Inspection Reports for Lincolnshire Place – Muncie
1600 N MORRISON ROAD, MUNCIE, IN, 47304
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 7, 2025, identified a deficiency for failing to employ a licensed administrator to manage day-to-day operations, which was substantiated in a complaint investigation. Earlier inspections showed a pattern of deficiencies related to resident care, including issues with dignity during meal service, medication administration by unqualified personnel, and documentation such as unsigned service plans. There was also a substantiated abuse complaint in November 2024 involving physical and verbal abuse by a staff member, which led to the termination of that employee. Most other 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 showed some improvement by January 2025 when a reinspection found it in compliance following prior deficiencies.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
3.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
17% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
41 residents
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 1
Date: May 7, 2025
Visit Reason
This visit was for the investigation of complaints IN00458477, IN00453983, and IN00454066. The investigation focused on allegations related to facility management and compliance.
Complaint Details
Complaint IN00458477 was substantiated with state deficiencies cited. Complaints IN00453983 and IN00454066 had no deficiencies related to the allegations.
Findings
The facility failed to employ a licensed administrator to manage day-to-day operations, affecting all 41 residents. The acting administrator was not licensed at the time of the survey but subsequently passed the licensing test.
Deficiencies (1)
Facility failed to employ a licensed administrator to manage day-to-day facility operations.
Report Facts
Residential Census: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyler Weilbaker | Administrator | Signed as the facility administrator on the report |
| RN 2 | Acting Administrator, Registered Nurse | Acting administrator at time of survey, not licensed at survey but passed licensing test on 5/6/25 |
Inspection Report
Re-Inspection
Census: 36
Deficiencies: 0
Date: Jan 10, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the State Residential Licensure Survey completed on November 22, 2024.
Findings
Lincolnshire Place-Muncie was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to the State Residential Licensure Survey.
Inspection Report
Renewal
Census: 37
Deficiencies: 5
Date: Nov 21, 2024
Visit Reason
This visit was for a State Residential Licensure Survey conducted on November 21 and 22, 2024.
Findings
The facility was found deficient in multiple areas including failure to maintain dignity during meal service, inadequate dementia training documentation for employees, unsigned resident service plans, improper insulin administration by unqualified personnel, and failure to implement a tuberculosis infection control program with annual risk assessments.
Deficiencies (5)
Failed to ensure dignity was maintained during meal service for 3 residents.
Failed to ensure newly employed staff had 6 hours of dementia training within 6 months of hire and long-standing employees had 3 hours annually; inservice training records lacked required documentation.
Failed to ensure service plans were signed by residents or their representatives for 2 residents.
Failed to ensure insulin was administered by qualified personnel for 1 resident.
Failed to adopt and implement a tuberculosis infection control program including annual TB risk assessments for residents.
Report Facts
Residents present: 37
Deficiency completion date: Jan 8, 2025
Dates of survey: Nov 21, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alyssa Butterfield | Executive Director | Signed the report and provided facility policy information |
| RN 9 | Identified as lacking dementia training documentation | |
| CNA 10 | Certified Nursing Aide | Identified as lacking dementia training documentation |
| CNA 11 | Certified Nursing Aide | Identified as lacking dementia training documentation |
| Maintenance 12 | Identified as lacking dementia training documentation | |
| CNA 13 | Certified Nursing Aide | Identified as lacking dementia training documentation |
| CNA 14 | Certified Nursing Aide | Identified as lacking dementia training documentation |
| Resident 13 | Resident involved in insulin administration deficiency | |
| CNA 5 | Certified Nursing Aide | Observed during meal service deficiency |
| CNA 6 | Certified Nursing Aide | Observed during meal service deficiency |
| CNA 7 | Certified Nursing Aide | Observed during meal service deficiency |
| CNA 8 | Certified Nursing Aide | Observed during meal service deficiency |
| QMA 2 | Qualified Medication Aide | Documented resident self-administration of insulin |
| QMA 3 | Qualified Medication Aide | Documented resident self-administration of insulin |
| QMA 4 | Qualified Medication Aide | Interviewed regarding insulin administration |
| Director of Nursing | Director of Nursing | Provided interviews and facility policy information |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 1
Date: Nov 7, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00446763 and IN00446801. Complaint IN00446763 had no deficiencies cited, while Complaint IN00446801 resulted in state deficiencies related to abuse allegations.
