Inspection Report Summary
The most recent inspection on February 12, 2025, found multiple deficiencies related to documentation, medication orders, service plans, and health statements, though no deficiencies were cited related to the complaints investigated. Earlier inspections showed a pattern of deficiencies primarily involving medication administration, clinical record accuracy, resident care documentation, infection control, and safety procedures. Several substantiated complaints involved issues such as resident-to-resident abuse, failure to report abuse, medication errors, and pest control problems, but enforcement actions like fines or license suspensions were not listed in the available reports. Most complaint investigations were unsubstantiated, with deficiencies generally focused on administrative and care process issues rather than immediate harm. The facility’s inspection history indicates ongoing challenges with documentation and medication management, with no clear trend of overall improvement or worsening.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
79% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
120 residents
Based on a February 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 6
Date: Feb 12, 2025
Visit Reason
This visit was for a State Residential Licensure Survey including the investigation of complaints IN00447809 and IN00452292. The complaints were investigated and no deficiencies related to the allegations were cited.
Complaint Details
Complaints IN00447809 and IN00452292 were investigated with no deficiencies related to the allegations cited.
Findings
The facility was found to have multiple deficiencies including failure to have the most recent annual survey results available, incomplete transfer/discharge documentation for some residents, incomplete or unsigned service plans, failure to follow physician's medication orders, lack of physician diet orders for several residents, and missing annual health statements for most residents reviewed.
Deficiencies (6)
Failed to ensure the most recent annual survey results were readily available for review.
Failed to ensure clinical records were accurate and complete related to lack of transfer/discharge documentation for 2 of 3 residents reviewed.
Failed to ensure Service Plans were signed and/or updated with changes related to self medication administration, home health services, hospice services, mental health services and therapy for 4 of 8 service plans reviewed.
Failed to ensure physician's orders were followed, related to medications not administered as ordered for 1 of 8 residents reviewed.
Failed to ensure there was a physician's order for a diet for 7 of 8 residents reviewed for dietary orders.
Failed to ensure each resident had a signed annual health statement for 7 of 8 records reviewed.
Report Facts
Residents reviewed for transfer/discharge documentation: 3
Residents reviewed for service plans: 8
Residents reviewed for medication administration: 8
Residents reviewed for dietary orders: 8
Residents reviewed for annual health statements: 8
Residential Census: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Westphal | Executive Director | Signed the report and mentioned in interview regarding survey binder and annual survey results |
| Administrator | Interviewed regarding missing annual survey results and transfer/discharge documentation | |
| Director of Nursing | Interviewed regarding service plans, medication administration, diet orders, and annual health statements | |
| Assistant Director of Nursing | Involved in auditing service plans and medication administration |
Inspection Report
Complaint Investigation
Census: 122
Deficiencies: 0
Date: Sep 12, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00440981.
Complaint Details
Complaint IN00440981 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations were cited. Belvedere Senior Housing was found to be in compliance with 410 IAC 16.2-5 in regard to the Investigation of Complaint IN00440981.
Inspection Report
Complaint Investigation
Census: 122
Deficiencies: 0
Date: Mar 18, 2024
Visit Reason
This visit was for the Investigation of Complaints IN00426912, IN00429098, and IN00429235.
Complaint Details
Complaints IN00426912, IN00429098, and IN00429235 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations were cited for any of the three complaints. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the investigation of these complaints.
Report Facts
Residential Census: 122
Inspection Report
Complaint Investigation
Census: 127
Deficiencies: 9
Date: Dec 6, 2023
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaint IN00421087.
Complaint Details
Complaint IN00421087 was investigated with no deficiencies related to the allegations cited.
Findings
The facility had no deficiencies related to the complaint allegations but was cited for multiple deficiencies including failure to invite the fire department to fire drills, insufficient CPR and first aid certified staff, incomplete annual inservice training, incomplete and unsigned resident service plans, unsanitary food preparation and storage conditions, incomplete clinical records, missing transfer/discharge forms, incomplete emergency information files, and inadequate infection control signage and tracking.
Deficiencies (9)
Failed to ensure the fire department was invited to participate in scheduled fire drills at least every six months.
Failed to ensure there was one staff member with current CPR certification scheduled for 8 of 33 shifts and current first aid certification for all 33 shifts reviewed.
Failed to ensure all staff received annual inservice training; a Qualified Medication Assistant did not complete required six-hour training.
