Inspection Report
Complaint Investigation
Census: 52
Capacity: 88
Deficiencies: 0
Jun 5, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00460022.
Findings
No deficiencies related to the allegations in Complaint IN00460022 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00460022 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type Total: 88
Census Payor Type Total: 52
Census by Bed Type: 33
Census by Bed Type: 19
Census by Bed Type: 36
Census by Payor Type: 14
Census by Payor Type: 19
Census by Payor Type: 19
Inspection Report
Census: 53
Capacity: 70
Deficiencies: 0
Jun 5, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
Stonecroft Health Campus was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, and also in compliance with Life Safety Code requirements including fire safety and sprinkler systems.
Report Facts
Certified beds: 70
Census: 53
Inspection Report
Renewal
Census: 51
Capacity: 85
Deficiencies: 2
May 20, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted from May 13 to May 20, 2025.
Findings
The facility was found to have deficiencies related to inaccurate documentation of a resident's code status and inaccurate Minimum Data Set (MDS) assessment coding for discharge status. Corrective actions and education were implemented to address these issues, and no adverse effects were noted.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure a resident's choice of code status was documented accurately for 1 of 2 residents reviewed for advanced directives (Resident 13). | SS=D |
| Failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for 1 of 1 residents reviewed for Resident Assessment (Resident 55). | SS=D |
Report Facts
Census by Bed Type: 85
Census by Payor Type: 51
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dawn Black | ED | Signed the inspection report |
Inspection Report
Annual Inspection
Deficiencies: 0
May 20, 2025
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure Survey.
Findings
Stonecroft Health Campus 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 of the Annual Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 52
Capacity: 86
Deficiencies: 0
Apr 22, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00457367.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00457367 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type Total: 86
Census Payor Type Total: 52
SNF Beds: 33
SNF/NF Beds: 19
Residential Beds: 34
Medicare Residents: 20
Medicaid Residents: 19
Other Residents: 13
Inspection Report
Complaint Investigation
Census: 50
Capacity: 82
Deficiencies: 0
Nov 26, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00447705.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00447705 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type Total: 82
Census Payor Type Total: 50
Inspection Report
Follow-Up
Census: 35
Deficiencies: 0
Oct 29, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00443577 completed on October 3, 2024.
Findings
Stonecroft Health Campus was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of Complaint IN00443577.
Complaint Details
Complaint IN00443577 was corrected.
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 1
Oct 3, 2024
Visit Reason
The visit was conducted for the investigation of Complaint IN00443577 related to allegations of neglect involving a resident with wandering and exit seeking behaviors.
Findings
The facility failed to protect the resident's right to be free from neglect for one of three residents reviewed for elopement. Resident B, who had dementia and was an elopement risk, exited the secured memory care unit and wandered approximately 0.7 miles from the facility before being located and returned safely. The facility's supervision and security measures were inadequate to prevent the elopement.
Complaint Details
Complaint IN00443577 was substantiated with state deficiencies cited related to neglect and failure to prevent elopement of Resident B.
Deficiencies (1)
| Description |
|---|
| Failure to protect the resident's right to be free from neglect related to elopement of Resident B. |
Report Facts
Residential Census: 35
Distance Resident Eloped: 0.7
Time Elopement Duration: 22
Minutes after exit door opened before search started by CNA 1: 3
Minutes after exit door opened before search started by CNA 2: 7
Alarm duration before CNA 2 checked outside: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dawn Black | Area Executive Director | Signed the report. |
| Director of Plant Operations | Conducted investigation and located Resident B after elopement. | |
| Registered Nurse 1 | RN | Interviewed regarding elopement event and search efforts. |
| Registered Nurse 2 | RN | Interviewed regarding elopement event and search efforts. |
| Qualified Medication Aide 1 | QMA | Interviewed about Resident B's behaviors and attempts to leave. |
| CNA 1 | Certified Nursing Assistant | Notified staff of Resident B missing and searched for Resident B. |
| CNA 2 | Certified Nursing Assistant | Turned off alarm and searched for Resident B. |
| Director of Health Services | DHS | Provided facility policy on elopement/missing resident. |
Inspection Report
Life Safety
Census: 46
Capacity: 70
Deficiencies: 1
Aug 6, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a), respectively.
Findings
The facility was found in compliance with Emergency Preparedness requirements but was not in compliance with Life Safety Code requirements due to improper use of power strips and extension cords in resident rooms. Immediate intervention was taken by removing the non-compliant power cords and extension cords.
Severity Breakdown
SS=B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure power strips in all resident rooms used outside the patient care vicinity met UL 1363 standards; power strips and extension cords were powering personal equipment in resident room 221 without proper UL listing. | SS=B |
Report Facts
Certified beds: 70
Census: 46
Residents affected: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dawn Black | Area Executive Director | Signed the report |
| Director of Plant Operations | Removed power cords and extension cords during survey and was educated on the deficiency | |
| Executive Director | Educated the Director of Plant Operations on the deficiency and involved in exit conference |
Inspection Report
Renewal
Census: 46
Capacity: 76
Deficiencies: 0
Jul 22, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted over multiple days in July 2024.
Findings
Stonecroft Health Campus was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Recertification and State Licensure Survey.
Report Facts
Census Bed Type: 76
Census Payor Type: 46
Inspection Report
Re-Inspection
Census: 46
Capacity: 70
Deficiencies: 0
Aug 22, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 07/17/23 by the Indiana Department of Health.
