Inspection Reports for Lake Meadows Senior Assisted Living
11570 E 126th St, Fishers, IN 46037, IN, 46037
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 13, 2025, found Lake Meadows Senior Assisted Living in compliance with regulations and no deficiencies. Earlier inspections showed a pattern of deficiencies related primarily to resident abuse prevention and staff training, including substantiated complaints of resident-to-resident physical and sexual abuse. Prior reports also cited issues with emergency response delays, personnel documentation, infection control, and food storage. Complaint investigations were mixed, with some substantiated cases involving abuse and neglect, while most complaints were unsubstantiated or corrected upon follow-up. The facility appears to have addressed previous deficiencies over time, as recent inspections show improvement and no current enforcement actions are listed in the available reports.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
31% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
109 residents
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Census: 109
Deficiencies: 0
Date: Jun 13, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to Investigation of Complaints IN00449071 and IN00458721 completed on May 7, 2025.
Complaint Details
Investigation of Complaints IN00449071 and IN00458721; both complaints were corrected.
Findings
Both complaints IN00449071 and IN00458721 were found to be corrected. Lake Meadows Senior Assisted Living was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR.
Report Facts
Residential Census: 109
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 1
Date: May 7, 2025
Visit Reason
This visit was for the investigation of complaints IN00458721, IN00449071, and IN00456759. Complaints IN00449071 and IN00458721 resulted in state deficiencies, while complaint IN00456759 did not.
Complaint Details
The investigation was triggered by complaints IN00458721 and IN00449071, which were substantiated with cited deficiencies. Complaint IN00456759 was not substantiated with deficiencies. The investigation included review of clinical records, interviews with residents and staff, and incident reports related to physical and sexual abuse allegations involving Resident B.
Findings
The facility failed to ensure residents were free from abuse for 2 of 4 residents reviewed (Residents G and L). Resident G was physically assaulted by Resident B, who was cognitively impaired and exhibited aggressive and inappropriate behaviors including physical assault and sexual misconduct. The facility implemented corrective actions including separation of residents, monitoring, staff in-service on elder abuse, and ongoing quality assurance interviews.
Deficiencies (1)
Failed to ensure residents were free from abuse, resulting in Resident G being physically assaulted and fearful of Resident B.
Report Facts
Facility Census: 111
Medication dosage: 25
Incident date: Apr 23, 2025
Compliance Date: May 23, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darlene Adair | Executive Director | Provided incident reports, interviews, and facility policies related to the investigation |
| Interim Director of Nursing | Interviewed regarding Resident B's placement and behavior management | |
| LPN 5 | Provided written statement and assisted during incident involving Resident G and Resident B | |
| CNA 3 | Provided written statement and witnessed incident involving Resident G and Resident B |
Inspection Report
Follow-Up
Census: 105
Deficiencies: 0
Date: Oct 29, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the State Residential Licensure Survey and Investigation of Complaint IN00440485 completed on August 21, 2024, conducted in conjunction with the Investigation of Complaint IN00445508.
Complaint Details
Complaint IN00440485 was investigated and found to be corrected. The visit was also in conjunction with Investigation of Complaint IN00445508.
Findings
Lake Meadows Senior Assisted Living was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to the State Residential Licensure Survey and Investigation of Complaint IN00440485. Complaint IN00440485 was corrected.
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 0
Date: Oct 29, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00445508 and was conducted in conjunction with a Post Survey Revisit to the State Residential Licensure Survey and Investigation of Complaint IN00440485 completed on August 21, 2024.
Complaint Details
Complaint IN00445508 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations of Complaint IN00445508 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the investigation.
Report Facts
Facility number: 14910
Residential Census: 105
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 9
Date: Aug 21, 2024
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaint IN00440485.
Complaint Details
Complaint IN00440485 was investigated with related state deficiencies cited at R0028 and R0185.
Findings
The facility was found deficient in multiple areas including residents' rights violations, neglect related to delayed CPR resulting in death, inadequate dementia-specific training for the Memory Care Director, personnel record inaccuracies, physical plant safety issues, food storage violations, infection control breaches related to COVID-19, and failure to obtain resident or representative signatures on service plans.
