Deficiencies per Year
4
3
2
1
0
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 1
Jul 1, 2025
Visit Reason
The visit was conducted for the investigation of Complaint IN00461532 regarding allegations of neglect at the facility.
Findings
The facility failed to protect a resident's right to be free from neglect, resulting in Resident B being left on the floor for multiple hours. Security footage and interviews confirmed neglectful treatment by staff.
Complaint Details
Complaint IN00461532 was substantiated with state deficiencies cited related to neglect. Resident B was left on the floor for approximately five hours, and staff failed to notify appropriate personnel. Security camera footage documented the neglectful behavior.
Deficiencies (1)
| Description |
|---|
| Facility failed to protect the resident's right to be free from neglect, resulting in Resident B being left on the floor for multiple hours. |
Report Facts
Residential Census: 70
Duration Resident Left on Floor: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Holder | Executive Director | Signed the report and plan of correction |
| CNA 3 | Named in neglect finding for throwing pillow and blanket at Resident B and leaving her on the floor | |
| CNA 1 | Witnessed neglect and was shown video by Resident B's daughter | |
| Qualified Medication Aide 1 | Reported not being informed about Resident B's fall during night shift |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 2
May 19, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00459080 and IN00459388. Complaint IN00459080 had no deficiencies cited, while complaint IN00459388 resulted in state deficiencies related to residents' rights violations.
Findings
The facility failed to protect residents' rights to be free from neglect and physical abuse. Resident B exited the secured memory care unit unsupervised multiple times, and Residents C, D, and E experienced physical abuse incidents involving Resident C. The facility implemented corrective actions including increased supervision, staff education, and environmental security improvements.
Complaint Details
Complaint IN00459080 - No deficiencies related to the allegations are cited. Complaint IN00459388 - State deficiencies related to the allegations are cited at R52.
Deficiencies (2)
| Description |
|---|
| Facility failed to protect the residents' right to be free from neglect for 1 of 3 residents reviewed; Resident B exited the secured unit unsupervised. |
| Facility failed to protect the residents' right to be free from physical abuse by another resident for 2 of 3 residents reviewed for abuse (Residents C, D, E). |
Report Facts
Residential Census: 66
Date of Compliance: Jun 16, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maurice Woolfolk | Executive Director | Signed the report |
| Director of Nursing | Interviewed regarding resident incidents and corrective actions | |
| Qualified Medication Aide 1 | Qualified Medication Aide | Reported Resident B's unsupervised exits |
| Housekeeper | Witnessed Resident B's exit and Resident C's aggressive behavior | |
| CNA 2 | Certified Nursing Assistant | Reported Resident B's exits and incidents involving Resident C |
| Administrator | Provided facility policies and incident reports |
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 3
May 5, 2025
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaints IN00457906 and IN00458982.
Findings
Complaint IN00457906 had no deficiencies related to the allegations. Complaint IN00458982 resulted in state deficiencies cited related to sanitation and safety standards, service plan signatures, and food and nutritional services.
Complaint Details
Complaint IN00457906 - No deficiencies related to the allegations. Complaint IN00458982 - State deficiencies related to sanitation, service plan signatures, and food handling were cited.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure the dumpster area was free of debris and lids were closed during observations. |
| Facility failed to ensure service plans were signed by the resident or resident's representative for 6 of 7 residents reviewed. |
| Facility failed to ensure food was served in a sanitary manner: foods not covered, labeled, or dated; scoop stored in bulk food container; staff touched multiple foods without washing hands or changing gloves; staff hair not covered in kitchen. |
Report Facts
Residents with unsigned service plans: 6
Residential Census: 67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maurice Woolfolk | Executive Director | Signed the report and provided policies during the inspection. |
| Dietary Manager | Interviewed regarding dumpster area cleanliness and food handling practices; observed during kitchen inspections. | |
| Cook 2 | Observed during food preparation and service with noted sanitary deficiencies. | |
| Server 3 | Interviewed regarding dumpster lid closure. | |
| Director of Nursing | Interviewed regarding service plan signature requirements and responsible for auditing service plans. |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 0
Apr 16, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00457574.
