Inspection Report
Life Safety
Census: 13
Capacity: 32
Deficiencies: 0
Jun 26, 2025
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 and Life Safety Code Requirements for Participation in Medicare/Medicaid. The facility is a one-story, fully sprinklered building with a fire alarm system and smoke detectors, with a detached barn that is not sprinklered.
Report Facts
Facility capacity: 32
Census: 13
Inspection Report
Renewal
Census: 267
Deficiencies: 0
May 27, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey.
Findings
Towne House Retirement Community was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Recertification and State Licensure Survey.
Report Facts
Census: 267
Census Bed Type - SNF: 10
Census Bed Type - NCC: 39
Census Bed Type - Residential: 218
Census Payor Type - Medicare: 10
Census Payor Type - Private: 257
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 0
Nov 21, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00445200 and IN00446988.
Findings
No deficiencies related to the allegations in complaints IN00445200 and IN00446988 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 these complaints.
Complaint Details
Complaint IN00445200 - No deficiencies related to the allegations are cited. Complaint IN00446988 - No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type - SNF: 10
Census Bed Type - NCC: 39
Total Census: 49
Census Payor Type - Medicare: 7
Census Payor Type - Other: 42
Inspection Report
Complaint Investigation
Census: 218
Deficiencies: 0
Sep 25, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00443445 at Towne House Retirement Community.
Findings
No deficiencies related to the allegations in Complaint IN00443445 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00443445 was investigated and found to have no deficiencies related to the allegations.
Inspection Report
Complaint Investigation
Census: 18
Deficiencies: 0
Sep 13, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00441668.
Findings
No deficiencies related to the allegations in Complaint IN00441668 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00441668 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF: 11
Census Bed Type - NCC: 7
Total Census: 18
Census Payor Type - Medicare: 7
Census Payor Type - Other: 4
Total Census Payor: 11
Inspection Report
Complaint Investigation
Census: 209
Deficiencies: 0
Aug 7, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00439899.
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 IN00439899 was investigated and found to have no deficiencies related to the allegations.
Inspection Report
Follow-Up
Census: 11
Capacity: 32
Deficiencies: 0
Aug 2, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Emergency Preparedness Survey conducted on 06/20/24 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.73.
Findings
Towne House Retirement Community was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Annual Inspection
Deficiencies: 0
Jun 28, 2024
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure, including the State Residential Licensure review completed on May 30, 2024.
Findings
Towne House Retirement Community 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 and the State Residential Licensure review.
Inspection Report
Life Safety
Census: 10
Capacity: 32
Deficiencies: 5
Jun 20, 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 NFPA 101 standards.
Findings
The facility was found not in compliance with Life Safety Code requirements due to deficiencies including lack of staff training on UL 300 hood system use, missing fire extinguisher signage, inadequate hood and grease drip pan cleaning, missing sprinkler coverage on an outdoor deck overhang, outdated sprinkler system gauges, missed annual inspection of a fire extinguisher, and failure to enforce portable space heater policies.
Severity Breakdown
SS=F: 1
SS=E: 2
SS=C: 1
SS=D: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Staff were not instructed in the use of the UL 300 hood system; missing signage for manual operation of fire extinguishing system; grease drip pans overflowing and baffles heavily contaminated in kitchen. | SS=F |
| Outside exit overhang/decking not provided with sprinkler coverage as required by NFPA 13. | SS=E |
| Four of eight sprinkler system gauges were not replaced or tested every 5 years with a calibrated gauge. | SS=C |
| One portable fire extinguisher in the elevator mechanical room missed annual inspection. | SS=E |
| Portable space heater in staff area was not inspected or tested and did not have label ensuring it does not exceed 212 degrees. | SS=D |
Report Facts
Facility capacity: 32
Census: 10
Sprinkler system gauges: 8
Sprinkler system gauges not replaced/tested: 4
Deck overhang dimensions: 7
Deck overhang dimensions: 6
Deficiencies cited: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hayley Carr | Executive Director | Named in relation to findings and exit conference |
| Assistant Executive Director | Participated in observations and interviews during survey | |
| Director of Environmental Services | Participated in observations and interviews during survey | |
| Dietary staff #1 | Interviewed regarding hood suppression system use |
Inspection Report
Renewal
Census: 260
Deficiencies: 5
May 30, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey, a Non-Certified Comprehensive Licensure Survey, and a Nurse Aid Training Review conducted May 28-30, 2024.
