Inspection Reports for River Terrace Health Care Center
400 CAYLOR BLVD, IN, 46714
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 20, 2025, was a complaint investigation and found no deficiencies related to the allegations. Earlier inspections showed a pattern of deficiencies primarily involving emergency preparedness, life safety code compliance, and medication documentation. Prior reports cited issues such as failure to conduct required emergency drills and training, incomplete testing and maintenance records for safety equipment, and medication labeling and monitoring errors. Complaint investigations were generally unsubstantiated or found no deficiencies related to the allegations, with one substantiated complaint not resulting in cited deficiencies. The facility’s inspection history shows some improvement in emergency preparedness and life safety compliance in recent follow-up surveys after earlier citations.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
7% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
59 residents
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 0
Jun 20, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00461853.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00461853 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 26
Census Residential beds: 33
Total Census: 59
Medicare residents: 1
Medicaid residents: 35
Other payor residents: 23
Inspection Report
Complaint Investigation
Census: 29
Capacity: 29
Deficiencies: 0
Mar 25, 2025
Visit Reason
This visit was for the investigation of complaints IN00455031, IN00455067, and IN00454871.
Findings
No deficiencies related to the allegations were cited for any of the complaints investigated. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaints IN00455031, IN00455067, and IN00454871 were investigated with no deficiencies found related to the allegations.
Report Facts
Census: 29
Total Capacity: 29
Medicare Census: 4
Medicaid Census: 16
Other Payor Census: 9
Inspection Report
Annual Inspection
Deficiencies: 0
Feb 17, 2025
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
River Terrace Health Care Center 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
Re-Inspection
Census: 28
Capacity: 30
Deficiencies: 0
Feb 13, 2025
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 01/24/25.
Findings
At this PSR survey, River Terrace Health Care Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility was fully sprinklered except for the maintenance building, and had a fire alarm system with smoke detection in corridors and resident rooms.
Report Facts
Facility capacity: 30
Census: 28
Inspection Report
Life Safety
Census: 26
Capacity: 30
Deficiencies: 5
Jan 24, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification survey were conducted by the Indiana Department of Health to assess compliance with emergency preparedness and life safety requirements for Medicare and Medicaid participating providers.
Findings
The facility was found not in compliance with emergency preparedness requirements due to failure to conduct required emergency plan exercises twice per year. Life Safety Code deficiencies included failure of a delayed egress door to release properly, lack of itemized records for emergency lighting and electrical receptacle testing, and use of a non-compliant power strip in a resident care area.
Severity Breakdown
SS=F: 1
SS=E: 1
SS=C: 2
SS=D: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills. | SS=F |
| Failed to ensure 1 of 2 delayed egress locking arrangements released the lock as required by Life Safety Code. | SS=E |
| Failed to maintain itemized records of inspections and tests for 7 of 7 battery backup emergency lights. | SS=C |
| Failed to ensure testing form for hospital grade electrical receptacles in 20 of 20 resident rooms showed each receptacle was tested. | SS=C |
| Failed to ensure 1 of 1 flexible cord power-strip in a patient care location met required UL rating. | SS=D |
Report Facts
Facility capacity: 30
Census: 26
Battery backup lights tested: 7
Resident sleeping rooms tested: 20
Residents potentially affected by delayed egress door deficiency: 15
Residents potentially affected by power strip deficiency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mallory Zehr | Administrator | Named in relation to findings and exit conferences |
| Maintenance Director | Named in relation to findings and interviews but no full name provided |
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 2
Jan 10, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from January 6 to January 10, 2025.
Findings
The facility was found to have deficiencies related to medication labeling, specifically failure to label open dates on insulin medications for one resident, and failure to document catheter output for another resident. Corrective actions and systemic changes were planned to address these issues. The facility was found in compliance with State Residential Licensure requirements.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure labeling of open date for insulin medications on medication carts for Resident 29. | SS=D |
| Failure to document catheter output for Resident 12 with a Foley catheter. | SS=D |
Report Facts
Census SNF/NF beds: 28
Census Residential beds: 31
Total Census: 59
Medicare census: 2
Medicaid census: 21
Other payor census: 5
Deficiency completion date: Jan 26, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mallory Zehr | Administrator | Signed the report and involved in receipt of policy documents |
| RN 2 | Registered Nurse involved in medication labeling deficiency observation and interview | |
| QMA 3 | Qualified Medical Assistant | Interviewed regarding medication labeling practices |
| CNA 4 | Certified Nursing Assistant | Interviewed regarding catheter output documentation and received in-service training |
| Director of Nursing | Director of Nursing | Interviewed regarding catheter output documentation importance and monitoring |
Inspection Report
Complaint Investigation
Census: 27
Capacity: 27
Deficiencies: 0
Nov 26, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00447770.
