Inspection Report Summary
The most recent inspection on January 30, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a mostly compliant pattern, with one substantiated complaint in August 2024 involving a delayed report to the Indiana Department of Health about unexplained bruising, which did not result in resident harm. Prior reports cited issues with notification after falls, resident supervision, staff training, and documentation, but no fines or enforcement actions were listed in the available reports. Most complaint investigations were unsubstantiated, and the facility corrected earlier cited deficiencies by April 2024. The record indicates improvement over time, with recent inspections showing compliance with regulations.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
52% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
97 residents
Based on a January 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 0
Date: Jan 30, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00451183.
Complaint Details
Complaint IN00451183 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations of Complaint IN00451183 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Report Facts
Residential Census: 97
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 0
Date: Oct 3, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00441943.
Complaint Details
Complaint IN00441943 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00441943 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: 106
Deficiencies: 1
Date: Aug 22, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00441295 regarding an allegation of failure to report an unusual occurrence involving unexplained bruising of a cognitively impaired resident's eye.
Complaint Details
Complaint IN00441295 was substantiated with a state deficiency cited at R0090 related to failure to report an unusual occurrence involving unexplained bruising of Resident B's eye.
Findings
The facility failed to notify the Indiana Department of Health of an unusual occurrence related to unexplained bruising under the right eye of Resident B. The bruise was observed and investigated, but reporting was delayed until the date of the survey. The resident was not harmed and ongoing care was provided. The facility reviewed all residents' records and conducted staff inservices to ensure compliance with reporting policies.
Deficiencies (1)
Failure to ensure the Indiana Department of Health was notified of an unusual occurrence related to unexplained bruising of a cognitively impaired resident's eye.
Report Facts
Residential Census: 106
Bruise size: 2.5
Plan of Correction Completion Date: Sep 4, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Ayersman | Executive Director | Signed the report and involved in review of resident records and policy compliance |
| Director of Nursing | Interviewed regarding the bruising incident and reporting procedures | |
| Administrator | Interviewed regarding the bruising investigation and reporting |
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 0
Date: Jul 24, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00437949 and IN00438269.
Complaint Details
Complaint IN00437949 and Complaint IN00438269 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00437949 and IN00438269 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Residential Census: 104
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 0
Date: Jun 18, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00436811.
Complaint Details
Complaint IN00436811 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00436811 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Residential Census: 101
Inspection Report
Re-Inspection
Census: 106
Deficiencies: 0
Date: Apr 24, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the State Residential Licensure Survey and the Investigation of Complaint IN00424859 completed on 2024-02-28, conducted in conjunction with the Investigation of Complaint IN00433098.
Complaint Details
Complaint IN00424859 was corrected. Complaint IN00433098 had no deficiencies related to the allegations cited.
Findings
Residences at Deer Creek was found to be in compliance with 410 IAC 16.2-5 regarding the PSR to the State Residential Licensure Survey and the PSR to Complaint IN00424859. No deficiencies related to Complaint IN00433098 were cited.
Report Facts
Residential Census: 106
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 0
Date: Apr 24, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00433098 and was conducted in conjunction with the Post Survey Revisit to the State Residential Licensure Survey and the Investigation of Complaint IN00424859 completed on 2/28/24.
Complaint Details
Complaint IN00433098 - No deficiencies related to the allegations are cited. Complaint IN00424859 - Corrected.
Findings
No deficiencies related to Complaint IN00433098 were cited, and Complaint IN00424859 was corrected. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the investigation of Complaint IN00433098.
Report Facts
Residential Census: 106
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 5
Date: Feb 28, 2024
Visit Reason
This visit was for a State Residential Licensure Survey including the investigation of three complaints (IN00423953, IN00424859, and IN00425475).
Complaint Details
Complaint IN00423953 - No deficiencies related to the allegations were cited. Complaint IN00424859 - State deficiency related to the allegations cited at R052. Complaint IN00425475 - No deficiencies related to the allegations were cited.
Findings
The facility was cited for deficiencies related to failure to timely notify responsible parties and physicians after a fall, inadequate supervision leading to a resident eloping, incomplete annual dementia training for staff, lack of job-specific orientation for new employees, and incomplete clinical records including failure to document neurological checks after falls.
Deficiencies (5)
Failed to ensure the resident's Responsible Party and/or Physician were notified timely after a fall for 1 of 10 records reviewed (Resident B).
Failed to ensure a resident was free from neglect related to inadequate supervision resulting in elopement for 1 of 3 residents reviewed (Resident B).
Failed to ensure required personnel annual dementia inservices were completed for 4 of 6 staff members reviewed (LPN 1, LPN 2, RN 1, Concierge).
Failed to ensure new employees had job specific orientation for 2 of 5 new employee files reviewed (Housekeeper 1 and Dishwasher 1).
Failed to ensure clinical records were complete and accurately documented related to monitoring bruises, follow-up documentation after falls, and neurological checks for 4 of 10 sampled residents (Residents 9, 10, 3, and 4).
Report Facts
Residential Census: 107
Staff missing dementia training: 4
New employees missing job specific orientation: 2
Residents sampled for clinical record review: 10
Residents with clinical record deficiencies: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding notification of falls, staff training, and clinical documentation. |
| LPN 1 | Licensed Practical Nurse | Staff member missing required annual dementia training. |
| LPN 2 | Licensed Practical Nurse | Staff member missing required annual dementia training. |
| RN 1 | Registered Nurse | Staff member missing required annual dementia training; no longer employed at facility. |
| Concierge | Concierge | Staff member missing required annual dementia training. |
| Business Office Manager | Business Office Manager | Interviewed regarding lack of job specific orientation for new employees. |
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 0
Date: Aug 16, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00403015 and IN00403757.
Complaint Details
Investigation of Complaints IN00403015 and IN00403757 found no deficiencies related to the allegations; both complaints were not substantiated.
Findings
No deficiencies related to the allegations in complaints IN00403015 and IN00403757 were cited. The facility was found to be in compliance with relevant regulations.
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