Inspection Report Summary
The most recent inspection on April 2, 2025, was a complaint investigation that found no deficiencies and the facility was in compliance with applicable regulations. Prior inspections showed a mixed pattern, with several citations related mainly to Life Safety Code issues such as incomplete sprinkler coverage, emergency lighting testing, and hazardous area enclosures, as well as some resident care concerns including medication security and abuse investigations. Complaint investigations were mostly unsubstantiated, except for one substantiated case of verbal and mental abuse in June 2024, which was addressed with staff terminations and correction prior to the survey. Enforcement actions such as fines or license suspensions were not listed in the available reports. The inspection history suggests some improvement in Life Safety compliance and resident care issues, although occasional deficiencies continue to appear.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
11.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
169% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
48% occupied
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 41
Capacity: 85
Deficiencies: 0
Date: Apr 2, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00456274.
Complaint Details
Investigation of Complaint IN00456274 found no deficiencies related to the allegations; the complaint was not substantiated.
Findings
No deficiencies related to the allegations in Complaint IN00456274 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 41
Total Capacity: 85
Inspection Report
Complaint Investigation
Census: 45
Capacity: 81
Deficiencies: 0
Date: Jan 2, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00450181.
Complaint Details
Investigation of Complaint IN00450181 found no deficiencies related to the allegations; the complaint was not substantiated.
Findings
No deficiencies related to the allegations in Complaint IN00450181 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 45
Total Capacity: 81
Inspection Report
Re-Inspection
Census: 45
Capacity: 70
Deficiencies: 0
Date: Dec 13, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 10/17/24 was performed to verify compliance with fire safety and licensure requirements.
Findings
The Springs at Lafayette was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered with a fire alarm system and smoke detection throughout.
Report Facts
Facility capacity: 70
Census: 45
Inspection Report
Life Safety
Census: 41
Capacity: 70
Deficiencies: 5
Date: Oct 17, 2024
Visit Reason
The survey was conducted as a Life Safety Code Recertification and State Licensure Survey 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 in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies included failure to document annual testing of all battery backup lights, failure to ensure hazardous areas were properly enclosed, lack of a shutoff switch for a cooktop in the Therapy Room, incomplete automatic sprinkler system coverage in a linen closet, and failure to maintain sprinkler system components such as missing PIV handle and FDC caps.
Deficiencies (5)
Failed to document annual testing for all battery backup lights; one battery operated light was not tested for 90 minutes within the last 12 months.
Failed to ensure 1 of over 18 hazardous areas (Activities Room storage closet) was separated by smoke resistant partitions and doors; door latch was obstructed.
Failed to ensure staff had access to a shutoff switch for 1 cooktop in the Therapy Room; no locked or timer switch provided.
Failed to provide complete automatic sprinkler system for 1 linen closet by the Legacy wing nurse's station.
Failed to maintain automatic sprinkler system; missing PIV handle, padlock, and FDC caps; internal pipe inspection needed.
Report Facts
Certified beds: 70
Census: 41
Emergency light test duration: 90
Cooking facility timer capacity: 120
Sprinkler system audit frequency: 2
Door audit frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Weaver | Executive Director | Named in relation to education and review of deficiencies during exit conference |
| Director of Plant Operations | Named in relation to findings and corrective actions for emergency lighting, hazardous areas, cooking facilities, sprinkler system |
Inspection Report
Renewal
Census: 39
Capacity: 74
Deficiencies: 3
Date: Sep 10, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey, conducted from September 3 to September 10, 2024.
Findings
The facility was found to have past noncompliance issues related to failure to notify a resident's representative of a fall and failure to ensure safety from elopement for a cognitively impaired resident, both corrected prior to the survey. Additionally, the facility failed to ensure medications were secured for residents who self-administer medications. Plans of correction were submitted for these deficiencies.
Deficiencies (3)
Failed to contact the resident's representative regarding a fall for 1 of 1 resident reviewed for notification (Resident 25).
Failed to ensure a cognitively impaired resident was safe from elopement for 1 of 3 residents reviewed for wandering (Resident 27).
Failed to ensure medications were secured for residents who self-administer medications for 2 of 2 residents reviewed (Residents 23 and 6).
Report Facts
Survey dates: 6
Census Bed Type - SNF/NF: 21
Census Bed Type - SNF: 18
Census Bed Type - Residential: 35
Total Capacity: 74
Census Payor Type - Medicare: 15
Census Payor Type - Medicaid: 21
Census Payor Type - Other: 3
Total Census: 39
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Thompson | Laboratory Director or Provider/Supplier Representative | Signed the report on 09/26/2024 |
Inspection Report
Renewal
Deficiencies: 0
Date: Sep 10, 2024
Visit Reason
The visit was conducted as a paper compliance review for the Recertification and State Licensure survey.
