
Other Payor Census: 9
Oasis Unit Census: 11
Oasis Unit Census: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Audra Rose | RN, Director of Nursing | Named as the Director of Nursing who was involved in notification and corrective actions related to resident incidents. |
| Employee 17 and Employee 23 interviewed regarding staffing and incidents on the Oasis Unit; no full names provided. | ||
| Employee 5 interviewed regarding resident supervision and care; no full name provided. |
Inspection Report
Renewal
Deficiencies: 0
Mar 2, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on November 22, 2022.
Findings
Asbury Towers Health Care 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 Survey.
Inspection Report
Follow-Up
Census: 45
Capacity: 48
Deficiencies: 2
Feb 23, 2023
Visit Reason
Post Survey Revisit (PSR) to the Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey conducted to verify correction of previous deficiencies.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. Deficiencies included failure to conduct required emergency preparedness exercises and failure to ensure proper fire resistance rating on a stairwell door.
Severity Breakdown
SS=F: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to conduct community-based or facility-based emergency preparedness exercises and maintain after action reports as required by 42 CFR 483.73(d)(2). | SS=F |
| Failure to ensure the first-floor center stairwell door had the required fire resistance rating of at least 1 hour; door was only rated at 30 minutes. | SS=E |
Report Facts
Certified beds: 48
Census: 45
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Audra Rose | RN, DON | Signed the report as Laboratory Director's or Provider/Supplier Representative |
| Maintenance Director | Interviewed regarding emergency preparedness exercises and stairwell door fire rating |
Inspection Report
Routine
Census: 41
Capacity: 48
Deficiencies: 12
Dec 13, 2022
Visit Reason
Routine Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health.
Findings
The facility was found not in compliance with several emergency preparedness, life safety, and maintenance requirements including failure to update emergency preparedness plans annually, incomplete emergency power system documentation, obstructed means of egress, inadequate fire door ratings, overdue sprinkler gauge replacements, lack of annual fire door inspections, and incomplete electrical receptacle testing.
Severity Breakdown
SS=C: 4
SS=E: 2
SS=F: 6
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to develop and maintain an emergency preparedness plan reviewed and updated at least annually. | SS=C |
| Failed to develop and maintain emergency preparedness policies and procedures reviewed and updated at least annually. | SS=C |
| Failed to develop and maintain an emergency preparedness communication plan reviewed and updated at least annually. | SS=C |
| Failed to develop and maintain an emergency preparedness training and testing program reviewed and updated at least annually. | SS=C |
| Failed to ensure exercises testing the emergency plan at least twice during the past year were conducted. | SS=F |
| Failed to implement emergency power system inspection, testing, and maintenance requirements including weekly documentation. | SS=F |
| Means of egress not continuously maintained free of obstructions; scale left in corridor reducing clear width. | SS=E |
| Stairwell door on first floor rated only 30 minutes instead of required 1 hour or more. | SS=E |
| Failed to ensure sprinkler system gauges were replaced or tested every 5 years. | SS=F |
| Failed to ensure annual inspection and testing on 8 of 8 fire door assemblies. | SS=F |
| Failed to ensure 204 nonhospital-grade electrical receptacles at resident room locations were tested at least annually. | SS=F |
| Failed to ensure written record of weekly inspections for the generator was maintained for 4 of 52 weeks. | SS=F |
Report Facts
Certified beds: 48
Census: 41
Deficiencies cited: 12
Fire door assemblies inspected: 8
Nonhospital-grade receptacles tested: 204
Weekly generator inspections missing: 4
Fire door rating: 30
Clear corridor width: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeanne Shillings | Administrative Assistant | Signed report |
| Maintenance Director | Interviewed and involved in findings related to emergency preparedness and maintenance | |
| Facility Administrator | Participated in exit conference |
Inspection Report
Annual Inspection
Census: 66
Capacity: 66
Deficiencies: 8
Nov 22, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted over November 15-22, 2022.
Findings
The facility was found deficient in multiple areas including failure to ensure laboratory tests were completed as recommended, improper food preparation sanitation, inadequate infection prevention and control practices, lack of annual abuse training for staff, incomplete criminal background checks for new hires, failure to submit required dementia care disclosure, insufficient first aid trained staff in Assisted Living, and incomplete annual inservice education for employees.
Severity Breakdown
SS=A: 1
SS=D: 2
SS=E: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure a pharmacy recommendation to have a resident's laboratory fasting lipid panel completed. | SS=A |
| Failed to ensure pureed food items were prepared in a sanitary manner during food preparation. | SS=D |
| Failed to ensure staff wore personal protective equipment (face shield) when providing care to a COVID-19 positive resident in droplet isolation. | SS=D |
| Failed to provide annual education for abuse prevention and dementia training for selected employees. | SS=E |
| Failed to ensure new hires had completed and clear criminal record reviews before starting work. | — |
| Failed to complete and submit a Dementia Care Disclosure form to the Indiana Department of Health for the Memory Care Unit. | — |
| Failed to provide a minimum of one First Aid trained employee on each shift for 7 of 7 days reviewed in Assisted Living. | — |
| Failed to ensure employees received annual abuse training for 4 of 5 randomly selected Assisted Living employees. | — |
Report Facts
Survey dates: 6
Census SNF/NF beds: 18
Census Residential beds: 48
Total census: 66
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 7
Census Payor Type - Other: 6
Number of employees missing annual abuse training: 4
Number of days reviewed for first aid trained staff: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Audra Rose | RN, Director of Nursing | Named in relation to laboratory fasting lipid panel deficiency and interview |
| Cook 9 | Cook | Observed preparing pureed food unsanitarily |
| RN 8 | Registered Nurse | Observed failing to wear face shield during medication administration to COVID-19 positive resident |
| Business Office Manager | Interviewed regarding missing employee training and background checks | |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies including training and background checks |
Inspection Report
Complaint Investigation
Census: 20
Capacity: 70
Deficiencies: 0
Nov 1, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00387780.
Findings
The complaint was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00387780 was substantiated; however, no deficiencies related to the allegations were cited.
Report Facts
Census SNF/NF: 20
Census Residential: 50
Total Census: 70
Total Capacity: 70
Census Payor Type Medicare: 7
Census Payor Type Medicaid: 9
Census Payor Type Other: 4
Total Census Payor Type: 20
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