Inspection Report Summary
The most recent inspection on April 15, 2025, identified deficiencies related to medication labeling and clinical record documentation following an unwitnessed fall. Earlier inspections showed a pattern of issues including medication administration errors, resident-to-resident abuse, incomplete fire safety procedures, and dietary service concerns. Complaint investigations substantiated deficiencies in areas such as abuse prevention, medication practices, fall management, and grievance handling, while most other complaints were unsubstantiated or corrected. Enforcement actions included staff suspension and termination related to a fall incident, but fines or license suspensions were not listed in the available reports. The facility’s inspection history shows ongoing challenges with compliance in clinical care and safety protocols, with some corrections noted but no clear sustained improvement trend.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
74% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
95 residents
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 2
Apr 15, 2025
Visit Reason
This visit was conducted for the investigation of two complaints, IN00452160 and IN00455467. Complaint IN00452160 resulted in a state deficiency citation, while Complaint IN00455467 had no deficiencies related to the allegations.
Findings
The facility was found deficient for failing to properly label two aspirin bottles with the resident's full name, physician's name, and dosage instructions for one medication cart. Additionally, the facility failed to maintain accurate clinical records related to documentation after an unwitnessed fall for one resident.
Complaint Details
Complaint IN00452160 was substantiated with a related state deficiency cited at R300. Complaint IN00455467 was not substantiated with no deficiencies cited.
Deficiencies (2)
| Description |
|---|
| Failed to label two aspirin bottles with the resident's full name, physician's name, and dosage instructions for 1 of 2 medication carts reviewed. |
| Failed to maintain clinical records that were accurately documented per policy related to documentation after an unwitnessed fall for 1 of 3 resident records reviewed. |
Report Facts
Residential Census: 95
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Smith | Director of Nursing | Named in relation to findings and corrective actions regarding medication labeling and clinical record documentation |
Inspection Report
Annual Inspection
Census: 96
Deficiencies: 6
Jan 16, 2025
Visit Reason
This visit was for a State Residential Licensure Survey conducted on January 15 and 16, 2025.
Findings
The facility was found noncompliant in several areas including failure to conduct quarterly fire drills on each shift, lack of written policies for maintenance and HVAC inspections, untimely updates to service plans related to hospice services, failure to follow physician's medication orders, lack of staff knowledge and monitoring of dishwasher temperatures, and incomplete transfer/discharge documentation.
Deficiencies (6)
| Description |
|---|
| Failed to ensure fire drills were conducted quarterly on each shift. |
| Failed to ensure written policies were in place related to facility maintenance equipment and annual HVAC inspection. |
| Failed to ensure Service Plans were updated timely related to hospice services and signed by resident or representative. |
| Failed to ensure physician's orders were followed related to medications not administered as ordered. |
| Failed to ensure staff was knowledgeable about dishwasher temperatures and that dishwasher temperatures were monitored. |
| Failed to ensure a transfer/discharge form was completed including resident's current condition, functional abilities, physical limitations, or reason for transfer. |
Report Facts
Residential Census: 96
New HVACs installed: 14
Missed medication administration dates: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Smith | Director of Nursing | Named in relation to findings on medication administration, service plan updates, and transfer documentation. |
Inspection Report
Follow-Up
Census: 93
Deficiencies: 0
Oct 8, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00440038 completed on August 13, 2024, and was conducted in conjunction with the Investigation of Complaint IN00443769.
Findings
Complaint IN00440038 was corrected, and no deficiencies related to Complaint IN00443769 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the PSR.
Complaint Details
Complaint IN00440038 was corrected; Complaint IN00443769 had no deficiencies related to the allegations.
Report Facts
Residential Census: 93
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 0
Oct 8, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00443769 and was conducted in conjunction with a Post Survey Revisit to the Investigation of Complaint IN00440038 completed on August 13, 2024.
Findings
No deficiencies related to the allegations of Complaint IN00443769 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the investigation.
Complaint Details
Investigation of Complaint IN00443769 found no deficiencies related to the allegations.
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 1
Aug 13, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00440038 regarding allegations of resident-to-resident abuse on the Memory Care Unit.
Findings
The facility failed to ensure effective interventions to prevent resident-to-resident abuse perpetrated by a cognitively impaired resident (Resident C) against other residents (Residents F, E, D, and B). This resulted in physical injuries including lacerations, bruises, and skin tears requiring hospital evaluation. The facility lacked consistent and effective plans to protect residents from abuse.
Complaint Details
Complaint IN00440038 was substantiated with state deficiencies cited related to resident-to-resident abuse on the Memory Care Unit. The investigation found multiple incidents of physical abuse by Resident C towards other residents, resulting in injuries and hospitalizations.
Deficiencies (1)
| Description |
|---|
| Failed to ensure interventions to prevent resident-to-resident abuse perpetrated by a cognitively impaired resident were effectively implemented. |
Report Facts
Residential Census: 104
Incident dates: 4
Plan of Correction Completion Date: Oct 1, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Smith | Director of Nursing | Named in relation to findings and plan of correction |
| Executive Director | Mentioned in interviews regarding Resident C's behavior and return to facility | |
| Memory Care Coordinator | Interviewed regarding Resident C's behaviors and staff concerns |
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 2
Apr 18, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00432156 regarding allegations related to dietary services and grievance handling.
