Deficiencies per Year
12
9
6
3
0
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 0
Jun 2, 2025
Visit Reason
This visit was for the investigation of Complaint IN00459862.
Findings
No deficiencies related to the 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 IN00459862 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 72
Census Bed Type - Residential: 28
Census Total: 100
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 47
Census Payor Type - Other: 22
Census Payor Type - Total: 72
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 0
Apr 21, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00454278.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00454278 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type Total: 111
SNF/NF Census: 80
Residential Census: 31
Census Payor Type Total: 80
Medicare Census: 4
Medicaid Census: 45
Other Payor Census: 31
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 25, 2025
Visit Reason
Paper compliance review to the Investigation of Complaints IN00453495, IN00453438, and IN00453757 ending on February 20, 2025.
Findings
The Terrace at Solarbron was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the investigations.
Complaint Details
The visit was related to investigations of complaints IN00453495, IN00453438, and IN00453757, with compliance found.
Inspection Report
Complaint Investigation
Census: 107
Capacity: 107
Deficiencies: 1
Feb 20, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00453495, IN00453438, and IN00453757 regarding alleged deficiencies at the facility.
Findings
The facility failed to ensure a newly admitted resident with a colostomy had immediate physician orders for its care. Orders for the care of the colostomy were missing upon admission but were later obtained and transcribed.
Complaint Details
The investigation was triggered by complaints IN00453495, IN00453438, and IN00453757. Federal/State deficiencies related to these allegations were cited at F-635.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a newly admitted resident had immediate physician orders for the care of a colostomy. | SS=D |
Report Facts
Census Bed Type - SNF/NF: 77
Census Bed Type - Residential: 30
Total Census: 107
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 43
Census Payor Type - Other: 27
Total Census Payor: 77
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Danielle McClarnon | Clinical Specialist | Signed the report |
| Licensed Practical Nurse 2 | Interviewed regarding colostomy care orders |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 112
Deficiencies: 0
Jan 27, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00450777.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00450777 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 82
Census Residential: 30
Total Census: 112
Census Payor Type Medicare: 4
Census Payor Type Medicaid: 45
Census Payor Type Other: 33
Total Census Payor Type: 82
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 24, 2025
Visit Reason
Paper compliance review related to the Recertification, State Licensure, and Investigation of Complaint IN00448045 ending on December 10, 2024.
Findings
The Terrace at Solarbron was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the Recertification, State Licensure, and Investigation of Complaint IN00448045 survey.
Inspection Report
Re-Inspection
Census: 112
Capacity: 126
Deficiencies: 0
Jan 22, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted to verify compliance with fire safety and licensure requirements.
Findings
The facility was found in compliance with Medicare participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility consists of two buildings, both fully sprinklered except for a detached maintenance garage.
Report Facts
Facility capacity: 91
Facility census: 81
Facility capacity: 35
Facility census: 31
Inspection Report
Life Safety
Census: 78
Capacity: 91
Deficiencies: 5
Dec 17, 2024
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 42 CFR 483.73 for Emergency Preparedness.
Findings
The facility was found not in compliance with Life Safety Code requirements including failure to maintain fire alarm system inspections, portable fire extinguisher maintenance, corridor door functionality, fire damper documentation, and electrical equipment testing. The Emergency Preparedness survey was found in compliance.
Severity Breakdown
SS=F: 4
SS=E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to maintain fire alarm system inspection documentation for semi-annual visual inspections as required by NFPA 72. | SS=F |
| Failed to ensure 30 of 30 portable fire extinguishers had documented annual maintenance in accordance with NFPA 10. | SS=F |
| Failed to ensure 2 of 2 corridor doors between kitchen and dining room closed completely and latched automatically. | SS=E |
| Failed to ensure documentation for inspection of 23 fire dampers was complete and descriptive as required by NFPA 90A and NFPA 80. | SS=F |
| Failed to conduct required maintenance and maintain complete documentation of inspections for Patient Care Related Electrical Equipment (PCREE). | SS=F |
Report Facts
Certified beds: 91
Census: 78
Assisted Living beds: 35
Assisted Living census: 31
Portable fire extinguishers inspected: 30
Fire dampers inspected: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robin Crowe | Administrator | Named in relation to plan of correction and exit conference |
| Brenda Buroker | Director, Long-Term Care Division, Indiana State Department of Health | Recipient of plan of correction letter |
Inspection Report
Annual Inspection
Census: 108
Deficiencies: 5
Dec 10, 2024
Visit Reason
This visit included a Recertification and State Licensure Survey and Investigation of Complaint IN00448045. It also included a State Residential Licensure Survey.
