Inspection Report Summary
The most recent inspection on April 22, 2025, cited deficiencies related to fall interventions after a cognitively impaired resident experienced a fall with injury. Earlier inspections showed a pattern of deficiencies involving resident supervision, medication management, and safety measures, including issues with chemical restraint use, elopement prevention, and dignity in care. Complaint investigations were mostly unsubstantiated, except for a few substantiated cases related to resident neglect, supervision failures, and safety concerns, but no fines or enforcement actions were listed in the available reports. Prior reports also noted sanitation and infection control issues, as well as staff certification and documentation deficiencies. The facility’s inspection history shows ongoing challenges with resident safety and care practices, with some recent focus on corrective actions following identified issues.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
74% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
122 residents
Based on a April 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 122
Deficiencies: 1
Apr 22, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00456733 and IN00456055. Complaint IN00456733 resulted in state deficiencies related to fall interventions, while complaint IN00456055 had no deficiencies cited.
Findings
The facility failed to implement fall interventions for a cognitively impaired resident, resulting in a fall with injury including a subdural hematoma. Interviews and record reviews revealed that wellness checks were not performed as required, and staff did not follow CNA assignment sheets during the night shift.
Complaint Details
Complaint IN00456733 was substantiated with state deficiencies cited related to fall interventions. Complaint IN00456055 was not substantiated with no deficiencies cited.
Deficiencies (1)
| Description |
|---|
| Failed to implement fall interventions for a cognitively impaired resident resulting in a fall with injury. |
Report Facts
Residential Census: 122
Survey Dates: 2
Completion Date for Plan of Correction: May 14, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jillian Pickett | Executive Director | Signed the report |
| LPN 1 | Interviewed regarding the fall incident and response | |
| LPN 3 | Interviewed regarding the fall incident and response | |
| QMA 2 | Interviewed regarding resident care during prior night shift |
Inspection Report
Complaint Investigation
Census: 123
Deficiencies: 1
Mar 12, 2025
Visit Reason
This visit was for a State Residential Licensure Survey which included the investigation of Complaint IN00455009. The complaint investigation was conducted to determine if there were deficiencies related to the allegations.
Findings
The facility was found to have failed to ensure residents were free of chemical restraints used for staff convenience for 3 of 3 residents reviewed. However, no deficiencies related to the complaint allegations were cited. The facility contested the finding, providing documentation and statements supporting the appropriate use of the medication ABH gel for residents' conditions.
Complaint Details
Complaint IN00455009 was investigated and no deficiencies related to the allegations were cited.
Severity Breakdown
Offense: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure residents were free of chemical restraints used for staff convenience for 3 of 3 residents reviewed for chemical restraint use (Residents 67, 32, and 101). | Offense |
Report Facts
Residents reviewed for chemical restraint use: 3
Residential Census: 123
Inspection Report
Complaint Investigation
Census: 125
Deficiencies: 0
Mar 3, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00453265 and IN00449822.
Findings
No deficiencies related to the allegations in complaints IN00453265 and IN00449822 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00453265 and IN00449822 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Residential Census: 125
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 0
Dec 9, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00448655 and IN00448005.
Findings
No deficiencies related to the allegations in complaints IN00448655 and IN00448005 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00448655 and Complaint IN00448005 were investigated and found to have no deficiencies related to the allegations.
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 0
Nov 14, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00446283.
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.
Complaint Details
Complaint IN00446283 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Residential Census: 120
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 0
Aug 30, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00440646 at Heritage Woods of Noblesville.
Findings
No deficiencies related to the allegations in Complaint IN00440646 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Complaint Details
Complaint IN00440646 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Residential Census: 120
Inspection Report
Complaint Investigation
Census: 123
Deficiencies: 1
Jul 31, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00438221 regarding allegations of abuse at the facility.
Findings
No deficiencies related to the complaint allegations were cited; however, an unrelated deficiency was found involving failure to ensure residents were treated with dignity and respect by staff during care for one resident (Resident C).
Complaint Details
Complaint IN00438221 was investigated with no deficiencies related to the allegations cited. The complaint involved an abuse allegation by Resident C's family, including video evidence of inappropriate staff behavior. The facility took immediate actions including suspension of the involved employee and initiated preventative measures such as skin assessments and psychosocial monitoring.
