Inspection Report Summary
The most recent inspection on March 12, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a pattern of deficiencies primarily involving emergency preparedness, life safety code compliance, resident care including medication management, infection control, and care planning. Complaint investigations were mostly unsubstantiated, except for one substantiated complaint in November 2022 related to wound care and supervision that led to elopement. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s recent inspections indicate improvement, with the latest surveys showing compliance following prior citations.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
14 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
233% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
57% occupied
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 47
Capacity: 82
Deficiencies: 0
Date: Mar 12, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00448449.
Complaint Details
Complaint IN00448449 was investigated and found to have no deficiencies related to the allegations.
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.
Report Facts
Census Bed Type Total: 82
Census Payor Type Total: 47
Census by Payor: 6
Census by Payor: 27
Census by Payor: 14
Inspection Report
Re-Inspection
Census: 50
Capacity: 60
Deficiencies: 0
Date: Jan 14, 2025
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey that exited on 12/02/24.
Findings
At this PSR survey, Southfield Village was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements for Medicare and Medicaid Participating Providers and Suppliers. The facility was fully sprinklered and protected by a diesel powered generator, with no deficiencies noted.
Report Facts
Certified beds: 60
Census: 50
Generator power: 200
Inspection Report
Life Safety
Census: 50
Capacity: 60
Deficiencies: 5
Date: Dec 2, 2024
Visit Reason
A Life Safety Code Recertification Survey and an Emergency Preparedness Survey were conducted by the Indiana Department of Health to assess compliance with Medicare and Medicaid participation requirements, including emergency preparedness and fire safety codes.
Findings
The facility was found not in compliance with emergency preparedness requirements due to lack of a system to track staff and residents during emergencies. Life Safety Code deficiencies included improper placement and labeling of kitchen cooking appliances, an incorrectly mounted kitchen extinguishing system pull station, failure to document emergency generator testing within 36 months, and use of flexible cords as substitutes for fixed wiring in resident rooms.
Deficiencies (5)
Failed to ensure emergency preparedness policies included a system to track location of on-duty staff and sheltered residents during and after an emergency.
Failed to provide an approved method for returning cooking appliances to their designed location under the kitchen hood extinguishing system.
Kitchen extinguishing system pull station mounted 59 inches above floor, exceeding required height of 42-48 inches.
Failed to document 36-month emergency generator testing for 1 of 1 emergency generators.
Used flexible cords and multi-plug adapters as substitutes for fixed wiring in resident rooms, violating electrical code.
Report Facts
Certified beds: 60
Census: 50
Emergency generator test duration: 4
Emergency generator test frequency: 36
Kitchen extinguishing system pull station height: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph M. Doran | Administrator | Named in relation to findings and exit conference |
| Lead Maintenance | Interviewed regarding deficiencies and corrective actions | |
| Director of Maintenance | Responsible for in-service training and corrective actions | |
| Culinary Manager | Responsible for staff in-service and equipment location inspections |
Inspection Report
Recertification
Census: 93
Deficiencies: 11
Date: Oct 31, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including investigation of Complaints IN00445775 and IN00446163.
Complaint Details
Complaints IN00445775 and IN00446163 were investigated with no deficiencies related to the allegations cited.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of elevated blood glucose levels, failure to provide bed hold policy upon hospitalization, failure to conduct quarterly care plan meetings, improper food storage and sanitation, infection control breaches, incomplete dementia training for staff, missing emergency information for a resident, lack of mental health assessment prior to admission for a resident, and incomplete tuberculosis testing and annual risk assessments.
Deficiencies (11)
Failed to notify physician of elevated blood glucose levels for 2 residents.
Failed to provide bed hold policy to a resident upon hospitalization.
Failed to have quarterly care plan meetings with residents or representatives for 2 residents.
Failed to store and seal food in a sanitary manner and failed to ensure serving utensils were clean.
Failed to ensure infection control practices were followed by staff cleaning isolation room and providing catheter care.
Failed to have an employee complete 6 hours of dementia training within required timeframe.
