Inspection Reports for The Crossings at Noblesville
7235 Riverwalk Way N, Noblesville, IN 46062, United States, IN, 46062
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 22, 2025, cited deficiencies related to personnel training, tuberculosis testing, medication administration, service plan signatures, and infection control, though no deficiencies were found related to the complaint investigated. Earlier inspections showed a mix of compliance and deficiencies, with prior issues including staffing shortages affecting resident care, incomplete service plan documentation, and food sanitation concerns. Complaint investigations were mostly unsubstantiated, except for one substantiated complaint in late 2023 involving service plan documentation and updates after resident falls. Enforcement actions such as fines or license suspensions were not listed in the available reports. The inspection history shows ongoing challenges with training and care documentation, with no clear pattern of overall improvement or worsening.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
10% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
84 residents
Based on a April 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 10
Date: Apr 22, 2025
Visit Reason
This visit was for a State Residential Licensure Survey which included the Investigation of Complaint IN00455923.
Complaint Details
Complaint IN00455923 was investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies were related to the complaint allegations. Multiple deficiencies were cited related to personnel training, tuberculosis testing, health screenings, job descriptions, medication administration, service plan signatures, medication order clarifications, and infection control.
Deficiencies (10)
Failed to ensure newly hired employees completed six hours of dementia training within six months of hire for 2 of 2 new employees.
Failed to ensure employees had 2-step tuberculin skin testing upon hire and annual TB tests for 5 of 5 new and 2 of 3 long term employees reviewed.
Failed to ensure newly hired employees had a health screen prior to resident contact for 5 of 5 newly hired employees reviewed.
Failed to ensure newly hired employees had signed job descriptions and job specific orientation for 5 of 5 newly hired employees reviewed.
Failed to ensure medications were administered safely and appropriately for 2 of 5 residents reviewed for medication administration.
Failed to ensure each resident had a service plan signed by the resident or their representative for 7 of 7 resident records reviewed.
Failed to clarify medication-specific administration instructions and failed to obtain physician orders to crush medications for 2 of 5 residents reviewed.
Failed to develop and implement an infection control program to analyze infectious symptom patterns and prevent spread of infection.
Failed to complete the 2-step tuberculin skin testing required prior to or upon admission for 2 of 7 residents reviewed.
Failed to ensure annual tuberculosis risk assessments were completed for 3 of 7 residents reviewed.
Report Facts
Residential Census: 84
Number of new employees missing dementia training: 2
Number of employees missing 2-step TB testing: 7
Number of residents missing signed service plans: 7
Number of residents missing 2-step TB skin testing: 2
Number of residents missing annual TB risk assessment: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janice A Pegues | Executive Director | Signed the inspection report |
| Business Office Manager | Interviewed regarding dementia training, TB testing, health screening, and job descriptions; indicated lack of documentation and new to position | |
| QMA 12 | Qualified Medication Aide | Observed administering medications unsafely to residents 33 and 42 |
| Director of Nursing | DON | Interviewed regarding medication administration, TB testing, and infection control policies |
| Assistant Director of Nursing | ADON | Interviewed regarding infection control and TB testing documentation |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 0
Date: Jan 16, 2025
Visit Reason
This visit was conducted for the investigation of Complaints IN00450240 and IN00451057.
Complaint Details
Investigation of Complaints IN00450240 and IN00451057 found no deficiencies related to the allegations; both complaints were not substantiated.
Findings
No deficiencies related to the allegations in Complaints IN00450240 and IN00451057 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Report Facts
Residential Census: 91
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 0
Date: Sep 24, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00442927.
Complaint Details
Complaint IN00442927 was investigated and found to have no related deficiencies.
Findings
No deficiencies related to the allegations in Complaint IN00442927 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Inspection Report
Renewal
Census: 84
Deficiencies: 2
Date: May 9, 2024
Visit Reason
This visit was for a State Residential Licensure Survey conducted on 5/8/24 and 5/9/24 to assess compliance with state regulations.
Findings
The facility was found deficient in ensuring employees had required annual dementia-specific training and in maintaining sanitary food preparation and serving practices in the kitchen.
Deficiencies (2)
Failure to ensure employees employed over one year had three hours of annual dementia-specific training.
Failure to prepare and distribute food under sanitary conditions in the facility kitchen, including improper glove use and handwashing by dietary staff.
Report Facts
Residential Census: 84
Annual dementia training hours documented: 1.5
Safe food handling monitoring period: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Aide 4 | Reviewed for annual dementia training; documented 1.5 hours | |
| CNA 5 | Reviewed for annual dementia training; documented 1.5 hours | |
| Housekeeper 6 | Reviewed for annual dementia training; lacked documentation | |
| Dietary Manager | Observed improperly handling food and gloves during meal preparation | |
| Business Office Manager | Business Office Manager (BOM) | Responsible for overseeing and monitoring dementia training compliance |
| Food & Beverage Director | Food & Beverage Director (FB) | Responsible for overseeing and monitoring dietary safe food handling and handwashing |
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 0
Date: Mar 13, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00430207, IN00430039, and IN00429927.
