Inspection Reports for Greenwood Meadows
1200 N State Rd 135, Greenwood, IN 46142, United States, IN, 46142
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 2, 2025, found no deficiencies related to complaint investigations. Earlier inspections showed a pattern of deficiencies primarily involving Life Safety Code compliance, such as issues with fire doors, emergency lighting, and corridor obstructions, as well as some resident care concerns including medication administration, monitoring of weight loss, and therapeutic diet provision. A substantiated complaint in March 2024 cited failures to protect a resident from verbal abuse and to promptly remove the alleged perpetrator, with corrective actions taken by the facility. Most complaint investigations were unsubstantiated or found no related deficiencies, and enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows improvement in recent complaint investigations, though Life Safety Code issues have recurred over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
10.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
145% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
146 residents
Based on a July 2025 inspection.
Census over time
Inspection Report
Annual Inspection
Deficiencies: 2
Dec 5, 2025
Visit Reason
The inspection was conducted to evaluate compliance with care planning and assessment accuracy requirements as part of the facility's annual survey.
Findings
The facility failed to ensure that one resident was included in their care planning process and failed to ensure an accurate MDS assessment for another resident, specifically related to PASARR Level II and depression diagnosis documentation.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure the resident was included in their care planning process for 1 of 1 resident reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure an accurate assessment for 1 of 25 residents reviewed for MDS assessment accuracy, including incorrect PASARR Level II and depression diagnosis coding. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for MDS assessment accuracy: 25
Residents affected: 1
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Indicated no documentation of resident inclusion in care planning process |
| MDS Coordinator | MDS Coordinator | Indicated errors in care planning inclusion and MDS assessment coding |
Inspection Report
Complaint Investigation
Census: 146
Deficiencies: 0
Jul 2, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00461322 and IN00462553 at Greenwood Meadows.
Findings
No deficiencies related to the allegations in complaints IN00461322 and IN00462553 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00461322 and Complaint IN00462553 were investigated with no deficiencies related to the allegations cited.
Report Facts
Census: 146
SNF/NF Beds: 124
SNF Beds: 22
Medicare Residents: 13
Medicaid Residents: 83
Other Residents: 50
Inspection Report
Complaint Investigation
Census: 149
Deficiencies: 0
Jun 5, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00460479.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00460479 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 149
Census Bed Type - SNF/NF: 126
Census Bed Type - SNF: 23
Census Payor Type - Medicare: 14
Census Payor Type - Medicaid: 81
Census Payor Type - Other: 54
Inspection Report
Complaint Investigation
Census: 145
Deficiencies: 0
Mar 13, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00455342.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00455342; no deficiencies related to the allegations were cited.
Report Facts
Census: 145
Census Bed Type - SNF/NF: 123
Census Bed Type - SNF: 22
Census Payor Type - Medicare: 17
Census Payor Type - Medicaid: 77
Census Payor Type - Other: 51
Inspection Report
Complaint Investigation
Census: 134
Deficiencies: 0
Feb 5, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00452786 and IN00452643 at Greenwood Meadows.
Findings
No deficiencies related to the allegations in complaints IN00452786 and IN00452643 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00452786 and Complaint IN00452643 were investigated with no deficiencies cited related to the allegations.
Report Facts
Census Bed Type Total: 134
Census Payor Type Total: 134
SNF/NF Beds: 114
SNF Beds: 20
Medicare Residents: 12
Medicaid Residents: 77
Other Residents: 45
Inspection Report
Complaint Investigation
Census: 133
Deficiencies: 0
Jan 30, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00452066.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00452066 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type Total: 133
Census Payor Type Total: 133
Medicare Census: 9
Medicaid Census: 82
Other Payor Census: 42
Inspection Report
Complaint Investigation
Census: 133
Deficiencies: 0
Dec 30, 2024
Visit Reason
This visit was conducted to investigate Complaints IN00449978 and IN00449058 at Greenwood Meadows.
