Inspection Report Summary
The most recent inspection on February 20, 2025, identified deficiencies related to food storage and sanitation practices in the kitchen. Earlier inspections showed a pattern of deficiencies involving food safety and sanitation, as well as issues with resident care documentation, medication labeling, and emergency preparedness. Complaint investigations were mostly unsubstantiated, except for one substantiated complaint in February 2025 regarding kitchen sanitation and one unrelated deficiency in December 2023 for late reporting of an unusual occurrence involving resident contact. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The inspection history indicates ongoing challenges with food service sanitation, with some improvement needed in timely reporting and resident care documentation.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
2.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% better than Indiana average
Indiana average: 4.2 deficiencies/year
Deficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
69 residents
Based on a February 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 1
Feb 20, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00445933 regarding food storage and sanitation practices in the facility kitchen.
Findings
The facility failed to store, serve, and prepare food under sanitary conditions, including dirty food equipment, food crumbs on floors and under appliances, undated food items, food splatter on ceiling tiles, grease buildup on cooking equipment, and improper meat storage. These deficiencies had the potential to affect all 69 residents receiving food from the kitchen.
Complaint Details
Complaint IN00445933 was substantiated with a state deficiency cited at R273 related to food and nutritional services.
Deficiencies (1)
| Description |
|---|
| Failed to store, serve, and prepare food under sanitary conditions related to dirty food equipment, food crumbs on the floor and under appliances, undated food in refrigerator and freezer, food splatter on ceiling tiles, grease buildup on stove top and fryer, dirty appliances, and improper meat storage. |
Report Facts
Residential Census: 69
Completion date for corrective actions: Mar 20, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tiffany Anderson | Executive Director | Signed the report |
| Dietary Service Director | Interviewed regarding kitchen sanitation and food storage deficiencies | |
| Administrator | Acknowledged kitchen concerns | |
| Director of Nursing | Acknowledged kitchen concerns |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 0
Sep 23, 2024
Visit Reason
This visit was conducted to investigate Complaint IN00443251 at Cedarhurst of Dyer.
Findings
No deficiencies related to the allegations in Complaint IN00443251 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00443251 was investigated and found to have no deficiencies related to the allegations.
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 0
Aug 29, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00437941.
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.
Complaint Details
Complaint IN00437941 was investigated and found to have no deficiencies related to the allegations.
Inspection Report
Renewal
Census: 71
Deficiencies: 7
Apr 4, 2024
Visit Reason
This visit was for a State Residential Licensure Survey conducted on April 3 and 4, 2024.
Findings
The facility was found deficient in multiple areas including failure to ensure timely physician notification for resident care issues, incomplete service plans, inadequate fire and disaster preparedness drills with local fire department participation, unsanitary food preparation conditions, improper labeling of over-the-counter medications, and incomplete clinical records related to insulin administration.
Deficiencies (7)
| Description |
|---|
| Failure to ensure follow up contact was made with the Physician and/or Nurse Practitioner related to an ear, nose, and throat consultation, and a delay in obtaining a urine sample and urinalysis results for 2 of 7 records reviewed. |
| Failure to ensure at least every 6 months, an attempt was made to hold a fire and disaster drill in conjunction with the local fire department. |
| Failure to ensure Service Plans were signed and revised as needed, related to foley catheter care and wound care, for 2 of 7 records reviewed. |
| Failure to ensure foley catheter care was completed and wound treatments were completed by a Home Health Agency for 1 of 7 sampled residents. |
| Failure to serve food under sanitary conditions related to dirty and greasy food equipment, expired leftovers, food not dated after prepared, and touching food with bare hands for 1 of 1 kitchens. |
| Failure to ensure over the counter medications were labeled with the resident's name as well as the Physician's name for 1 of 5 residents observed during medication administration. |
| Failure to ensure clinical records were complete and accurately documented related to insulin administration for 1 of 7 records reviewed. |
Report Facts
Residents reviewed: 7
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents observed: 5
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaqueisha Johnson | Director of Nursing | Named in relation to findings about delayed physician notification and other nursing deficiencies |
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 1
Dec 11, 2023
Visit Reason
This visit was conducted for the investigation of two complaints, IN00414849 and IN00420280, related to the facility.
Findings
No deficiencies were cited related to the allegations in both complaints. However, an unrelated deficiency was cited regarding failure to notify the Indiana Department of Health (IDOH) of an unusual occurrence involving sexual contact between residents unable to give consent.
Complaint Details
Complaint IN00414849 and Complaint IN00420280 were investigated with no deficiencies related to the allegations cited. The cited deficiency was unrelated to the complaints. The incident involved two residents (Residents H and J) where Resident J was found fondling Resident H's breast without consent. The incident was reported late to IDOH on 12/18/23. The Executive Director acknowledged the failure to timely report and outlined corrective actions including weekly interviews and monitoring to ensure timely reporting of abuse allegations.
Deficiencies (1)
| Description |
|---|
| Failure to notify the Indiana Department of Health of an unusual occurrence related to sexual contact involving residents unable to give consent. |
Report Facts
Residential Census: 77
Survey Dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tiffany Anderson | Executive Director | Named in relation to the deficiency regarding failure to report unusual occurrence to IDOH and responsible for corrective actions. |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 0
Jun 14, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00401864.
Findings
No deficiencies related to the allegations were cited. Cedarhurst of Dyer was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Complaint Details
Investigation of Complaint IN00401864 found no deficiencies related to the allegations.
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 0
Jan 11, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00391602.
Findings
The complaint IN00391602 was found to be unsubstantiated due to lack of evidence, and the facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Complaint Details
Complaint IN00391602 was investigated and found to be unsubstantiated due to lack of evidence.
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 0
Sep 19, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00380676.
Findings
The complaint IN00380676 was found to be unsubstantiated due to lack of evidence, and the facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00380676 was investigated and found to be unsubstantiated due to lack of evidence.
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