Failed to ensure resident service plans were reviewed and signed by residents or representatives for 6 of 8 plans reviewed; plans were inaccurate or incomplete regarding ostomy, oxygen use, catheter care, and self-medication administration.
Failed to store, serve, and prepare food under sanitary conditions including dirty equipment, food crumbs on clean surfaces, improperly stored and undated food, and improper hand hygiene during food preparation.
Failed to ensure clinical records were accurate and complete related to no Physician notification of lab results, lack of documentation of home health services, insulin not given as ordered, and missing blood pressure monitoring.
Failed to ensure a transfer/discharge form was completed for a resident discharged from the facility.
Failed to ensure current emergency information files were complete for 5 of 6 residents reviewed, missing emergency contacts, phone numbers, and hospital preferences.
Failed to ensure infection control guidelines were implemented, including lack of signage alerting visitors of COVID-19 outbreak status and no system for tracking infections.
Report Facts
Residents present: 127
Fire drills required: 12
Shifts reviewed: 33
COVID-19 positive residents: 16
Inspection Report
Complaint Investigation
Census: 122
Deficiencies: 0
Date: Oct 6, 2023
Visit Reason
This visit was conducted to investigate two complaints, IN00413011 and IN00415787, regarding the facility.
Complaint Details
Complaint IN00413011 and IN00415787 were investigated and found to have no deficiencies related to the allegations; the complaints were not substantiated.
Findings
No deficiencies related to the allegations in complaints IN00413011 and IN00415787 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Residential Census: 122
Inspection Report
Complaint Investigation
Census: 126
Deficiencies: 0
Date: Jun 27, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00411158.
Complaint Details
Complaint IN00411158 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations were cited. Belvedere Senior Housing was found to be in compliance with 410 IAC 16.2-5 in regard to the Investigation of Complaint IN00411158.
Inspection Report
Complaint Investigation
Census: 123
Deficiencies: 1
Date: May 17, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00405363 and was conducted in conjunction with the Post Survey Revisit to Complaint IN00404254 completed on 3/22/23.
Complaint Details
Complaint IN00405363 was substantiated with state deficiencies cited at R0149. Complaint IN00404254 was not corrected.
Findings
The facility failed to maintain an effective pest control program related to continuing occurrences of cockroaches observed in a resident room on the third floor. Multiple pest control treatments and inspections were documented, but issues persisted due to lack of systematic monitoring.
Deficiencies (1)
Failure to maintain an effective pest control program related to continuing occurrences of cockroaches in a resident room on the third floor.
Report Facts
Residential Census: 123
Dates of pest control invoices: 4
QA audit frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Erickson | Executive Director | Signed the report |
| Assistant Maintenance Director | Interviewed regarding pest control issues and monitoring practices |
Inspection Report
Complaint Investigation
Census: 123
Deficiencies: 1
Date: May 17, 2023
Visit Reason
This visit was the Post Survey Revisit (PSR) to the Investigation of Complaint IN00404254 completed on 3/22/23 and was done in conjunction with the Investigation of Complaint IN00405363.
Complaint Details
Complaint IN00404254 was not corrected. Complaint IN00405363 had state deficiencies related to the allegations cited at R0149. The nurse failed to report the abuse allegation on 5/8/23 as required. The nurse had been inserviced on abuse reporting on 3/25/23. The facility failed to implement a systemic plan of correction to prevent recurrence.
Findings
The facility failed to ensure allegations of mistreatment were reported timely to the Administrator for 1 of 2 residents reviewed for abuse (Resident F). The nurse on duty did not inform the Administrator or Director of Nursing after the resident reported the allegation, despite prior inservice training. The facility failed to implement a systemic plan of correction to prevent recurrence.
Deficiencies (1)
Failed to ensure allegations of mistreatment were reported timely to the Administrator for 1 of 2 residents reviewed for abuse (Resident F).
Report Facts
Residential Census: 123
Survey Date: May 17, 2023
Plan of Correction Completion Date: Jun 13, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Erickson | Executive Director | Signed as Laboratory Director's or Provider/Supplier Representative |
| Director of Nursing | Interviewed regarding failure to report abuse allegation |
Inspection Report
Complaint Investigation
Census: 124
Deficiencies: 3
Date: Mar 22, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00404254 concerning allegations of resident-to-resident abuse and failure to report abuse.