Findings
No deficiencies related to the allegations in Complaints IN00449978 and IN00449058 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00449978 - No deficiencies related to the allegations are cited. Complaint IN00449058 - No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type - SNF/NF: 111
Census Bed Type - SNF: 22
Census Bed Type - Total: 133
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 89
Census Payor Type - Other: 40
Census Payor Type - Total: 133
Inspection Report
Complaint Investigation
Census: 140
Deficiencies: 0
Dec 9, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00447599 and IN00448136 at Greenwood Meadows.
Findings
No deficiencies related to the allegations in complaints IN00447599 and IN00448136 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00447599 - No deficiencies related to the allegations are cited. Complaint IN00448136 - No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type: 140
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 88
Census Payor Type - Other: 47
Inspection Report
Re-Inspection
Census: 144
Capacity: 169
Deficiencies: 0
Dec 6, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 10/07/24 was performed to verify compliance with previous deficiencies.
Findings
Greenwood Meadows was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code. The facility was fully sprinklered with appropriate fire alarm and smoke detection systems.
Inspection Report
Life Safety
Census: 135
Capacity: 169
Deficiencies: 7
Oct 7, 2024
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 standards.
Findings
The facility was found not in compliance with several Life Safety Code requirements including corridor width obstructions, emergency lighting battery failure, missing sprinkler system inspection documentation, overdue portable fire extinguisher maintenance, lack of combustion air for dryers, combustible decorations on corridor doors, and improper operation of a rolling steel fire door.
Severity Breakdown
SS=E: 3
SS=F: 2
SS=D: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to meet clear corridor width requirements due to furniture stored on both sides of the corridor reducing unobstructed width to six feet. | SS=E |
| Battery powered emergency lighting system failed to illuminate when tested. | SS=F |
| Failed to document monthly wet sprinkler gauge inspections for the most recent twelve months. | SS=F |
| One of 23 portable fire extinguishers was not maintained at intervals not more than one year apart. | SS=D |
| Dryer room failed to be continuously provided with intake combustion air from outside due to unsynchronized Louvre systems. | SS=D |
| Two corridor doors had combustible paper decorations exceeding allowed coverage and were not fire retardant. | SS=E |
| Rolling steel fire door between kitchen and main dining room was not self-closing, automatic closing, or connected to fire alarm system. | SS=E |
Report Facts
Certified beds: 169
Census: 135
Portable fire extinguishers: 23
Corridors with width issues: 1
Corridor doors with combustible decorations: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laura Carter | Executive Director | Signed report and participated in exit conference |
| Maintenance Director | Named in multiple findings related to corridor furniture, emergency lighting, sprinkler system, fire extinguishers, dryer room combustion air, combustible decorations, and rolling steel door | |
| Field Maintenance Supervisor | Participated in observations and exit conference related to multiple deficiencies | |
| Director of Property Management | Participated in record reviews and interviews related to sprinkler system and rolling steel door |
Inspection Report
Renewal
Census: 133
Capacity: 133
Deficiencies: 3
Sep 23, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted over multiple days in September 2024.
Findings
The facility was cited for deficiencies including failure to notify a provider of abnormal lab results for one resident, failure to monitor and intervene for significant weight loss in another resident, and failure to provide a therapeutic diet for a diabetic resident. Plans of correction and systemic changes were proposed for each deficiency.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to notify a provider of laboratory results that fell outside of clinical reference ranges for 1 of 5 residents reviewed for unnecessary medications (Resident 105). | SS=D |
| Failed to monitor weights and implement interventions for a resident with assessed significant weight loss (Resident 27). | SS=D |
| Failed to ensure a resident with type 2 diabetes mellitus received a therapeutic diet (Resident 283). | SS=D |
Report Facts
Census: 133
Total Capacity: 133
Survey Dates: 5
Residents with abnormal blood glucose not reported: 5
Weight loss percentage: 11.58
Weight loss percentage: 6.45
Weight loss percentage: 6.67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Provided interviews and facility policies related to blood glucose monitoring, weight monitoring, and diet management |
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 23, 2024
Visit Reason
The visit was a paper compliance review for the Annual Recertification and State Licensure survey conducted on September 23, 2024.
