Inspection Report Summary
The most recent inspection on March 11, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a pattern of deficiencies primarily involving staff training, medication administration, resident neglect related to dementia care, food safety, and confidentiality issues. Several complaint investigations were substantiated, including cases of verbal abuse by staff, missed medications, resident elopement, and food temperature monitoring failures, but enforcement actions such as fines or license suspensions were not listed in the available reports. Most complaints without substantiated deficiencies were found to be unsubstantiated, and follow-up visits confirmed correction of prior issues. The facility’s record shows some improvement over time, with the most recent inspections indicating fewer or no deficiencies compared to earlier reports.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
7% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
110 residents
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 0
Date: Mar 11, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00454075.
Complaint Details
Investigation of Complaint IN00454075 found no deficiencies related to the allegations; facility was compliant.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 42 CFR 483, Subpart B and 410 IAC 16.2-5 regarding the complaint.
Report Facts
Facility number: 14148
Residential census: 110
Inspection Report
Original Licensing
Census: 104
Deficiencies: 1
Date: Jan 16, 2025
Visit Reason
This visit was for a State Residential Licensure Survey conducted on January 14, 15, and 16, 2025.
Findings
The facility failed to ensure dementia education was completed for 2 of 10 staff members reviewed. Specifically, Staff Member 5 and Staff Member 6 did not have completed dementia training in their records.
Deficiencies (1)
Failure to ensure dementia education was completed for 2 of 10 staff members reviewed (Staff Member 5 and 6).
Report Facts
Residential Census: 104
Staff members reviewed for dementia training: 10
Staff members without completed dementia training: 2
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 0
Date: Oct 21, 2024
Visit Reason
This visit was conducted for the Investigation of Complaint IN00439976.
Complaint Details
Complaint IN00439976 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 42 CFR 483, Subpart B and 410 IAC 16.2-5 regarding the complaint investigation.
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 3
Date: Jul 30, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00438318, which involved allegations of verbal abuse and other related concerns at the facility.
Complaint Details
Complaint IN00438318 was substantiated with state deficiencies cited related to verbal abuse, medication administration failures, and confidentiality breaches. The verbal abuse involved staff member 8 verbally abusing Resident H, leading to termination of the staff member. Medication administration failures involved Resident D missing multiple doses of prescribed medications due to unavailability. Confidentiality breach involved Resident B's medication documentation being taken by Resident D's family member, resulting in police involvement.
Findings
The facility was found to have failed to ensure a resident was free from verbal abuse by a staff member, failed to provide prescribed medications as ordered for a resident, and failed to safeguard confidential resident information from unauthorized use by other residents and visitors.
Deficiencies (3)
Facility failed to ensure a resident was free from verbal abuse by a staff member.
Facility failed to ensure residents were provided their prescribed medications as ordered for one resident.
Facility failed to safeguard clinical record information against unauthorized use, resulting in a HIPPA violation.
Report Facts
Residential Census: 116
Missed medication dates: 26
Missed medication dates: 3
Missed medication dates: 3
Missed medication dates: 6
Audit completion date: Aug 9, 2024
Plan of correction completion date: Aug 30, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lori L Lindsey-Clarkston | Executive Director | Named as Executive Director involved in interviews and oversight of the investigation. |
| Staff member 8 | Found to have verbally abused Resident H and was terminated from employment. | |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration and staff education. |
Inspection Report
Complaint Investigation
Census: 133
Deficiencies: 0
Date: Jul 3, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00434964.
Complaint Details
Complaint IN00434964 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 42 CFR 483, Subpart B and 410 IAC 16.2-5 regarding the complaint investigation.
Inspection Report
Complaint Investigation
Census: 133
Deficiencies: 3
Date: Mar 20, 2024
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaints IN00429614 and IN00421330.
Complaint Details
Complaints IN00429614 and IN00421330 were investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies were cited related to the complaints. Deficiencies were found related to personnel TB screening, food and nutritional services, and pharmaceutical services including medication administration errors.
Deficiencies (3)
Facility failed to screen new hire staff utilizing the 2-step process for TB testing for 5 of 5 staff reviewed.
Food was not labeled and dated in the main kitchen; waste containers were uncovered; dishwasher temperature logs were incomplete.
Facility failed to ensure medications were given as ordered for 1 of 6 residents reviewed for medication administration.