Failed to ensure current emergency information was in the Resident Emergency Binder for 1 resident.
Failed to obtain a Mental Health assessment for a resident prior to admission.
Failed to establish an infection control program that includes surveillance and follow-up.
Failed to complete 1st and 2nd step tuberculosis tests for 3 residents.
Failed to perform annual Tuberculosis Risk Assessment for 2 residents.
Report Facts
Survey dates: 8
Census: 93
Deficiencies cited: 11
Residents affected: 2
Residents affected: 2
Residents affected: 3
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper 3 | Failed to wear gown when cleaning isolation room | |
| CNA 4 | Failed to change gloves during catheter care | |
| Director of Nursing | DON | Interviewed regarding blood glucose notification and care plan meetings |
| Assistant Director of Nursing | ADON | Failed to complete required dementia training |
| Director of Food Services | Observed food sanitation deficiencies | |
| Social Services Director | SSD | Interviewed regarding care plan meetings |
| Assisted Living Director | ALD | Interviewed regarding emergency binder, mental health assessment, and TB testing |
Inspection Report
Renewal
Deficiencies: 0
Date: Oct 31, 2024
Visit Reason
The inspection was conducted as a Paper Compliance to the Recertification and Licensure Survey.
Findings
Southfield Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 regarding the Paper Compliance to the Recertification and Licensure Survey.
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 0
Date: Oct 16, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00441881.
Complaint Details
Complaint IN00441881 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00441881 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 48
SNF/NF beds: 38
SNF beds: 10
Medicare residents: 4
Medicaid residents: 29
Other payor residents: 15
Inspection Report
Complaint Investigation
Census: 53
Capacity: 94
Deficiencies: 0
Date: Jul 10, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00434076.
Complaint Details
Complaint IN00434076 was investigated and found to have no deficiencies related to the allegation.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type - SNF: 14
Census Bed Type - SNF/NF: 39
Census Bed Type - Residential: 41
Total Capacity: 94
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 28
Census Payor Type - Other: 5
Current Census: 53
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 0
Date: Apr 18, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00429574.
Complaint Details
Complaint IN00429574 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00429574 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 51
Census SNF/NF beds: 37
Census SNF beds: 14
Census Payor Type Medicare: 6
Census Payor Type Medicaid: 24
Census Payor Type Other: 21
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 1
Date: Feb 21, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00427667 regarding residents' ability to self-administer medications.
Complaint Details
Complaint IN00427667 was investigated and state deficiencies related to the allegations were cited at R0216. The citation relates to failure to ensure residents' ability to self-administer medications was properly managed and observed.
Findings
The facility failed to ensure residents' ability to self-administer medications was followed per their medication self-administration assessment form for 3 of 4 residents reviewed (Residents C, D, and E). Medications were left unsecured at bedside or counters without proper observation or orders, and nursing staff did not consistently observe medication consumption as required by policy.
Deficiencies (1)
Failure to ensure residents' ability to self-administer medications was followed per their medication self-administration assessment form for 3 of 4 residents reviewed.
Report Facts
Residential Census: 43
Medications left unsecured: 3
Med pass observations frequency: 2
Med pass observations frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph M. Doran | Administrator | Signed the report |
| Licensed Practical Nurse (LPN) 2 | Interviewed regarding medication administration practices for Residents C, D, and E | |
| Director of Nursing (DON) | Interviewed regarding medication observation policies and procedures | |
| Resident Service Coordinator | Provided current medication administration policies |
Inspection Report
Re-Inspection
Census: 53
Capacity: 60
Deficiencies: 0
Date: Jan 19, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted for the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 11/21/2023 by the Indiana Department of Health.
Findings
At this Post Survey Revisit, Southfield Village was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, as well as with Life Safety Code requirements including fire safety and state licensure regulations.
Report Facts
Certified beds: 60
Census: 53
Inspection Report
Life Safety
Census: 50
Capacity: 60
Deficiencies: 9
Date: Nov 21, 2023
Visit Reason
Life Safety Code Recertification Survey conducted to evaluate compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.
