Inspection Reports for Lutheran Life Villages
351 N ALLEN CHAPEL RD, IN, 46755
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 19, 2025, found the facility in compliance with Emergency Preparedness and Life Safety Code requirements, with no deficiencies cited. Earlier inspections showed a mixed pattern, with some deficiencies related to resident privacy, trauma-informed care, medication documentation, and life safety maintenance such as sprinkler corrosion and fire damper inspections. Complaint investigations were consistently unsubstantiated, with no deficiencies found related to allegations in multiple complaint surveys. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. The facility appears to have addressed prior issues through corrective actions and education, showing some improvement in recent inspections.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
29% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
77% occupied
Based on a March 2025 inspection.
Census over time
Inspection Report
Life Safety
Census: 76
Capacity: 99
Deficiencies: 0
Mar 19, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Participation in Medicare/Medicaid. The facility is a one-story building with a basement, fully sprinklered except for the garage, and has a fire alarm system with smoke detection in corridors and resident rooms.
Report Facts
Certified beds: 99
Census: 76
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 3, 2025
Visit Reason
The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Lutheran Life Villages was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Annual Inspection
Census: 75
Capacity: 75
Deficiencies: 1
Feb 18, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted over multiple days in February 2025.
Findings
The facility was found to have deficiencies related to failure to ensure privacy of medical records for 2 of 8 residents reviewed, specifically involving unattended medication carts and computer screens displaying private resident information visible to passersby. The facility implemented education and auditing measures to address these issues.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure privacy of medical records for 2 of 8 residents reviewed, with unattended medication carts and computer screens displaying private resident information visible to passersby. | SS=D |
Report Facts
Census: 75
Total Capacity: 75
Residents reviewed: 8
Residents with privacy deficiency: 2
BIMS score: 10
BIMS score: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sadie Fenstermaker | Administrator | Signed the report and provided policy information |
| LPN 2 | Licensed Practical Nurse | Observed leaving computer screen open and acknowledged privacy breach |
| DON | Director of Nursing | Observed medication pass and conducted audits and education on privacy |
Inspection Report
Re-Inspection
Census: 69
Capacity: 99
Deficiencies: 0
May 30, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 03/18/24 was performed to verify compliance with prior deficiencies.
Findings
At this PSR survey, Lutheran Life Villages 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
Complaint Investigation
Census: 76
Capacity: 76
Deficiencies: 0
May 24, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00434732.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Complaint Details
Complaint IN00434732 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 76
Total Capacity: 76
Medicare Census: 8
Medicaid Census: 44
Other Payor Census: 24
Inspection Report
Complaint Investigation
Census: 72
Capacity: 72
Deficiencies: 0
Apr 25, 2024
Visit Reason
This visit was conducted for the investigation of Complaints IN00431081 and IN00432773.
Findings
No deficiencies related to the allegations in Complaints IN00431081 and IN00432773 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00431081 and Complaint IN00432773 were investigated with no deficiencies related to the allegations cited.
Report Facts
Medicare census: 6
Medicaid census: 40
Other payor census: 26
Inspection Report
Life Safety
Census: 69
Capacity: 99
Deficiencies: 2
Mar 18, 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 in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively on 03/18/2024.
Findings
The facility was found in compliance with Emergency Preparedness Requirements. However, the Life Safety Code survey identified deficiencies including corrosion on a sprinkler head in the kitchen dishing room and a past due fire damper inspection. Corrective actions and plans for ongoing monitoring were documented.
Severity Breakdown
Level 1: 1
Level F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 2 sprinklers in the kitchen dishing room were free of corrosion, which could affect staff and up to 20 residents in one smoke compartment. | Level 1 |
| Failed to ensure 1 of 1 fire damper system was inspected and maintained after the first year and at least every four years as required, affecting all residents. | Level F |
Report Facts
Certified beds: 99
Census: 69
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sadie Fenstermaker | Administrator | Named in relation to findings and exit conference |
| Maintenance Director | Named in relation to sprinkler head corrosion finding and fire damper inspection deficiency |
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 13, 2024
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey completed on February 27, 2024.
Findings
Lutheran Life Villages was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Annual Inspection
Census: 72
Capacity: 72
Deficiencies: 2
Feb 27, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted over multiple days from February 21 to 27, 2024.
