Inspection Report Summary
The most recent inspection on July 7, 2025, found no deficiencies related to the complaints investigated. Earlier inspections showed some deficiencies primarily involving medication storage and labeling, unsigned service plans, and issues with food handling and documentation. Complaint investigations during this period were consistently unsubstantiated, with no deficiencies cited related to the allegations. There were no fines, immediate jeopardy findings, or enforcement actions listed in the available reports. The overall trend suggests the facility has addressed prior issues, as recent inspections have not identified new deficiencies.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
2.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
36% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
111 residents
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 0
Date: Jul 7, 2025
Visit Reason
This visit was for the investigation of complaints IN00461767 and IN00461931.
Complaint Details
Complaint IN00461767 - No deficiencies related to the allegations are cited. Complaint IN00461931 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations were cited for either complaint. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the investigation of these complaints.
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 2
Date: Mar 20, 2025
Visit Reason
This visit was for a State Residential Licensure Survey and included the investigation of Complaint IN00449400.
Complaint Details
Complaint IN00449400 was investigated and no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the complaint allegations were cited. However, deficiencies were found related to unsigned service plans for 2 of 5 residents reviewed and improper medication storage and labeling on medication carts and in medication rooms.
Deficiencies (2)
Facility failed to ensure signed service plans were in place for 2 of 5 residents reviewed (Resident 113 and Resident 114).
Facility failed to store medications appropriately and failed to date and label medications for 2 of 2 medication carts and 1 medication room observed.
Report Facts
Residential Census: 110
Residents reviewed for service plans: 5
Medication carts observed: 2
Medication rooms observed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Libby Mellinger | Administrator | Signed the report |
| Director of Nursing (DON) | Interviewed regarding service plan deficiencies and medication storage issues | |
| Licensed Practical Nurse 3 (LPN 3) | Signed service plans for Residents 113 and 114 | |
| Wellness Director | Provided medication storage and labeling policy and responsible for medication cart audits |
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 0
Date: Dec 12, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00448209.
Complaint Details
Complaint IN00448209 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: 115
Deficiencies: 0
Date: Nov 26, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00446785.
Complaint Details
Complaint IN00446785 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00446785 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Report Facts
Residential Census: 115
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 0
Date: Jun 6, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00435897.
Complaint Details
Complaint IN00435897 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: 120
Deficiencies: 6
Date: Mar 27, 2024
Visit Reason
This visit was for a State Residential Licensure Survey which included the Investigation of Complaint IN00419089.
Complaint Details
Complaint IN00419089 was investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies were related to the complaint allegations. Several deficiencies were cited including failure to submit a timely Alzheimer's/Dementia Special Care Unit disclosure form, failure to obtain fingerprints for an employee prior to work, failure to ensure sanitary food handling, medication administration errors, improper food labeling and storage, and medication labeling issues.
Deficiencies (6)
Failed to submit an Alzheimer's/Dementia Special Care Unit disclosure form in a timely manner for 44 residents on the dementia unit.
Failed to obtain fingerprints as part of a background check prior to allowing an employee to work.
Failed to ensure food was served under sanitary conditions related to hand hygiene while serving lunch.
Failed to hold blood pressure medication per parameters for 1 of 5 residents reviewed for medication errors.
Failed to ensure all foods were labeled, dated, and sealed; emergency food supplies were inadequate; and trash cans were open in the kitchen.
Failed to ensure medication open dates were correct, medications were not expired, and resident medication had only one pharmacy label for 3 of 13 medications reviewed.
Report Facts
Residents on dementia unit: 44
Residents in census: 120
Residents reviewed for medication errors: 5
Residents medications reviewed: 13
Dates medication administered below parameter: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Libby Mellinger | Administrator | Signed the report. |
| Employee 12 | LPN | Employee allowed to work without completed fingerprint background check. |
| Food Service Employee 7 | Observed touching resident's food with ungloved and unwashed hands. | |
| QMA 9 | Qualified Medical Aide | Reviewed medication cart and medication storage, identified medication labeling and expiration issues. |
| Executive Director | Executive Director | Provided information and interviews related to deficiencies and policies. |
| Dietary Manager | Dietary Manager | Provided information on food handling and kitchen observations. |
| Wellness Coordinator | Wellness Coordinator | Interviewed regarding medication administration errors. |
Inspection Report
Complaint Investigation
Census: 125
Deficiencies: 0
Date: May 19, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00405283.
Complaint Details
Complaint IN00405283 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations were cited. Traditions At North Willow were found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
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