Findings
No deficiencies related to the allegations in Complaint IN00447770 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00447770 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 27
Total Capacity: 27
Medicare Census: 1
Medicaid Census: 19
Other Payor Census: 7
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 0
Jun 7, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00434993.
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.
Complaint Details
Complaint IN00434993 was investigated and found to have no deficiencies related to the allegations.
Inspection Report
Re-Inspection
Census: 28
Capacity: 30
Deficiencies: 0
Apr 9, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 03/07/24.
Findings
At this PSR survey, River Terrace Health Care Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility was fully sprinklered in resident areas and had a fire alarm system with smoke detection; the maintenance building was not sprinklered.
Report Facts
Facility capacity: 30
Census: 28
Inspection Report
Life Safety
Census: 28
Capacity: 30
Deficiencies: 5
Mar 7, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively, to assess compliance with emergency preparedness and life safety requirements.
Findings
The facility was found not in compliance with Emergency Preparedness training requirements, emergency lighting testing, sprinkler system maintenance, fire drills, and generator testing. Deficiencies included failure to conduct annual emergency preparedness training, monthly and annual testing of battery backup emergency lights, weekly inspection of dry pipe sprinkler system gauges and valves, quarterly fire drills on each shift, and monthly generator load testing and weekly inspections.
Severity Breakdown
SS=F: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to conduct annual emergency preparedness training and demonstrate staff knowledge of emergency procedures. | SS=F |
| Failed to ensure 7 of 7 battery backup emergency lights were properly tested monthly and annually. | SS=F |
| Failed to maintain weekly inspection of dry pipe sprinkler system's gauges and valves as required. | SS=F |
| Failed to conduct fire drills on each shift for 1 of 4 quarters. | SS=F |
| Failed to maintain complete written records of monthly generator load testing for 4 of 12 months and weekly inspections for 16 of 52 weeks. | SS=F |
Report Facts
Facility capacity: 30
Census: 28
Battery backup emergency lights: 7
Months without monthly generator load testing: 4
Weeks without weekly generator inspection: 16
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 6, 2024
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure survey conducted on February 20, 2024.
Findings
River Terrace Health Care Center 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: 76
Capacity: 76
Deficiencies: 2
Feb 20, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including investigations of healthcare Complaint IN00427720 and residential Complaint IN00424346.
Findings
The facility was found to have deficiencies related to failure to monitor medication refrigerator temperatures and inaccurate reporting of nursing hours to the Payroll-Based Journal system. No deficiencies were cited related to the complaints investigated.
Complaint Details
Complaint IN00427720 and Complaint IN00424346 were investigated with no deficiencies related to the allegations cited.
Severity Breakdown
Level D: 1
Level A: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure refrigerator temperatures were monitored for 1 of 1 medication rooms reviewed; temperature logs had multiple missing entries and refrigerator temperature was found at 30 degrees, outside recommended range. | Level D |
| Failed to ensure accurate reporting to the Payroll-Based Journal system regarding nursing hours for 1 of 1 quarter reviewed; several dates had no registered nurse hours reported despite coverage. | Level A |
Report Facts
Census SNF/NF beds: 30
Census Residential beds: 46
Total Census: 76
Medicare Census: 2
Medicaid Census: 13
Other Payor Census: 15
Dates with missing refrigerator temperature logs: 15
Refrigerator temperature: 30
PBJ infraction dates: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rod Craft | Administrator | Signed report and provided facility policy information |
| Director of Nursing | Director of Nursing | Interviewed regarding refrigerator temperature monitoring and quality improvement |
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 0
Nov 9, 2023
Visit Reason
This visit was conducted for the Investigation of Complaint IN00420809 and included a COVID-19 infection control survey.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Complaint IN00420809 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 72
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 35
Census Payor Type - Other: 35
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 0
Oct 19, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00418062.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00418062 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 29
Census Residential: 42
Total Census: 71
Census Payor Medicaid: 37
Census Payor Other: 34
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 0
Apr 13, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00404634.