Findings
The facility was found deficient in trauma-informed care for one resident with a history of trauma, failing to recognize and identify triggers. Additionally, the facility failed to ensure proper documentation of behaviors prior to administration of PRN psychotropic medications for one resident. Plans of correction and staff education were implemented.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to recognize and identify triggers for a resident with a history of trauma (Resident 5). | SS=D |
| Facility failed to ensure behaviors were documented prior to administration of PRN psychotropic medication for a resident (Resident 31). | SS=D |
Report Facts
Census: 72
Total Capacity: 72
Medicare Census: 8
Medicaid Census: 34
Other Payor Census: 30
Survey Dates: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sadie Fenstermaker | Administrator | Signed the report and provided facility policy information |
| Resident 5 | N/A | Subject of trauma-informed care deficiency |
| Resident 31 | N/A | Subject of psychotropic medication documentation deficiency |
| Director of Nursing | DON | Provided interviews and implemented corrective actions |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 73
Deficiencies: 0
Nov 21, 2023
Visit Reason
This visit was conducted for the investigation of two complaints, IN00421852 and IN00421918.
Findings
No deficiencies related to the allegations in either complaint were cited. The facility was found to be in compliance with relevant regulations regarding the complaints investigated.
Complaint Details
Complaint IN00421852 and Complaint IN00421918 were investigated with no deficiencies found related to the allegations.
Report Facts
Census Bed Type: 73
Medicare residents: 2
Medicaid residents: 41
Other payor residents: 30
Inspection Report
Complaint Investigation
Census: 69
Capacity: 69
Deficiencies: 0
Oct 10, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00417616 and IN00418184.
Findings
No deficiencies related to the allegations in complaints IN00417616 and IN00418184 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaints IN00417616 and IN00418184 found no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 69
Census total residents: 69
Census Medicare residents: 6
Census Medicaid residents: 36
Census other payor residents: 27
Inspection Report
Complaint Investigation
Census: 68
Capacity: 68
Deficiencies: 0
Aug 15, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00414345.
Findings
No deficiencies related to the allegations of Complaint IN00414345 were cited. Lutheran Life Villages was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00414345 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare residents: 3
Medicaid residents: 38
Other residents: 27
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 6, 2023
Visit Reason
The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Lutheran Life Villages was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 78
Capacity: 99
Deficiencies: 0
Mar 2, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Participation in Medicare/Medicaid. The facility is fully sprinklered except for a garage providing facility services which was not sprinklered.
Report Facts
Certified beds: 99
Census: 78
Inspection Report
Annual Inspection
Census: 76
Capacity: 76
Deficiencies: 4
Feb 20, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00401421.
Findings
The facility was found to have deficiencies related to quality of care including failure to ensure proper orders and treatments for a skin tear, oxygen tubing changes, pain management non-pharmacologic interventions, and hospice service coordination. The complaint was unsubstantiated due to lack of evidence.
Complaint Details
Complaint IN00401421 was unsubstantiated due to lack of evidence. No deficiencies related to the allegations were cited.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure orders, treatments, and assessments for a skin tear were completed for 1 of 3 residents reviewed (Resident 57). | SS=D |
| Failed to ensure oxygen tubing changes were performed according to standards in 2 of 2 residents reviewed (Resident 15 and Resident 67). | SS=D |
| Failed to ensure non-pharmacologic interventions were implemented for 2 of 5 residents reviewed (Resident 8 and Resident 75). | SS=D |
| Failed to ensure instructions for contacting the correct hospice company were clearly communicated to staff for 1 of 3 residents reviewed (Resident 67). | SS=D |
Report Facts
Survey dates: 5
Census SNF/NF: 69
Census SNF: 7
Total census: 76
Medicare census: 5
Medicaid census: 39
Other payor census: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sadie Fenstermaker | Administrator | Signed the report |
| LPN 3 | Licensed Practical Nurse | Named in skin tear dressing deficiency for Resident 57 |
| LPN 5 | Licensed Practical Nurse | Named in oxygen tubing and pain management deficiencies |
| LPN 6 | Licensed Practical Nurse | Named in hospice services deficiency |
| DON | Director of Nursing | Reviewed orders, provided education, and developed audit tools for multiple deficiencies |
| ED | Executive Director | Provided current policy on Skin Management |
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