Findings
The Springs at Lafayette 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 for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 0
Date: Aug 7, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00439532 and IN00437540 at The Springs at Lafayette.
Complaint Details
Investigation of Complaints IN00439532 and IN00437540 found no deficiencies related to the allegations; both complaints were not substantiated.
Findings
No deficiencies related to the allegations in complaints IN00439532 and IN00437540 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type - SNF/NF: 22
Census Bed Type - SNF: 16
Census Bed Type - Residential: 33
Census Total: 71
Census Payor Type - Medicare: 13
Census Payor Type - Medicaid: 22
Census Payor Type - Other: 3
Census Payor Type - Total: 38
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 1
Date: Jun 18, 2024
Visit Reason
This visit was conducted for the investigation of two complaints, IN00435669 and IN00436493, related to allegations of abuse at the facility.
Complaint Details
The investigation substantiated verbal abuse by two staff members towards Resident C, resulting in emotional distress. Staff Member 2 and 3 were terminated for substantiated resident abuse.
Findings
The facility was found to have failed to ensure a cognitively impaired resident was free from verbal and mental abuse by staff members. Two staff members were terminated for substantiated resident abuse. The deficient practice was corrected prior to the survey date.
Deficiencies (1)
Facility failed to ensure a cognitively impaired resident was free from verbal and mental abuse by staff members.
Report Facts
Census: 64
SNF/NF beds: 20
SNF beds: 13
Residential beds: 31
Medicare residents: 8
Medicaid residents: 18
Other payor residents: 7
Total payor residents: 33
BIMS score: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member 2 | Named in verbal abuse finding and terminated for substantiated resident abuse | |
| Staff Member 3 | Named in verbal abuse finding and terminated for substantiated resident abuse | |
| Staff Member 6 | Reported abuse incident to supervisor and provided care to Resident C | |
| Staff Member 5 | Witnessed inappropriate language by Staff Member 3 | |
| Staff Member 7 | Overheard verbal abuse and separated Resident C from abusive staff | |
| Staff Member 8 | Reported on staff suspension and re-education on abuse |
Inspection Report
Life Safety
Capacity: 14
Deficiencies: 0
Date: Mar 13, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Preoccupancy Survey conducted on 02/23/24 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a). The visit was related to remodeling part of the 200 wing into a locked unit.
Findings
The Springs at Lafayette was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility is fully sprinklered with a fire alarm system and smoke detection in corridors and resident rooms.
Report Facts
Unit capacity: 14
Census: 0
Inspection Report
Life Safety
Census: 60
Capacity: 70
Deficiencies: 9
Date: Feb 23, 2024
Visit Reason
A Life Safety Code and Preoccupancy survey was conducted due to remodeling of part of the 200 Wing into a locked unit.
Findings
The facility was found not in compliance with Life Safety Code requirements including door hardware installation, means of egress obstructions, locking arrangements, exit signage, HVAC return air use in corridors, electrical equipment use, and resident room physical standards.
Deficiencies (9)
Failed to ensure 1 of 1 door to the newly renovated locked unit was fully installed with all hardware; missing a screw in the center hinge of the left door.
Failed to maintain the means of egress free from obstructions in 1 of 2 corridors within the unit; items stored in corridor outside resident rooms #221 and #223.
Failed to ensure the means of egress through 1 of 2 exits were readily accessible; locked unit doors code not posted at door.
Failed to ensure doors within a required means of egress were not equipped with a latch or lock requiring a tool or key from the egress side unless permitted.
Failed to ensure exit signage was properly posted; door to courtyard not posted with EXIT or NO EXIT sign.
Failed to ensure egress corridors were not used as a portion of a return air system serving adjoining rooms.
Could not assure extension cords and power strips used in patient care vicinities met required UL standards; lamps with powered outlets used in resident rooms.
Failed to provide access for nurse call lights in 1 of 13 resident sleeping rooms; call light extension with call button missing.
Failed to provide a resident bed in 1 of 13 resident sleeping rooms; mattress in box without bedframe.