Findings
Greenwood Meadows was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Routine
Deficiencies: 3
Sep 23, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication management, nutrition, and dietary needs for residents at Greenwood Meadows nursing home.
Findings
The facility failed to notify a physician of abnormal blood glucose results for one resident, failed to monitor and intervene for significant weight loss in another resident, and failed to ensure a diabetic resident received a therapeutic diabetic diet consistent with hospital discharge instructions.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to notify a provider of laboratory results that fell outside of clinical reference ranges for 1 of 5 residents reviewed for unnecessary medications (Resident 105). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to monitor weights and implement interventions for a resident with assessed significant weight loss (Resident 27). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a resident with type 2 diabetes mellitus received a therapeutic diet (Resident 283). | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Blood glucose readings above 400 mg/dL: 5
Weight loss percentage: 11.58
Weight loss percentage: 6.67
Additional calories from benecalorie supplement: 330
Blood sugar range: 130
Blood sugar range: 260
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided facility policies and interviews regarding blood glucose monitoring, weight monitoring, and dietary procedures. |
Inspection Report
Complaint Investigation
Census: 137
Deficiencies: 0
Aug 27, 2024
Visit Reason
This visit was conducted for the investigation of three complaints (IN00437249, IN00440875, and IN00441764) and included a Covid-19 Focused Infection Control Survey.
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 federal and state regulations regarding the complaints and the Covid-19 infection control survey.
Complaint Details
Complaints IN00437249, IN00440875, and IN00441764 were investigated and no deficiencies related to the allegations were cited.
Report Facts
Census Bed Type - SNF/NF: 117
Census Bed Type - SNF: 20
Census Total: 137
Census Payor Type - Medicare: 13
Census Payor Type - Medicaid: 80
Census Payor Type - Other: 44
Census Payor Type - Total: 137
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 27, 2024
Visit Reason
The inspection was conducted as a standard annual survey of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, indicating the facility met all required standards at the time of the survey.
Inspection Report
Complaint Investigation
Census: 134
Deficiencies: 0
May 14, 2024
Visit Reason
This visit was conducted to investigate complaints IN00433513 and IN00434088 at Greenwood Meadows.
Findings
No deficiencies related to the allegations in complaints IN00433513 and IN00434088 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00433513 and Complaint IN00434088 were investigated with no deficiencies found related to the allegations.
Report Facts
Census Bed Type: 134
SNF/NF beds: 112
SNF beds: 22
Census Payor Type - Medicare: 10
Census Payor Type - Medicaid: 73
Census Payor Type - Other: 51
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 16, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00428632 completed on March 13, 2024.
Findings
Greenwood Meadows was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Complaint Investigation.
Complaint Details
Investigation of Complaint IN00428632 completed on March 13, 2024; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 133
Deficiencies: 2
Mar 13, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00428632 and IN00429267. Complaint IN00428632 resulted in federal/state deficiencies related to abuse and neglect, while complaint IN00429267 had no deficiencies cited.
Findings
The facility failed to protect a resident's right to be free from verbal abuse by a staff member (CNA 1) and failed to immediately remove the alleged perpetrator from the facility. The investigation confirmed CNA 1 used foul language toward Resident B and did not leave the facility when instructed, requiring police intervention. The facility has since suspended CNA 1 and implemented staff education and monitoring to prevent recurrence.
Complaint Details
Complaint IN00428632 was substantiated with deficiencies cited at F600 and F610 related to abuse and neglect. Complaint IN00429267 had no deficiencies cited.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to protect a resident's right to be free from verbal abuse by a staff member. | SS=D |
| Failed to follow abuse policy and ensure alleged perpetrator was immediately removed from the facility. | SS=D |
Report Facts
Census: 133
Deficiencies cited: 2
Residents reviewed for abuse: 3
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in verbal abuse finding and failure to leave facility when instructed |
| LPN 1 | Licensed Practical Nurse | Reported abuse, intervened during incident, and called police |
| Administrator | Provided witness statement and oversaw investigation | |
| DON | Director of Nursing | Informed of incident and directed removal of CNA 1 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Mar 13, 2024
Visit Reason
The inspection was conducted in response to a complaint alleging verbal abuse by a staff member (CNA 1) towards a resident (Resident B). The investigation focused on ensuring resident protection from abuse and verifying the facility's response to the alleged abuse.
