The most recent inspection on May 15, 2025, found no deficiencies related to the complaints investigated. Earlier inspections showed a mix of results, with some deficiencies noted in April 2025 related to staff CPR and first aid certification, annual training, and medication administration. Prior reports cited issues with kitchen sanitation, food safety, resident health statements, and tuberculosis testing, as well as a late license renewal application. Complaint investigations were consistently unsubstantiated, with no deficiencies related to the allegations. The facility’s inspection history shows some recurring themes in staff training and health compliance, but the most recent findings suggest improvement in addressing these areas.
Deficiencies (last 3 years)
Deficiencies (over 3 years)2.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
This visit was for the investigation of complaints IN00458508 and IN00458776.
Findings
No deficiencies related to the allegations in complaints IN00458508 and IN00458776 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00458508 and Complaint IN00458776 were investigated with no deficiencies cited related to the allegations.
This visit was for a State Residential Licensure Survey including the investigation of complaints IN00452215 and IN00449992.
Findings
No deficiencies were cited related to the complaints. However, deficiencies were found related to personnel CPR and first aid certification, annual resident rights and dementia training for staff, and medication administration errors for one resident.
Complaint Details
Complaints IN00452215 and IN00449992 were investigated with no deficiencies related to the allegations cited.
Deficiencies (3)
Description
Facility failed to ensure a staff member with current CPR and first aid certificates was always on site for 8 of 21 shifts reviewed.
Facility failed to ensure employees received annual resident rights and dementia training for 9 of 10 staff members reviewed.
Facility failed to ensure staff followed a physician's order to administer medication three times a day, follow hold parameters, and notify physician when orders were not followed for 1 of 6 residents reviewed.
Report Facts
Shifts without CPR/First Aid certified staff: 8Staff without required annual training: 9Residents reviewed for medication errors: 6
This visit was conducted for the investigation of Complaint IN00435704.
Findings
No deficiencies related to the allegations in Complaint IN00435704 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Complaint Details
Complaint IN00435704 was investigated and found to have no deficiencies related to the allegations.
This visit was for a State Residential Licensure Survey conducted on May 20 and 21, 2024 to assess compliance with state regulations for residential care facilities.
Findings
The facility was found deficient in maintaining kitchen sanitation and food safety standards, ensuring annual health statements for residents were completed, and completing required two-step Tuberculosis testing for residents. Specific issues included expired and improperly dated food items, missing health statements for 4 of 7 residents, and incomplete TB testing for 1 of 3 residents reviewed.
Deficiencies (3)
Description
Failed to ensure the kitchen was maintained in accordance with state and local sanitation and safe food handling standards, including expired products and improperly dated/open food items.
Failed to ensure annual health statements indicating residents were free of infectious disease were completed for 4 of 7 residents reviewed.
Failed to ensure the 2-step Tuberculosis testing was completed one to three weeks after the first step for 1 of 3 residents reviewed.
Report Facts
Residential Census: 26Residents missing annual health statement: 4Residents missing proper 2-step TB testing: 1Expired buttermilk containers: 15Biscuits left in open box: 50Breadcrumb bag weight: 5Rice box weight: 25
Employees Mentioned
Name
Title
Context
Food and Beverage Director
Interviewed regarding kitchen sanitation and food safety deficiencies
Executive Director
Interviewed regarding facility policy on annual health statements
This was an offsite Licensure Investigation Survey conducted to assess compliance with state residential licensure requirements, specifically regarding timely submission of the facility's license renewal application.
Findings
The facility failed to submit a renewal application at least 45 days prior to the expiration of its license. The current license expired on December 31, 2022, but the renewal application was received on January 4, 2023, which was late.
Deficiencies (1)
Description
Failure to submit a renewal application at least 45 days prior to license expiration.
Report Facts
Days late for renewal application: 4Days required prior to expiration for renewal submission: 45
Employees Mentioned
Name
Title
Context
Rita Shew
Executive Director
Signed the report and plan of correction.
Lisa Newcomb
Licensing Manager for Five Star Senior Living
Named in the plan of correction as recipient of renewal notifications.
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