Inspection Reports for Traditions at Reagan Park
1176 KINGWOOD DRIVE, AVON, IN, 46123
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 14, 2025, identified multiple deficiencies including issues with safety assessments of side rails and mobility bars, improper chemical and food storage, failure to notify physicians of condition changes, undated medications, and missing annual health statements for new admissions. Earlier inspections showed a pattern of deficiencies related to medication management, staff qualifications and training, reporting incidents, and environmental safety, with some complaints substantiated but most complaint investigations resulting in no cited deficiencies. Main themes across reports included medication storage and documentation, resident safety measures, and staff screening and training. Complaint investigations were mostly unsubstantiated or did not result in deficiencies related to the allegations, though one substantiated complaint did not lead to cited deficiencies. The facility’s inspection history shows ongoing challenges with regulatory compliance, with no clear pattern of improvement over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
26% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
81 residents
Based on a May 2025 inspection.
Census over time
Inspection Report
Renewal
Census: 81
Deficiencies: 5
Date: May 14, 2025
Visit Reason
This visit was for a State Residential Licensure Survey conducted on May 13 and 14, 2025, to assess compliance with state regulations for the facility.
Findings
The survey identified multiple deficiencies including failure to properly assess and monitor side rails and mobility bars for safety, improper storage of chemicals with dry food, failure to notify physicians of resident condition changes, failure to date certain medications, and lack of annual health statements for new admissions.
Deficiencies (5)
Facility failed to prevent potential accidents when half side rails and mobility bars were installed without initial assessments and ongoing safety monitoring for 3 of 5 residents reviewed.
Facility failed to ensure dry foods and chemical cleaners were stored separately, potentially affecting all 81 residents.
Facility failed to notify physician of a change in condition after a resident sustained a skin tear, lacking documentation of physician notification and ongoing monitoring.
Facility failed to date insulin pens, eye drops, and tuberculin testing serum in medication carts and medication rooms.
Facility failed to ensure all new admissions had an annual health statement verifying freedom from communicable diseases.
Report Facts
Residents reviewed for side rail safety: 5
Residents affected by chemical storage deficiency: 81
Residents reviewed for annual health statements: 3
Length of skin tear: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Indi Paysinger | Executive Director | Signed the report and plan of correction |
| LPN 6 | Licensed Practical Nurse | Interviewed regarding side rail assessments and wound care |
| Maintenance Director | Observed and measured side rails and mobility bars | |
| Director of Nursing | DON | Interviewed regarding wound care and physician notification |
| Regional Nurse Consultant | Provided facility policies and interviewed about side rail policy | |
| Dietary Manager | DM | Interviewed about chemical storage |
| Wellness Director | Interviewed about medication dating and corrective actions |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 0
Date: Feb 21, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00449886.
Complaint Details
Complaint IN00449886 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations are cited. Traditions at Reagan Park was found to be in compliance with 410 IAC 16.2-5 in regard to the Investigation of Complaint IN00449886.
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 7
Date: May 8, 2024
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of multiple complaints (IN00429840, IN00431773, IN00432433, IN00432567, and IN00432537) related to allegations of deficient practices at the facility.
Complaint Details
This visit included investigation of complaints IN00429840, IN00431773, IN00432433, IN00432567, and IN00432537. Deficiencies related to these complaints were cited at various tags including R116, R117, R119, R90, and R148.
Findings
The facility was found deficient in multiple areas including failure to adequately report an elopement incident, hiring an unlicensed staff member who performed nursing duties, lack of proper employee orientation and screening, failure to maintain a safe environment to prevent resident elopement, improper medication storage and labeling, and incomplete clinical records regarding medication indications.
Deficiencies (7)
Failed to adequately report an elopement to the Indiana Department of Health by omitting key elements of the accident including the resident's cognitive and behavioral status.
Failed to ensure appropriate and specific policies/procedures were written and implemented for screening prospective employees, resulting in hiring an unlicensed staff member.
Failed to ensure a new hire nursing staff member was provided appropriate job-specific orientation and training and failed to maintain documentation of orientation.
Failed to ensure a safe and secure environment for a resident with dementia to prevent elopement from the facility.
Failed to ensure medications were secure for a resident who self-administered their own medications.
Failed to appropriately store and label prescription and over-the-counter medications for multiple residents.
Failed to indicate the reason for medication usage/diagnosis in clinical records for multiple residents.
Report Facts
Residents present: 76
Survey dates: 3
Deficiency completion dates: Jul 1, 2024
Temperature: 33
Resident count: 20
Employee records reviewed: 5
Residents reviewed for medication storage: 13
Residents reviewed for medication indication: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee 66 | Unlicensed staff member | Hired without proper license verification, performed nursing duties, and was terminated after medication errors |
| Charles Boswell | Executive Director | Signed report and involved in administrative oversight |
| Memory Care Director | Provided information about Resident C's elopement and care | |
| Director of Nursing | Interviewed regarding Employee 66's hiring and license verification | |
| Business Office Manager | Responsible for background checks and new hire procedures | |
| Assistant Vice President of Operations | Responsible for educating Executive Director on incident reporting policy |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 4
Date: Dec 20, 2022
Visit Reason
This visit was for a State Residential Licensure Survey which included the Investigation of Complaint IN00396818.
Complaint Details
Complaint IN00396818 was substantiated but no deficiencies related to the allegations were cited.
Findings
The complaint was substantiated but no deficiencies related to the allegations were cited. Deficiencies were found related to residents' rights regarding dementia care disclosure, failure to report an unusual occurrence, dishwasher sanitation issues, and lack of a comprehensive mental health care plan for a resident with major mental illness.
Deficiencies (4)
Failed to ensure residents received a copy of the facility's Dementia Care Disclosure form upon admission and failed to submit an updated copy to the Indiana Department of Health.
Failed to report an unusual occurrence to the Department of Health after a resident was struck by a car in the facility parking lot resulting in injury.
Dishwasher did not maintain correct wash temperature and sanitizer bucket had inadequate chemical concentration, risking improper cleaning of kitchen utensils.
Failed to ensure a Medicaid resident with major mental illness had a comprehensive care plan developed within 30 days after admission.
Report Facts
Residents in Memory Care Unit potentially affected by dementia care disclosure deficiency: 20
Residents receiving food from kitchen: 95
Total residents present during inspection: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CJ Boswell | Executive Director | Interviewed regarding dementia care disclosure and incident reporting deficiencies. |
| Director of Nursing | Interviewed regarding accident involving Resident 4 and care plan documentation. | |
| Licensed Practical Nurse 10 | Responded to Resident 4's accident in parking lot. | |
| Certified Dietary Manager | Reported dishwasher temperature issues and sanitation concerns. | |
| Community Relations Director | Responsible for auditing dementia care disclosure form provision. | |
| Wellness Director | Educated on mental health care plan requirements and responsible for audits. |
Viewing
Loading inspection reports...