Findings
The facility failed to ensure a grievance was completed and investigated related to a family member's concern about dietary services, and failed to meet dietary requirements by serving food to which a resident was allergic on two occasions.
Complaint Details
Complaint IN00432156 was substantiated with state deficiencies cited at R039 and R270 related to grievance handling and dietary service failures.
Deficiencies (2)
| Description |
|---|
| Failed to ensure a grievance was completed and investigated related to a family member's concern regarding dietary services for 1 of 3 residents reviewed. |
| Failed to ensure dietary requirements were met related to a resident being served food to which she was allergic on two occasions. |
Report Facts
Residential Census: 103
Medication dosage: 12.5
Dates of incidents: Incidents occurred on 4/5/24 and 4/14/24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee 1 | Named in dietary service incident involving serving orange juice to allergic resident | |
| Dietary Manager | Responsible for dietary service oversight and corrective actions | |
| Director of Nursing | Interviewed regarding grievance follow-up and awareness of incident | |
| Executive Director | Interviewed regarding awareness of dietary incident and grievance investigation |
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 2
Jan 18, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00416996 regarding medication administration and injectable medication practices.
Findings
The facility failed to ensure insulin was administered as ordered for one resident and failed to ensure injectable medications were given only by licensed personnel or certified QMA for two residents. Several instances of insulin administration when blood sugar was below ordered thresholds were documented, and uncertified QMA administered insulin.
Complaint Details
Complaint IN00416996 was substantiated with state deficiencies cited related to medication administration and injectable medication practices.
Deficiencies (2)
| Description |
|---|
| Failed to ensure insulin was given as ordered for 1 of 3 residents reviewed for medication administration (Resident B). |
| Failed to ensure injectable medications were given only by licensed nurse or certified QMA for 2 of 3 residents reviewed for insulin administration (Residents C and D). |
Report Facts
Residential Census: 98
Insulin doses administered below blood sugar threshold: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Searfeaair Sutherland | LPN, Director of Nursing | Interviewed and provided information regarding medication administration and certification issues. |
Inspection Report
Renewal
Census: 59
Deficiencies: 11
Aug 15, 2023
Visit Reason
This visit was for a State Residential Licensure Survey conducted on August 15 and 16, 2023.
Findings
The facility was found noncompliant in multiple areas including failure to invite the local fire department to fire drills, inadequate qualifications of the Memory Care Unit Director, insufficient CPR certified staff during some shifts, incomplete dementia training for staff, missing semi-annual resident evaluations, unapproved menus by a registered dietician, incomplete resident clinical records retention, missing discharge summaries, incomplete emergency information files, missing annual health statements, and lack of required tuberculosis testing and screening.
Deficiencies (11)
| Description |
|---|
| Failed to invite the local fire department to participate in scheduled fire drills at least every six months. |
| Failed to ensure the Director of the Memory Care Unit had the required education and experience. |
| Failed to ensure at least one staff member with current CPR and first aid certification was on site for a four-hour period on 8/13/23. |
| Failed to ensure annual dementia training had been completed for 3 of 5 employees reviewed. |
| Failed to ensure each resident had a semi-annual evaluation completed for 3 of 7 residents reviewed. |
| Failed to serve meals from a menu approved by a Registered Dietician. |
| Failed to maintain resident records for a period of five years for 5 of 6 residents who resided in the facility prior to 5/1/23. |
| Failed to complete a discharge summary and transfer form for 1 of 2 closed records reviewed. |
| Failed to ensure the resident Emergency Binder contained all necessary information for 3 of 5 residents reviewed. |
| Failed to ensure each resident record included an annual health statement for 4 of 7 resident records reviewed. |
| Failed to ensure residents received annual and admission tuberculosis (TB) tests or screenings for 7 of 7 residents reviewed. |
Report Facts
Residents affected: 59
Residents affected: 14
Shifts reviewed: 12
Residents reviewed: 7
Employees reviewed: 5
Residents affected: 59
Residents affected: 5
Residents affected: 3
Residents affected: 4
Residents reviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in relation to fire drill deficiency and corrective action. | |
| Administrator | Interviewed regarding fire drills, memory care director qualifications, dementia training, and menu discrepancies. | |
| Memory Care Unit Director | Named in relation to qualifications deficiency and emergency binder updates. | |
| Director of Nursing | DON | Named in relation to memory care director role, semi-annual evaluations, clinical records, discharge summaries, emergency binder, health statements, and TB testing. |
| Business Office Manager | Named in relation to dementia training corrective actions. | |
| Culinary Director | Named in relation to dementia training and menu discrepancies. | |
| Dementia Care Coordinator | Named in relation to dementia training and emergency binder updates. | |
| Cook 1 | Observed during meal service related to menu discrepancy. |
Inspection Report
Re-Inspection
Census: 56
Deficiencies: 0
Jun 1, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to investigate Complaints IN00403196 and IN00404476 completed on 3/29/2023.