Deficiencies (1)
| Description |
|---|
| Failure to ensure residents were treated with dignity and respect by staff during care for 1 of 3 residents reviewed for abuse (Resident C). |
Report Facts
Residential Census: 123
Survey Date: Jul 31, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| HHA 3 | Health Care Assistant | Employee identified in abuse allegation and involved in inappropriate care of Resident C |
| Jillian Pickett | Executive Director | Administrator who conducted interviews and provided facility investigation file |
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 0
Jun 25, 2024
Visit Reason
This visit was conducted to investigate Complaints IN00436239 and IN00435382 at Heritage Woods of Noblesville.
Findings
No deficiencies related to the allegations in Complaints IN00436239 and IN00435382 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaints IN00436239 and IN00435382 found no deficiencies related to the allegations; both complaints were not substantiated.
Report Facts
Residential Census: 120
Inspection Report
Renewal
Census: 120
Deficiencies: 1
May 10, 2024
Visit Reason
This visit was for a State Residential Licensure Survey conducted on May 8, 9, and 10, 2024, to assess compliance with state regulations.
Findings
The facility failed to ensure sanitation and safe food handling practices in the kitchen, specifically with uncovered and unlabeled food items in the freezer and refrigerator. The Dietary Manager acknowledged the issues and corrective actions were planned.
Deficiencies (1)
| Description |
|---|
| Uncovered and unlabeled frozen soup in the freezer and chopped salad greens in the refrigerator, violating sanitation and safe food handling standards. |
Report Facts
Residential Census: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jillian Pickett | Executive Director | Signed the report |
| Dietary Manager | Interviewed regarding food handling deficiencies |
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 2
Feb 1, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00426672 and IN00425749 related to resident neglect and medication security issues.
Findings
The facility failed to ensure residents were free from neglect, specifically regarding supervision to prevent elopement of cognitively impaired residents and failed to secure medications properly, resulting in missing medication for a resident.
Complaint Details
Complaint IN00426672 related to neglect and elopement risk; Complaint IN00425749 related to medication security and missing medication.
Deficiencies (2)
| Description |
|---|
| Failure to ensure residents were free from neglect as evidenced by lack of supervision to prevent elopement of cognitively impaired residents. |
| Failure to secure medications administered by the facility and failure to ensure medication cabinets used by residents who self-administered medications were secure, resulting in missing medication. |
Report Facts
Residents self-administering medications: 39
Missing pills: 10
Resident census: 119
Inspection Report
Complaint Investigation
Census: 122
Deficiencies: 0
Dec 29, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00423518 and IN00420451.
Findings
No deficiencies related to the allegations in complaints IN00423518 and IN00420451 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaints IN00423518 and IN00420451 found no deficiencies related to the allegations.
Report Facts
Residential Census: 122
Inspection Report
Renewal
Census: 119
Deficiencies: 2
Aug 3, 2023
Visit Reason
This visit was for a State Residential Licensure Survey conducted on August 3 and 4, 2023, to assess compliance with state residential licensure requirements.
Findings
The facility was found deficient in maintaining locked and alarmed exit doors on a locked dementia unit, and in implementing an infection control program to analyze patterns of infectious symptoms. No residents were found to be adversely affected by these deficiencies.
Deficiencies (2)
| Description |
|---|
| Failed to ensure exit doors on a locked dementia unit were kept locked and alarmed for 4 of 4 doors that exited to the courtyard. |
| Failed to implement an infection control program to analyze patterns of known infectious symptoms, impacting all 119 residents. |
Report Facts
Residential Census: 119
Residents with URI symptoms in May 2023: 11
Residents prescribed antibiotic medication in June 2023: 50
Residents with symptoms documented in June 2023: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Charles Boswell | Regional Director of Operations | Signed the report |
| QMA 7 | Interviewed regarding phone notification system for secure unit | |
| CNA 5 | Interviewed about courtyard access and door locking times | |
| CNA 12 | Interviewed about courtyard door locking and alarm system | |
| CNA 9 | Interviewed and accompanied observation of courtyard door | |
| LPN 3 | Accompanied observation of Sun Room exit door | |
| Administrator | Interviewed regarding policies related to secure unit and exit doors | |
| DON | Director of Nursing | Provided infection control policy and interviewed about infection control program |
| QMA 2 | Interviewed about reporting new respiratory symptoms |
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 0
Jun 8, 2023
Visit Reason
This visit was for the investigation of complaints IN00409724 and IN00410175.