Findings
The facility was found deficient in multiple areas including failure to provide required Medicare coverage notices, improper medication labeling, inadequate infection prevention and control practices, unsafe and unsanitary environment conditions, and failure to timely review pharmacist medication recommendations.
Complaint Details
Complaint IN00448045 was investigated with Federal/State deficiencies cited related to the allegations.
Severity Breakdown
SS=D: 2
SS=E: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure a SNF-ABN Form and Notice of Medicare Non-Coverage was provided following the end of Medicare skilled services for a resident. | SS=D |
| Failed to ensure medications were labeled properly for medication carts observed. | SS=D |
| Failed to ensure infection control practices and standards were performed during wound care and equipment cleaning. | SS=E |
| Failed to provide a safe and sanitary environment; odors present and resident wall soiled with paint chipped. | SS=E |
| Failed to ensure pharmacist medication recommendations were reviewed and notification sent to physician in a timely manner. | — |
Report Facts
Census SNF/NF beds: 79
Census Residential beds: 29
Total Census: 108
Medicare census: 3
Medicaid census: 49
Other payor census: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Danielle McClarnon | RN, CS | Laboratory Director's or Provider/Supplier Representative's signature on report |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 104
Deficiencies: 0
Nov 12, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00446253 at the Terrace At Solarbron facility.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00446253 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 76
Census Residential beds: 28
Total licensed capacity: 104
Census Medicare residents: 5
Census Medicaid residents: 50
Census Other payor residents: 21
Total census residents: 76
Inspection Report
Complaint Investigation
Census: 84
Capacity: 110
Deficiencies: 0
Sep 24, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00442750.
Findings
No deficiencies related to the allegations in Complaint IN00442750 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00442750 was investigated and found to have no deficiencies related to the allegations.
Report Facts
SNF/NF census: 84
Residential census: 26
Total capacity: 110
Medicare census: 9
Medicaid census: 46
Other payor census: 29
Total census: 84
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 13, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00437789 and IN00438377 ending on July 11, 2024.
Findings
Terrace at Solarbron was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00437789 and IN00438377; paper compliance review found facility in compliance.
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 1
Jul 11, 2024
Visit Reason
This visit was conducted for the investigation of multiple nursing home and residential complaints, including IN00437051, IN00437789, IN00435664, IN00438377, IN00436509, and IN00436054, focusing on allegations related to care provision.
Findings
The facility was found to have failed to provide adequate activities of daily living (ADL) care, specifically bathing, to 4 of 4 residents reviewed. Deficiencies related to complaints IN00437789 and IN00438377 were cited at F677, while other complaints had no deficiencies cited.
Complaint Details
The investigation involved multiple complaints. Complaints IN00437789 and IN00438377 had federal/state deficiencies cited at F677 related to ADL care. Complaints IN00437051, IN00435664, IN00436509, and IN00436054 had no deficiencies related to the allegations cited.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide ADL care (bathing) to 4 of 4 residents reviewed, including Residents L, N, P, and Q, with inconsistent shower/bathing provision and documentation. | SS=E |
Report Facts
Census SNF/NF: 77
Census Residential: 25
Total Census: 102
Complaint Investigation Dates: Survey dates: July 8, 9, 10, 11, 2024
Deficiency Count: 1
Inspection Report
Complaint Investigation
Census: 77
Capacity: 106
Deficiencies: 0
May 23, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00431143.
Findings
No deficiencies related to the allegations in Complaint IN00431143 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00431143 was investigated and found to have no deficiencies related to the allegations.
Report Facts
SNF/NF census: 77
Residential census: 29
Total census: 106
Medicare census: 2
Medicaid census: 48
Other payor census: 27
Total payor census: 77
Inspection Report
Follow-Up
Census: 86
Capacity: 91
Deficiencies: 0
Apr 18, 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 11/13/23.
Findings
The facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements, including fire safety and sprinkler systems. The facility has a capacity of 91 beds with a census of 86 at the time of the survey, including an Assisted Living section with 35 beds and a census of 31.
Report Facts
Certified beds: 91
Census: 86
Assisted Living beds: 35
Assisted Living census: 31
Inspection Report
Complaint Investigation
Census: 79
Capacity: 111
Deficiencies: 0
Feb 22, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00426021 at The Terrace At Solarbron.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00426021 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 79
Census Residential: 32
Total Census: 79
Total Capacity: 111
Census Payor Type Medicare: 2
Census Payor Type Medicaid: 49
Census Payor Type Other: 28
Inspection Report
Complaint Investigation
Census: 85
Capacity: 117
Deficiencies: 0
Jan 9, 2024
Visit Reason
This visit was for the investigation of complaints IN00425326 and IN00425570.