Findings
No deficiencies related to the allegations in Complaint IN00457574 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00457574 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Residential Census: 69
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 1
Feb 13, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00451202.
Findings
No deficiencies related to the complaint allegations were cited. However, an unrelated deficiency was found regarding failure to notify the state health department of a vacancy in the Administrator's position and failure to employ a licensed Administrator, potentially affecting all 69 residents.
Complaint Details
Complaint IN00451202 was investigated and no deficiencies related to the allegations were cited.
Severity Breakdown
UNK: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to notify the state health department of a vacancy in the Administrator's position and failed to employ a licensed Administrator for the facility. | UNK |
Report Facts
Residential Census: 69
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brady McClure | Executive Director | Named as Interim Administrator and responsible party in the plan of correction |
| Greg Gramm | Regional Vice President of Operations | Named as responsible party in the plan of correction |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 0
Jan 3, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00449146.
Findings
No deficiencies related to the allegations in Complaint IN00449146 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Complaint Details
Complaint IN00449146 was investigated and found to have no related deficiencies; the complaint was not substantiated.
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 1
Nov 21, 2024
Visit Reason
This visit was conducted for the investigation of two complaints, IN00447355 and IN00446460, related to the facility's compliance with post fall evaluations and fall risk assessments.
Findings
The facility failed to ensure post fall evaluations and fall risk assessments were completed for a resident with multiple falls, violating the facility's policy. One complaint was substantiated with deficiencies cited, while the other complaint had no deficiencies related to the allegations.
Complaint Details
Complaint IN00447355 was substantiated with state deficiencies cited at R214. Complaint IN00446460 was not substantiated with no deficiencies related to the allegations cited.
Deficiencies (1)
| Description |
|---|
| Failure to ensure post fall evaluations and fall risk assessments were completed for a resident with multiple falls as required by facility policy. |
Report Facts
Residential Census: 67
Falls reviewed: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linsey Fitterling | Executive Director | Signed the report |
| Qualified Medication Aide (QMA) 1 | Interviewed regarding Resident B's fall risk and checks | |
| Director of Nursing (DON) | Interviewed regarding post fall investigations and fall risk assessments not completed |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 0
Sep 9, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00442036.
Findings
No deficiencies related to the allegations in Complaint IN00442036 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Complaint Details
Complaint IN00442036 was investigated and found to have no deficiencies related to the allegations.
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 0
Aug 22, 2024
Visit Reason
This visit was conducted for the investigation of four complaints: IN00440195, IN00441069, IN00441452, and IN00441634.
Findings
No deficiencies related to the allegations in any of the four complaints were cited. The facility was found to be in compliance with relevant regulations regarding these complaints.
Complaint Details
Complaints IN00440195, IN00441069, IN00441452, and IN00441634 were investigated and no deficiencies related to the allegations were found.
Inspection Report
Original Licensing
Census: 34
Deficiencies: 2
Jul 18, 2024
Visit Reason
This visit was for an Initial State Residential Licensure Survey and included the investigation of Complaint IN00438000.
Findings
No deficiencies were cited related to the complaint allegations. Deficiencies were found related to food and nutritional services regarding staff hair not being covered in the kitchen, and infection control related to missing annual health statements for 6 residents.
Complaint Details
Complaint IN00438000 was investigated with no deficiencies related to the allegations cited.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure foods were served in a sanitary and safe manner; staff hair was not covered while in the kitchen food preparation area. |
| Facility failed to ensure a physician's annual health statement indicating the resident was free of communicable disease was obtained upon admission for 6 residents. |
Report Facts
Residents reviewed for annual health statement: 6
Census: 34
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linsey Fitterling | Executive Director | Signed the report and completed in-service trainings related to deficiencies. |
| Dietary Manager | Observed with uncovered hair in kitchen food preparation area. | |
| Server 2 | Observed with uncovered hair in kitchen food preparation area. | |
| Cook 3 | Observed with uncovered facial hair in kitchen food preparation area. | |
| Resident Services Director | Indicated staff hair was to be covered and conducted in-service trainings and audits related to infection control deficiencies. | |
| Director of Clinical Services | Indicated a policy for annual health statements was not available. |
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