Findings
No deficiencies related to the allegations were cited for either complaint. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the investigation of the complaints.
Complaint Details
Complaint IN00409724 and Complaint IN00410175 were investigated with no deficiencies cited related to the allegations.
Report Facts
Residential Census: 119
Inspection Report
Complaint Investigation
Census: 124
Deficiencies: 3
Apr 21, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00406722 regarding allegations related to resident safety and facility management.
Findings
The facility failed to report the elopement of a cognitively impaired resident from the secured memory care unit and failed to ensure hazardous materials were secured and secured doors were operational to prevent resident elopement. These deficiencies had the potential to affect 30 ambulatory residents and resulted in one resident leaving the secured unit unsupervised.
Complaint Details
Complaint IN00406722 was substantiated with state deficiencies cited related to the allegations of resident elopement and safety concerns.
Deficiencies (3)
| Description |
|---|
| Failure to report to appropriate agencies the elopement of a cognitively impaired resident from the secured memory care unit. |
| Failure to ensure hazardous materials were secured out of reach of cognitively impaired residents. |
| Failure to ensure secured doors were operational to prevent resident elopement. |
Report Facts
Residential Census: 124
Potentially affected residents: 30
Residents on secured memory care unit: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerilyn McCullough-Gooding | Administrator | Named in relation to findings about failure to report and facility management |
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 29, 2022
Visit Reason
Paper compliance review to the Investigation of Complaint IN00391791 completed on October 20, 2022.
Findings
Heritage Woods of Noblesville was found to be in compliance with 410 IAC 16.2-5 regarding the paper compliance review to the Investigation of Complaint IN00391791.
Complaint Details
Investigation of Complaint IN00391791; paper compliance review found in compliance.
Inspection Report
Routine
Census: 113
Deficiencies: 11
Dec 8, 2022
Visit Reason
This visit was for a State Residential Licensure Survey conducted on December 6, 7, and 8, 2022.
Findings
The facility was found deficient in multiple areas including personnel screening and orientation, staff certification in CPR and First Aid, employee health screenings, expired nursing license, sanitation and safety standards, resident service plan documentation, medication management and storage, and tuberculosis (TB) testing and documentation for residents.
Deficiencies (11)
| Description |
|---|
| Failed to ensure background and reference checks were completed for 4 of 5 employee files prior to start date. |
| Failed to ensure staff member was CPR certified and trained in First Aid for 7 of 21 shifts reviewed. |
| Failed to provide job specific orientation to newly hired staff members for 5 of 5 staff reviewed. |
| Failed to administer TB skin testing prior to starting employment for 5 of 5 staff reviewed. |
| Allowed Licensed Practical Nurse to administer care with an expired license. |
| Failed to store trash in a safe and sanitary manner; trash bags were piled on floors near elevators and resident rooms. |
| Failed to ensure assessments were completed and service plans signed by resident or representative for 3 of 8 residents reviewed. |
| Failed to assure medications in resident rooms were secured for 2 of 5 residents observed during medication administration. |
| Failed to initiate a physician's medication order for 1 of 7 residents reviewed for medications. |
| Failed to obtain and document residents' tuberculin skin test for 4 of 7 residents reviewed for TB testing. |
| Failed to ensure residents were current with documentation of an annual tuberculin test or annual tuberculin health screening for 2 of 7 residents reviewed. |
Report Facts
Residential Census: 113
Shifts lacking CPR/First Aid certified staff: 7
Employees with incomplete background checks: 4
Employees with incomplete TB skin testing: 5
Employees with incomplete job orientation: 5
Employees with expired license: 1
Residents with incomplete service plans: 3
Residents with unsecured medications: 2
Residents lacking physician medication order: 1
Residents lacking documented TB skin test: 4
Residents lacking annual TB health screening: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Harrison | Regional Director of Operations (RDO) | Named in relation to conducting in-service training and oversight of corrective actions. |
| LPN 2 | Licensed Practical Nurse | Worked with expired nursing license during inspection period. |
| Qualified Medication Aide 3 | QMA | Mentioned in relation to medication administration and background check deficiencies. |
| Qualified Medication Aide 5 | QMA | Mentioned in relation to job orientation and TB skin testing deficiencies. |
| Home Health Aide 6 | HHA | Mentioned in relation to background check and orientation deficiencies. |
| Certified Nursing Assistant 7 | CNA | Mentioned in relation to background check and orientation deficiencies. |
| Director of Nursing | DON | Interviewed multiple times regarding deficiencies and corrective actions. |
| Business Office Manager | BOM | Interviewed regarding incomplete employee file information and corrective actions. |
| Administrator | Facility Administrator | Interviewed regarding sanitation issues and corrective actions. |
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 0
Nov 30, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00395314 and IN00394856.
