Inspection Report Summary
The most recent inspection on March 18, 2025, found two deficiencies related to medication self-administration evaluations and food labeling and expiration practices. Earlier inspections showed a pattern of deficiencies mostly involving medication management, food safety, and emergency preparedness, with some substantiated complaints related to resident abuse and reporting failures. Inspectors cited issues such as failure to ensure residents were free from abuse, incomplete abuse investigations, untimely reporting of incidents, unsanitary food storage, and incomplete fire drills. Complaint investigations were generally unsubstantiated except for two substantiated abuse-related findings in 2023, but no fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s recent inspections suggest some ongoing challenges with compliance, though the number and severity of deficiencies appear to have decreased compared to earlier reports.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
6.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
60% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
43 residents
Based on a March 2025 inspection.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 2
Date: Mar 18, 2025
Visit Reason
This visit was for a State Residential Licensure Survey and included the Investigation of Complaint IN00454711.
Complaint Details
Complaint IN00454711 was investigated and no deficiencies related to the allegation were cited.
Findings
No deficiencies related to the complaint allegation were cited. Two deficiencies were found: the facility failed to ensure a timely self-administration medication evaluation for one resident, and failed to ensure food was labeled, dated, and discarded after expiration in the kitchen and dining room.
Deficiencies (2)
Failed to ensure a self-administration evaluation was completed timely for 1 of 3 residents reviewed for self-administration of medication (Resident B).
Failed to ensure food was labeled, dated, and discarded after expiration in 1 kitchen and 1 dining room, potentially affecting all 43 residents.
Report Facts
Residential Census: 43
Deficiency completion date: Apr 25, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rick Walworth | Executive Director | Signed the report |
| Director of Nursing | Interviewed regarding medication self-administration policy and findings | |
| Director of Dining | Interviewed regarding food labeling and expiration findings |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 0
Date: Dec 30, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00448979.
Complaint Details
Complaint IN00448979 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00448979 were cited. The facility was found to be in compliance with applicable regulations.
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 0
Date: Aug 16, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00440164.
Complaint Details
Complaint IN00440164 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: 39
Deficiencies: 0
Date: Jun 27, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00437016.
Complaint Details
Complaint IN00437016 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: 39
Deficiencies: 0
Date: Jun 25, 2024
Visit Reason
This visit was conducted for the investigation of four complaints: IN00436418, IN00436368, IN00436026, and IN00433915.
Complaint Details
Complaints IN00436418, IN00436368, IN00436026, and IN00433915 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the four complaints were cited. The facility was found to be in compliance with the relevant regulations.
Report Facts
Residential Census: 39
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 6
Date: Apr 2, 2024
Visit Reason
This visit was for a State Residential Licensure Survey which included the Investigation of Complaint IN00430785.
Complaint Details
Complaint IN00430785 was investigated and no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found deficient in several areas including failure to complete quarterly fire drills on each shift, failure to ensure PRN medications administered by QMAs were approved by licensed nurses, failure to store food under sanitary conditions in the kitchen, failure to secure medications appropriately in a resident's room, failure to ensure controlled substance audit sheets were signed by nursing staff, and failure to maintain a clean medication refrigerator free of staff food.
Deficiencies (6)
Facility failed to complete a fire drill every quarter on each shift.
Facility failed to ensure PRN medications administered by a Qualified Medication Aide (QMA) were approved by a licensed nurse prior to administration for 4 of 8 residents reviewed.
Facility failed to store food under sanitary conditions, including undated and improperly sealed foods and general kitchen cleanliness issues.
Facility failed to secure medications appropriately in a resident's room for 1 of 1 resident reviewed for self-administration of medication.
Facility failed to ensure Controlled Substance Audit Sheets were signed by on-coming and off-going nursing staff.
Facility failed to ensure a medication refrigerator was clean and failed to ensure staff foods were not stored in the medication refrigerator.
Report Facts
Residents present: 39
Fire drills required: 12
PRN medication administration errors: 4
Controlled Substance Audit Sheet missing signatures: 11
Residents affected by PRN medication deficiency: 13
Residents affected by medication security deficiency: 3
Residents affected by medication refrigerator deficiency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tara Carney | Executive Director | Signed the inspection report |
| Maintenance Director | Interviewed regarding fire drill deficiencies and corrective actions | |
| Director of Nursing | Director of Nursing | Interviewed regarding PRN medication administration and medication policies |
| QMA 4 | Qualified Medication Aide | Involved in PRN medication administration without nurse approval |
| QMA 6 | Qualified Medication Aide | Involved in PRN medication administration without nurse approval |
| LPN 5 | Licensed Practical Nurse | Interviewed regarding controlled substance audit sheets and medication refrigerator |
| Cook 2 | Interviewed regarding kitchen sanitation and food storage | |
| Dietary Services Supervisor | Dietary Services Supervisor | Interviewed regarding kitchen sanitation and cleaning schedules |
| Administrator | Administrator | Provided policies and interviewed regarding kitchen sanitation and medication storage |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 0
Date: Nov 6, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00418122 and IN00419591.
Complaint Details
Investigation of Complaints IN00418122 and IN00419591 found no deficiencies related to the allegations; facility was in compliance.
Findings
No deficiencies related to the allegations in complaints IN00418122 and IN00419591 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Residential Census: 31
Inspection Report
Follow-Up
Census: 33
Deficiencies: 0
Date: Sep 20, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00413497 completed on 2023-08-01.
Complaint Details
Complaint IN00413497 was corrected.
Findings
Brookdale Granger was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of Complaint IN00413497.