Findings
The facility failed to protect a resident from verbal abuse by a staff member and failed to immediately remove the alleged perpetrator from the facility. The investigation confirmed that CNA 1 used foul language towards Resident B and refused to leave the facility when instructed, requiring police intervention.
Complaint Details
Complaint IN00428632 involved allegations of verbal abuse by CNA 1 towards Resident B. The complaint was substantiated based on interviews and record review. The facility failed to immediately remove CNA 1 after the incident, requiring police involvement.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to protect a resident's right to be free from verbal abuse by a staff member. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow the abuse policy and ensure an alleged perpetrator of abuse was immediately removed from the facility. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for abuse: 3
Residents affected: 1
Date of incident: Feb 29, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Reported and intervened in the verbal abuse incident involving CNA 1 and Resident B |
| CNA 1 | Certified Nursing Assistant | Alleged perpetrator of verbal abuse towards Resident B |
| Administrator | Provided witness statements and managed the investigation | |
| DON | Director of Nursing | Informed about the incident and provided facility policy on abuse |
Inspection Report
Complaint Investigation
Census: 144
Deficiencies: 0
Feb 7, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00427333 and IN00426842.
Findings
No deficiencies related to the allegations in complaints IN00427333 and IN00426842 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00427333 and Complaint IN00426842 were investigated with no deficiencies found related to the allegations.
Report Facts
Census Bed Type - SNF: 22
Census Bed Type - SNF/NF: 122
Total Census: 144
Census Payor Type - Medicare: 15
Census Payor Type - Medicaid: 73
Census Payor Type - Other: 56
Inspection Report
Complaint Investigation
Census: 151
Deficiencies: 0
Jan 18, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00424089 and IN00424184.
Findings
No deficiencies related to the allegations in complaints IN00424089 and IN00424184 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00424089 - No deficiencies related to the allegations are cited. Complaint IN00424184 - No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type - SNF: 25
Census Bed Type - SNF/NF: 126
Total Census: 151
Census Payor Type - Medicare: 23
Census Payor Type - Medicaid: 71
Census Payor Type - Other: 57
Inspection Report
Complaint Investigation
Census: 141
Deficiencies: 0
Dec 13, 2023
Visit Reason
This visit was for the Investigation of Complaints IN00419302 and IN00422035.
Findings
No deficiencies related to the allegations in complaints IN00419302 and IN00422035 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaints IN00419302 and IN00422035 found no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF: 22
Census Bed Type - SNF/NF: 119
Total Census: 141
Census Payor Type - Medicare: 16
Census Payor Type - Medicaid: 73
Census Payor Type - Other: 52
Inspection Report
Re-Inspection
Census: 141
Capacity: 169
Deficiencies: 0
Nov 27, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 10/02/23.
Findings
At this PSR survey, Greenwood Meadows was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Report Facts
Certified beds: 169
Census: 141
Inspection Report
Life Safety
Census: 140
Capacity: 169
Deficiencies: 9
Oct 2, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal regulations and state codes.
Findings
The facility was found not in compliance with several Life Safety Code requirements including emergency power system testing, corridor door self-closing and latching, exit door code accessibility, hazardous area separations, sprinkler system maintenance, smoke barrier door functionality, and fire drill scheduling. The emergency generator monthly load testing was not performed within required intervals.