Findings
The facility was found to be in compliance with 410 IAC 16.2-5 regarding the PSR to Investigation of Complaints IN00403196 and IN00404476, with both complaints corrected.
Complaint Details
Investigation of Complaints IN00403196 and IN00404476; both complaints were corrected.
Report Facts
Residential Census: 56
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 4
Mar 29, 2023
Visit Reason
This visit was for the investigation of complaints IN00403196 and IN00404476 concerning resident care and facility management issues.
Findings
The facility failed to notify a resident's family about a significant change in condition related to a new wound, failed to ensure a resident was free from sexual abuse by another resident, failed to report an unusual occurrence to the State Agency, and failed to provide proper wound care including obtaining and following physician orders.
Complaint Details
The investigation was triggered by complaints IN00403196 and IN00404476. Complaint IN00403196 involved failure to notify family and failure to report unusual occurrences. Complaint IN00404476 involved failure to provide proper wound care and failure to prevent sexual abuse.
Deficiencies (4)
| Description |
|---|
| Failed to notify a resident's family about a change in condition related to a new wound requiring treatment for 1 of 3 residents reviewed for wounds (Resident C). |
| Failed to ensure a resident was free from sexual abuse by another resident for 1 of 3 residents reviewed for abuse (Resident D). |
| Failed to report an unusual occurrence to the State Agency related to two residents found unclothed in a room alone (Residents C and B). |
| Failed to ensure a resident received treatment for wounds related to not obtaining a Physician's Order for wound care and providing incorrect treatment after a Physician's Order was received for 1 of 3 residents reviewed for wound care (Resident C). |
Report Facts
Residential Census: 70
Wound size: 10
Wound size: 5
Wound size: 3
Wound size: 1.5
Timeframe for audit tracking: 6
Timeframe for chart audit: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirly Keller | Executive Director | Signed the report and mentioned in interviews regarding incident reporting. |
| Director of Nursing | Interviewed regarding failure to notify family, wound care orders, and incident reporting. | |
| Memory Care Director | Interviewed regarding resident monitoring and care following incidents. | |
| Caregiver 1 | Interviewed regarding instructions to keep resident's door closed and female residents out. |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 0
Jan 4, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00391149, IN00393299, and IN00397071.
Findings
Complaints IN00391149 and IN00393299 were found unsubstantiated due to lack of evidence. Complaint IN00397071 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 IN00391149 - Unsubstantiated due to lack of evidence. Complaint IN00393299 - Unsubstantiated due to lack of evidence. Complaint IN00397071 - Substantiated. No deficiencies related to the allegations are cited.
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 1
Aug 22, 2022
Visit Reason
This visit was for the investigation of Complaints IN00387655 and IN00388494, in conjunction with a Post Survey Revisit to previous complaints completed on June 16, 2022.
Findings
The facility failed to implement the Fall Management policy related to care of a resident post fall (Resident C). The resident was found on the floor on 7/24/22, but staff failed to report the fall appropriately, resulting in a hip fracture requiring surgery. The CNA involved was suspended and terminated, and agency staff were placed on a Do Not Return list. Corrective actions and staff education were planned to prevent recurrence.
Complaint Details
Complaint IN00387655 and IN00388494 were substantiated with state deficiencies cited. Other complaints IN00375944, IN00378128, IN00379613, and IN00380591 were corrected.
Deficiencies (1)
| Description |
|---|
| Failure to implement the Fall Management policy related to care of a resident post fall for 1 of 3 residents reviewed (Resident C). |
Report Facts
Residential Census: 62
Date of fall observation: Jul 24, 2022
Date of survey: Aug 22, 2022
Completion date for corrective actions: Sep 8, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Resident Care Director | Interviewed regarding the fall incident and corrective actions |
| CNA 1 | Certified Nursing Assistant | Admitted to picking up resident after fall without reporting; suspended and terminated |
Inspection Report
Follow-Up
Census: 62
Deficiencies: 0
Aug 22, 2022
Visit Reason
This visit was for the Post Survey Revisit (PSR) to the Investigation of Complaints IN00375944, IN00378128, IN00379613, and IN00380591 completed on June 16, 2022, and was in conjunction with the Investigation of Complaints IN00387655 and IN00388494.
Findings
Complaints IN00375944, IN00378128, IN00379613, and IN00380591 were corrected. Complaints IN00387655 and IN00388494 were substantiated with state deficiencies cited at R0091. Brentwood at Laporte was found to be in compliance with 410 IAC 16.2-5 regarding the PSR to the Investigation of Complaints.
Complaint Details
Complaint IN00387655 - Substantiated. State deficiencies related to the allegations are cited at R0091. Complaint IN00388494 - Substantiated. State deficiencies related to the allegations are cited at R0091.
Report Facts
Residential Census: 62
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