Inspection Report Summary
The most recent inspection on July 1, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a pattern of deficiencies primarily involving care planning, communication with hospice providers, infection control practices, and life safety code compliance, including fire safety system maintenance. Complaint investigations were mostly unsubstantiated, though some were substantiated with citations related to wound care orders, infection control, physical restraint use, and resident privacy. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility appears to have addressed many prior issues, with recent inspections showing improved compliance in emergency preparedness and complaint investigations.
Deficiencies (last 5 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a July 2025 inspection.
Census over time
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Housekeeper 2 | Indicated resident rooms were cleaned daily and described cleaning practices. | |
| Administrator | Provided the current Housekeeping general policy with a revision date of 5/16/25. |
Inspection Report
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Complaint Investigation| Name | Title | Context |
|---|---|---|
| Eric Will | Executive Director | Signed the report |
| Director Of Nursing (DON) | Provided statements regarding nursing responsibilities and wound care orders during the investigation | |
| LPN 2 | Provided information about wound orders and hospital discharge reports | |
| RN 3 | Provided current treatment orders policy and skin integrity & pressure ulcer/injury prevention policy |
Inspection Report
Complaint InvestigationInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Director Of Nursing (DON) | Indicated nurses' responsibility to obtain wound orders promptly and discussed issues related to wound orders for Resident B and Resident C | |
| LPN 2 | Provided information on wound orders process and steps to take if wound orders are missing | |
| RN 3 | Provided current treatment orders policy and skin integrity & pressure ulcer/injury prevention and management policy |
Inspection Report
Follow-UpInspection Report
Life Safety| Name | Title | Context |
|---|---|---|
| Krista Adams | Executive Director | Named in relation to findings and plan of correction |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided interviews and indicated expectations regarding notification and care plans; provided policies related to skin management and documentation. |
| Administrator | Administrator | Provided policies related to changes in resident condition, nursing documentation, and care plan development. |
| Licensed Practical Nurse 7 | LPN | Indicated Resident T did not get showers because she was difficult to get up. |
| Certified Nurse Aide 10 | CNA | Indicated residents got showers twice a week and showers were documented on shower sheets. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Provided multiple interviews and policies related to care plan deficiencies, notification failures, restorative nursing, neurological assessments, and hospice communication. |
| Administrator | Administrator | Provided policies and interviews related to care plans, restorative nursing, hospice communication, and nurse staffing. |
| RN 3 | Registered Nurse | Indicated water should not be in medication cart bottom and discussed medication storage. |
| RN 5 | Registered Nurse | Indicated no loose pills should be in medication carts. |
| LPN 7 | Licensed Practical Nurse | Indicated Resident T did not get showers because she was difficult to get up. |
| LPN 9 | Licensed Practical Nurse | Discussed access to hospice portal and communication with hospice staff. |
| LPN 11 | Licensed Practical Nurse | Indicated hospice binders were replaced by online portal. |
| CNA 10 | Certified Nurse Aide | Indicated residents got showers twice a week and showers were documented on sheets not part of clinical record. |
| QMA 8 | Qualified Medication Aide | Unaware of hospice portal change to online system. |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Brenda Buroker | Director Division of Long Term Care | Named in correspondence related to the survey. |
| Krista Adams | Executive Director | Signed plan of correction response. |
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Plan of CorrectionInspection Report
Complaint InvestigationInspection Report
Complaint InvestigationInspection Report
Complaint InvestigationInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Krista Adams | Executive Director | Signed plan of correction and correspondence related to the complaint survey |
| LPN 1 | Observed failing to properly don PPE in COVID-19 isolation rooms | |
| CNA 1 | Observed failing to properly don PPE in COVID-19 isolation rooms |
Inspection Report
Complaint InvestigationInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| LPN 1 | Observed improperly donning PPE and interviewed regarding PPE requirements. | |
| CNA 1 | Observed improperly donning PPE. | |
| Administrator | Administrator | Provided current COVID-19 policy during inspection. |
Inspection Report
Life SafetyInspection Report
Complaint InvestigationInspection Report
Life Safety| Name | Title | Context |
|---|---|---|
| Krista Adams | Executive Director | Named in relation to findings and plan of correction |
| Brenda Buroker | Director Division of Long Term Care, Indiana State Department of Health | Recipient of survey report |
| Maintenance Director | Interviewed and involved in findings related to sprinkler system, smoke barrier, water heaters, and fire drills |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Krista Adams | Executive Director | Signed plan of correction and involved in responses |
| Brenda Buroker | Director Division of Long Term Care | Indiana State Department of Health official receiving report |
Inspection Report
RenewalInspection Report
Routine| Name | Title | Context |
|---|---|---|
| CNA 5 | Certified Nurse Aide | Observed providing care and reported on resident bathing preferences and refusals |
| CNA 7 | Certified Nurse Aide | Reported on shower documentation and schedule |
| MDS Coordinator | Provided information on MDS assessment policies and errors | |
| Director of Nursing | Director of Nursing (DON) | Provided information on care plan conferences, policies, and staffing |
| RN 9 | Registered Nurse | Interviewed regarding oxygen orders and care plan |
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Complaint Investigation| Name | Title | Context |
|---|---|---|
| Christina Wilson | Executive Director | Signed the report |
| CNA 1 | Observed giving bed bath without pulling privacy curtain | |
| ADON | Assistant Director of Nursing | Provided policy on dignity and privacy; interviewed regarding hospice notification |
| DON | Director of Nursing | Responsible for hospice notification and education on privacy practices |
| LPN 1 | Licensed Practical Nurse | Indicated hospice is normally called before sending resident to ER |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| CNA 1 | Observed giving Resident B a bed bath without pulling privacy curtain. | |
| ADON | Assisted Director of Nursing | Provided policy on dignity and privacy; indicated no documentation of hospice notification. |
| LPN 1 | Licensed Practical Nurse | Indicated hospice is normally called before sending a resident to the ER. |
| DON | Director of Nursing | Indicated hospice was in the building when Resident B was sent to the hospital; no documentation provided. |
Inspection Report
Complaint InvestigationInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Heather Keesee | RN, RDCS | Signed the report as Laboratory Director or Provider/Supplier Representative |
Inspection Report
Complaint InvestigationInspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| LPN 3 | Indicated unawareness of resident self-administering inhaler and observed with surgical mask under N95 mask during tracheostomy care. | |
| DON | Director of Nursing | Indicated no resident had self-administration orders and discussed restorative care issues. |
| SSD | Social Services Director | Indicated failure to notify Ombudsman of transfers and discussed behavior tracking and care plans. |
| CNA 3 | Observed with surgical mask under nose and face shield, improper mask use during resident transfer and food cart delivery. | |
| CNA 2 | Indicated no restorative aide and did not perform range of motion. | |
| Corporate Nurse Consultant | Provided multiple current facility policies and discussed restorative care and infection control. | |
| Dietary Manager | Discussed menu substitutions, supply issues, and resident food complaints. | |
| IP Nurse | Infection Preventionist Nurse | Indicated incomplete PPE use during COVID-19 testing and discussed infection control policies. |
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