Inspection Reports for Primrose Retirement Community of Anderson

IN, 46011

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Inspection Report Complaint Investigation Census: 34 Deficiencies: 1 Apr 24, 2025
Visit Reason
This visit was for a State Residential Licensure Survey and included the investigation of Complaint IN00454759.
Findings
No deficiencies related to the complaint allegations were cited. However, the facility failed to verify annually that residents were free from infectious tuberculosis for 4 of 7 residents reviewed, lacking annual health statements for Residents 13, 18, 6, and 32.
Complaint Details
Complaint IN00454759 was investigated with no deficiencies related to the allegations cited.
Deficiencies (1)
Description
Facility failed to verify by statement annually that residents were free from infectious tuberculosis for 4 of 7 residents reviewed (Residents 13, 18, 6, and 32).
Report Facts
Residential Census: 34 Residents reviewed lacking annual health statements: 4 Charts audited weekly: 5 Charts audited bi-weekly: 5 Charts audited monthly: 5 Compliance threshold percentage: 95
Employees Mentioned
NameTitleContext
Hervey LawrenceAdministratorNamed in relation to inability to provide policy on annual health statements
Inspection Report Complaint Investigation Census: 28 Deficiencies: 0 Feb 4, 2025
Visit Reason
This visit was conducted for the Investigation of Complaint IN00450834.
Findings
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.
Complaint Details
Complaint IN00450834 was investigated and found to have no deficiencies related to the allegations.
Inspection Report Complaint Investigation Census: 30 Deficiencies: 0 Nov 12, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00445919.
Findings
No deficiencies related to the allegations of Complaint IN00445919 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Complaint Details
Complaint IN00445919 was investigated and found to have no deficiencies related to the allegations.
Inspection Report Complaint Investigation Census: 39 Deficiencies: 0 Jun 5, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00434376 and IN00434307 at Primrose Retirement Community of Anderson.
Findings
No deficiencies related to the allegations in complaints IN00434376 and IN00434307 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the investigation of these complaints.
Complaint Details
Investigation of Complaints IN00434376 and IN00434307 found no deficiencies related to the allegations.
Report Facts
Residential Census: 39
Inspection Report Complaint Investigation Census: 30 Deficiencies: 4 May 3, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00432559, IN00432225, IN00430109, and IN00429616 regarding the facility's compliance with food safety and nutritional services standards.
Findings
The facility failed to store, prepare, and distribute food under safe sanitary conditions, including undated and unlabeled food items in refrigerators, improper dishwasher temperatures, and inadequate handwashing and food handling practices by dietary staff.
Complaint Details
The investigation was triggered by four complaints (IN00432559, IN00432225, IN00430109, IN00429616) all related to food safety and nutritional services deficiencies.
Deficiencies (4)
Description
Failure to store, prepare, and distribute food under safe sanitary conditions, including undated and unlabeled food items in refrigerators.
Dishwasher temperatures were not consistently maintained at required levels, and sanitizer concentration was not properly monitored.
Dietary staff failed to take food temperatures prior to serving and demonstrated improper handwashing and glove use, leading to potential contamination.
Kitchen equipment such as drip pans and exhaust hood had heavy residue and grease buildup.
Report Facts
Residents impacted: 30 Dishwasher temperature readings: 91 Dishwasher temperature readings: 99 Dishwasher temperature readings: 120 Dishwasher temperature readings: 103 Dishwasher temperature readings: 135 Food age in days: 16 Food age in days: 14 Food age in days: 13 Food age in days: 7 Handwashing duration: 15 Completion date for systemic changes: May 15, 2024
Employees Mentioned
NameTitleContext
LaShelle CrawleyExecutive DirectorSigned as the facility representative on the inspection report.
Dietary Employee 2Observed failing to date and label food, improper handwashing, and unsafe food handling practices.
Dietary Employee 3Interviewed regarding food storage and dishwasher temperature knowledge.
Dietary ManagerResponsible for instructing employees on food safety, added labeling and cleaning to shift checklists, and monitoring logs.
AdministratorAccompanied surveyor during dishwasher area observation and provided facility policies.
Inspection Report Complaint Investigation Census: 41 Deficiencies: 0 Feb 2, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00427051 at Primrose Retirement Community of Anderson.
Findings