Findings
No deficiencies related to the allegations in Complaint IN00404634 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00404634 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 28
Census Bed Type - Residential: 39
Census Total: 67
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 13
Census Payor Type - Other: 13
Census Payor Type - Total: 28
Inspection Report
Annual Inspection
Deficiencies: 0
Feb 15, 2023
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey conducted on January 24, 2023.
Findings
River Terrace Health Care Center 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
Routine
Census: 29
Capacity: 30
Deficiencies: 3
Feb 7, 2023
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification survey were conducted by the Indiana Department of Health to assess compliance with emergency preparedness requirements and fire safety standards.
Findings
The facility was found in substantial compliance with Emergency Preparedness Requirements and Life Safety Code standards. However, deficiencies were cited for failure to conduct annual emergency preparedness training with documented staff knowledge, failure to analyze and document emergency plan drills, and failure to maintain internal pipe inspection documentation for the sprinkler system.
Severity Breakdown
SS=C: 2
SS=F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to conduct annual training for the Emergency Preparedness Program and demonstrate staff knowledge. | SS=C |
| Failed to analyze and maintain complete documentation for emergency preparedness drills and exercises. | SS=C |
| Failed to maintain documentation of internal pipe inspection for sprinkler system as required every 5 years. | SS=F |
Report Facts
Facility capacity: 30
Census: 29
Date of inspection: Feb 7, 2023
Date of last emergency preparedness training: Feb 22, 2022
Date of last internal pipe inspection: Aug 30, 2019
Date systemic changes to emergency preparedness training and testing to be completed: Mar 3, 2023
Date systemic changes to sprinkler system maintenance to be completed: Feb 23, 2023
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 7, 2023
Visit Reason
The document reports on paper compliance for the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey conducted on 02/07/2023.
Findings
River Terrace Healthcare Center was found in compliance with the Emergency Preparedness Requirements and Life Safety Code requirements for Medicare and Medicaid participating providers and suppliers.
Report Facts
Survey date: Feb 7, 2023
Inspection Report
Annual Inspection
Census: 41
Capacity: 28
Deficiencies: 1
Jan 24, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey including a State Residential Licensure Survey conducted on January 19, 20, 23, and 24, 2023.
Findings
The facility failed to ensure that adverse side effects of psychotropic medications were monitored for one resident (Resident 18) despite multiple physician orders requiring monitoring. Documentation of side effect monitoring was absent in medication administration records and nurses notes. The facility implemented corrective actions including audits, staff inservices, and a quality assurance program to ensure compliance. The facility was found in compliance with state residential licensure requirements overall.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to monitor and document adverse side effects of psychotropic medications for Resident 18 as required by physician orders and facility policy. | SS=D |
Report Facts
Survey dates: 4
Census: 41
Total licensed capacity: 28
Residents reviewed: 5
Performance improvement audit sample size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 3 | Interviewed regarding side effect monitoring procedures | |
| Director of Nursing (DON) | Interviewed regarding side effect monitoring policies and documentation | |
| Nurse Practitioner | Provided psychiatric assessment and medication monitoring notes for Resident 18 |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 0
Nov 28, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00394507.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00394507 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Residential Census: 41
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 0
Oct 20, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00390502.
Findings
The complaint IN00390502 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Complaint IN00390502 was investigated and found to be unsubstantiated due to lack of evidence.
Report Facts
Census: 70
Census Bed Type - SNF/NF: 30
Census Bed Type - Residential: 40
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 31
Census Payor Type - Other: 38
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 0
Sep 8, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00388826.
Findings
The complaint IN00388826 was substantiated; however, no State Residential Findings related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Complaint Details
Complaint IN00388826 was substantiated but no state residential findings related to the allegations were cited.
Inspection Report
Complaint Investigation
Census: 27
Capacity: 27
Deficiencies: 0
Jul 26, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00383958.
Findings
The complaint was found to be unsubstantiated and no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00383958 was investigated and found to be unsubstantiated with no deficiencies cited.
Report Facts
Census Bed Type: 27
Medicare Census: 2
Medicaid Census: 14
Other Payor Census: 11
Loading inspection reports...