Findings
Stonecroft Health Campus was found in compliance with Requirements for Participation Medicare/Medicaid, Life Safety From Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Annual Inspection
Deficiencies: 0
Jul 28, 2023
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey completed on June 21, 2023.
Findings
Stonecroft Health Campus was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 68
Capacity: 70
Deficiencies: 5
Jul 17, 2023
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Findings
The facility was found not in compliance with life safety requirements including fire-rated construction deficiencies, improper exit signage, interior wall finish flame spread rating documentation missing, corridor door propping, and incomplete firestopping of smoke barrier penetrations. Immediate interventions were taken and corrective actions planned.
Severity Breakdown
SS=E: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide two-hour fire-rated construction of 1 of 2 separation walls between the assisted living and health care portions of the building, with a damaged astragal causing a gap in fire doors. | SS=E |
| Failed to ensure 2 of 2 exit signs near the Legacy Unit were marked with directional indicators to identify the direction of travel to the public way. | SS=E |
| Failed to ensure materials used as an interior finish in 1 of 4 smoke compartments had a flame spread rating of Class A or Class B; missing documentation for wood finish in entrance lobby. | SS=E |
| Failed to ensure 1 of over 100 corridor doors had a means suitable for keeping the door closed, was propped open with a handheld weight near the Rehab Room. | SS=E |
| Failed to ensure penetrations caused by passage of wire/conduit through 1 of 4 smoke barrier walls were properly firestopped, leaving a half inch gap. | SS=E |
Report Facts
Certified beds: 70
Census: 68
Residents affected: 30
Residents affected: 20
Residents affected: 25
Residents affected: 15
Staff affected: 4
Visitors affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dawn Black | Area Executive Director | Signed plan of correction and referenced in report |
| Director of Plant Operations | Named in multiple findings related to fire door gap, exit signage, interior finish, corridor door propping, and smoke barrier penetration |
Inspection Report
Annual Inspection
Census: 40
Capacity: 61
Deficiencies: 2
Jun 21, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted from June 14 to June 21, 2023.
Findings
The facility was found to have deficiencies related to failure to provide written notification of transfer or discharge and failure to provide written notice of the bed-hold policy to residents or their representatives for 5 of 5 residents reviewed for hospitalization. The facility was found to be in compliance with the State Residential Licensure Survey requirements.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure written notification required for transfer and discharge was given to the resident and resident representative for 5 of 5 residents reviewed. | SS=E |
| Failed to ensure notification of the bed-hold policy was provided in writing to the resident or resident representative for 5 of 5 residents reviewed for hospitalization. | SS=E |
Report Facts
Survey dates: 6
Residents affected: 5
Census Bed Type: 40
Total Capacity: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Bales | Clinical Support RN | Signed the report |
| Director of Nursing (DON) | Interviewed regarding lack of written notifications to residents and representatives | |
| Administrator | Provided facility policy 'Guidelines for Transfer and Discharge' dated 5/3/17 |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 71
Deficiencies: 0
Apr 14, 2023
Visit Reason
This visit was conducted for the Investigation of Complaint IN00404650.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations regarding the complaint.
Complaint Details
Complaint IN00404650 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 49
Total Capacity: 71
Inspection Report
Re-Inspection
Census: 32
Deficiencies: 0
Mar 10, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00401211 completed on February 17, 2023.
Findings
Stonecroft Health Campus was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of Complaint IN00401211.
Complaint Details
Complaint IN00401211 was investigated and found to be corrected.
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 1
Feb 17, 2023
Visit Reason
This visit was conducted as an investigation of Complaint IN00401211, which was substantiated with state deficiencies cited related to the allegations.
Findings
The facility failed to protect the residents' right to be free from neglect for one resident who eloped from the secured dementia unit and was found outside. The root cause was identified as improper use of a red button that unlocked all facility doors, including the secured unit.
Complaint Details
Complaint IN00401211 was substantiated. The investigation found neglect related to a resident eloping from a secured dementia unit due to a staff error involving door unlocking mechanisms.
Deficiencies (1)
| Description |
|---|
| Facility failed to protect the residents right to be free from neglect for 1 of 1 residents reviewed for elopement. A resident exited the secured dementia unit and was found outside. |
Report Facts
Residential Census: 71
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Bales | Clinical Support RN | Signed the report |
| Administrator | Interviewed regarding root cause of elopement | |
| DHS (Director of Health Services) | Provided timeline of events and education to staff |
Inspection Report
Re-Inspection
Census: 31
Capacity: 70
Deficiencies: 0
Aug 18, 2022
Visit Reason
A Post-Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 06/06/22 was performed by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
Stonecroft Health Campus was found in compliance with Requirements for Participation Medicare/Medicaid, Life Safety From Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility is fully sprinklered with a fire alarm system and smoke detection throughout.
Inspection Report
Complaint Investigation
Census: 30
Capacity: 59
Deficiencies: 0
Aug 17, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00387509.
Findings
Stonecroft Health Campus was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Investigation of Complaint IN00387509. The complaint was unsubstantiated due to lack of evidence.
Complaint Details
Complaint IN00387509 - Unsubstantiated due to lack of evidence.
Report Facts
Census Bed Type: 59
Census Payor Type: 30
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 0
Aug 4, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00382283.
Findings
The complaint was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00382283 was substantiated. No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type Total: 66
Census Payor Type Total: 33
SNF/NF Census: 17
SNF Census: 16
Residential Census: 33
Medicare Census: 13
Medicaid Census: 15
Other Payor Census: 5
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