No deficiencies related to the allegations in Complaint IN00427051 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Complaint Details
Complaint IN00427051 was investigated and found to have no deficiencies related to the allegations.
Inspection Report Complaint Investigation Census: 35 Deficiencies: 2 Jan 10, 2024
Visit Reason
This visit was for a State Residential Licensure Survey which included the investigation of Complaint IN00423661 related to food and nutritional services.
Findings
The facility failed to have resident meal menus reviewed and approved by a Registered Dietician and failed to prevent the consumption of unpasteurized eggs used in food preparation, potentially affecting all 35 residents.
Complaint Details
Complaint IN00423661 was investigated and state deficiencies related to the allegations were cited at R0269.
Deficiencies (2)
Description
Facility failed to have resident meal menus reviewed and approved by a Registered Dietician for nutritional requirements.
Facility failed to prevent the consumption of unpasteurized eggs for the preparation of soft-cooked eggs.
Report Facts
Residents affected: 35 Residents affected: 12
Employees Mentioned
NameTitleContext
LaShelle CrawleyExecutive DirectorSigned the report
AdministratorInterviewed regarding dietary manager absence and menu approval
Cook 3Interviewed about menu development and lack of dietician review
Cook 1Interviewed about use of unpasteurized eggs
Cook 2Interviewed as interim kitchen manager unaware of unpasteurized egg concerns
Inspection Report Complaint Investigation Census: 71 Deficiencies: 1 Nov 16, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00420761 related to allegations concerning individualized service plans at the facility.
Findings
The facility failed to ensure that 4 of 4 reviewed residents (Residents B, C, D, and E) had current, individualized service plans that were signed and dated by both the facility representative and the resident or their representative.
Complaint Details
Complaint IN00420761 was investigated and found related to the cited deficiency at R0217 regarding individualized service plans.
Deficiencies (1)
Description
Failure to ensure residents had a signed and dated individualized service plan for 4 of 4 residents reviewed (Residents B, C, D, and E).
Report Facts
Residential Census: 71 Residents reviewed for corrections: 4
Employees Mentioned
NameTitleContext
LaShelle CrawleyDirector of NursingProvided service plans for Residents B, C, D, and E which were not signed/acknowledged by the facility nor the resident/representative
Assistant Director of NursingInterviewed and observed clinical records for Residents B, C, D, and E; unable to locate service plans
Inspection Report Complaint Investigation Census: 29 Deficiencies: 0 Jun 21, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00409241.
Findings
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.
Complaint Details
Complaint IN00409241 was investigated and found to have no deficiencies related to the allegations.
Inspection Report Renewal Census: 31 Deficiencies: 6 Dec 29, 2022
Visit Reason
This visit was for a State Residential Licensure Survey conducted on December 27, 28, and 29, 2022 to assess compliance with state regulations.
Findings
The facility failed to ensure timely evaluations of individual resident needs upon admission and semi-annually for 7 residents, lacked current self-administration medication assessments for 2 residents, failed to maintain signed and dated individualized service plans for 7 residents, did not retain clinical records for discharged resident 101, lacked an infection control program for tracking infections, and failed to obtain annual health statements for 4 residents.
Deficiencies (6)
Description
Failed to ensure each resident had an evaluation of individual needs completed upon admission and/or semi-annually for 7 residents.
Failed to ensure residents who self-administered medication had a current self medication administration assessment completed for 2 residents.
Failed to ensure each resident had a signed and dated individualized service plan for 7 residents.
Failed to maintain clinical records for discharged resident 101.
Failed to develop and maintain an infection control program to include a system to analyze patterns of known infectious symptoms.
Failed to ensure residents had an annual health statement for 4 residents.
Report Facts
Residents reviewed for evaluation deficiency: 7 Residents reviewed for self-administration medication assessment deficiency: 2 Residents reviewed for individualized service plan deficiency: 7 Residents reviewed for annual health statement deficiency: 4 Antibiotic prescriptions: 9 Residents at census during inspection: 31
Employees Mentioned
NameTitleContext
Diana GuinnExecutive DirectorSigned the report and identified facility deficiencies during interviews

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