The most recent inspection on March 31, 2025, found the facility in compliance with no deficiencies related to the prior complaint investigation. Earlier inspections showed a pattern of deficiencies primarily involving resident care issues such as neglect, inadequate incontinence care, and failure to have CPR-certified staff on duty, as well as some food service sanitation and staff licensing concerns. Several complaints were substantiated with citations for neglect and training failures, including a substantiated complaint in February 2025 regarding CPR certification and resident neglect. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility appears to be addressing prior issues, as the most recent re-inspection found no deficiencies related to the earlier substantiated complaints.
Deficiencies (last 3 years)
Deficiencies (over 3 years)2.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
36% better than Indiana average
Indiana average: 4.2 deficiencies/year
Deficiencies per year
43210
2023
2024
2025
Census
Latest occupancy rate78 residents
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
This visit was conducted for the investigation of Complaint IN00452620 regarding allegations of neglect and failure to have CPR certified staff on duty.
Findings
The facility failed to ensure a resident was free from neglect when CPR was not administered to a resident found unresponsive and without a pulse. Additionally, the facility did not have a CPR certified staff member with hands-on skills validation on duty for 20 of 21 shifts reviewed.
Complaint Details
Complaint IN00452620 was substantiated with state deficiencies cited related to neglect and CPR certification failures.
Deficiencies (2)
Description
Failed to ensure a resident was free from neglect when CPR was not provided to a resident found unresponsive and without a pulse.
Failed to ensure staff on duty met CPR requirements including hands-on skills validation training for 20 of 21 shifts reviewed.
Report Facts
Residential Census: 77Shifts without certified CPR staff: 20
Employees Mentioned
Name
Title
Context
Tiffany Tribble
Administrator
Signed the report
QMA 2
Found resident unresponsive and did not perform CPR due to uncertainty about code status and lack of hands-on CPR certification
CNA 3
Did not perform CPR and lacked hands-on CPR certification
Director of Health and Wellness
Indicated resident should have received CPR and was unaware why CPR was not administered
Director of Nursing
Indicated CPR training was completed online and was unaware hands-on skills validation was required
This visit was conducted for the investigation of complaint IN00451311 regarding allegations of inadequate incontinence care.
Findings
The facility failed to ensure incontinence care was provided for 3 of 3 residents reviewed (Residents B, C, and D). Multiple staff interviews and record reviews confirmed residents were found saturated with urine and feces due to lack of timely care by CNA 8.
Complaint Details
Complaint IN00451311 was substantiated with state deficiencies cited at R240 related to inadequate incontinence care by CNA 8. Multiple staff and resident interviews confirmed the allegations.
Deficiencies (1)
Description
Failed to ensure incontinence care was provided for 3 of 3 residents reviewed for incontinence care (Residents B, C, and D).
Report Facts
Residential Census: 79Survey Dates: 2Residents reviewed for incontinence care: 3
Employees Mentioned
Name
Title
Context
Tiffany Tribble
Administrator
Signed the report and provided interview confirming residents had not been provided incontinent care by CNA 8
This visit was for a State Residential Licensure Survey and included the Investigation of Complaint IN00440426.
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.
Complaint Details
Complaint IN00440426 was investigated and found to have no deficiencies related to the allegations.
This visit was conducted for the investigation of Complaint IN00427877 regarding state deficiencies related to the allegations cited at R006 and R117.
Findings
The facility failed to discharge a resident who required extensive assistance with transfers and toileting and failed to ensure staff were properly trained on the use of a stand-up lift for that resident. The resident was discharged shortly after the survey, and corrective actions including staff retraining and audits were planned.
Complaint Details
Complaint IN00427877 was investigated with state deficiencies cited related to the allegations at tags R006 and R117.
Deficiencies (2)
Description
Failed to discharge a resident who required extensive assistance with transfers and toileting and used a stand-up lift not appropriate for the resident's needs.
Failed to ensure staff were trained on the use of a stand-up lift for the resident using mechanical lifts.
Report Facts
Resident census: 78Staff assistance required: 2Staff assistance required: 3Completion date for corrective actions: Apr 1, 2024
This visit was conducted for the investigation of Complaints IN00416271 and IN00423904.
Findings
No deficiencies related to the allegations in Complaints IN00416271 and IN00423904 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaints IN00416271 and IN00423904 found no deficiencies related to the allegations; facility was compliant.
This visit was for a State Residential Licensure Survey conducted on August 22 and 23, 2023, to assess compliance with state regulations for residential facilities.
Findings
The facility was found deficient in ensuring staff had current CPR and First Aid certifications for multiple shifts, a Home Health Aide lacked a valid license, and food service sanitation standards were not fully met including improper thawing of meat, uncovered trash cans, unclean floors, incomplete refrigerator temperature logs, and staff not wearing beard guards.
Deficiencies (3)
Description
Failed to ensure staff met CPR and First Aid certification requirements for 17 of 42 shifts reviewed.
Failed to ensure a Home Health Aide had a valid license.
Failed to maintain food preparation and serving areas in accordance with sanitation and safe food handling standards, including uncovered trash can, unclean floors, improper thawing of meat, incomplete refrigerator temperature logs, and staff not wearing beard guards.
Report Facts
Shifts without CPR/First Aid coverage: 17Residential Census: 75Dates with incomplete refrigerator temperature logs: 6
Employees Mentioned
Name
Title
Context
Tiffany Tribble
Executive Director
Interviewed regarding missing CPR and First Aid certifications and HHA licensure issues.
This visit was conducted for the investigation of complaints IN00396672 and IN00398120.
Findings
Both complaints were substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00396672 - Substantiated with no deficiencies cited. Complaint IN00398120 - Substantiated with no deficiencies cited.
Report Facts
Residential Census: 58
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