Deficiencies (9)
Residents were not treated with dignity and respect; fear of coercion or threats of reprisal was present.
Delay in initiation of CPR for Resident 10 resulted in anoxic brain injury and death.
Memory Care Director lacked required 12 hours of dementia-specific training within three months of hire.
Staff member employed with nursing license name not matching government issued ID at time of hire.
Residents lacked a working and timely method to summon staff; call lights and pagers were malfunctioning or unavailable.
Cleaning chemicals stored in unlocked cabinet accessible to residents on enhanced care unit.
Residents and/or representatives were not involved in or did not sign service plans for 3 of 5 residents reviewed.
Improper food storage in refrigerator and freezer including uncovered food, unlabeled containers, and food stored on the floor.
Trash can containing used PPE from COVID-19 positive resident was positioned outside the resident's room instead of inside.
Report Facts
Residents reviewed for dignity: 11
Residents on enhanced care unit: 15
Residents in facility: 110
Residents affected by call light deficiency: 110
Memory Care residents: 17
Employee files reviewed: 5
Employee workdays: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident B | Named in dignity and respect deficiency interviews. | |
| Resident S | Named in dignity and respect deficiency interviews and service plan signature deficiency. | |
| Resident 10 | Resident involved in delayed CPR and neglect deficiency resulting in death. | |
| Resident 111 | Named in service plan signature deficiency. | |
| Licensed Practical Nurse 11 | LPN | Personnel record name mismatch deficiency. |
| Director of Nursing | DON | Interviewed and provided multiple clarifications related to deficiencies. |
| Administrator | ADM | Interviewed and provided schedule and investigation information. |
| Director of Maintenance | DOM | Interviewed regarding call light system and cleaning chemical storage. |
| Certified Nursing Assistant 5 | CNA | Interviewed regarding pager issues and call light response. |
| Memory Care Director | Dementia Care Director | Deficient in required dementia-specific training. |
| Director of Memory Care and Engagement | DMCE | Provided information on dementia training hours. |
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 4
Date: May 15, 2024
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00417358, IN00419137, IN00417524, IN00421537, IN00427851, and IN00427292) regarding resident abuse and other concerns at Lake Meadows Senior Assisted Living.
Complaint Details
Complaints investigated included IN00417358, IN00419137, IN00417524, IN00421537, IN00427851, and IN00427292. Some complaints were substantiated with state deficiencies cited (IN00417358, IN00417524, IN00427292), while others had no deficiencies related to allegations.
Findings
The facility failed to protect residents from physical abuse by other residents, failed to ensure sufficient trained staff for insulin administration, and failed to implement proper cleaning and sanitizing policies for shared equipment. Several incidents of resident-to-resident physical altercations were documented with no injuries but inadequate monitoring and intervention. Additionally, a resident with elevated blood sugar was instructed to self-administer insulin without proper assessment or physician orders. The facility also lacked documentation for cleaning the ice machine and soda nozzles.
Deficiencies (4)
Failed to protect residents from physical abuse by other residents (Residents C, M, N, P, and R).
Failed to ensure staff were available and trained to provide insulin administration for Resident F.
Failed to implement written policy and procedure to ensure cleaning, disinfecting, and sterilization of equipment used by more than one person in a common area (ice machine and soda nozzles).
Failed to notify a physician and assess Resident F's ability to safely self-administer insulin after elevated blood sugar readings.
Report Facts
Resident count: 114
Blood sugar reading: 335
Insulin dosage: 8
Deficiency completion date: May 28, 2024
Deficiency completion date: May 17, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darlene Adair | Executive Director | Signed report and involved in interviews regarding facility operations |
| QMA 3 | Reported Resident F's elevated blood sugar and inability to administer insulin; followed ADON instructions | |
| ADON | Assistant Director of Nursing | Instructed QMA 3 and coordinated response to Resident F's insulin administration issue |
| DON | Director of Nursing | Provided incident reports and participated in interviews regarding resident abuse and insulin administration |
| Culinary Manager | Responsible for cleaning logs and sanitation of ice machine and soda nozzles |
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 0
Date: Aug 3, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00414339.
Complaint Details
Complaint IN00414339 was investigated and found to have no related deficiencies; the complaint was not substantiated.