Report Facts
Facility capacity: 70
Census: 60
Residents affected by corridor obstruction: 13
Staff affected by corridor obstruction: 4
Visitors affected by corridor obstruction: 2
Residents affected by locking arrangement deficiency: 16
Residents affected by exit signage deficiency: 13
Residents affected by HVAC deficiency: 13
Residents affected by electrical equipment deficiency: 13
Residents affected by nurse call light deficiency: 1
Residents affected by missing bed deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Weaver | Executive Director | Interviewed and present during observations and exit conference |
| Senior Director of Construction | Interviewed and present during observations and exit conference | |
| Director of Plant Operations | Responsible for corrective actions and education related to deficiencies |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 0
Date: Jan 2, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00422154, IN00423677, and IN00424205 at The Springs at Lafayette.
Complaint Details
Complaints IN00422154, IN00423677, and IN00424205 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00422154, IN00423677, and IN00424205 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census Bed Type: 69
Census Payor Type: 52
SNF beds: 30
SNF/NF beds: 22
Residential beds: 17
Medicare residents: 20
Medicaid residents: 19
Other residents: 13
Inspection Report
Re-Inspection
Census: 60
Capacity: 70
Deficiencies: 0
Date: Oct 12, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 08/21/23 was performed to verify compliance with previous findings.
Findings
The Springs at Lafayette was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code. The facility was fully sprinklered with a fire alarm system and smoke detection throughout.
Report Facts
Facility capacity: 70
Census: 60
Inspection Report
Life Safety
Census: 59
Capacity: 70
Deficiencies: 1
Date: Aug 21, 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 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements due to combustible decorations in the receiving dock area. Specifically, an open case of 6-Hour chafer fuel with exposed wicks was observed, posing a fire hazard.
Deficiencies (1)
Failure to ensure the receiving dock was maintained in accordance with NFPA 101 section 19.7.5.6 prohibiting combustible decorations unless exceptions are met; open containers of chafer fuel with exposed wicks were found.
Report Facts
Certified beds: 70
Census: 59
Containers of chafer fuel: 24
Chafer fuel containers with tops off: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Weaver | Executive Director | Signed report and involved in education on combustible decorations |
| Director of Plant Operations | Acknowledged deficiency, removed chafer fuel, educated on combustible decorations, and responsible for monitoring | |
| Facilities Maintenance Support Director | Acknowledged deficiency during observation | |
| Director of Food Service | Educated on combustible decorations |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 0
Date: Aug 15, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00414831.
Complaint Details
Complaint IN00414831 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type Total: 59
Census Payor Type Total: 37
Census Bed Type SNF: 16
Census Bed Type SNF/NF: 21
Census Bed Type Residential: 22
Census Payor Type Medicare: 11
Census Payor Type Medicaid: 15
Census Payor Type Other: 11
Inspection Report
Annual Inspection
Census: 21
Capacity: 58
Deficiencies: 8
Date: Jul 19, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey including a State Residential Licensure Survey conducted on July 13, 14, 17, 18 and 19, 2023.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident room preferences and privacy, inadequate investigation of abuse allegations, failure to provide scheduled bathing, noncompliance with pressure ulcer prevention orders, lack of physician orders for monitoring devices, failure to educate on antipsychotic medication risks, insufficient CPR and First Aid certified staff coverage, and incomplete controlled substance counts.
Deficiencies (8)
Failed to ensure residents had reasonable accommodations for personal belongings, privacy, and room space.
Failed to thoroughly investigate an alleged abuse incident involving a Certified Resident Care Assistant.
Failed to ensure resident received bathing as scheduled in May and June 2023.
Failed to ensure physician's orders and care plan interventions were followed for pressure ulcer prevention.
Failed to obtain physician's order and care plan for use of wanderguard monitoring bracelet.
Failed to educate resident or representative about risks of antipsychotic medications.
Failed to ensure staff met CPR and First Aid certification requirements for multiple shifts.
Failed to verify controlled substance counts for medication carts with required signatures.
Report Facts
Census: 21
Total Capacity: 58
Deficiency counts: 8
Shifts without CPR/First Aid coverage: 12
Baths missed: 9
Audit frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Thompson | Director of Health Services | Signed report and involved in abuse investigation |
Inspection Report
Renewal
Deficiencies: 0
Date: Jul 19, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on July 19, 2023.
Findings
The Springs of Lafayette 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 to the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 0
Date: Jun 19, 2023
Visit Reason
This visit was conducted for the investigation of three complaints: IN00403327, IN00404087, and IN00410857.
Complaint Details
Complaints IN00403327, IN00404087, and IN00410857 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type - SNF: 20
Census Bed Type - SNF/NF: 19
Census Bed Type - Residential: 23
Total Census: 62
Census Payor Type - Medicare: 12
Census Payor Type - Medicaid: 15
Census Payor Type - Other: 12
Total Census Payor: 39
Inspection Report
Life Safety
Census: 51
Capacity: 70
Deficiencies: 0
Date: Mar 16, 2023
Visit Reason
A Life Safety Code and Pre-Occupancy survey was conducted to remove rooms #226 and #227 from bed inventory, convert comprehensive rooms to residential rooms, and increase bed capacity in certain rooms as conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The Springs at Lafayette was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility is fully sprinklered with a fire alarm system and smoke detection in all resident areas.
