Deficiencies per Year
12
9
6
3
0
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Life Safety
Census: 14
Capacity: 24
Deficiencies: 1
May 21, 2025
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 the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Findings
The facility was found not in compliance due to failure to provide an approved method to ensure cooking appliances in the kitchen hood extinguishing system were returned to their approved design location after maintenance or cleaning. Carriages were installed to correct this deficiency and systemic changes including audits were implemented.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide an approved method for returning cooking appliances to a specific location in the kitchen hood extinguishing system. | SS=E |
Report Facts
Certified beds: 24
Census: 14
Audit frequency: 8
Audit frequency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jasmine Kemp | Associate Executive Director | Signed the report |
| Director of Environmental Services | Interviewed and involved in findings and corrective actions | |
| Assistant Executive Director | Participated in exit conference | |
| Executive Director | Participated in exit conference |
Inspection Report
Renewal
Census: 307
Deficiencies: 8
May 9, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey including a Non-Certified Comprehensive Licensure Survey and a State Residential Licensure Survey conducted May 5-9, 2025.
Findings
The facility was found deficient in multiple areas including failure to develop and implement comprehensive care plans for residents at risk of falls and elopement, failure to ensure proper antibiotic stewardship and testing prior to antibiotic use, medication labeling discrepancies, medication storage and security issues, and environmental safety hazards such as bed entrapment risks and improper documentation of assist bars on side rails.
Severity Breakdown
SS=D: 4
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to develop and implement a comprehensive, person-centered care plan related to falls, intrusive wandering, and elopement for Resident 5. | SS=D |
| Failed to review and revise a care plan for Resident 9 related to ambulation without walker and bathroom habits. | SS=D |
| Failed to complete proper testing to confirm infection before putting Resident 5 on an antibiotic. | SS=D |
| Failed to ensure Resident 38 received a urinalysis for targeted treatment for suspected UTI. | SS=D |
| Failed to identify and prevent potential entrapment hazards between mattress and bedframe and failed to ensure appropriate assessments and monitoring for seatbelt use on motorized scooter for Resident 38; also failed to document assist bars on side rail assessments for Residents 39, 18, 26, and 25. | — |
| Failed to ensure residents were free from medication errors related to pharmacy labels and EMAR orders not matching for Resident 16. | — |
| Failed to ensure all medications with expiration dates different from manufacturer dates were properly labeled for Resident 17. | — |
| Failed to ensure medication carts were locked when unattended and medications stored properly for medication cart and medication room. | — |
Report Facts
Census Bed Type: 10
Census Bed Type: 52
Census Bed Type: 245
Total Census: 307
Census Payor Type: 6
Census Payor Type: 4
Census Payor Type: 10
Gap measurement: 6.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mindy Kantz | RN, Executive Director | Signed the inspection report |
| QMA 35 | Qualified Medication Aide | Involved in medication administration and discrepancy for Resident 16 |
| LPN 38 | Licensed Practical Nurse | Involved in medication administration and discrepancy for Resident 16 |
| LPN 36 | Licensed Practical Nurse | Nursing manager involved in medication storage observations |
| Director of Nursing | Director of Nursing | Provided policies and interviews regarding care plans, antibiotic stewardship, medication errors, and safety |
| Maintenance Director | Measured mattress gap and investigated bed safety concerns | |
| Executive Director | Executive Director | Participated in bed safety observations and interviews |
| Administrator | Administrator | Participated in bed safety observations and interviews |
Inspection Report
Renewal
Deficiencies: 0
May 9, 2025
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on May 9, 2025.
Findings
Hoosier Village 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 Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 0
Mar 12, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00445557.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00445557 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF: 10
Census Bed Type - NCC: 52
Census Total: 62
Census Payor Type - Medicare: 7
Census Payor Type - Other: 3
Census Payor Total: 10
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 1
Jul 24, 2024
Visit Reason
This visit was for the investigation of Non-Certified Comprehensive (NCC) Complaints IN00437440, IN00437580, and IN00439205. Deficiencies related to complaint IN00437580 were cited.
Findings
The facility failed to ensure post-fall assessments were completed for 1 of 3 NCC residents reviewed for accidents (Resident F). Resident F had multiple falls in May 2024 with no documentation of required post-fall neurological checks, 15-minute checks, or vital signs. The facility lacked a policy and procedure for nursing follow-up assessments after unwitnessed falls and needed to update the electronic health record system to ensure timely documentation.
Complaint Details
Complaint IN00437580 was substantiated with state deficiencies cited related to failure to complete post-fall assessments for Resident F. Complaints IN00437440 and IN00439205 had no deficiencies related to the allegations.
Deficiencies (1)
| Description |
|---|
| Failure to ensure post-fall assessments were completed for Resident F including 15 minute checks, neurological checks, and vital signs. |
Report Facts
Census: 63
Falls reviewed: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mindy Kantz | RN, Executive Director | Signed the report and referenced as Director of Nursing (DON) in findings |
Inspection Report
Re-Inspection
Census: 12
Capacity: 24
Deficiencies: 0
May 28, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 04/16/24 by the Indiana Department of Health.