Findings
No deficiencies related to the allegations in Complaint IN00414339 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Residential Census: 114
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 7
Date: May 11, 2023
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaints IN00399914 and IN00407732.
Complaint Details
Complaint IN00399914 - No deficiencies related to the allegations are cited. Complaint IN00407732 - State deficiencies related to the allegations are cited at R0187.
Findings
The facility was found deficient in multiple areas including failure to conduct monthly fire drills, incomplete employee screening and orientation documentation, lack of required training documentation, missing licensure for one employee, improper hot water temperature control, and inadequate food storage and temperature monitoring.
Deficiencies (7)
Failed to ensure fire drills were conducted monthly.
Failed to ensure screening for newly hired employees by not conducting reference checks for 3 of 5 employee files reviewed.
Failed to ensure a record of orientation was kept in the personnel files of newly hired employees for 3 of 5 employee files reviewed.
Failed to ensure resident rights, abuse, and dementia training was documented as provided upon hire and continued thereafter for annual training for 5 of 5 employee files reviewed.
Failed to ensure employee files contained a licensure and/or certification for 1 of 53 employees at the facility.
Failed to ensure water temperatures were maintained between 100 degrees and 120 degrees Fahrenheit.
Failed to ensure adequate food storage related to proper thawing of food and obtaining food temperatures prior to serving meals.
Report Facts
Residential Census: 116
Survey dates: May 9, 10, and 11, 2023
Fire drills required: 12
Employee files reviewed: 5
Employee files missing reference checks: 3
Employee files missing orientation records: 3
Employee files missing training documentation: 5
Employees missing licensure: 1
Water temperature readings: Multiple readings above 120 degrees Fahrenheit in resident rooms.
Food thawing dates: Food pulled from freezer on 5/4/23 with wet paper underneath.
Food temperature log missing entries: Multiple dates missing food temperature documentation prior to meal service.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darlene Adair | Executive Director | Signed the report and involved in interviews regarding employee file maintenance. |
| Maintenance Director | Interviewed regarding fire drills and hot water temperature issues. | |
| Director of Nursing | DON | Interviewed regarding employee licensure and personnel files. |
| Qualified Medication Aide 2 | QMA | Employee file missing reference checks, orientation, and training documentation. |
| Qualified Medication Aide 3 | QMA | Employee file missing reference checks, orientation, and training documentation. |
| Qualified Medication Aide 4 | QMA | Employee file missing annual training documentation. |
| Qualified Medication Aide 6 | QMA | Employee missing licensure; was terminated. |
| Housekeeping Staff 5 | Employee file missing reference checks, orientation, and training documentation. | |
| Dementia Care Coordinator | Employee file missing annual training documentation. | |
| Dietary Manager | Interviewed regarding food thawing and storage practices. |
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 0
Date: Jan 11, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00398694.
Complaint Details
Complaint IN00398694 - Substantiated. No deficiencies related to the allegations are cited.
Findings
Complaint IN00398694 was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Inspection Report
Complaint Investigation
Census: 122
Deficiencies: 1
Date: Aug 2, 2022
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00374433, IN00374688, IN00374709, IN00375181, IN00377517, IN00377582, IN00379452, and IN00379587) and included a Residential COVID-19 Quality Assurance Walk Through.
Complaint Details
Complaints IN00374433, IN00374688, IN00374709, IN00375181, IN00377517, and IN00377582 were unsubstantiated due to lack of evidence. Complaints IN00379452 and IN00379587 were substantiated but no State Residential Findings related to the allegations were cited.
Findings
Most complaints were unsubstantiated due to lack of evidence, except two complaints which were substantiated but had no State Residential Findings related to the allegations. An unrelated deficiency was cited regarding failure to report a resident-to-resident physical contact incident to the Indiana Department of Health (IDOH).
Deficiencies (1)
Failure to follow facility policy by not reporting an allegation of resident-to-resident physical contact to the Indiana Department of Health for 1 of 2 incidents reviewed (Resident D and Resident E).
Report Facts
Complaint investigations: 8
Residential Census: 122
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed and indicated inability to find where the incident was reported to IDOH; stated responsibility of Executive Director to report such incidents. |
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