Findings
No deficiencies related to the allegations in complaints IN00425326 and IN00425570 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00425326 and IN00425570 found no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 85
Census Bed Type - Residential: 32
Total Capacity: 117
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 46
Census Payor Type - Other: 36
Total Census Payor Type: 85
Inspection Report
Re-Inspection
Census: 81
Capacity: 110
Deficiencies: 0
Dec 8, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification, State Licensure Survey and PSR to Investigation of Complaint IN00420287 completed on October 31, 2023.
Findings
The Terrace At Solarbron was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification, State Licensure Survey and PSR to the Investigation of Complaint IN00420287.
Complaint Details
Complaint IN00420287 was corrected.
Report Facts
Census SNF/NF beds: 81
Census Residential beds: 29
Total Census: 110
Census Payor Type Medicare: 8
Census Payor Type Medicaid: 44
Census Payor Type Other: 21
Total Census Payor Type: 81
Inspection Report
Life Safety
Census: 91
Capacity: 91
Deficiencies: 4
Nov 13, 2023
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 federal regulations.
Findings
The facility was found in substantial compliance with Emergency Preparedness Requirements but had deficiencies related to emergency power system testing documentation, outdated battery-operated smoke alarms, incomplete elevator firefighter recall testing documentation, incomplete fire drill transmission documentation, and missing documentation for emergency generator load testing.
Severity Breakdown
SS=C: 1
SS=E: 2
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to provide complete documentation for the testing of the Emergency Power Standby System, specifically a four-hour load test within the past 36 months. | SS=C |
| Failed to replace battery-operated smoke alarms installed in 67 resident sleeping rooms that were past due for replacement (manufactured in 1998 or 2000). | SS=E |
| Failed to ensure documentation was provided for monthly testing of 1 elevator firefighter recall; documentation only included 4 months in 2023. | SS=E |
| Failed to ensure 12 fire drill reports included complete documentation of transmission of fire alarm signal to monitoring company/fire department. | SS=F |
Report Facts
Certified beds: 91
Census: 91
Assisted Living beds: 35
Assisted Living census: 33
Battery-operated smoke alarms: 67
Fire drill reports missing transmission documentation: 12
Elevator firefighter recall test documentation months: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark McElwee | Administrator | Named in relation to review of findings during exit conference |
| Maintenance Supervisor | Present during record review and interviews; confirmed deficiencies and corrective actions |
Inspection Report
Renewal
Census: 30
Deficiencies: 12
Oct 31, 2023
Visit Reason
This visit was for a State Residential Licensure Survey including a Recertification and State Licensure Survey.
Findings
The facility had multiple deficiencies including failure to assess residents for self-administration of medications, failure to notify physicians and families of significant changes, inaccurate MDS assessments, improper use of sit to stand lift leading to a fall with fracture, inadequate treatment of UTIs, failure to follow respiratory care orders, incomplete posted nurse staffing information, incomplete medication storage temperature logs, food served at inappropriate temperatures, and musty odor in hallways.
Complaint Details
Complaint IN00419670 and IN00419853 had no deficiencies related to the allegations cited. Complaint IN00420287 had Federal/State deficiencies related to the allegations cited at F580.
Severity Breakdown
SS=D: 5
SS=G: 1
SS=E: 4
SS=C: 1
: 2
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to ensure residents self-administering medications were assessed for capability (Resident 69). | SS=D |
| Failure to notify attending physician and resident's family of significant changes (Residents M and F). | SS=D |
| Failure to ensure MDS assessment was completed accurately for dialysis resident (Resident 50). | SS=D |
| Failure to ensure sit to stand lift was used according to policy leading to fall with fracture (Resident M). | SS=G |
| Failure to provide appropriate treatment to prevent recurring UTIs (Resident M). | SS=D |
| Failure to ensure residents received necessary respiratory care including following oxygenation orders and dating oxygen tubing and humidification bottles (Residents 13, 22, 31, 44, 45). | SS=E |
| Failure to post accurate nurse staffing information daily. | SS=C |
| Failure to ensure proper labeling and temperature logging of drugs and biologicals in medication storage rooms. | SS=E |
| Failure to ensure food was served at palatable temperatures. | SS=E |
| Failure to provide a safe and sanitary environment due to musty odor in East Hallway. | SS=D |
| Failure to ensure PRN medications administered by QMA were authorized by licensed nurse (Residents 2, 3, 6, 7). | — |
| Failure to ensure pharmacy medication regimen reviews were completed at least every 60 days (Residents 2, 3, 5, 6, 7, 8). | — |
Report Facts
Survey dates: October 23, 24, 25, 26, 27, 30 & 31, 2023
Resident census: 30
Medication administration refrigerator temperature missing logs: 12
Medication administration refrigerator temperature missing logs: 4
Medication administration refrigerator temperature missing logs: 3
Food temperature: 101.6
Food temperature: 111
Food temperature: 65.7
PRN medication administrations without authorization: 11
Pharmacy medication regimen reviews missing: 6
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 0
Aug 16, 2023
Visit Reason
This visit was for the investigation of complaints IN00414395, IN00413356, and IN00409074.