Report Facts
Residents present: 133
Staff with incomplete TB testing: 5
Residents reviewed for medication administration: 6
Residents with medication errors: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lori L Lindsey-Clarkston | Executive Director | Signed report and involved in administrative oversight |
| Staff Member 6 | Indicated medication should have been given and was notified by PCP | |
| Staff Member 7 | Did not give medication to Resident K | |
| Staff Member 8 | Did not give medication to Resident K |
Inspection Report
Complaint Investigation
Census: 133
Deficiencies: 7
Date: Apr 10, 2023
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaints IN00404536, IN00404943, IN00405633, and IN00401860.
Complaint Details
This visit included investigation of complaints IN00404536, IN00404943, IN00405633, and IN00401860. Deficiencies related to complaints IN00404536, IN00401860, and IN00405633 were cited. Complaint IN00404943 had no deficiencies related to the allegations.
Findings
The facility was found deficient in multiple areas including staff first aid certification, dementia training, tuberculosis screening for employees and residents, pet vaccination records, food labeling and dating, and medication controlled substance reconciliation.
Deficiencies (7)
Facility failed to ensure staff on duty met first aid training requirements for 4 of 21 shifts reviewed.
Facility failed to ensure staff received dementia training for 1 of 10 staff members reviewed.
Facility failed to perform employee health screenings for tuberculosis using the two-step skin test for 3 of 5 employees and yearly TB screening for 3 of 5 staff reviewed.
Facility failed to ensure a resident's pet was current with regular examinations and vaccinations by a licensed veterinarian for 1 of 17 resident pets reviewed.
Facility failed to ensure food was labeled and dated in the open kitchen and dry storage area for 1 of 1 kitchen reviewed.
Facility failed to ensure reconciliation of controlled drugs were completed for 1 of 1 medication room reviewed.
Facility failed to screen residents for yearly Tuberculosis for 6 of 7 residents reviewed.
Report Facts
Shifts without first aid certified staff: 4
Staff reviewed for dementia training: 10
Employees missing TB screening: 6
Resident pets reviewed: 17
Residents missing yearly TB screening: 6
Narcotic count reconciliation missing entries: 147
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lori L Lindsey-Clarkston | Executive Director | Interviewed regarding staff training and facility policies. |
| LPN 8 | Interviewed regarding controlled drug reconciliation process. | |
| LPN 4 | Interviewed regarding controlled drug reconciliation process. | |
| Director of Nursing | DON | Interviewed regarding narcotic count reconciliation and staff training. |
Inspection Report
Follow-Up
Census: 130
Deficiencies: 0
Date: Mar 30, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigations of Complaints IN00393077, IN00398338, and IN00401170 to verify correction of previous deficiencies.
Complaint Details
This visit was related to three complaints: IN00393077, IN00398338, and IN00401170. All complaints were found to be corrected.
Findings
The facility was found to be in compliance with 410 IAC 16.2-5 regarding the PSRs to the investigations of the three complaints, all of which were corrected.
Report Facts
Residential Census: 130
Inspection Report
Follow-Up
Census: 130
Deficiencies: 0
Date: Mar 30, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00401170 completed on February 8, 2023, conducted in conjunction with PSRs to Investigations of Complaints IN00393077 and IN00398338.
Complaint Details
This visit was related to complaint investigations IN00401170, IN00393077, and IN00398338, all of which were corrected.
Findings
Glasswater Creek of Lafayette, LLC was found to be in compliance with 410 IAC 16.2-5 regarding the PSR to Investigation of Complaint IN00401170. All three complaints were corrected.
Report Facts
Residential Census: 130
Inspection Report
Follow-Up
Census: 130
Deficiencies: 0
Date: Mar 30, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00398338 completed on January 19, 2023, conducted in conjunction with PSRs for Complaints IN00393077 and IN00401170.
Complaint Details
This visit was related to complaint investigations IN00398338, IN00393077, and IN00401170. All complaints were corrected.
Findings
The facility was found to be in compliance with 410 IAC 16.2-5 regarding the PSR to Investigation of Complaint IN00398338. All three complaints were corrected.
Report Facts
Residential Census: 130
Inspection Report
Complaint Investigation
Census: 132
Deficiencies: 2
Date: Feb 8, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00401170, which was substantiated with related state residential findings cited.
Complaint Details
Complaint IN00401170 was substantiated with state residential findings related to food temperature monitoring and ice machine sanitation.