Complaint Details
Complaint IN00404254 was substantiated with state deficiencies cited related to allegations of resident-to-resident abuse involving Residents B, J, D, F, C, and G. The Administrator was unaware of the requirement to report abuse allegations to the Indiana Department of Health.
Findings
The facility failed to ensure residents were free from resident-to-resident abuse involving inappropriate sexual comments, pictures, and videos sent by a male resident to female residents. The facility also failed to report allegations of abuse to the Indiana Department of Health and failed to develop a service plan for the resident exhibiting behavioral symptoms and substance abuse.
Deficiencies (3)
Failed to ensure residents were free from resident-to-resident abuse related to inappropriate picture, video, and sexual comments by a male resident to female residents.
Failed to report allegations of abuse to the Indiana Department of Health for 6 residents.
Failed to develop and initiate a Service Plan for an independent resident with behavioral symptoms and substance abuse.
Report Facts
Residential Census: 124
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sandra L. Erickson | Administrator | Named as the Administrator who was interviewed and responsible for facility management. |
| Director of Nursing | Interviewed regarding lack of Service Plan and abuse reporting; name not provided. |
Inspection Report
Complaint Investigation
Census: 126
Deficiencies: 6
Date: Feb 7, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00400230, which was substantiated with state deficiencies cited related to the allegations.
Complaint Details
Complaint IN00400230 was substantiated with state deficiencies cited at R0036, R0054, R0216, R0240, R0305, and R0349.
Findings
The facility failed to notify physicians of significant changes in residents' conditions, failed to maintain confidentiality of resident information, failed to properly evaluate residents for self-administration of medications, failed to ensure residents received necessary care and services including medication administration and lab tests, failed to provide timely medication delivery, and failed to maintain complete and accurate clinical records.
Deficiencies (6)
Failed to ensure residents' physicians were notified of condition changes, medication changes, and as ordered by the physician related to high blood sugar, high blood pressure, and medications not received as ordered for 3 of 7 residents reviewed.
Failed to ensure confidential information was not released without the resident's consent for 1 of 7 residents reviewed.
Failed to ensure residents were properly evaluated for self-administration of medications for 2 of 3 residents reviewed.
Failed to ensure residents received necessary care and services related to medications not being administered as ordered, blood sugars not checked as ordered, assessments for changes in condition not completed, and a laboratory test not completed as ordered for 4 of 7 residents reviewed.
Failed to ensure a resident who self-administers medications received an ordered medication in a timely manner for 1 of 1 resident reviewed.
Failed to ensure a resident's record was complete and had accurate documentation related to blood sugar levels for 1 of 7 residents reviewed.
Report Facts
Residential Census: 126
Deficiencies cited: 6
Blood sugar readings: 505
Blood pressure reading: 170100
Medication dosage: 12
Medication dosage: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sandra L Erickson | Administrator | Signed report and involved in resident rights confidentiality issue |
| Director of Nursing | Interviewed regarding failure to notify physicians, medication administration, and clinical record deficiencies | |
| QMA 1 | Observed medication pass and acknowledged medication availability issues | |
| LPN 1 | Interviewed regarding medication coverage by insurance and notification procedures |
Inspection Report
Complaint Investigation
Census: 125
Deficiencies: 4
Date: Nov 22, 2022
Visit Reason
The visit was conducted for the investigation of Complaint IN00383250, which was substantiated with a state deficiency cited related to the allegations.
Complaint Details
Complaint IN00383250 was substantiated with a state deficiency cited at R0240 related to medication administration and other unrelated deficiencies.
Findings
The facility failed to ensure a resident was evaluated for self-administration of medications, failed to administer medication as ordered by a physician, failed to obtain prior authorization for PRN medications before administration, and failed to ensure staff performed hand hygiene during medication administration.
Deficiencies (4)
Failed to ensure a resident was evaluated for self-administration of medications for 1 of 5 residents observed.
Failed to ensure a medication was administered as ordered by a physician for 1 of 5 residents reviewed.
Failed to ensure PRN medications were authorized by an RN or LPN prior to administration for 2 of 5 residents reviewed.
Failed to ensure staff washed their hands or completed hand hygiene as indicated by accepted professional practice during medication pass observation for 3 of 5 residents observed.
Report Facts
Residential Census: 125
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Erickson | Administrator | Signed as Laboratory Director's or Provider/Supplier Representative. |
| QMA 1 | Qualified Medication Aide | Named in findings related to medication administration and hand hygiene deficiencies. |
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