Inspection Report Summary
The most recent inspection on March 13, 2025, identified a deficiency related to missing documentation of physician-ordered vital signs for one resident. Earlier inspections showed a pattern of deficiencies involving resident care documentation, medication assessments, resident service plan signatures, food safety, employee health screenings, and environmental sanitation. Complaint investigations substantiated issues such as neglect after a resident was left on the floor unattended for about two hours and failures in staff training and response. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows ongoing challenges with documentation and care processes, with no clear trend of improvement or worsening over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
29% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
48 residents
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 1
Date: Mar 13, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00442324 regarding concerns about the documentation of physician-ordered vital signs.
Complaint Details
Complaint IN00442324 was substantiated with state deficiencies cited related to the allegations about missing vital sign documentation.
Findings
The facility failed to ensure that physician-ordered vital signs were documented in the medical record for 1 of 3 residents reviewed (Resident B). Specifically, vital signs such as blood pressure, pulse, oxygen saturation, and weight were not documented for several months as ordered.
Deficiencies (1)
Failed to ensure physician-ordered vital signs were documented in the medical record for Resident B.
Report Facts
Residents present: 48
Survey dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kourtney Harvey | Executive Director | Signed the report |
| Director of Nursing | Interviewed regarding vital sign policy and documentation issues |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 5
Date: Jul 29, 2024
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaint IN00438591.
Complaint Details
Complaint IN00438591 - State deficiencies related to the allegations are cited at R216 and R349.
Findings
The facility was found deficient in multiple areas including failure to complete self-administration medication assessments, unsigned resident service plans, improper food labeling and sanitation practices, failure to document and assess a resident injury, and lack of annual health statements for residents.
Deficiencies (5)
Failed to ensure a self-administration of medication assessment was completed prior to allowing the resident to self-administer medications for 1 of 1 resident reviewed.
Failed to ensure resident service plans were signed by the resident or resident representative for 6 of 7 residents reviewed.
Failed to ensure food items had open dates and were closed off from air, dishwasher did not reach appropriate temperatures, sanitizer solution concentration was inadequate, and clean metal serving pans were not completely dry prior to storing for 2 of 3 kitchens reviewed.
Failed to assess and document in the resident's clinical record an injury which resulted in a bruise on the wrist for 1 of 1 resident reviewed.
Failed to ensure residents had an annual health statement verifying no evidence of tuberculosis in an infectious stage upon admission and yearly thereafter for 7 of 7 residents reviewed.
Report Facts
Residential Census: 45
Survey Dates: 2024-07-29 to 2024-07-30
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James P Kesler | Executive Director | Signed report and involved in policy review and corrective action plans |
| CNA 1 | Mentioned in relation to resident behavior and incident statements | |
| CNA 3 | Mentioned in relation to resident behavior and incident statements | |
| Director of Nursing | Director of Nursing | Provided interviews regarding medication self-administration and injury assessment |
| Dietary Manager | Dietary Manager | Provided interviews regarding kitchen sanitation and dishwasher operation |
| Wellness Director | Wellness Director | Completed self-administration assessments and responsible for monitoring corrective actions |
Inspection Report
Complaint Investigation
Census: 19
Deficiencies: 5
Date: Aug 21, 2023
Visit Reason
This visit was for a State Residential Licensure Survey which included the Investigation of Complaint IN00406348.
Complaint Details
Complaint IN00406348 was investigated and state deficiencies related to the allegations were cited at R144.
Findings
The facility was found deficient in ensuring 24-hour CPR and first aid coverage, completion of required tuberculosis (TB) screenings for employees, maintaining a sanitary environment in a vacant room, performing yearly HVAC inspections, and ensuring resident service plans were signed by residents or responsible parties.
Deficiencies (5)
Failed to ensure 24-hour CPR and first aid coverage for staff during August 13 to August 18, 2023.
Failed to ensure 2 of 3 new employees completed 2-step PPD TB testing and 1 of 2 existing employees had annual TB screening.
Failed to maintain a sanitary environment in room 322, with used tissue and feces found on the bathroom floor.
Failed to have yearly inspection records for heating and air conditioning system.
Failed to ensure resident service plans were signed by the resident or responsible party for 3 of 7 residents reviewed.
Report Facts
Shifts without CPR coverage: 8
Shifts without first aid coverage: 20
Residential Census: 19
Number of residents reviewed for service plans: 7
Number of residents with unsigned service plans: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Smith | Executive Director | Interviewed regarding facility policies and deficiencies. |
Inspection Report
Follow-Up
Census: 22
Deficiencies: 0
Date: Jan 4, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00392795 completed on October 31, 2022.
Complaint Details
Complaint IN00392795 - Corrected.
Findings
Willow Lake Place was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of Complaint IN00392795.
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 1
Date: Oct 31, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00392795, which was substantiated with state deficiencies related to neglect cited.
Complaint Details
Complaint IN00392795 was substantiated. The resident was found on the floor and left unattended for about two hours until emergency services arrived. Staff failed to assist or properly respond to the fall, including failure to use mechanical lift due to lack of training and refusal to assist by some staff members.
Findings
The facility failed to ensure a resident (Resident B) was free from neglect when he was found on the floor in his room and left there for approximately two hours until assistance arrived via 911. Staff failed to assist the resident off the floor and did not respond appropriately to the fall.
Deficiencies (1)
Failure to ensure a resident was free from neglect when left on the floor for approximately two hours after a fall.
Report Facts
Residential Census: 21
Time resident left on floor: 2
Date of fall: Oct 15, 2022
Date of survey: Oct 31, 2022
Date of corrective action completion: Nov 17, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Smith | Administrator | Signed the report |
| QMA 1 | Placed on administrative leave for failure to assist resident after fall | |
| CNA 2 | Reported fall, attempted to get help, assisted resident on floor | |
| CNA 3 | Assisted resident on floor, reported QMA 1 did not place 911 call | |
| CNA 5 | Unable to assist due to staffing, informed of fall | |
| Director of Health Services | Indicated staff need training on mechanical lift use | |
| Regional Director of Care Services | Conducted chart audit and corrective actions | |
| Executive Director | Provided staff re-education and responsible for compliance monitoring |
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