Findings
Both complaints were substantiated; however, no State Residential Findings related to the allegations were cited. The facility was found to be in compliance with relevant regulations regarding these complaints.
Complaint Details
Complaint IN00395314 - Substantiated with no state findings cited. Complaint IN00394856 - Substantiated with no state findings cited.
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 1
Oct 19, 2022
Visit Reason
This visit was conducted for the investigation of three complaints (IN00391451, IN00390553, and IN00391791) at Heritage Woods of Noblesville.
Findings
The investigation substantiated complaints IN00391451 and IN00390553 with no state residential findings cited. Complaint IN00391791 was substantiated with state residential findings related to failure to provide adequate supervision to prevent elopement of a cognitively impaired resident (Resident B).
Complaint Details
Complaint IN00391451 - Substantiated with no state residential findings cited. Complaint IN00390553 - Substantiated with no state residential findings cited. Complaint IN00391791 - Substantiated with state residential findings cited at R0060 related to Resident B's elopement.
Deficiencies (1)
| Description |
|---|
| Failure to provide reasonable access to any resident by entities or individuals providing health, social, legal, and other services, specifically inadequate supervision to prevent elopement of a cognitively impaired resident. |
Report Facts
Residential Census: 108
Survey Date: Oct 19, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerilyn McCullough-Gooding | Administrator | Signed as the facility administrator on the report. |
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 6
Sep 16, 2022
Visit Reason
This visit was for the investigation of multiple complaints (IN00389303, IN00389404, IN00389652, IN00389658, IN00389939, and IN00389947) related to Heritage Woods of Noblesville.
Findings
The facility was found deficient in multiple areas including failure to respond timely to call lights, failure to notify family of resident condition decline, failure to maintain an updated and accessible state survey binder, neglect related to supervision and skin care, failure to maintain cleanliness in resident apartments, and failure to provide and document personal care and assistance with activities of daily living for residents reviewed.
Complaint Details
Complaints IN00389303, IN00389404, IN00389652, IN00389658, IN00389939, and IN00389947 were substantiated with state deficiencies cited related to allegations in multiple areas including call light response, resident neglect, notification failures, and cleanliness.
Deficiencies (6)
| Description |
|---|
| Failure to ensure call lights were responded to in an adequate amount of time for residents on the Memory Care Unit. |
| Failure to notify family of a cognitively impaired resident of a decline in condition and hospital transfer. |
| Failure to ensure the state survey binder was updated with past surveys and accessible to residents, visitors, and family members. |
| Failure to prevent neglect of two residents regarding adequate supervision to prevent elopement and provision of skin care. |
| Failure to ensure a resident's apartment was cleaned for sanitation. |
| Failure to provide and document showers and assistance with activities of daily living for residents reviewed. |
Report Facts
Residents on Memory Care Unit: 30
Call light response times: 105
Survey dates: 4
Residential Census: 117
Deficiencies cited: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident D | Named in call light response time deficiency and cleanliness findings. | |
| Resident G | Named in notification of condition decline and skin care deficiency. | |
| Resident B | Named in elopement and personal care deficiencies. | |
| QMA 1 | Qualified Medication Aide | Interviewed regarding call light response and shower documentation. |
| CNA 2 | Certified Nursing Assistant | Interviewed regarding call light response and shower documentation. |
| DON | Director of Nursing | Interviewed regarding call light response, notification failures, and documentation policies. |
| Maintenance Director | Interviewed regarding door locking and elopement incident. | |
| Administrator | Interviewed regarding notification and survey binder accessibility. |
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