Inspection Report Summary
The most recent inspection on February 20, 2025, found no deficiencies related to the investigation of three complaints and confirmed the facility’s compliance with state residential licensure regulations. Earlier inspections showed a mix of findings, including multiple deficiencies noted in December 2023 related to safety drills, staff certifications, facility maintenance, medication labeling, and documentation, as well as a late renewal application in August 2023. Complaint investigations from 2023 included a substantiated case of physical abuse by a staff member and issues with injury reporting, service plan revisions, and health follow-up, but most other complaints were unsubstantiated or corrected. No fines, immediate jeopardy findings, or license suspensions were listed in the available reports. The inspection history shows some improvement in recent complaint investigations, with the latest surveys indicating compliance and no new deficiencies.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
21% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
98 residents
Based on a February 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 0
Date: Feb 20, 2025
Visit Reason
This visit was for a State Residential Licensure Survey, which included the investigation of three complaints: IN00452888, IN00452820, and IN00452670.
Complaint Details
Complaints IN00452888, IN00452820, and IN00452670 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with the applicable state residential licensure regulations.
Report Facts
Residential Census: 98
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 0
Date: Aug 14, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00439868.
Complaint Details
Complaint IN00439868 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
Routine
Census: 97
Deficiencies: 8
Date: Dec 20, 2023
Visit Reason
This visit was for a State Residential Licensure Survey conducted on December 20 and 21, 2023.
Findings
The facility was found to have multiple deficiencies including failure to make the survey binder readily accessible to residents, lack of fire department participation in fire drills, insufficient CPR and First Aid certified staff on some shifts, failure to conduct yearly HVAC inspections, unsanitary dumpster and kitchen areas, unlabeled over-the-counter medications, and incomplete resident transfer documentation.
Deficiencies (8)
Failed to ensure a resident's right to examine the results of the most recent annual survey as the survey binder was not readily accessible to residents or visitors.
Failed to attempt to hold fire and disaster drills in conjunction with the local fire department at least every six months.
Failed to have at least one staff member certified in CPR and First Aid on each shift during the reviewed week.
Failed to ensure the facility's heating and ventilating systems had been inspected at least yearly.
Failed to ensure dumpster ground area was free of rubbish debris.
Failed to ensure the kitchen was clean and in good repair, including grease splatter, grime on vented slates, and gaps in drywall.
Failed to label over-the-counter medications with resident's name, apartment number, and date opened for one resident.
Failed to ensure a resident who was sent to the hospital had a complete transfer form including required documentation.
Report Facts
Residents affected: 97
Deficiency count: 8
Survey dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dana Milner | Laboratory Director or Provider/Supplier Representative | Signed the report |
| QMA 1 | Qualified Medication Aide | Observed administering medication and noted for unlabeled OTC medications |
| Director of Nursing | Director of Nursing | Provided schedules and interview regarding CPR certification and transfer documentation |
| Maintenance Director | Maintenance Director | Interviewed regarding survey binder location, fire drills, and HVAC inspections |
| Marketing Manager | Marketing Manager | Interviewed regarding survey binder accessibility and fire drill policy |
| Dietary Manager | Dietary Manager | Interviewed and observed regarding kitchen cleanliness and dumpster area |
| Sales Director | Sales Director | Placed the survey binder in the main lobby after deficiency was identified |
Inspection Report
Renewal
Deficiencies: 1
Date: Aug 28, 2023
Visit Reason
The inspection was an offsite Licensure Investigation Survey conducted to review the facility's compliance with state licensing requirements, specifically regarding timely submission of the renewal application.
Findings
The facility failed to submit a renewal application at least 45 days prior to the expiration of its license, as the renewal application was postmarked August 7, 2023, after the license expired on July 31, 2023. A Plan of Correction was submitted to address this deficiency.
Deficiencies (1)
Failure to submit a renewal application at least 45 days prior to license expiration.
Report Facts
Days late for renewal application: 7
Required days prior to expiration for renewal submission: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dana Milner | ED | Signed the report as Laboratory Director or Provider/Supplier Representative |
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 0
Date: Jul 10, 2023
Visit Reason
This visit was for the investigation of complaints IN00412465 and IN00412598, in conjunction with a Post Survey Revisit to investigation of complaint IN00409923 completed on 2023-06-06.
