Inspection Report Summary
The most recent inspection on December 31, 2024, found no deficiencies related to the complaint investigated. Earlier inspections showed a pattern of deficiencies primarily involving Life Safety Code compliance, including issues with sprinkler system maintenance and oxygen storage security, as well as care plan development, medication management, infection control, and food safety. Complaint investigations were generally substantiated but did not result in cited deficiencies. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows some improvement in Life Safety Code compliance over time, although care and safety-related issues appeared intermittently in prior surveys.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
121% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
28 residents
Based on a December 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 0
Dec 31, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00447668.
Findings
No deficiencies related to the allegations in Complaint IN00447668 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaint IN00447668 found no deficiencies related to the allegations.
Report Facts
Census: 28
SNF beds: 4
NF beds: 24
Medicare residents: 2
Medicaid residents: 24
Other payor residents: 2
Inspection Report
Life Safety
Census: 30
Capacity: 36
Deficiencies: 2
Oct 22, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 10/22/2024.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies included failure to maintain sprinkler system inspection documentation and failure to secure and properly mark the outside oxygen storage area.
Severity Breakdown
SS=C: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to maintain documentation of monthly inspections for wet system control valves of the sprinkler system as required by NFPA 25. | SS=C |
| Failed to ensure the outside oxygen storage area was locked and provided with required precautionary signage. | SS=E |
Report Facts
Certified beds: 36
Census: 30
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brenda Shepherd | Executive Director | Named as facility representative during exit conference |
| Maintenance Director | Interviewed regarding sprinkler system and oxygen storage deficiencies |
Inspection Report
Life Safety
Deficiencies: 0
Oct 22, 2024
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey conducted on 10/22/24.
Findings
Hickory Creek at Peru 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 (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Renewal
Census: 31
Capacity: 31
Deficiencies: 7
Sep 30, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted on September 25, 26, 27 and 30, 2024.
Findings
The facility was found deficient in several areas including insufficient surety bond coverage for resident personal funds, failure to develop and revise comprehensive person-centered care plans, failure to ensure residents received appropriate therapeutic diets, failure to post nurse staffing data timely, improper medication labeling and storage, and failure to follow infection control practices during insulin administration.
Severity Breakdown
SS=E: 1
SS=D: 6
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure the Surety Bond amount was sufficient to cover the Resident's personal fund account affecting all 31 residents. | SS=E |
| Failed to develop a comprehensive person-centered care plan for a resident with positioning issues (Resident 11). | SS=D |
| Failed to revise care plans for fluid consumption for a resident (Resident 4). | SS=D |
| Failed to ensure a resident received the appropriate therapeutic diet for dialysis (Resident 4). | SS=D |
| Failed to post daily nurse staffing data timely. | SS=D |
| Failed to ensure medication carts were free from loose pills and medications were labeled in one medication storage area. | SS=D |
| Failed to ensure infection control practices were followed when administering insulin (Resident 13). | SS=D |
Report Facts
Surety Bond amount: 25000
Surety Bond amount: 35000
Census: 31
Total Capacity: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brenda Shepherd | Executive Director | Signed the report and responsible for oversight. |
| RN 4 | Mentioned in medication storage and insulin administration deficiencies. | |
| Director of Nursing | Director of Nursing | Interviewed regarding care plans, diet orders, nurse staffing postings, medication storage, and insulin administration. |
| Business Office Manager | Business Office Manager | Interviewed regarding surety bond amount and resident funds. |
| Administrator | Administrator | Interviewed regarding surety bond coverage and policy. |
| Social Service Director | Social Service Director | Provided policies related to care plans and dialysis care. |
| CNA 2 | Certified Nursing Assistant | Interviewed about resident positioning. |
Inspection Report
Renewal
Deficiencies: 0
Sep 30, 2024
Visit Reason
The visit was conducted as a Paper Compliance Review to the Recertification and Licensure Survey.
Findings
Hickory Creek at Peru was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 regarding the Paper Compliance Review to the Recertification and Licensure survey.
Inspection Report
Life Safety
Census: 29
Capacity: 36
Deficiencies: 0
Jan 4, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 11/06/23 was performed by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this Life Safety Code survey, Hickory Creek at Peru was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinklered except for detached oxygen storage and maintenance/storage sheds.
Report Facts
Facility capacity: 36
Census: 29
Inspection Report
Re-Inspection
Census: 29
Deficiencies: 0
Nov 8, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 10/10/2023.
Findings
Hickory Creek at Peru was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey.
Report Facts
Census: 29
Census Bed Type Total: 29
Census Payor Type Total: 29
Inspection Report
Life Safety
Census: 29
Capacity: 36
Deficiencies: 2
Nov 6, 2023
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) and related NFPA standards.
Findings
The facility was found not in compliance with Life Safety Code requirements due to two main deficiencies: an exposed junction box without a cover plate in the sprinkler riser room, and a sink located too close to electrical panel boxes without ground-fault circuit-interrupter protection, posing electrical shock hazards.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 1 sprinkler riser room was maintained in a safe operating condition; exposed wires hanging from a junction box without a cover plate. | SS=E |
| Failed to ensure 1 of over 1 wet location was protected against electric shock; sink located too close to 3 electrical panel boxes without ground-fault circuit-interrupter protection. | SS=E |
Report Facts
Certified beds: 36
Census: 29
Residents potentially affected: 14
Employees potentially affected: 4
Visitors potentially affected: 2
Electrical panels near sink: 3
Electric panels in mechanical room: 6
Distance from sink to electrical panel: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brenda Shepherd | Executive Director | Named as facility representative and involved in exit conference |
| Maintenance Director | Interviewed regarding deficiencies and corrective actions |
Inspection Report
Annual Inspection
Census: 31
Capacity: 31
Deficiencies: 8
Oct 10, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from October 3 to 10, 2023.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of resident changes, incomplete care plans, delayed care plan meetings, inadequate bowel management, failure to follow up on urinary tract infection treatments, improper storage of respiratory equipment, delayed physician response to pharmacy recommendations, and unsanitary food storage and preparation conditions.