Findings
No deficiencies related to the allegations were cited for any of the complaints. The facility 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 the complaints.
Complaint Details
Complaints IN00414395, IN00413356, and IN00409074 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 84
Census Residential: 32
Total Census: 116
Census Payor Medicare: 15
Census Payor Medicaid: 49
Census Payor Other: 20
Total Census Payor: 84
Inspection Report
Complaint Investigation
Census: 79
Capacity: 113
Deficiencies: 0
Apr 28, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00402871.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00402871 was investigated and found to have no deficiencies related to the allegation.
Report Facts
Census SNF/NF beds: 79
Census Residential beds: 34
Total Census: 113
Census Payor Medicare: 11
Census Payor Medicaid: 49
Census Payor Other: 19
Total Census Payor: 79
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 0
Jan 18, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00399281, IN00398666, IN00399364, and IN00397994 at the facility.
Findings
All four complaints were substantiated; however, no deficiencies related to the 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 in regard to the complaints investigated.
Complaint Details
Complaints IN00399281, IN00398666, IN00399364, and IN00397994 were all substantiated with no deficiencies cited related to the allegations.
Report Facts
Census bed type - SNF/NF: 78
Census bed type - Residential: 37
Total census: 115
Census payor type - Medicare: 5
Census payor type - Medicaid: 34
Census payor type - Other: 39
Total census payor type: 78
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 0
Nov 9, 2022
Visit Reason
This visit was for the Investigation of Nursing Home Complaint IN00393472, which included the Investigation of Residential Complaint IN00393472.
Findings
Complaint IN00393472 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 IN00393472 - Substantiated. No deficiencies related to the allegations are cited.
Report Facts
SNF/NF Census: 83
Residential Census: 37
Total Census: 120
Medicare Census: 22
Medicaid Census: 41
Other Payor Census: 20
Total Payor Census: 83
Inspection Report
Re-Inspection
Census: 122
Deficiencies: 0
Aug 5, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00382723 completed on 6/24/22, conducted in conjunction with Post Survey revisits to Complaints IN00385110, IN00384394 and the COVID-19 Focused Infection Control Survey completed on July 13, 2022.
Findings
The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to Investigation of Complaints IN00382723 survey.
Complaint Details
Complaints IN00382723 were corrected as of this visit.
Report Facts
Census Bed Type - SNF/NF: 83
Census Bed Type - Residential: 39
Census Bed Type - Total: 122
Census Payor Type - Medicare: 18
Census Payor Type - Medicaid: 45
Census Payor Type - Other: 20
Census Payor Type - Total: 83
Inspection Report
Re-Inspection
Census: 122
Deficiencies: 0
Aug 5, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00385110 and IN00384394 completed on 7/13/22, including the PSR to the COVID-19 Focused Infection Control Survey completed on 7/13/22. It was also in conjunction with the PSR to the Investigation of Complaint IN00382723 completed on 6/24/22.
Findings
The Terrace at Solarbron was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to Investigation of Complaints IN00385110 and IN00384394 and the PSR to the COVID-19 Focused Infection Control Survey.
Complaint Details
Complaints IN00384394 and IN00385110 were corrected as of this visit.
Report Facts
Census Bed Type - SNF/NF: 83
Census Bed Type - Residential: 39
Census Bed Type - Total: 122
Census Payor Type - Medicare: 18
Census Payor Type - Medicaid: 45
Census Payor Type - Other: 20
Census Payor Type - Total: 83
Inspection Report
Complaint Investigation
Census: 122
Deficiencies: 0
Aug 2, 2022
Visit Reason
This visit was for the Investigation of Complaints IN00385967 and IN00385740, and for a COVID-19 Focused Infection Control Survey, including a Residential COVID-19 Quality Assurance Walk Through.
Findings
Both complaints IN00385967 and IN00385740 were substantiated, but no deficiencies related to the 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 investigations and the COVID-19 Focused Infection Control Survey.
Complaint Details
Complaint IN00385967: Substantiated with no deficiencies cited. Complaint IN00385740: Substantiated with no deficiencies cited.
Report Facts
SNF/NF census: 82
Residential census: 40
Total census: 122
Medicare census: 15
Medicaid census: 45
Other payor census: 22
Total payor census: 82
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