Complaint Details
Complaint IN00446801 was substantiated with state deficiencies cited. Complaint IN00446763 had no deficiencies related to the allegations.
Findings
The facility failed to prevent physical and verbal abuse of a cognitively impaired resident (Resident D) by a staff member. Observations, record reviews, interviews, and video evidence confirmed the abuse, including rough handling and verbal insults by CNA 3. The staff member was terminated following investigation.
Deficiencies (1)
Failed to prevent physical and verbal abuse of a cognitively impaired resident by a facility staff member.
Report Facts
Residential Census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alyssa Butterfield | Executive Director | Signed the report |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 0
Date: Sep 20, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00442288.
Complaint Details
Complaint IN00442288 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations were cited. Lincolnshire Place was found to be in compliance with 410 IAC 16.2-5 in regard to the Investigation of Complaint IN00442288.
Inspection Report
Census: 31
Deficiencies: 4
Date: Feb 14, 2024
Visit Reason
This visit was for a State Residential Licensure Survey conducted on February 13 and 14, 2024.
Findings
The facility was found deficient in several areas including failure to ensure first aid certification on every shift, incomplete semi-annual self-medication administration assessments for residents self-administering insulin, failure to meet dietary requirements for residents on mechanical soft diets, and failure to timely notify physicians and document pharmacy recommendations for residents.
Deficiencies (4)
Failed to ensure every shift had an employee who was first aid certified for 2 of 21 shifts reviewed.
Failed to ensure residents who self-administered insulin had self-medication administration assessments completed semi-annually for 2 of 2 residents reviewed.
Failed to meet residents' daily dietary requirements for 3 of 3 residents on mechanical soft diets; all were served the same gumbo meal which was not appropriate.
Failed to notify the physician, document physician notification, and address pharmacy recommendations in a timely manner for 2 of 5 residents reviewed.
Report Facts
Census: 31
Shifts without first aid certified employee: 2
Residents reviewed for self-medication assessment: 2
Residents on mechanical soft diets reviewed: 3
Residents reviewed for pharmacy recommendations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alyssa Butterfield | Executive Director | Signed the report |
| Director of Nursing | Interviewed regarding first aid certification lapses, self-medication assessments, and pharmacy recommendations | |
| QMA 4 | Observed administering insulin and interviewed regarding resident medication administration | |
| Home Health Aid 3 | Interviewed regarding diet served to residents | |
| Dietary Manager | Interviewed regarding diet preparation and errors |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 0
Date: Nov 3, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00418398.
Complaint Details
Complaint IN00418398 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations are cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 0
Date: Jun 6, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00409972.
Complaint Details
Complaint IN00409972 was investigated and found to have no related deficiencies.
Findings
No deficiencies related to the allegations in Complaint IN00409972 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Report Facts
Residential Census: 34
Inspection Report
Renewal
Census: 26
Deficiencies: 3
Date: Jan 19, 2023
Visit Reason
This visit was for a State Residential Licensure Survey conducted on January 19 and 20, 2023.
Findings
The facility was found noncompliant in posting required contact information for local health and human services agencies, lacked resident or representative signatures on service plans for 5 of 7 clinical records reviewed, and failed to maintain kitchen equipment in a clean and sanitary manner.
Deficiencies (3)
Failed to post the contact information and addresses of local health and human services agencies in an accessible area.
Failed to ensure service plans were signed by residents and/or their representatives for 5 of 7 clinical records reviewed.
Failed to maintain kitchen equipment in a clean, safe, sanitary manner, including griddle, drip pans, and ovens.
Report Facts
Residential Census: 26
Number of clinical records with unsigned service plans: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alyssa Butterfield | Administrator In Training | Interviewed regarding posting of advocacy agency contact information and facility policies |
| Director of Nursing | Interviewed regarding unsigned service plans and auditing procedures | |
| Dietary Manager | Interviewed regarding kitchen cleanliness and cleaning schedules |
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 0
Date: Nov 17, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00390059.
Complaint Details
Complaint IN00390059 - Substantiated. No deficiencies related to the allegations are cited.
Findings
Complaint IN00390059 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.
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 0
Date: Jul 28, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00383680.
Complaint Details
Complaint IN00383680 was substantiated. No deficiencies related to the allegation were cited.
Findings
Complaint IN00383680 was substantiated, but no deficiencies related to the allegation were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
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