Inspection Report Summary
The most recent inspection on June 18, 2025, found the facility in compliance with Emergency Preparedness and Life Safety Code requirements, with no deficiencies cited. Prior inspections showed a pattern of deficiencies related mainly to resident care, including person-centered care planning, assistance with activities of daily living such as bathing, and medication management. Several complaint investigations found no deficiencies, but some substantiated complaints resulted in citations for issues like inadequate ADL care, infection control lapses related to catheter care, and medication errors. Enforcement actions such as fines or license suspensions were not listed in the available reports. The inspection history suggests some ongoing challenges in care delivery, with the most recent survey showing improvement in safety and emergency preparedness compliance.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
2% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
89% occupied
Based on a June 2025 inspection.
Census over time
Inspection Report
Life Safety
Census: 80
Capacity: 90
Deficiencies: 0
Date: Jun 18, 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).
Findings
The facility was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, and with Life Safety Code requirements including fire safety and sprinkler systems. The facility is fully sprinklered with a fire alarm system and smoke detection in resident areas.
Report Facts
Facility capacity: 90
Census: 80
Inspection Report
Annual Inspection
Census: 82
Capacity: 82
Deficiencies: 3
Date: May 30, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from May 27 to May 30, 2025.
Findings
The facility was found deficient in developing and implementing person-centered care plans for residents, providing adequate ADL care including showers or baths, and maintaining a medication error rate below 5 percent. Specific deficiencies included failure to ensure bed positioning and call light placement per care plans, failure to provide scheduled showers or baths to dependent residents, and a medication error rate of 27.59 percent for one resident receiving medications via gastric tube.
Deficiencies (3)
Failed to ensure person-centered care plans were developed and implemented for 3 residents including falls, call bell use, and Wander Guard device use.
Failed to provide showers or baths as scheduled for 4 of 6 residents reviewed for ADL care.
Medication error rate exceeded 5 percent for 1 resident with 8 errors out of 29 opportunities during medication pass.
Report Facts
Census: 82
Total Capacity: 82
Medication error rate: 27.59
Medication opportunities observed: 29
Medication errors observed: 8
Residents reviewed for ADL care: 6
Residents not provided showers/baths as scheduled: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandon Burns | Executive Director | Signed the inspection report |
| LPN 3 | Licensed Practical Nurse | Observed preparing and administering medications to Resident 233 with errors |
| Qualified Medication Aide 9 | Observed bed positioning for Resident 1 and unsure about proper bed position | |
| Director of Nursing | Director of Nursing | Provided shower schedule and medication administration oversight |
| Social Service Director | Social Service Director | Interviewed regarding care plan for Wander Guard device |
| Memory Care Director | Memory Care Director | Interviewed regarding showering policy for residents with COVID |
| Regional Support | Provided current Enteral Tube - Medication Administration policy |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 80
Deficiencies: 0
Date: Aug 26, 2024
Visit Reason
This visit was conducted for the investigation of three complaints: IN00441548, IN00438236, and IN00440364.
Complaint Details
Complaint IN00441548, IN00438236, and IN00440364 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 80
Total Capacity: 80
Medicare Census: 1
Medicaid Census: 41
Other Payor Census: 38
Inspection Report
Life Safety
Census: 78
Capacity: 90
Deficiencies: 0
Date: Jun 17, 2024
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).
Findings
The facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements for Medicare and Medicaid participation. The facility is fully sprinklered except for several wood framed portable sheds outside the east unit east exit which were not sprinklered.
Report Facts
Facility capacity: 90
Census: 78
Number of portable sheds: 5
Inspection Report
Renewal
Census: 79
Capacity: 79
Deficiencies: 7
Date: May 17, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from May 13 to May 17, 2024.
Findings
The facility was found deficient in multiple areas including resident dignity and rights, transfer and discharge documentation, ADL care and bathing, tube feeding management, medication availability, medical record accuracy, and timely reporting of unusual occurrences.
Deficiencies (7)
Failed to maintain a resident's dignity by leaving Resident 75 exposed without proper covering.
Failed to ensure documents were sent to the hospital upon transfer for Resident 80.
Failed to ensure residents who required assistance with ADLs received showers as scheduled for 6 of 7 residents reviewed.