Severity Breakdown
SS=C: 3
SS=E: 6
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to implement emergency power system inspection, testing, and maintenance requirements; monthly load testing was greater than 40 days apart. | SS=C |
| One corridor door set in the 500 Hall would not self close and latch into the door frame. | SS=E |
| Means of egress through 2 of 7 exits were not readily accessible due to incorrect or missing exit door codes. | SS=E |
| Failed to ensure 3 of over 18 hazardous areas were separated by smoke resistant partitions and doors; issues included door frame separation, unsealed pipe penetrations, and missing self-closing device on storage room door. | SS=E |
| Failed to maintain ceiling construction in refreshment pantry storage room; missing ceiling tiles could delay sprinkler activation. | SS=E |
| Two corridor doors to resident sleeping rooms (Room 401 and Room 520) had impediments to closing and latching, failing to resist passage of smoke. | SS=E |
| One set of smoke barrier doors by Room 304 was held open with a magnetic device and the door dragged on the floor, preventing full self-closing and smoke restriction. | SS=E |
| Failed to conduct quarterly fire drills at unexpected times on the third shift for 4 of 4 quarters; most drills occurred around 5:00 a.m. | SS=C |
| Failed to document emergency generator monthly load testing for one month; load testing intervals exceeded 40 days. | SS=C |
Report Facts
Certified beds: 169
Census: 140
Emergency generator rating: 275
Days between monthly load tests: 40
Third shift fire drills: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laura Dyer | Executive Director | Named in relation to exit conference and findings review |
Inspection Report
Annual Inspection
Census: 140
Capacity: 140
Deficiencies: 2
Sep 14, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00416539.
Findings
The facility was found deficient in two areas: failure to ensure proper catheter care to prevent urinary tract infections for one resident, and failure to maintain and post accurate daily nurse staffing information sheets. No deficiencies were related to the complaint investigation.
Complaint Details
Complaint IN00416539 was investigated and no deficiencies related to the allegations were cited.
Severity Breakdown
Level D: 1
Level C: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure a resident with an indwelling catheter received care to prevent urinary tract infections; catheter tubing and bag were resting on the floor. | Level D |
| Failure to ensure the daily nurse staffing information sheet was changed each day, broken down by licensed staff categories, and maintained for 18 months. | Level C |
Report Facts
Census: 140
Licensed Capacity: 140
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laura Dyer | Executive Director | Signed the report as Laboratory Director or Provider/Supplier Representative |
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 14, 2023
Visit Reason
The inspection was a paper compliance review for the Annual Recertification and State Licensure Survey conducted on September 14, 2023.
Findings
Greenwood Meadows was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure Survey.
Inspection Report
Routine
Deficiencies: 2
Sep 14, 2023
Visit Reason
The inspection was conducted to assess compliance with care standards related to catheter care and nurse staffing documentation at Greenwood Meadows nursing home.
Findings
The facility failed to ensure appropriate catheter care for a resident with an indwelling catheter, resulting in tubing touching the floor despite care plans. Additionally, the facility did not maintain daily nurse staffing information sheets properly, failing to update them daily, break down hours by staff category, and retain them for the required 18 months.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Level of Harm - Potential for minimal harm: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide appropriate care for residents with indwelling catheters to prevent urinary tract infections, with catheter tubing and bag resting on the floor. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to post nurse staffing information daily, break down total hours by licensed staff categories, and maintain staffing sheets for 18 months. | Level of Harm - Potential for minimal harm |
Report Facts
Residents affected: 1
Residents affected: 1
Dates of urinalysis indicating UTI: 5/16/23, 6/19/23, 7/21/23
Date of catheter care plan: 5/5/23
Date of antibiotic order: 9/13/23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| 100 hall Unit Manager | Interviewed regarding catheter care and observed tubing touching the floor | |
| Administrator | Interviewed regarding nurse staffing information sheet update frequency | |
| Regional Director of Clinical (RDC) | Interviewed regarding nurse staffing information sheet changes and availability | |
| Director of Nursing | Provided facility policy on nurse staffing data and retention requirements |
Inspection Report
Complaint Investigation
Census: 137
Deficiencies: 0
Aug 9, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00412753 and IN00414685.
Findings
No deficiencies related to the allegations in complaints IN00412753 and IN00414685 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00412753 - No deficiencies related to the allegations are cited. Complaint IN00414685 - No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type: 137
Census Payor Type - Medicare: 24
Census Payor Type - Medicaid: 72
Census Payor Type - Other: 41
Census Bed Type - SNF: 20
Census Bed Type - SNF/NF: 117
Inspection Report
Complaint Investigation
Census: 134
Deficiencies: 0
Jul 5, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00411823.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00411823 found no deficiencies related to the allegations.