Severity Breakdown
SS=D: 6
SS=G: 1
SS=F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to notify physician of resident change in condition related to bowel movements and constipation. | SS=D |
| Failure to develop and implement comprehensive care plans including for gastrointestinal reflux disease, tremors, and antidepressant use. | SS=D |
| Failure to conduct timely care plan meetings including resident and/or representative participation. | SS=D |
| Failure to provide care planned interventions during periods of constipation resulting in hospitalization for small bowel obstruction. | SS=G |
| Failure to ensure appropriate treatment and follow-up for urinary tract infections including urology consultation. | SS=D |
| Failure to properly store respiratory equipment for oxygen therapy. | SS=D |
| Failure to ensure timely physician response to pharmacist recommendations regarding medication regimen. | SS=D |
| Failure to ensure food items in freezer were dated/labeled, dispose of expired foods, and maintain cleanliness of dishwasher, freezer, and toaster in kitchen. | SS=F |
Report Facts
Census: 31
Total Capacity: 31
Survey Dates: 5
Pharmacy recommendation response time: 98
Inspection Report
Complaint Investigation
Census: 32
Capacity: 32
Deficiencies: 0
Jan 24, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00399198.
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 IN00399198 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Census Bed Type: 32
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 24
Census Payor Type - Other: 5
Inspection Report
Re-Inspection
Census: 32
Capacity: 36
Deficiencies: 1
Oct 28, 2022
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 09/13/22.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements due to failure to maintain one Post Indicator Valve (PIV) on the automatic sprinkler system as required by NFPA 25. A repair quote was obtained and repair was scheduled to begin on 11/18/2022.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to maintain 1 of 1 Post Indicator Valve (PIV) on the automatic sprinkler system in accordance with NFPA 25. | SS=F |
Report Facts
Certified beds: 36
Census: 32
Deficiencies cited: 1
Repair start date: Nov 18, 2022
Systemic changes completion date: Dec 12, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brenda Shepherd | Executive Director | Signed report and participated in exit conference |
| Maintenance Director | Acknowledged deficiency and discussed repair plans |
Inspection Report
Life Safety
Deficiencies: 0
Oct 28, 2022
Visit Reason
Post Survey Revisit (PSR) on 10/28/22 to the Life Safety Code Recertification and State Licensure Survey conducted on 09/13/22.
Findings
Hickory Creek at Peru 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, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Routine
Census: 32
Capacity: 36
Deficiencies: 7
Sep 13, 2022
Visit Reason
Routine Emergency Preparedness and Life Safety Code recertification survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Emergency Preparedness requirements including failure to annually review and update the Emergency Preparedness Plan, Policies and Procedures, Communication Plan, and Training Program. Additionally, the facility failed to conduct required emergency preparedness training and testing exercises annually or twice per year as required. Life Safety Code deficiencies included failure to instruct kitchen staff on the use of the UL 300 hood system and failure to maintain the Post Indicator Valve (PIV) on the sprinkler system.
Severity Breakdown
SS=F: 6
SS=E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to review and update the Emergency Preparedness Plan at least annually. | SS=F |
| Failed to review and update the Emergency Preparedness Policies and Procedures at least annually. | SS=F |
| Failed to review and update the Emergency Preparedness Communication Plan at least annually. | SS=F |
| Failed to review and update the Emergency Preparedness Training Program at least annually. | SS=F |
| Failed to conduct emergency preparedness exercises at least twice per year including unannounced staff drills. | SS=F |
| Failed to ensure kitchen staff were instructed in the use of the UL 300 hood fire extinguishing system. | SS=E |
| Failed to maintain the Post Indicator Valve (PIV) on the automatic sprinkler system to close completely. | SS=F |
Report Facts
Certified beds: 36
Census: 32
Deficiencies cited: 7
Inspection Report
Complaint Investigation
Census: 33
Capacity: 33
Deficiencies: 0
Aug 30, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00388113.
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 IN00388113 - Substantiated. No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type: 33
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 26
Census Payor Type - Other: 4
Inspection Report
Annual Inspection
Census: 32
Capacity: 32
Deficiencies: 1
Aug 4, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00379975.
Findings
The complaint was substantiated but no deficiencies related to the allegations were cited. However, the facility was found deficient in infection prevention and control practices, specifically failure to ensure PPE use and hand hygiene during medication administration.
Complaint Details
Complaint IN00379975 was substantiated, but no deficiencies related to the allegations were cited.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure PPE was worn and hand hygiene performed during medication pass for 1 of 1 observations. | SS=D |
Report Facts
Census: 32
Total Capacity: 32
Survey Dates: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 2 | Licensed Practical Nurse | Observed failing to perform hand hygiene and PPE use during medication administration |
| LPN 1 | Licensed Practical Nurse | Interviewed regarding medication administration procedures |
| Director of Nursing | Director of Nursing | Provided facility policies and interviewed about infection control expectations |
Inspection Report
Renewal
Deficiencies: 0
Aug 4, 2022
Visit Reason
Paper Compliance to the Recertification and Licensure Survey completed on 8/4/22.
Findings
Hickory Creek at Peru was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2, in regard to the Paper Compliance Review to the Recertification and Licensure survey.
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