Findings
The facility was cited for deficiencies related to failure to develop individualized baseline care plans, failure to maintain current physician orders for wound care, unsafe transfer assistance resulting in a resident fall, and failure to maintain kitchen sanitation including unlabeled and expired food items and improper sanitizer concentration.
Severity Breakdown
SS=D: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to develop a person-centered, individualized baseline care plan with instructions needed to provide effective care for a resident with a catheter. | SS=D |
| Failure to ensure physician orders were current for wound care to a surgical incision for a resident. | SS=D |
| Failure to ensure safe transfer assistance for a resident, resulting in a fall and skin tear. | SS=D |
| Failure to ensure kitchen sanitation was maintained, including unlabeled and expired food items and sanitizer solution below effective concentration. | SS=D |
| Failure to ensure kitchen sanitation was maintained and opened food items were labeled and dated in the Retirement Center kitchen. | — |
Report Facts
Census: 260
Residents in Residential Census: 208
Sanitizer solution concentration: 150
Sanitizer solution required concentration range: 200-400
Fall audit period: 6
Care plan audit period: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hayley Carr | Executive Director | Signed report and interviewed regarding care plan deficiencies |
| Director of Nursing | Interviewed regarding care plan and wound care deficiencies and fall incident | |
| Dietary Manager | Interviewed regarding kitchen sanitation and food labeling deficiencies | |
| Executive Chef | Interviewed regarding sanitizer solution concentration and kitchen sanitation | |
| Licensed Practical Nurse 10 | Provided therapy binder document regarding resident transfer assistance | |
| Physical Therapist 11 | Interviewed regarding resident transfer clearance | |
| Physical Therapy Assistant 12 | Interviewed regarding resident transfer clearance |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 0
Feb 27, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00427666.
Findings
No deficiencies related to the complaint 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.
Complaint Details
Complaint IN00427666 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF: 12
Census Bed Type - NCC: 40
Total Census: 52
Census Payor Type - Medicare: 12
Census Payor Type - Other: 40
Inspection Report
Complaint Investigation
Census: 39
Capacity: 39
Deficiencies: 0
Jan 3, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00423703 and IN00423919.
Findings
No deficiencies related to the allegations in complaints IN00423703 and IN00423919 were cited. The facility was found to be in compliance with applicable regulations regarding these complaints.
Complaint Details
Investigation of Complaints IN00423703 and IN00423919 found no deficiencies related to the allegations; both complaints were not substantiated.
Report Facts
Census Bed Type: 39
Total Capacity: 39
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 0
Jul 28, 2023
Visit Reason
This visit was for the investigation of complaints IN00413007 and IN00413111.
Findings
No deficiencies related to the allegations in complaints IN00413007 and IN00413111 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00413007 - No deficiencies related to the allegations are cited. Complaint IN00413111 - No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type - SNF: 9
Census Bed Type - NCC: 30
Census Total: 39
Census Payor Type - Medicare: 4
Census Payor Type - Other: 35
Inspection Report
Annual Inspection
Deficiencies: 0
May 24, 2023
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure survey conducted on April 24, 2023.
Findings
Towne House Retirement Community 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
Life Safety
Census: 11
Capacity: 32
Deficiencies: 0
May 11, 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 and Life Safety Code requirements for Medicare and Medicaid Participating Providers and Suppliers. The facility is fully sprinklered except for a detached barn used for storage and maintenance.
Report Facts
Facility capacity: 32
Census: 11
Inspection Report
Annual Inspection
Census: 240
Deficiencies: 2
Apr 24, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the investigation of Complaint IN00404093.
