The most recent inspection on July 16, 2025, found no deficiencies related to the complaint investigated and confirmed compliance with state residential licensure regulations. Earlier inspections showed a mix of findings, including substantiated complaints with deficiencies related to personnel records, food service cleanliness, and a failure to initiate CPR on a resident with a CPR advance directive. Complaint investigations were mostly unsubstantiated except for a few substantiated cases involving documentation and care issues. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. The facility’s record shows improvement over time, with recent inspections consistently free of cited deficiencies.
Deficiencies (last 3 years)
Deficiencies (over 3 years)1.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
This visit was for a State Residential Licensure Survey and included the Investigation of Complaint IN00461233.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with the applicable state residential licensure regulations.
Complaint Details
Complaint IN00461233 was investigated and found to have no deficiencies related to the allegations.
This visit was conducted for the investigation of Complaint IN00443130.
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.
Complaint Details
Complaint IN00443130 was investigated and found to have no deficiencies related to the allegations.
This visit was conducted for the investigation of Complaint IN00409147.
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.
Complaint Details
Complaint IN00409147 was investigated and found to have no deficiencies related to the allegations.
This visit was conducted for the investigation of Complaint IN00402455 regarding allegations of neglect related to failure to initiate CPR on a resident with a CPR advance directive.
Findings
The facility failed to initiate CPR on Resident B who had a CPR advance directive. The clinical record lacked documentation of pulse assessment or CPR initiation. Staff responded timely to the call pendant and notified EMS, but CPR was not performed due to circumstances including fire department restrictions and staff certification limitations.
Complaint Details
Complaint IN00402455 was substantiated with a state deficiency cited at R0052 related to failure to initiate CPR on Resident B.
Deficiencies (1)
Description
Failure to initiate CPR on a resident with a CPR advance directive.
Report Facts
Residential Census: 101Date of incident: Feb 22, 2023Date of survey: Mar 20, 2023
Employees Mentioned
Name
Title
Context
LPN 2
Licensed Practical Nurse
Responded to Resident B's call, notified EMS, and was involved in the incident.
CNA 3
Certified Nurse Aide
Responded to Resident B's call pendant and notified LPN 2.
Director of Nursing
Director of Nursing
Interviewed regarding the incident and facility policies on CPR.
This visit was for a State Residential Licensure Survey including the investigation of Complaints IN00397084 and IN00393841.
Findings
The facility was found to have deficiencies related to personnel records and food and nutritional services. Specifically, missing employee references and orientation documentation were noted, and the kitchen was found unclean and in disrepair, affecting all residents receiving meals.
Complaint Details
Complaint IN00397084 was substantiated with a related state deficiency cited at R0273. Complaint IN00393841 was substantiated but no deficiencies related to the allegations were cited.
Deficiencies (3)
Description
Failed to ensure an employee's references were documented for 1 of 5 personnel files reviewed (LPN 4).
Failed to ensure documentation of general and specific orientation was completed for 2 of 5 personnel files reviewed (CNA 5 and LPN 3).
Failed to ensure the kitchen and equipment were clean and in good repair during 3 of 3 kitchen observations, including frost buildup, grease accumulation, and food particles.