Complaint Details
Investigation of Complaints IN00430207, IN00430039, and IN00429927 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00430207, IN00430039, and IN00429927 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 0
Date: Feb 29, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00429502.
Complaint Details
Complaint IN00429502 was investigated and found to have no deficiencies related to the allegations.
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 investigation.
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 2
Date: Feb 22, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00428364 and IN00423883. Complaint IN00428364 had no deficiencies related to the allegations, while complaint IN00423883 resulted in state deficiencies being cited.
Complaint Details
Complaint IN00428364 - No deficiencies related to the allegations are cited. Complaint IN00423883 - State deficiencies related to the allegations are cited at R0117 and R0240.
Findings
The facility failed to ensure sufficient staffing levels to meet residents' ADL care needs, particularly bathing and shower assistance, for 4 of 4 residents reviewed. Staffing shortages led to missed showers and incomplete ADL care, especially on the dementia unit. The facility also failed to ensure residents received needed shower assistance based on individual needs and preferences.
Deficiencies (2)
Failed to ensure staffing levels sufficient to meet the needs of residents for ADL care, including bathing and showering assistance.
Failed to ensure residents received needed shower assistance based on individual needs and preferences.
Report Facts
Residential Census: 90
Staffing shortfalls: 3
Residents on dementia unit: 15
Residents requiring toileting assistance every two hours: 11
Residents requiring assistance for all ADLs: 12
Residents requiring toileting assistance every hour: 1
Residents requiring two people to assist with ADLs: 1
Residents requiring assistance with showering: 34
Resident B showers in January 2024: 1
Resident B partial baths in January 2024: 8
Resident B showers in February 2024 (through 2/14): 1
Resident B partial baths in February 2024 (through 2/14): 4
Resident C stand-by assistance showers in January 2024: 13
Resident C showers in February 2024: 0
Resident F showers in January 2024: 4
Resident F partial baths in January 2024: 7
Resident F showers in February 2024 (through 2/20): 2
Resident F partial baths in February 2024 (through 2/20): 4
Resident E partial baths in January 2024: 7
Resident E partial baths in February 2024 (through 2/21): 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janice A. Pegues | Executive Director | Signed the report. |
| Director of Nursing | DON | Provided staffing patterns and facility policies; interviewed regarding staffing and ADL concerns. |
| Director of Resident Care | DRC | Responsible for overseeing and monitoring nursing schedules and staffing levels. |
| Dementia Unit Director | Reviewed ADL flow records with DON; involved in addressing staffing and care concerns. |
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 1
Date: Nov 6, 2023
Visit Reason
The visit was conducted to investigate Complaints IN00420022 and IN00420707. Deficiencies related to Complaint IN00420022 were cited, while no deficiencies were found related to Complaint IN00420707.
Complaint Details
Complaint IN00420022 was substantiated with state deficiencies cited at R0217. Complaint IN00420707 was not substantiated with no deficiencies cited.
Findings
The facility failed to ensure that service plans were signed by the resident or resident representative and failed to review and update service plans after resident falls as required by facility policy. This deficiency was identified in 4 of 4 residents reviewed for falls (Residents B, C, D, and E).
Deficiencies (1)
Failure to ensure service plans were signed by the resident or resident representative and failure to review and update service plans after falls for 4 of 4 residents reviewed.
Report Facts
Residential Census: 88
Number of residents reviewed for falls: 4
Number of falls for Resident E: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janice Pegues | Executive Director | Signed the report as Laboratory Director's or Provider/Supplier Representative |
| Director of Resident Services | Interviewed on 11/6/23 regarding service plans not being signed and not in appropriate charts | |
| Director of Resident Care | DRC | Responsible for working with nursing team to upload and retain fall interventions and service plans, and in-servicing nursing team members on Fall Management and Investigation Policy |
Inspection Report
Original Licensing
Census: 88
Deficiencies: 0
Date: Jul 19, 2023
Visit Reason
This visit was for a State Residential Licensure Survey conducted on July 18 and 19, 2023.
Findings
Five Star Residences of Noblesville was found to be in compliance with 410 IAC 16.2-5 in regard to the State Residential Licensure Survey.
Inspection Report
Renewal
Census: 73
Deficiencies: 0
Date: Oct 7, 2022
Visit Reason
This visit was for a State Residential Licensure Survey conducted on October 6 and 7, 2022.
Findings
Five Star Residences of Noblesville was found to be in compliance with 410 IAC 16.2-5 regarding the State Residential Licensure Survey.
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