Findings
At this PSR Life Safety Code survey, Hoosier Village was found in compliance with Requirements for Participation in Medicare, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC). The facility was fully sprinklered and had appropriate fire alarm and smoke detection systems.
Inspection Report
Life Safety
Census: 12
Capacity: 24
Deficiencies: 4
Apr 16, 2024
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 483.70(a) and NFPA 101 standards.
Findings
The facility was found not in compliance with Life Safety Code requirements, with deficiencies including blocked means of egress, missing drip trays on kitchen range hood system, cooktops not powered off when not in use, sprinkler obstructions due to storage within 18 inches of ceiling, and improper use of power strips and extension cords.
Severity Breakdown
SS=E: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| One of ten means of egress was blocked by a parked car at the end of the sidewalk and the sidewalk was uneven with a 2-3 inch drop. | SS=E |
| Missing drip trays from the kitchen range hood system and a cooktop/range in the therapy area not being turned off when not in use. | SS=E |
| Sprinkler heads in the Medical Supply Closet were obstructed by boxes stored less than 18 inches from the ceiling. | SS=E |
| Power strips and extension cords were improperly used as substitutes for fixed wiring in resident rooms, DON office, and nurse's station. | SS=E |
Report Facts
Deficiencies cited: 4
Facility capacity: 24
Census: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mindy Kantz | Executive Director | Signed the report and participated in exit conference. |
| Environmental Services Director | Interviewed during observations and acknowledged findings. |
Inspection Report
Recertification
Census: 306
Deficiencies: 10
Mar 22, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey including a Non-Certified Comprehensive Licensure Survey and investigation of Complaint IN00419238.
Findings
The facility was found deficient in multiple areas including failure to develop baseline care plans within 48 hours of admission, failure to revise care plans for advance directives, improper medication storage and labeling, unsecured medications in resident rooms, failure to properly manage respiratory equipment, inadequate investigation of medication misappropriation, and insufficient fall prevention and follow-up assessments.
Complaint Details
Complaint IN00419238 was investigated with no deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 5
Deficiencies (10)
| Description | Severity |
|---|---|
| Baseline care plan was not developed within 48 hours of admission for Resident 216. | SS=D |
| Comprehensive care plan was not revised to meet wishes for advance directive planning for Resident 8. | SS=D |
| Medications were left at resident bedsides without physician orders or assessments for Residents 168 and 169. | SS=D |
| Respiratory equipment was not dated or bagged for Residents 3 and 168. | SS=D |
| Medications and biologicals were not properly labeled or stored in medication carts and rooms for Residents 3 and 217. | SS=D |
| Unsecured over-the-counter medications were found in Resident 45 and Resident 28's rooms without self-administration assessments or physician orders. | — |
| Failure to thoroughly investigate misappropriation of controlled narcotic medications and prevent further potential abuse involving LPNs 2 and 3. | — |
| Failure to ensure adequate supervision and fall prevention interventions for Resident 25 with history of falls and fractures. | — |
| Failure to complete thorough post-fall assessments, interdisciplinary team reviews, and revise interventions to prevent future falls for Resident 8. | — |
| Failure to properly label and date medications and biologicals in medication storage rooms and carts for multiple residents. | — |
Report Facts
Survey dates: 5
Census: 306
Residents reviewed for baseline care plan deficiency: 4
Residents reviewed for advance directive care plan revision: 2
Residents reviewed for medication storage: 8
Residents reviewed for respiratory equipment: 3
Residents reviewed for medication labeling: 8
Residents reviewed for unsecured medications: 3
Nursing staff educated on drug diversion: 15
Residents reviewed for falls: 3
Residents reviewed for medication storage labeling: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mindy Kantz | Executive Director | Signed the report and involved in oversight. |
| LPN 2 | Licensed Practical Nurse | Involved in medication misappropriation, terminated. |
| LPN 3 | Licensed Practical Nurse | Involved in medication misappropriation, terminated. |
| RN 4 | Registered Nurse | Witnessed medication destruction but did not observe properly, counseled. |
Inspection Report
Renewal
Deficiencies: 0
Mar 22, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on March 22, 2024.
Findings
Hoosier Village 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 Recertification and State Licensure Survey.
Inspection Report
Re-Inspection
Census: 2
Capacity: 24
Deficiencies: 1
Aug 8, 2023
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 06/14/23.
Findings
The facility was found in compliance with Emergency Preparedness Requirements. However, a deficiency was cited for the courtyard fence gates not swinging in the direction of egress travel, which was corrected during the survey. Staff were educated and ongoing monitoring was planned to ensure compliance.
Severity Breakdown
SS=B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The courtyard fence gates did not swing in the direction of egress travel, impeding means of egress. | SS=B |
Report Facts
Certified beds: 24
Census: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Participated in observations and exit conference regarding deficiency | |
| Environmental Services Director | Participated in observations, agreed with deficiency, and involved in corrective actions |
Inspection Report
Life Safety
Census: 5
Capacity: 24
Deficiencies: 11
Jun 14, 2023
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.70(a) and related regulations.