Complaint Details
Complaint IN00412465 - No deficiencies related to the allegation(s) are cited. Complaint IN00412598 - No deficiencies related to the allegation(s) are cited. Complaint IN00409923 - Corrected.
Findings
No deficiencies related to complaints IN00412465 and IN00412598 were cited. Complaint IN00409923 was corrected. The facility was found to be in compliance with relevant regulations.
Report Facts
Residential Census: 103
Inspection Report
Follow-Up
Census: 103
Deficiencies: 0
Date: Jul 10, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to Investigation of Complaint IN00409923 completed on 2023-06-06, conducted in conjunction with Investigations of Complaints IN00412465 and IN00412598 completed on 2023-07-10.
Complaint Details
Complaint IN00409923 was corrected. Complaints IN00412465 and IN00412598 had no deficiencies related to the allegations cited.
Findings
Complaint IN00409923 was corrected. No deficiencies related to Complaints IN00412465 and IN00412598 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the PSR to Investigation of Complaint IN00409923.
Report Facts
Residential Census: 103
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 1
Date: Jun 6, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00409923 regarding allegations of physical abuse of a resident by a staff member.
Complaint Details
Complaint IN00409923 was substantiated with findings of physical abuse by CNA 3 against Resident B. The CNA was suspended and then terminated. The facility reported the incident to the Indiana Department of Health on 06/02/23 and conducted a full investigation including video review and resident assessment.
Findings
The facility failed to ensure that one of four residents reviewed for abuse was not subjected to physical abuse by a staff member. Security video evidence showed a CNA physically striking Resident B. The CNA was immediately terminated following the investigation.
Deficiencies (1)
Facility failed to ensure Resident B was not subjected to physical abuse by a staff member.
Report Facts
Residential Census: 103
Date of incident: Jun 1, 2023
Date of report to state: Jun 2, 2023
Date of survey completion: Jun 6, 2023
Training hours: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dana Milner | Executive Director | Signed the report and involved in investigation oversight |
| CNA 3 | Certified Nursing Assistant | Staff member who physically abused Resident B and was terminated |
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 0
Date: May 22, 2023
Visit Reason
This visit was conducted for the investigation of three complaints: IN00406628, IN00408245, and IN00408248.
Complaint Details
Complaints IN00406628, IN00408245, and IN00408248 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Residential Census: 98
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 0
Date: Mar 9, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00403491.
Complaint Details
Complaint IN00403491 - No deficiencies related to the allegation is cited.
Findings
No deficiencies related to the allegation were cited. Greenbriar Village was found to be in compliance with 410 IAC 16.2-5 in regard to the Investigation of Complaint IN00403491.
Report Facts
Residential Census: 98
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 3
Date: Feb 21, 2023
Visit Reason
This visit was for the investigation of complaints IN00401690, IN00401349, and IN00393176 at Greenbriar Village.
Complaint Details
Complaint IN00401690, IN00401349, and IN00393176 were substantiated with state deficiencies cited at R0091, R0217, and R0240 related to abuse reporting, service plan revisions, and health services.
Findings
The facility was found to have substantiated deficiencies related to failure to report an injury of unknown origin, failure to revise service plans for residents with behavioral and fall risks, and failure to follow through with nutrition recommendations and post-fall assessments for certain residents.
Deficiencies (3)
Failed to report an injury of unknown origin for 1 of 3 residents reviewed for abuse (Resident B).
Failed to revise residents' service plans regarding fall risk and behaviors for 3 residents (Residents B, D, and F).
Failed to follow through with nutrition recommendations, timely address significant weight loss, and complete post-fall assessments for 2 residents (Residents B and F).
Report Facts
Residents reviewed for abuse: 3
Residents reviewed for falls: 3
Residents reviewed for weight loss: 3
Resident B census: 97
Resident F falls: 5
Resident B weight loss percentage: 4.6
Resident F weight loss percentage: 5.4
Inspection Report
Follow-Up
Census: 95
Deficiencies: 0
Date: Aug 22, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00382184 and IN00383132 completed on July 2, 2022.
Complaint Details
This visit was related to complaints IN00382184 and IN00383132. Both complaints were corrected.
Findings
Greenbriar Village was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of Complaints IN00382184 and IN00383132.
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