Report Facts
Facility capacity: 70
Census: 51
Inspection Report
Complaint Investigation
Census: 54
Capacity: 85
Deficiencies: 0
Date: Sep 23, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00390092.
Complaint Details
Complaint IN00390092 was substantiated; however, no deficiencies related to the allegations were cited.
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.
Report Facts
Census Bed Type Total: 85
Census Payor Type Total: 54
Inspection Report
Life Safety
Census: 47
Capacity: 70
Deficiencies: 3
Date: Aug 30, 2022
Visit Reason
The visit was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 standards.
Findings
The facility was found not in compliance with Life Safety Code requirements due to obstructions in one corridor and failure to maintain and test emergency lighting properly. Immediate interventions were taken to remove obstructions and replace faulty emergency lighting.
Deficiencies (3)
Failed to maintain means of egress free from obstructions in 1 of 8 corridors; specifically, two 3 drawer dressers not on wheels were stored in the corridor outside resident rooms #327 and #330.
Failed to ensure battery powered emergency light at the facility generator was maintained and operational; the light failed to illuminate during testing.
Failed to ensure battery backup lights were tested monthly for 30 seconds and annually for 90 minutes with written records maintained.
Report Facts
Certified beds: 70
Census: 47
Residents potentially affected: 16
Staff potentially affected: 4
Visitors potentially affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Plant Operations | Named in relation to removal of corridor obstructions and replacement/testing of emergency lighting | |
| Executive Director | Educated Director of Plant Operations on means of egress and emergency lighting requirements |
Inspection Report
Life Safety
Deficiencies: 0
Date: Aug 30, 2022
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey was conducted.
Findings
The Springs of Lafayette was found in compliance with Requirements for Participation in 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
Recertification
Census: 29
Deficiencies: 15
Date: Aug 9, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey. This visit also included the Investigation of Nursing Home Complaints IN00372237 and IN00369472.
Complaint Details
Complaint IN00372237 - Substantiated. Federal/State deficiencies related to the allegations are cited at F550. Complaint IN00369472 - Substantiated. Federal/State deficiencies related to the allegations are cited at F676.
Findings
The facility was found to be in compliance with 410 IAC 16.2-5 in regard to the State Residential Licensure Survey. Complaints IN00372237 and IN00369472 were substantiated with related federal/state deficiencies cited. Deficiencies included issues with resident rights, advanced directives, PASARR coordination, activities of daily living, quality of care, mobility, accident prevention, catheter care, respiratory care, bedrails, pharmacy services, psychotropic medication use, medication labeling and storage, and environmental conditions.
Deficiencies (15)
Failed to ensure a resident was free of staff using their cellular phone on face time while in the resident's room.
Failed to ensure a resident's code status had been updated.
Failed to ensure a PASARR was completed when the resident was prescribed an antipsychotic medication and given a mental health diagnosis of hallucinations.
Failed to ensure showers were completed and documented for residents reviewed for bathing.
Failed to assess and document skin conditions for residents reviewed for non-pressure skin conditions.
Failed to assess and treat a resident for potential left foot drop.
Failed to monitor a post-fall injury for a resident who received an anticoagulant.
Failed to assess and document a strong urine odor for a resident with a urinary catheter.
Failed to date oxygen tubing and humidity bottles, administer correct oxygen amount, and use correct route for oxygen.
Failed to have signed bedrail consent, physician orders and care plan for side rails for a resident.
Failed to dispose of schedule II medications with compromised packaging.
Failed to ensure medications brought in from outside source were labeled.
Failed to ensure diagnoses were appropriate for antipsychotic medication use, symptoms documented, and gradual dose reductions addressed timely.
Failed to ensure medications and biologicals were labeled and stored in locked compartments with proper temperature controls.
Failed to ensure a resident's room walls were painted and maintained.
Report Facts
Survey dates: 7
Census: 29
Deficiencies cited: 14
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 9, 2022
Visit Reason
Paper compliance review to the Recertification and State Licensure survey and the Investigation of Nursing Home Complaints IN00372237 and IN00369472.
Findings
The Springs of Lafayette 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 to the Recertification and State Licensure Survey and the Investigation of Nursing Home Complaints IN00372237 and IN00369472.
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