Findings
The facility was found not in compliance with several Life Safety Code requirements including emergency power system testing, means of egress obstructions, smoke detector maintenance, fire alarm system testing and maintenance, sprinkler system maintenance, smoke barrier penetrations, and fire drill documentation.
Severity Breakdown
SS=F: 7
SS=E: 1
SS=C: 2
SS=D: 2
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to implement emergency power system inspection, testing and maintenance requirements; 36-month emergency generator testing documentation for four continuous hours was not available for review. | SS=F |
| One of ten means of egress was obstructed due to a locked courtyard exit gate. | SS=E |
| Incomplete documentation for preventative maintenance of smoke detectors in all resident rooms; smoke detectors were tested annually instead of monthly. | SS=F |
| Semi-annual fire alarm system inspection documentation was not available; a heat detector in the kitchen was outdated and needed replacement. | SS=F |
| Fire alarm system was not maintained in accordance with NFPA 72; semi-annual visual inspections were missing and system defects were not corrected timely. | SS=F |
| Fire alarm system out of service policy incomplete; did not include required statement about evacuation or fire watch if system is out for more than 4 hours. | SS=C |
| Two of ten sprinkler system gauges were not replaced or tested every 5 years; seven of eight dry pendant sprinklers in screened porch were corroded and needed replacement. | SS=F |
| Sprinkler system out of service policy incomplete; did not include required statement about evacuation or fire watch if system is out for more than 10 hours. | SS=C |
| Openings through ceiling smoke barrier were not protected to maintain fire resistance rating; a 4x4 inch hole was found in the employee break room ceiling. | SS=D |
| A 4x4 inch hole in the ceiling smoke barrier in the Staff Lounge was not sealed, compromising smoke barrier integrity. | SS=D |
| Fire drills conducted between 6:00 a.m. and 9:00 p.m. did not include activation of the fire alarm system and transmission of the fire alarm signal. | SS=F |
Report Facts
Certified beds: 24
Census: 5
Deficiency counts: 11
Fire drills missing activation: 1
Sprinkler gauges not replaced: 2
Corroded sprinklers: 7
Inspection Report
Renewal
Census: 232
Capacity: 290
Deficiencies: 10
May 12, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a Non-Certified Comprehensive Licensure Survey and a State Residential Licensure Survey conducted May 9-12, 2023.
Findings
The facility was cited for multiple deficiencies including incomplete baseline and comprehensive care plans, failure to monitor high-risk medications, improper medication storage and labeling, inadequate infection control practices, incomplete employee health screenings, and failure to update resident service plans and communicate pharmacy recommendations to physicians.
Severity Breakdown
SS=D: 5
SS=E: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| Baseline care plans lacked documentation of resident medication monitoring for 2 of 5 residents reviewed. | SS=D |
| Comprehensive care plans were not reviewed/revised in a timely manner for 3 of 7 residents reviewed. | SS=D |
| Medications were left unattended at bedside of a confused resident. | SS=D |
| Failed to ensure appropriate care and maintenance of a G/J tube; nurse flushed jejunostomy tube without proper physician order documentation. | SS=D |
| Failed to ensure residents received appropriate monitoring for potential side effects related to high risk medications for 4 of 5 residents reviewed. | SS=E |
| Medications not properly stored in medication rooms and a bottle of over-the-counter vitamins lacked appropriate labeling. | SS=E |
| Failed to ensure appropriate hand hygiene was performed during a treatment procedure for 1 resident. | SS=D |
| Failed to ensure a complete 2-step TB skin test and physical health assessment were completed for an employee prior to employment. | — |
| Failed to ensure a resident's service plan was updated for self-administration of medications. | — |
| Failed to ensure pharmacy recommendations were communicated to the resident's personal physician with documented response. | — |
Report Facts
Survey dates: 4
Census: 232
Total capacity: 290
Residents reviewed for baseline care plans: 5
Residents reviewed for comprehensive care plans: 7
Residents reviewed for medication monitoring: 5
Residents reviewed for medication storage: 7
Employee records reviewed: 5
Inspection Report
Plan of Correction
Deficiencies: 0
May 12, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on May 12, 2023.
Findings
Hoosier Village 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 Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 273
Deficiencies: 0
Sep 6, 2022
Visit Reason
This visit was conducted for the investigation of Nursing Home Complaint IN00379973 and included the investigation of Residential Complaint IN00377518.
Findings
Complaint IN00379973 was found to be unsubstantiated due to lack of evidence. Complaint IN00377518 was substantiated but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00379973 - Unsubstantiated due to lack of evidence. Complaint IN00377518 - Substantiated with no deficiencies cited related to the allegations.
Report Facts
Census Bed Type Total: 273
Census Bed Type SNF: 3
Census Bed Type NCC: 45
Census Bed Type Residential: 225
Census Payor Type Medicare: 3
Census Payor Type Other: 45
Census Payor Type Total: 48
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