Report Facts
Census Bed Type Total: 134
Census Payor Type Total: 134
SNF/NF Beds: 119
SNF Beds: 15
Medicare Residents: 11
Medicaid Residents: 74
Other Payor Residents: 49
Inspection Report
Complaint Investigation
Census: 140
Deficiencies: 0
May 17, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00402035 and IN00402986.
Findings
No deficiencies related to the allegations in complaints IN00402035 and IN00402986 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00402035 and Complaint IN00402986 were investigated with no deficiencies cited related to the allegations.
Report Facts
Census Bed Type: 140
Census Payor Type - Medicare: 16
Census Payor Type - Medicaid: 70
Census Payor Type - Other: 54
Inspection Report
Complaint Investigation
Census: 139
Deficiencies: 0
Feb 3, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00399929.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00399929 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Census: 139
SNF/NF beds: 118
SNF beds: 21
Medicare residents: 19
Medicaid residents: 65
Other payor residents: 55
Inspection Report
Complaint Investigation
Census: 142
Deficiencies: 0
Jan 19, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00399286.
Findings
The complaint was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00399286 was investigated and found unsubstantiated due to lack of evidence.
Report Facts
Census Bed Type Total: 142
Census Payor Type Total: 142
SNF/NF Census: 121
SNF Census: 21
Medicare Census: 21
Medicaid Census: 74
Other Payor Census: 47
Inspection Report
Re-Inspection
Census: 139
Capacity: 169
Deficiencies: 0
Jan 11, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 11/17/22 was performed to verify compliance with fire safety and licensure requirements.
Findings
Greenwood Meadows was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered with appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 169
Census: 139
Inspection Report
Complaint Investigation
Census: 132
Deficiencies: 0
Jan 6, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00398172.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00398172 was substantiated, but no deficiencies related to the allegations were cited.
Report Facts
Census Bed Type Total: 132
Census Payor Type Total: 132
SNF/NF Census: 112
SNF Census: 20
Medicare Census: 23
Medicaid Census: 70
Other Payor Census: 39
Inspection Report
Complaint Investigation
Census: 137
Deficiencies: 0
Dec 21, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00396500.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00396500 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Census Bed Type Total: 137
Census Payor Type Medicare: 25
Census Payor Type Medicaid: 79
Census Payor Type Other: 33
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 19, 2022
Visit Reason
Paper compliance review to the Investigation of Complaint IN00394996 completed on November 22, 2022.
Findings
Greenwood Meadows was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Complaint Details
Investigation of Complaint IN00394996 completed on November 22, 2022; paper compliance review found the facility in compliance.
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 22, 2022
Visit Reason
The inspection was conducted in response to a complaint (IN00394996) regarding medication administration errors at the facility.
Findings
The facility failed to ensure rapid acting insulin was administered to the correct resident, resulting in Resident B receiving Resident C's insulin dose. The error was identified after Resident B reported feeling low and subsequent blood sugar monitoring and treatment were provided. The clinical record for Resident B lacked a diabetes diagnosis and a physician's order for insulin aspart. Staff training and monitoring plans were implemented following the incident.
Complaint Details
This Federal tag relates to Complaint IN00394996.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure administration of rapid acting insulin to the correct resident, resulting in insulin being given to the wrong resident. | SS=D |
Report Facts
Insulin dose administered in error: 14
Blood sugar levels: 58
Blood sugar levels: 63
Blood sugar levels: 71
Glucagon dose: 1
Blood sugar levels: 119
Blood sugar levels: 141
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| R. Shane McFall | Executive Director | Signed the report. |
| RN 1 | Registered Nurse | Administered insulin to the wrong resident. |
| Director of Nursing | Director of Nursing | Provided nursing skills competency and facility policy documents; involved in notification and follow-up. |
Inspection Report
Life Safety
Census: 134
Capacity: 169
Deficiencies: 3
Nov 17, 2022
Visit Reason
The survey was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Life Safety Code requirements, including issues with corridor doors not latching properly to resist smoke passage, breaches in smoke barrier walls, and incomplete annual inspection and testing of all fire door assemblies.
