Inspection Report Summary
The most recent inspection on March 5, 2025, identified deficiencies related to employing an unlicensed personal care assistant and unsanitary food storage and preparation practices. Earlier inspections showed a pattern of various deficiencies, including medication administration errors, infection control issues, and food sanitation concerns. Several complaint investigations were conducted, with most complaints found unsubstantiated, though some substantiated complaints involved medication errors and failure to prevent resident elopement. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows ongoing challenges with staff certification, medication management, and sanitation, with no clear trend of overall improvement or worsening.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
6.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
62% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
99 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
Renewal
Census: 99
Deficiencies: 2
Date: Mar 5, 2025
Visit Reason
This visit was for a State Residential Licensure Survey conducted on March 4 and 5, 2025 to assess compliance with state residential regulations.
Findings
The facility was found deficient for employing an unlicensed personal care assistant without current certification and for unsanitary food storage and preparation practices, including staff not wearing hair nets and food stored beneath a leaking freezer condenser line.
Deficiencies (2)
Facility failed to ensure an unlicensed employee providing more than limited assistance was certified as a home health aide or CNA.
Facility failed to ensure food was stored and served in a sanitary manner; staff hair was not covered and food was stored beneath a freezer condenser water line with condensation and ice.
Report Facts
Personal care assistants reviewed: 26
Residents present: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Holstein | Executive Director | Provided information regarding certification status and facility policies |
Inspection Report
Renewal
Deficiencies: 1
Date: Feb 18, 2025
Visit Reason
This was an offsite Licensure Investigation Survey conducted to review the facility's compliance with the requirement to submit a timely renewal application for their residential care facility license.
Findings
The facility failed to submit their license renewal application at least 45 days prior to the expiration of their current license, which expired on January 31, 2025. The renewal application and payment were postmarked February 2, 2025, which was late.
Deficiencies (1)
Facility failed to submit renewal application at least 45 days prior to license expiration.
Report Facts
Days late for renewal application submission: 2
Days required for timely submission: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Holstein | Executive Director | Signed the report and plan of correction |
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 0
Date: Jan 14, 2025
Visit Reason
This visit was for the Investigation of Complaints IN00450771 and IN00450732.
Complaint Details
Investigation of Complaints IN00450771 and IN00450732 found no deficiencies related to the allegations; facility was in compliance.
Findings
No deficiencies related to the allegations in complaints IN00450771 and IN00450732 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Report Facts
Residential Census: 99
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 0
Date: Oct 16, 2024
Visit Reason
This visit was conducted for the Investigation of Complaint IN00445006.
Complaint Details
Complaint IN00445006 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: 94
Deficiencies: 0
Date: Aug 9, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00440440.
Complaint Details
Complaint IN00440440 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: 94
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 1
Date: Jul 17, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00437910, IN00437350, IN00438368, and IN00438009.
Complaint Details
Complaint IN00438009 was substantiated with state deficiencies cited at R241 related to medication administration. Complaints IN00437910, IN00437350, and IN00438368 had no deficiencies related to the allegations.
Findings
The facility failed to ensure a medication was administered per the physician's order for 1 of 3 residents reviewed (Resident B). Specifically, a Rivastigmine patch was not changed as ordered, resulting in a medication administration error. No adverse effects were noted from this error.
Deficiencies (1)
Failed to ensure medication was administered per physician's order for Resident B; Rivastigmine patch was not changed as ordered.
Report Facts
Residential Census: 101
Medication administration error: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Holstein | Executive Director | Signed the report |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 0
Date: Jun 24, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00435597.
Complaint Details
Complaint IN00435597 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 applicable regulations regarding the complaint.
Inspection Report
Renewal
Census: 89
Deficiencies: 2
Date: May 1, 2024
Visit Reason
This visit was for a State Residential Licensure Survey conducted on April 30 and May 1, 2024, to assess compliance with state residential licensure requirements.
Findings
The facility was found noncompliant for failing to have a copy of the Residents' Rights available in a publicly accessible area during the survey and for failing to follow infection control standards by not performing hand hygiene or wearing gloves during eye drop administration for one resident.
Deficiencies (2)
Failed to ensure a copy of the Residents' Rights was available in a publicly accessible area for 2 of 2 days during the survey.