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 2
Date: Aug 1, 2023
Visit Reason
This visit was conducted for the investigation of complaint IN00413497 regarding allegations of resident-to-resident abuse at Brookdale Granger.
Complaint Details
Complaint IN00413497 was substantiated with state deficiencies cited related to allegations of resident-to-resident abuse involving Resident D and Resident F. The facility failed to report the incident timely and failed to notify the resident's family promptly.
Findings
The facility failed to ensure a resident was free from abuse when Resident F threw a chair at Resident D causing injury. The facility also failed to properly report the incident to the State Agency and notify the resident's family in a timely manner. An internal investigation was incomplete and the facility did not follow their abuse reporting policy.
Deficiencies (2)
Failed to ensure a resident was free from abuse when Resident F threw a chair at Resident D causing injury.
Failed to report the resident-to-resident abuse incident to the State Agency within 24 hours and failed to notify the resident's legally responsible party timely.
Report Facts
Residential Census: 46
Deficient residents: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Woodcox | Area Director | Signed the inspection report |
| LPN 2 | Licensed Practical Nurse | Witnessed and documented the abuse incident and notified administrator, physician, and family |
| Administrator | Interviewed regarding the incident and investigation |
Inspection Report
Re-Inspection
Census: 42
Deficiencies: 0
Date: Jul 14, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00408794 completed on June 2, 2023.
Complaint Details
Complaint IN00408794 was corrected.
Findings
Brookdale Granger was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of Complaint IN00408794.
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 0
Date: Jun 20, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00410511.
Complaint Details
Complaint IN00410511 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: 41
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 2
Date: Jun 2, 2023
Visit Reason
This visit was conducted for the investigation of Residential Complaint IN00408794 at Brookdale Granger.
Complaint Details
Complaint IN00408794 was investigated with no deficiencies related to the allegations cited. The complaint involved an incident where Home Health Aide 2 was verbally and physically aggressive with Resident C. The Executive Director was not notified timely of the abuse allegation, which was reported on 5/30/23 despite the incident occurring on 5/28/23.
Findings
No deficiencies related to the complaint allegations were cited; however, unrelated deficiencies were identified. The facility failed to ensure a resident was free from abuse and failed to timely notify the administrator of an abuse allegation involving Resident C.
Deficiencies (2)
Failed to ensure a resident was free from abuse for 1 of 2 incidents reviewed involving verbal and physical aggression by a Home Health Aide towards Resident C.
Failed to implement abuse policy and notify the Administrator timely of an allegation of abuse for 1 of 2 incidents reviewed.
Report Facts
Residential Census: 40
Incident Date: May 28, 2023
Survey Dates: Jun 1, 2023
Survey Dates: Jun 2, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tara Carney | Executive Director | Named as the Executive Director involved in the investigation and notification process. |
| Dana Hakes | HWD | Responsible for re-inservicing associates on abuse policy. |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 8
Date: Apr 20, 2023
Visit Reason
This visit was for a State Residential Licensure Survey including the investigation of multiple complaints (IN00404115, IN00401456, IN00397288, IN00391267, IN00391324, IN00389222, IN00385467).
Complaint Details
This visit included investigation of complaints IN00404115, IN00401456, IN00397288, IN00391267, IN00391324, IN00389222, and IN00385467. Deficiencies related to complaint IN00401456 were cited at R273. No deficiencies related to other complaints were cited.
Findings
The facility was found deficient in several areas including failure to conduct fire and disaster drills with the local fire department every six months, incomplete and unsigned service plans for residents, failure to prepare and serve modified diets according to physician orders, unsanitary food storage and preparation practices, missing hospital preferences in emergency files, lack of an effective infection control program, missing annual health statements for residents, and incomplete tuberculosis testing documentation.
Deficiencies (8)
Failed to ensure a fire and disaster drill was attempted every six months in conjunction with the local fire department affecting 54 residents.
Failed to ensure the service plan regarding fall risk was implemented and revised as needed for 1 of 5 residents and failed to ensure 2 of 7 service plans were signed and dated.
Failed to prepare and serve modified diets for 8 of 40 residents with physician orders for modified diets.
Failed to ensure food was stored, prepared and served in a sanitary manner in the kitchen, with issues including unclean floors, unlabeled and undated food items, and improper glove use.
Failed to ensure emergency files for residents included hospital preference for 3 of 7 records reviewed.
Failed to establish an infection control program that included a system to analyze patterns of infectious symptoms and ongoing surveillance.
Failed to ensure an annual health statement was in place for 2 of 7 resident charts reviewed.
Failed to ensure Tuberculin Test on or prior to admission and second step were completed for 2 of 7 resident charts reviewed.
Report Facts
Residents affected by fire drill deficiency: 54
Residents with modified diet orders: 8
Residents with missing hospital preference: 3
Residents missing annual health statement: 2
Residents missing complete Tuberculin testing: 2
Residents reviewed for service plan deficiencies: 5
Residents with unsigned service plans: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tara Carney | Executive Director | Interviewed regarding fire drill deficiencies and confirmed lack of fire drill with local fire department; also involved in policy provision and corrective actions. |
| Clinical Specialist | Interviewed regarding service plan deficiencies, infection control program, and tuberculosis testing; provided policies and confirmed findings. | |
| Food Service Supervisor (FSS) | Observed during meal service and interviewed regarding food preparation and diet modifications. | |
| Cook 5 | Observed during meal service and noted for improper food preparation and handling. | |
| Maintenance Manager | In-serviced on fire drill regulations and responsible for scheduling fire drills with local fire department. | |
| CNA 6 and CNA 7 | Interviewed regarding fall interventions for Resident E. | |
| CNA 8 | Interviewed and observed assisting Resident E with transfers. |
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