Findings
The facility was found not in compliance with several Life Safety Code requirements including emergency preparedness exercises, emergency power system testing and documentation, fire door functionality, sprinkler system maintenance, fire drills, electrical equipment safety, and egress lighting.
Deficiencies (9)
Failed to conduct emergency preparedness exercises at least twice per year including unannounced staff drills.
Failed to implement emergency power system inspection, testing, and maintenance requirements including missing documentation for generator load testing and transfer times.
Fire doors in the two-hour fire wall separation did not fully close and latch, allowing potential smoke and fire spread.
Sprinkler system lacked spare sprinklers properly stored in cabinets and a sprinkler wrench on premises.
Failed to conduct quarterly fire drills on each shift for 2 of 4 quarters.
Mechanical closet corridor door did not latch properly, failing to resist passage of smoke.
Exit discharge lighting was inadequate and not confirmed to be connected to emergency power.
Mechanical room sprinkler escutcheon plate was dislodged, leaving annular space around sprinkler head.
Extension cord used as substitute for fixed wiring and power strip improperly secured and dangling.
Report Facts
Certified beds: 60
Census: 50
Deficiencies cited: 10
Fire drills missing: 6
Generator monthly tests missing: 4
Inspection Report
Annual Inspection
Census: 43
Capacity: 96
Deficiencies: 8
Date: Oct 31, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including investigation of Complaints IN00420013 and IN00420247.
Complaint Details
Complaint IN00420013 and Complaint IN00420247 were investigated with no deficiencies related to the allegations cited.
Findings
The facility was cited for multiple deficiencies including inaccurate resident assessments, incomplete care plans, failure to update fall care plans, inadequate grooming assistance, missed medication notification, improper respiratory equipment cleaning and labeling, failure to wear appropriate PPE during aerosolizing procedures, and lack of documentation of quarterly fire drills.
Deficiencies (8)
Failed to ensure a Quarterly MDS assessment was completed accurately for 1 of 23 reviewed residents (Resident 4).
Failed to develop a comprehensive person-centered care plan for 1 of 24 residents reviewed (Resident 46).
Failed to update the fall care plan with a new intervention after a fall for 1 of 2 residents reviewed for falls (Resident 9).
Failed to provide grooming for a female resident with facial hair for 1 of 2 residents reviewed for activities of daily living (Resident 206).
Failed to ensure physician orders were followed and physician notified of a missed medication for 1 of 13 reviewed for medication (Resident 36).
Failed to ensure respiratory equipment was cleaned per physician orders and humidifier bottles and tubing were dated and stored adequately for 4 of 4 reviewed for oxygen (Residents 5, 37, 11, and 47).
Failed to ensure staff wore appropriate personal protective equipment during an aerosolizing procedure for 1 of 2 residents reviewed for infection control (Resident 37).
Failed to ensure documentation of quarterly fire drills were maintained from January 2023 to November 2023.
Report Facts
Survey dates: 7
Census Bed Type: 96
Residential census: 43
Deficiencies cited: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph M. Doran | Administrator | Signed report and involved in administrative oversight |
| RN 4 | Registered Nurse | Observed removing nebulizer equipment and admitted failure to wear gloves during aerosolizing procedure |
| RN 5 | Registered Nurse | Interviewed regarding medication availability and notification procedures |
| RN 6 | Registered Nurse | Interviewed regarding medication availability and oxygen tubing changes |
| LPN 7 | Licensed Practical Nurse | Interviewed regarding oxygen tubing change procedures |
| LPN 2 | Licensed Practical Nurse | Interviewed regarding oxygen tubing dating |
| Director of Nursing | Director of Nursing | Provided policies and interviews regarding care plans, medication errors, infection control, and fire drills |
| Activities Director | Director of Activities | Interviewed regarding care plan for Resident 46 |
| CNA 8 | Certified Nursing Assistant | Interviewed regarding grooming assistance |
| CNA 9 | Certified Nursing Assistant | Interviewed regarding grooming assistance |
Inspection Report
Renewal
Deficiencies: 0
Date: Oct 31, 2023
Visit Reason
The inspection was conducted as a Paper Compliance to the Recertification and Licensure Survey.