Failed to follow infection control standards by not performing hand hygiene or wearing gloves during administration of eye drops for 1 of 5 residents reviewed.
Report Facts
Residential Census: 89
Survey Dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Holstein | Executive Director | Provided information regarding Residents' Rights availability |
| Qualified Medication Aide 1 | Observed failing to perform hand hygiene and wear gloves during eye drop administration | |
| Director of Wellness | Provided facility policy on medication administration and indicated lack of policy on eye drop administration |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 1
Date: Apr 3, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00430382 related to medication administration errors at the facility.
Complaint Details
Complaint IN00430382 was substantiated with state deficiencies cited related to the allegations of medication administration errors.
Findings
The facility failed to ensure staff followed a physician's order when a discontinued medication patch was administered to one resident. The medication error was investigated, corrective actions were planned, and systemic changes were proposed to prevent recurrence.
Deficiencies (1)
Failed to ensure staff followed physician's order when a medication was administered after it had been discontinued for 1 of 3 residents reviewed (Resident B).
Report Facts
Residential Census: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Holstein | Executive Director | Signed the report |
| Memory Care Director | Interviewed regarding the medication error and investigation | |
| Director of Nursing | Interviewed and provided documentation related to the medication error investigation | |
| QMA | Admitted to administering the discontinued medication patch |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 0
Date: Feb 23, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00425089.
Complaint Details
Complaint IN00425089 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00425089 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Residential Census: 93
Inspection Report
Renewal
Census: 75
Deficiencies: 3
Date: May 11, 2023
Visit Reason
This visit was for a State Residential Licensure Survey conducted on May 11 and 12, 2023, to assess compliance with state regulations for residential care facilities.
Findings
The facility was found deficient in ensuring staff with current first aid certification were onsite at all times, completing semi-annual resident evaluations timely, and maintaining sanitary food storage and preparation areas. Corrective actions and monitoring plans were outlined for each deficiency.
Deficiencies (3)
Failed to ensure a staff member with current first aid certification worked onsite at all times for 4 of 7 days reviewed.
Failed to ensure a semi-annual evaluation was completed for 1 of 7 residents reviewed for semi-annual evaluations.
Failed to ensure food was stored in a sanitary manner; food was stored beneath a water line and the theater popcorn machine was not clean and had an undated container of popcorn oil.
Report Facts
Residential Census: 75
Days without first aid certified staff: 4
Residents reviewed for semi-annual evaluations: 7
Residents missing semi-annual evaluation: 1
Food storage days observed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Holstein | Executive Director | Provided schedule and certification cards; interviewed regarding deficiencies and corrective actions |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 0
Date: Feb 27, 2023
Visit Reason
This visit was conducted for the investigation of four complaints identified as IN00402050, IN00402366, IN00395997, and IN00395684.
Complaint Details
Complaints IN00402050, IN00402366, IN00395997, and IN00395684 were all unsubstantiated due to lack of evidence.
Findings
All four complaints were found to be unsubstantiated due to lack of evidence, and the facility was found to be in compliance with relevant regulations regarding the investigation of these complaints.
Report Facts
Residential Census: 87
Inspection Report
Re-Inspection
Census: 84
Deficiencies: 0
Date: Jan 20, 2023
Visit Reason
This visit was for a Post Survey Revisit (PSR) to the PSR completed on November 23, 2022 to the State Residential Licensure Survey completed on August 9, 2022.
Findings
Gentry Park was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to the PSR to the State Residential Licensure Survey.
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 0
Date: Nov 23, 2022
Visit Reason
This visit was for the investigation of complaints IN00392792 and IN00394221, conducted in conjunction with multiple Post Survey Revisits (PSRs) related to previous complaint investigations and a State Residential Licensure Survey.
Complaint Details
Complaint IN00394221 - Unsubstantiated due to lack of evidence. Complaint IN00392792 - Unsubstantiated due to lack of evidence. Complaint IN00391488 - Corrected. Complaint IN00389858 - Corrected. Complaint IN00388861 - Corrected.