Severity Breakdown
SS=E: 2
SS=F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 4 of over 50 corridor doors to resident sleeping rooms had no impediment to closing and latching into the door frame and would resist the passage of smoke. | SS=E |
| Failed to ensure 1 of 9 smoke barrier walls were protected to maintain the fire resistance of the smoke barrier due to holes not firestopped. | SS=E |
| Failed to ensure annual inspection and testing of all fire door assemblies were completed in accordance with LSC requirements; annual inspection documentation did not include all fire doors in the facility. | SS=F |
Report Facts
Certified beds: 169
Census: 134
Corridor doors with issues: 4
Smoke barrier walls with breaches: 1
Additional fire doors inspected: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| R. Shane McFall | Executive Director | Named in relation to review of findings and exit conference |
Inspection Report
Complaint Investigation
Census: 137
Deficiencies: 0
Nov 1, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00393430.
Findings
The complaint IN00393430 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00393430 was investigated and found unsubstantiated due to lack of evidence.
Report Facts
Census: 137
Census SNF/NF beds: 118
Census SNF beds: 19
Census Payor Type Medicare: 19
Census Payor Type Medicaid: 77
Census Payor Type Other: 41
Inspection Report
Annual Inspection
Census: 136
Capacity: 136
Deficiencies: 5
Oct 24, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00391836, IN00391512, and IN00390215.
Findings
The facility was found deficient in several areas including failure to complete self-medication administration assessments, failure to notify physicians of changes in condition after falls, failure to implement care plan interventions for falls, failure to maintain residents' highest practicable well-being including follow-up on skin conditions and diabetes care, and failure to ensure ongoing assessment and communication regarding dialysis treatments.
Complaint Details
Complaint IN00391836 was unsubstantiated due to lack of evidence. Complaint IN00391512 was substantiated but no deficiencies related to the allegations were cited. Complaint IN00390215 was unsubstantiated due to lack of evidence.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure a self medication administration assessment was completed for 1 of 7 residents observed for medication administration. | SS=D |
| Failed to notify the physician of a change in condition for 1 of 4 residents reviewed for falls. | SS=D |
| Failed to implement care plan interventions for 1 of 4 residents reviewed for falls; neon tape was not applied to wheelchair breaks. | SS=D |
| Failed to ensure care and services were provided to maintain the residents highest practicable well being for 1 of 2 residents reviewed for skin conditions and 1 of 3 residents reviewed for hospitalizations. | SS=D |
| Failed to ensure ongoing assessment and oversight of the resident before, during, and after dialysis treatments, including monitoring the resident's condition during treatments, and failed to have ongoing communication and collaboration with the dialysis facility for 1 of 1 resident reviewed for dialysis services. | SS=D |
Report Facts
Census SNF/NF beds: 117
Census SNF beds: 19
Total Census: 136
Medicare residents: 15
Medicaid residents: 78
Other payor residents: 43
Dialysis visits without communication notes: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| R. Shane McFall | Executive Director | Signed the report |
| Qualified Medication Aide 1 | Observed handing medication to Resident 220 without self-medication assessment | |
| Director of Nursing Services | DNS | Interviewed regarding medication administration and fall physician notification |
| Director of Health Services | DHS | Interviewed regarding fall interventions, dialysis communication, and policies |
| Licensed Practical Nurse 1 | Interviewed regarding Resident 88's condition and care | |
| Registered Nurse 1 | Interviewed regarding Resident 88's condition and care |
Inspection Report
Annual Inspection
Deficiencies: 0
Oct 24, 2022
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Greenwood Meadows was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 132
Deficiencies: 0
Sep 7, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00383644 and included a COVID-19 Focused Infection Control Survey.
Findings
The complaint IN00383644 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation and the COVID-19 survey.
Complaint Details
Complaint IN00383644 was unsubstantiated due to lack of evidence.
Report Facts
Census Bed Type: 132
Census Payor Type - Medicare: 18
Census Payor Type - Medicaid: 80
Census Payor Type - Other: 34
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