Findings
Southfield Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 regarding the Paper Compliance to the Recertification and Licensure Survey.
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 0
Date: Jul 20, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00410110.
Complaint Details
Complaint IN00410110 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type - SNF/NF: 37
Census Bed Type - SNF: 11
Census Total: 48
Census Payor Type - Medicare: 9
Census Payor Type - Medicaid: 25
Census Payor Type - Other: 14
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 12, 2023
Visit Reason
The visit was conducted as a paper compliance review related to the investigation of Complaint IN00393530 completed on November 16, 2022.
Complaint Details
Complaint IN00393530 was investigated and the facility was found to be in compliance based on paper review.
Findings
Southfield Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 regarding the paper compliance to the complaint investigation.
Inspection Report
Complaint Investigation
Census: 53
Capacity: 53
Deficiencies: 2
Date: Nov 16, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00393530, which was substantiated with federal and state deficiencies cited.
Complaint Details
Complaint IN00393530 was substantiated. The investigation found deficiencies related to wound care and supervision leading to elopement.
Findings
The facility failed to ensure physician-ordered dressing changes and wound care were administered per order for one resident, and failed to adequately supervise a cognitively impaired resident who eloped from the facility. Both deficiencies were substantiated and corrective actions were planned.
Deficiencies (2)
Failed to ensure physician ordered dressing changes and wound care were administered per order for 1 of 2 residents reviewed for dressing changes (Resident C).
Failed to ensure a resident with severe cognitive impairment was adequately supervised for elopement (Resident G).
Report Facts
Census: 53
Total Capacity: 53
Residents with Medicare: 8
Residents with Medicaid: 26
Residents with Other payor: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph M. Doran | Administrator | Signed report and mentioned in interviews |
Inspection Report
Re-Inspection
Census: 55
Capacity: 60
Deficiencies: 0
Date: Oct 6, 2022
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification Survey conducted on 09/06/22 was performed to verify compliance with fire safety regulations.
Findings
At this PSR Life Safety Code survey, Southfield Village was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered and protected by a diesel powered generator.
Report Facts
Certified beds: 60
Census: 55
Generator power: 200
Inspection Report
Life Safety
Census: 50
Capacity: 60
Deficiencies: 4
Date: Sep 6, 2022
Visit Reason
A Life Safety Code Recertification Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and the 2012 edition of the NFPA 101 Life Safety Code.
Findings
The facility was found not in compliance with Life Safety Code requirements, including issues with hazardous area door closures, corridor door latching, lack of GFCI protection in a wet location, and combustible materials stored too close to oxygen storage. Corrective actions were planned and documented.
Deficiencies (4)
Failed to ensure hazardous area doors (soiled linen room, clean linen room, 200 hall storage) fully close and latch.
Failed to ensure resident room door (Room 112) fully closes and latches.
Failed to provide ground fault circuit interrupter (GFCI) protection for a light switch in a wet location (hand washing sink in 300 Hall storage room).
Failed to ensure combustible materials were separated by at least 5 feet from oxygen storage equipment in oxygen storage room.
Report Facts
Certified beds: 60
Census: 50
Residents affected: 18
Staff affected: 4
Visitors affected: 2
Residents affected: 16
Staff affected: 4
Visitors affected: 2
Plastic mouth rinse bins: 200
Plastic bed bathtubs: 300
Inspection Report
Recertification
Census: 42
Deficiencies: 16
Date: Jul 26, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey including a State Residential Licensure Survey.