Findings
The facility was found to be in compliance with Indiana State Department of Health regulations. Complaints IN00394221 and IN00392792 were unsubstantiated due to lack of evidence, while complaints IN00391488, IN00389858, and IN00388861 were corrected.
Report Facts
Residential Census: 91
Facility Number: 13766
Inspection Report
Follow-Up
Census: 91
Deficiencies: 0
Date: Nov 23, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to multiple complaint investigations and a State Residential Licensure Survey to verify correction of previous deficiencies.
Complaint Details
Complaints IN00388861, IN00389858, and IN00391488 were corrected. Complaints IN00394221 and IN00392792 were unsubstantiated due to lack of evidence.
Findings
The facility was found to be in compliance with Indiana State Department of Health regulations related to the PSR to Investigation of Complaint IN00388861. Several complaints were corrected, while two complaints were unsubstantiated due to lack of evidence.
Report Facts
Residential Census: 91
Inspection Report
Follow-Up
Census: 91
Deficiencies: 0
Date: Nov 23, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to multiple complaint investigations and a State Residential Licensure Survey to verify correction of previous deficiencies.
Complaint Details
Complaints IN00391488, IN00389858, and IN00388861 were corrected. Complaints IN00394221 and IN00392792 were unsubstantiated due to lack of evidence.
Findings
The facility was found to be in compliance with Indiana State Department of Health regulations. Several complaints were corrected, while two complaints were unsubstantiated due to lack of evidence.
Report Facts
Residential Census: 91
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Nov 23, 2022
Visit Reason
The inspection was conducted as part of the annual State Residential Licensure Survey to assess compliance with sanitation, safety, pet care, and food service regulations.
Findings
The facility was found to have deficiencies including unclean floors and heated tray holding carts, lack of annual veterinary examinations for resident pets, and failure to implement systemic plans of correction from a prior survey dated August 9, 2022.
Deficiencies (3)
Facility failed to ensure a clean and sanitary environment; carpet and hardwood floors were dirty in the East Hallway and Memory Care Unit.
Facility failed to ensure annual veterinary examinations for 3 resident pets (Resident 4, Resident 5, Resident 12).
Facility failed to maintain a heated tray holding cart in a clean manner on the Memory Care unit.
Report Facts
Deficiency citation date: Aug 9, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Holstein | Executive Director | Named as Executive Director providing policies and involved in interviews regarding deficiencies |
Inspection Report
Follow-Up
Census: 91
Deficiencies: 0
Date: Nov 23, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to multiple complaint investigations and a State Residential Licensure Survey. The visit was conducted to verify corrections of previous deficiencies and investigate complaints IN00389858, IN00388861, IN00391488, IN00392792, and IN00394221.
Complaint Details
Complaints IN00389858, IN00388861, and IN00391488 were corrected. Complaints IN00394221 and IN00392792 were unsubstantiated due to lack of evidence.
Findings
The facility was found to be in compliance with the Indiana State Department of Health regulations regarding the PSR to Investigation of Complaint IN00389858. Complaints IN00389858, IN00388861, and IN00391488 were corrected, while complaints IN00394221 and IN00392792 were unsubstantiated due to lack of evidence.
Report Facts
Residential Census: 91
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 2
Date: Oct 6, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00391488, which was substantiated with state deficiencies cited related to the allegations.
Complaint Details
Complaint IN00391488 was substantiated. The investigation found that Resident B exited the facility multiple times, including following a new resident's family out the memory care doors and holding open a fire exit door. The facility lacked documentation on wanderguard initiation and checks. The Administrator was not licensed in Indiana and no licensed administrator was appointed.
Findings
The facility neglected to prevent a cognitively impaired resident (Resident B) from exiting the facility multiple times, posing an elopement risk. Additionally, the facility failed to ensure a licensed administrator was appointed to work in the facility.
Deficiencies (2)
Facility neglected to prevent a cognitively impaired resident from exiting the facility for 1 of 3 residents reviewed for elopement (Resident B).
Facility failed to ensure a licensed administrator was appointed to work in the facility.