Findings
The facility was found to have deficiencies related to failure to ensure code status was clearly indicated for two residents and failure to ensure oxygen tubing and oxygen humidifier bottle were routinely changed and labeled for one resident. No deficiencies related to the complaint allegations were cited.
Complaint Details
Complaint IN00404093 was investigated and no deficiencies related to the allegations were cited.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure the code status was clearly indicated for 2 of 6 residents (Resident 8 and Resident 11). | SS=D |
| Failed to ensure oxygen tubing and oxygen humidifier bottle were routinely changed and labeled for 1 of 1 resident reviewed (Resident 4). | SS=D |
Report Facts
Census Bed Type - SNF: 6
Census Bed Type - Residential: 193
Census Bed Type - NCC: 41
Total Census: 240
Census Payor Type - Medicare: 6
Census Payor Type - Private: 234
Total Census Payor: 240
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brenda Buroker | Director of Long Term Care | Named in plan of correction responses |
| Mark Price | Associate Executive Director | Signed the report and named in plan of correction |
Inspection Report
Complaint Investigation
Census: 13
Capacity: 13
Deficiencies: 0
Feb 13, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00401166.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00401166 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Census SNF beds: 13
Census total residents: 13
Census Medicare residents: 8
Census other payor residents: 5
Inspection Report
Complaint Investigation
Census: 256
Deficiencies: 0
Nov 10, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00392016.
Findings
The complaint IN00392016 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00392016 was investigated and found unsubstantiated due to lack of evidence.
Report Facts
Census Bed Type - SNF: 5
Census Bed Type - Residential: 213
Census Bed Type - NCC: 38
Total Census: 256
Census Payor Type - Medicare: 3
Census Payor Type - Other: 253
Inspection Report
Life Safety
Census: 8
Capacity: 32
Deficiencies: 0
Oct 11, 2022
Visit Reason
A 2nd Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 07/07/22 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.73. The 1st PSR was conducted on 09/07/22.
Findings
At this PSR survey, Towne House Retirement Community was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility is a one-story, fully sprinklered Type V (111) construction with a fire alarm system and smoke detection in corridors and resident rooms.
Report Facts
Facility capacity: 32
Census: 8
Inspection Report
Complaint Investigation
Census: 249
Deficiencies: 0
Sep 12, 2022
Visit Reason
This visit was for the investigation of Complaint IN00388292.
Findings
The complaint IN00388292 was found to be unsubstantiated due to lack of evidence. Towne House Retirement Community was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the complaint investigation.
Complaint Details
Complaint IN00388292 was unsubstantiated due to lack of evidence.
Report Facts
Census Bed Type - SNF: 10
Census Bed Type - Residential: 200
Census Bed Type - NCC: 39
Total Census: 249
Census Payor Type - Medicare: 6
Census Payor Type - Other: 243
Inspection Report
Re-Inspection
Census: 8
Capacity: 32
Deficiencies: 1
Sep 7, 2022
Visit Reason
A Post Survey Revisit (PSR) to the Emergency Preparedness Survey conducted on 07/07/22 was conducted by the Indiana Department of Health to verify correction of previous deficiencies related to life safety and fire protection.
Findings
The facility was found not in compliance with life safety requirements related to direct-vent gas fireplaces lacking electrically supervised carbon monoxide detection. Corrective actions were planned including installation of detectors by 10/05/2022.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 2 direct-vent fireplaces were protected by electrically supervised carbon monoxide detection as required by LSC 19.5.2.3(2) and NFPA 54. | SS=F |
Report Facts
Facility capacity: 32
Census: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Riegling | Executive Director | Named in plan of correction and exit conference |
| Assistant Executive Director | Interviewed regarding deficiency and corrective action | |
| Maintenance Director | Interviewed regarding deficiency and corrective action | |
| Director of Environmental | Present during exit conference | |
| Maintenance Tech | Present during exit conference |
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