Findings
The facility failed to ensure food temperatures were checked and recorded prior to serving meals on multiple dates in December 2022, January 2023, and February 2023, potentially affecting all 132 residents. Additionally, the facility failed to ensure the ice machine in the kitchen was cleaned and ice cubes were safe for resident consumption, also potentially affecting all residents.
Deficiencies (2)
Failed to ensure food temperatures were checked prior to serving meals in December 2022, January 2023, and February 2023.
Failed to ensure the ice machine was cleaned and ice cubes were safe for residents.
Report Facts
Residents potentially affected: 132
Residents potentially affected: 132
Dates missing temperature records: 10
Date of compliance: Feb 25, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Aide 3 | Interviewed regarding food temperature checks and ice machine substance | |
| Cook 2 | Interviewed regarding food temperature checks and documentation | |
| Administrator In Training (AIT) | Interviewed regarding missing temperature records and ice machine servicing | |
| Acting Dietary Manager | Interviewed regarding missing temperature records and ice machine cleaning | |
| Dietary Aide 4 | Reported mold-like substance on ice machine ice cubes |
Inspection Report
Complaint Investigation
Census: 134
Deficiencies: 1
Date: Jan 19, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00398338, which was substantiated with a related State Residential Finding cited at R0052.
Complaint Details
Complaint IN00398338 was substantiated. The resident left the facility unnoticed for 43 minutes before the police contacted the facility. The resident was found one mile away, unharmed, and placed on 1:1 observation until discharge. The facility had no locked doors and residents were free to leave, but staff were unaware the resident had left until the alarm sounded. The police found the resident before the facility notified them.
Findings
The facility failed to ensure a resident with dementia was free from neglect when the resident exited the facility through an alarmed exit door and was off facility property for approximately 43 minutes, traveling one mile away. The resident was unharmed but the staff were not aware the resident had left until the alarm sounded and the police contacted the facility.
Deficiencies (1)
Failed to ensure a resident with dementia was free from neglect when the resident exited the facility through an alarmed exit door and was off facility property for one of four residents reviewed for neglect.
Report Facts
Residential Census: 134
Minutes resident was missing: 43
Distance resident traveled: 1
Residents audited: 58
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DeAnna Zimmerman | Director of Nursing | Named as Director of Nursing responsible for notification and oversight related to the deficiency |
Inspection Report
Complaint Investigation
Census: 131
Deficiencies: 0
Date: Dec 19, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00395089.
Complaint Details
Complaint IN00395089 was unsubstantiated due to lack of evidence.
Findings
The complaint IN00395089 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.
Inspection Report
Complaint Investigation
Census: 133
Deficiencies: 1
Date: Oct 28, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00393077, which was substantiated with state deficiencies cited related to the allegations.
Complaint Details
Complaint IN00393077 was substantiated. The investigation found neglect related to a resident with dementia leaving the facility unnoticed and not signing out in the log book as required.
Findings
The facility failed to ensure a resident with dementia was free from neglect when the resident exited the facility through a non-alarmed exit door and was outside late at night for an undetermined amount of time without staff knowledge. The resident was found unharmed by police approximately half a mile from the facility and placed on increased monitoring. The resident's dementia diagnosis was not timely added to the record, and care plans were not updated accordingly.
Deficiencies (1)
Failed to ensure a resident with dementia was free from neglect when the resident exited the facility through a non-alarmed exit door and was outside late at night for an undetermined amount of time without staff knowledge.
Report Facts
Residential Census: 133
SLUMS score: 15
Distance resident found from facility: 0.5
Check frequency: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lori L Lindsey-Clarkston | RN, Administrator in Training | Provided the Indiana State Department of Health Survey Report System document and signed the report |
| CNA 3 | Confirmed resident was returned by police and was unaware resident had left the building | |
| Director of Nursing | DON | Indicated dementia diagnosis was not added to resident notes and no new service plan was created |
| CNA 2 | Observed resident on 10/22/2022 and was unaware resident had left the building |
Inspection Report
Re-Inspection
Census: 128
Deficiencies: 0
Date: Aug 24, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00374334, IN00375469, and IN00383332 completed on June 23, 2022.
Complaint Details
This was a complaint-related visit involving three complaints (IN00374334, IN00375469, IN00383332), all of which were corrected.
Findings
The facility was found to be in compliance with 410 IAC 16.2-5 regarding the Post Survey Revisit Investigation of the three complaints, all of which were corrected.
Report Facts
Residential Census: 128
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