Report Facts
Residential Census: 87
Date of incident: Sep 29, 2022
Date of survey: Oct 6, 2022
Date of plan of correction completion: Oct 23, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Emily Bennett | RDO | Laboratory Director or Provider/Supplier Representative who signed the report |
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 1
Date: Sep 27, 2022
Visit Reason
This visit was for the investigation of complaints IN00389357 and IN00389898. Complaint IN00389357 was unsubstantiated due to lack of evidence, while complaint IN00389898 was substantiated with related state deficiencies cited.
Complaint Details
Complaint IN00389357 was unsubstantiated due to lack of evidence. Complaint IN00389898 was substantiated with state deficiencies cited at R53 related to verbal abuse of Resident B.
Findings
The facility failed to ensure a resident was free from verbal abuse for 1 of 3 residents reviewed (Resident B). A CNA was rude to Resident B, admitted the behavior, and was removed from the facility. The resident had a fall related to the incident but had no injury or recall of the event. Facility policies on abuse were reviewed and corrective actions including staff education and monitoring were implemented.
Deficiencies (1)
Facility failed to ensure a resident was free from verbal abuse for 1 of 3 residents reviewed (Resident B).
Report Facts
Residential Census: 90
Incident date: Sep 10, 2022
Audit duration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Emily Bennett | RDO | Laboratory Director or Provider/Supplier Representative who signed the report |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 1
Date: Aug 29, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00388861, which was substantiated with state deficiencies cited related to the allegations.
Complaint Details
Complaint IN00388861 was substantiated. The investigation found that Resident B exited the facility multiple times without alarms sounding, posing a risk to the resident and others.
Findings
The facility neglected to prevent a cognitively impaired resident (Resident B) from exiting the facility multiple times, despite alarms on exit doors and staff interventions. Resident B was subsequently transferred to a secure memory care unit.
Deficiencies (1)
Facility neglected to prevent a cognitively impaired resident from exiting the facility.
Report Facts
Residential Census: 91
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 10
Date: Aug 9, 2022
Visit Reason
This visit was for a State Residential Licensure Survey and included the Investigation of Complaint IN00386775, which was unsubstantiated due to lack of evidence.
Complaint Details
Complaint IN00386775 was investigated and found to be unsubstantiated due to lack of evidence.
Findings
The facility was found deficient in multiple areas including failure to post the location of the most recent annual State survey, insufficient staff with current First Aid certification on some shifts, unclean floors, untimely veterinary examinations for resident pets, missing admission weights for some residents, unsigned service plans, unclean heated tray holding cart, improper medication administration technique for inhaled steroids, missing annual health statements, and incomplete two-step tuberculin skin testing.
Deficiencies (10)
Failed to provide residents a posted, readily accessible notice of the location of the most recent annual State survey.
Failed to ensure a minimum of 1 employee with current First Aid certification on each shift for 4 of 7 days reviewed.
Failed to ensure a clean and sanitary environment; floors were dirty with debris and black stains.
Failed to ensure annual veterinary examinations were completed in a timely manner for 6 of 9 residents who housed pets.
Failed to ensure resident's weight was taken or documented upon admission for 2 of 7 residents reviewed.
Failed to ensure service plans were signed and dated by the resident or resident's representative for 7 of 7 residents reviewed.
Failed to maintain a heated tray holding cart in a clean manner on the Memory Care unit.
Failed to ensure staff were competent to administer a steroid inhaler; resident was not instructed to rinse mouth after use.
Failed to ensure annual health statements were documented indicating no evidence of tuberculosis in an infectious stage for 6 of 7 residents reviewed.
Failed to ensure a second step tuberculin skin test was completed prior to or upon admission for 2 of 7 residents reviewed.
Report Facts
Survey dates: August 8 and 9, 2022
Residential Census: 84
Days lacking First Aid certified staff: 4
Number of residents with untimely veterinary exams: 6
Residents missing admission weight: 2
Residents missing signed service plans: 7
Residents missing annual health statements: 6
Residents missing second step TB test: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wellness Partner 1 | Observed administering inhaled steroid medication incorrectly to Resident 8 | |
| Executive Director | Provided policies and interviews regarding multiple deficiencies | |
| Director of Nursing | Provided policy and interview regarding weights, service plans, and medication administration | |
| Wellness Director | Interviewed regarding missing service plan signatures and health statements | |
| Memory Care Director | Interviewed regarding cleanliness of heated tray holding cart |
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