Inspection Report Summary
The most recent inspection on July 8, 2025, found no deficiencies related to the complaints investigated. Earlier inspections showed a mix of findings, including some deficiencies related to medication administration, documentation, and service plan signatures. Prior reports also noted issues with staff conduct and employment screening, including a substantiated complaint involving verbal abuse by a staff member that led to termination. Most complaint investigations were unsubstantiated or found no deficiencies, and no fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s record shows some recurring themes in documentation and medication management, but recent inspections indicate improvement in compliance.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
76% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
114 residents
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 0
Date: Jul 8, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00462895 and IN00461230.
Complaint Details
Complaint IN00462895 - No deficiencies related to the allegations are cited. Complaint IN00461230 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations in complaints IN00462895 and IN00461230 were cited. The facility was found to be in compliance with applicable regulations.
Inspection Report
Complaint Investigation
Census: 147
Deficiencies: 1
Date: May 7, 2025
Visit Reason
This visit was for a State Residential Licensure Survey which included the investigation of Complaint IN00458300.
Complaint Details
Complaint IN00458300 was investigated and state deficiencies related to the allegations were cited at R217. The citation relates to the unsigned service plan for Resident D.
Findings
The facility failed to ensure a resident's service plan was signed and dated by the resident or resident's representative for 1 of 8 residents reviewed. Specifically, Resident D's service plan was not signed. The Executive Director confirmed the form should have been signed when discussed with the family.
Deficiencies (1)
Failed to ensure a resident's service plan was signed and dated by the resident or resident's representative for 1 of 8 residents reviewed (Resident D).
Report Facts
Residential Census: 147
Residents reviewed for signed service plans: 8
Survey dates: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cari Branshaw | Executive Director | Named as Executive Director who indicated the resident had a service plan but it was not signed |
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 0
Date: Jan 29, 2025
Visit Reason
This visit was conducted for the Investigation of Complaint IN00451738.
Complaint Details
Complaint IN00451738 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 applicable regulations regarding the complaint.
Report Facts
Residential Census: 107
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 0
Date: Nov 22, 2024
Visit Reason
This visit was conducted for the Investigation of Complaint IN00447455.
Complaint Details
Complaint IN00447455 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 complaint investigation.
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 1
Date: Oct 9, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00443540 regarding medication administration issues at the facility.
Complaint Details
Complaint IN00443540 was substantiated with state deficiencies cited related to medication administration errors and documentation failures.
Findings
The facility failed to ensure medications were administered as ordered by the physician for 3 residents reviewed (Residents B, C, and D). Multiple instances of missed or undocumented insulin doses were identified, and staff member 2 did not document medication administration or notify the physician as required.
Deficiencies (1)
Failed to ensure medications were given as ordered by the resident's physician for 3 residents (Residents B, C, and D).
Report Facts
Residents reviewed for medication administration: 3
Residential Census: 104
Medication omissions documented: 7
Medication omissions documented: 1
Medication omissions documented: 3
Audit frequency: 4
Audit frequency: 4
Audit frequency: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cari Branshaw | Executive Director | Signed report and involved in re-education and oversight of medication administration |
| Staff member 2 | Named in medication administration deficiencies and disciplinary action | |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration documentation and involved in re-education and audits |
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 0
Date: May 17, 2024
Visit Reason
This visit was for a State Residential Licensure Survey and included the investigation of three complaints: IN00429232, IN00433486, and IN00434535.
Complaint Details
Complaints IN00429232, IN00433486, and IN00434535 were investigated and no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with the applicable state residential licensure regulations.
Report Facts
Residential Census: 98
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 0
Date: Oct 2, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00411480.
Complaint Details
Complaint IN00411480 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 complaint investigation.
Report Facts
Residential Census: 104
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 0
Date: May 25, 2023
Visit Reason
This visit was for a State Residential Licensure Survey which included the Investigation of Complaint IN00407895.
Complaint Details
Complaint IN00407895 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 the State Residential Licensure Survey requirements.
Report Facts
Residential Census: 98
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 2
Date: Feb 6, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00394648, which was substantiated with related findings cited at R0053 and R0116.
Complaint Details
Complaint IN00394648 was substantiated. The complaint involved verbal abuse by staff member 2 towards Resident B, including derogatory comments and rude behavior. Staff member 2 was suspended and terminated following investigation. The facility also failed to complete reference checks for several employees prior to hiring.
Findings
The facility was found to have failed to ensure a resident was free from verbal abuse by a staff member, and failed to implement proper employment screening procedures including reference checks for several employees.
Deficiencies (2)
Facility failed to ensure a resident was free from verbal abuse related to a staff member's direct comment to a resident.
Facility failed to ensure written procedures were implemented for employment screenings, specifically reference checks, for 4 of 5 employees reviewed.
Report Facts
Residents reviewed for verbal abuse: 3
Employees reviewed for reference checks: 5
Attempts to contact staff member 2: 3
BIMS score: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joe Smart | Executive Director | Provided interview and signed report; involved in investigation and corrective action. |
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 0
Date: Aug 17, 2022
Visit Reason
This visit was for Investigation of Residential Complaints IN00386570 and IN00387403, conducted in conjunction with a Post Survey Revisit to the Investigation of Residential Complaint IN00383708 completed on July 7, 2022.
Complaint Details
Complaint IN00386570 - Substantiated with no deficiencies cited. Complaint IN00387403 - Unsubstantiated due to lack of evidence. Complaint IN00383708 - Corrected.
Findings
Complaint IN00386570 was substantiated but no deficiencies related to the allegations were cited. Complaint IN00387403 was unsubstantiated due to lack of evidence. Complaint IN00383708 was corrected. The facility was found to be in compliance with relevant regulations regarding these complaints.
Report Facts
Residential Census: 104
Inspection Report
Follow-Up
Census: 104
Deficiencies: 0
Date: Aug 17, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Residential Complaint IN00383708 completed on July 7, 2022, conducted in conjunction with the Investigation of Residential Complaints IN00386570 and IN00387403.
Complaint Details
Complaint IN00383708 - Corrected. Complaint IN00386570 - Substantiated with no deficiencies cited. Complaint IN00387403 - Unsubstantiated due to lack of evidence.
Findings
Complaint IN00383708 was corrected. Complaint IN00386570 was substantiated but no deficiencies related to the allegations were cited. Complaint IN00387403 was unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations regarding complaints IN00386570 and IN00387403.
Report Facts
Residential Census: 104
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