Findings
The facility was found out of compliance in multiple areas including failure to develop comprehensive care plans, revise care plans timely, provide timely showers, ensure proper use of splints and slings, prevent falls, address significant weight loss timely, maintain respiratory equipment properly, complete AIMS evaluations and gradual dose reductions for psychotropic medications, label and date medications properly, follow puree diet recipes, maintain food safety and sanitation in the kitchen, complete pre-admission assessments, obtain admission weights, ensure service plans are signed, and follow medication administration policies.
Deficiencies (16)
Failed to develop a comprehensive care plan for anticoagulant and antidepressant medication for 1 of 22 residents.
Failed to revise comprehensive care plans for arm sling use and falls for 2 of 22 residents.
Failed to ensure showers were provided timely for 1 of 3 residents reviewed for ADL care.
Failed to ensure therapy recommended splint and sling were worn for 1 of 3 residents reviewed for positioning and mobility.
Failed to ensure a resident remained free from injury from a fall for 1 of 3 residents reviewed for accidents.
Failed to ensure oxygen tubing and distilled water were dated and continuous positive airway pressure (CPAP)/bi-level positive airway pressure (BIPAP) mask and tubing were placed in a bag when not in use for 2 of 2 residents reviewed for respiratory.
Failed to ensure the AIMS evaluation was completed for 2 of 2 residents reviewed, gradual dose reduction and appropriate diagnoses for an antipsychotropic medication for 1 of 2 residents reviewed for unnecessary medication.
Failed to ensure medications were labeled appropriately and dated when opened in 1 of 2 medication storage observations.
Failed to ensure recipes were followed for puree diets for 3 of 3 residents who receive a puree diet.
Failed to ensure food items in the freezer were dated/labeled and sealed securely after opening, failed to ensure used by dates on foods, failed to dispose of expired foods, failed to ensure cooking utensils/puree mixers/ice machine/refrigerators/reach in freezer/sandwich cooler were clean and in good condition, failed to have fans without a buildup of dust in 1 of 1 kitchen observed.
Failed to ensure that the resident had a pre-admission assessment for 1 of 5 residents reviewed for admission assessments.
Failed to ensure an admission weight was completed for 1 out of 7 residents reviewed for weights.
Failed to ensure that the resident reviewed and signed the service plan for 3 of 5 residents reviewed for semi-annual service plan revisions.
Failed to ensure that the resident had a diet order for 1 of 5 residents reviewed for dietary needs.
Failed to ensure 1 of 1 staff observed administering medication followed the facility's policy and professional standards in regards to insulin administration.
Failed to ensure that all the required information was provided in the Emergency Information File for 2 of 5 residents reviewed for emergency services.
Report Facts
Survey dates: 7
Residents reviewed for care plans: 22
Residents reviewed for ADL care: 3
Residents reviewed for respiratory: 2
Residents reviewed for psychotropic medication: 2
Residents reviewed for medication storage: 2
Residents reviewed for dietary needs: 5
Residents reviewed for admission assessments: 5
Residents reviewed for weights: 7
Residents reviewed for service plan signatures: 5
Residents reviewed for diet orders: 5
Residents reviewed for medication administration: 5
Residents reviewed for emergency services: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 16 | Licensed Practical Nurse | Observed administering insulin without priming the insulin pen |
| Cook 2 | Observed preparing pureed foods without measuring ingredients | |
| Cook 3 | Observed preparing pureed foods without measuring ingredients and with unclean utensils | |
| Director of Nursing | Director of Nursing | Provided policies and interviews regarding care plan, medication, and other deficiencies |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided policies and interviews regarding respiratory equipment and care plan education |
| Dietary Manager | Dietary Manager | Provided interviews and responses regarding food safety and nutrition |
| Resident Service Coordinator | Resident Service Coordinator | Provided interviews and policies regarding admission assessments and service plans |
| RN 7 | Registered Nurse | Observed medication storage with unlabeled and undated medications |
Inspection Report
Renewal
Deficiencies: 0
Date: Jul 26, 2022
Visit Reason
The inspection was conducted as a Paper Compliance to the Recertification and Licensure Survey.
Findings
Southfield Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 regarding the Paper Compliance to the Recertification and Licensure Survey.
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