Failed to ensure physician orders were followed and nutritional feedings were administered properly for 2 residents with feeding tubes.
Failed to ensure routine medications were available and dispensed according to physician's orders for Resident 71.
Failed to maintain accurate medical records for 1 resident related to psychotherapy documentation and for 1 resident related to departure and return documentation.
Failed to accurately report dates of incidences or report unusual occurrences timely to the Indiana Department of Health for 2 residents with falls resulting in major injuries.
Report Facts
Census: 79
Total Capacity: 79
Survey Dates: 5
Residents affected by ADL bathing deficiency: 6
Residents reviewed for tube feeding deficiency: 2
Residents reviewed for medication availability deficiency: 5
Residents reviewed for medical record accuracy deficiency: 5
Residents reviewed for incident reporting deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandon Burns | Executive Director | Signed report and referenced in plan of correction |
| RN 11 | Registered Nurse | Interviewed regarding resident dignity and feeding tube care |
| CNA 15 | Certified Nursing Aide | Interviewed regarding resident dignity and feeding tube care |
| RN 3 | Registered Nurse | Interviewed regarding hospital transfer documentation |
| LPN 7 | Licensed Practical Nurse | Interviewed regarding medication availability and feeding tube documentation |
| DON | Director of Nursing | Interviewed regarding medication availability, incident reporting, and transfer documentation |
| Administrator | Provided policies and interviewed regarding documentation and incident reporting | |
| Social Services | Interviewed regarding psychotherapy documentation |
Inspection Report
Renewal
Deficiencies: 0
Date: May 17, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure survey ending on May 17, 2024.
Findings
Cypress Grove Rehabilitation Center was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 81
Capacity: 81
Deficiencies: 0
Date: Mar 15, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00430249.
Complaint Details
Complaint IN00430249 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare residents: 4
Medicaid residents: 33
Other residents: 44
Inspection Report
Complaint Investigation
Census: 78
Capacity: 78
Deficiencies: 0
Date: Mar 8, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00428782 at Cypress Grove Rehabilitation Center.
Complaint Details
Complaint IN00428782 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 78
Total Capacity: 78
Medicare Residents: 3
Medicaid Residents: 35
Other Payor Residents: 40
Inspection Report
Complaint Investigation
Census: 83
Capacity: 83
Deficiencies: 1
Date: Nov 29, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00421148 regarding deficiencies related to catheter care and urinary tract infection prevention.
Complaint Details
Complaint IN00421148 was substantiated with deficiencies cited at F690 related to catheter care and infection control.
Findings
The facility failed to ensure routine catheter care and infection control measures were provided for 3 of 4 residents reviewed, resulting in catheter tubing and bags being observed on the floor and missed catheter care as ordered by physicians. Multiple residents had documented missed catheter care and catheter changes, increasing risk for urinary tract infections.
Deficiencies (1)
Failure to provide routine catheter care and maintain infection control measures to prevent urinary tract infections for residents with catheters.
Report Facts
Census: 83
Total Capacity: 83
Residents with catheter care deficiencies: 3
Residents reviewed for catheter care: 4
Missed catheter care dates for Resident C: 5
Missed catheter changes for Resident C: 2
Missed catheter care dates for Resident D: 18
Missed catheter care dates for Resident F: 8
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 29, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00421148 survey ending on November 29, 2023.
Complaint Details
Investigation of Complaint IN00421148; facility found in compliance.
Findings
Cypress Grove Rehabilitation Center was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Investigation of Complaint IN00421148 survey.
Inspection Report
Complaint Investigation
Census: 80
Capacity: 80
Deficiencies: 2
Date: Nov 1, 2023
Visit Reason
This visit was conducted for the investigation of three complaints (IN00419448, IN00419136, and IN00418030). Complaint IN00419136 was substantiated with deficiencies cited, while the other two complaints had no deficiencies related to the allegations.
Complaint Details
Complaint IN00419136 was substantiated with federal/state deficiencies cited at F677 related to ADL care. Complaints IN00419448 and IN00418030 had no deficiencies related to the allegations.
Findings
The facility failed to provide adequate activities of daily living (ADL) care, specifically bathing and respecting bathing preferences, to 4 of 4 residents reviewed. Additionally, the facility failed to ensure proper hand hygiene and glove use during care for 2 residents. Deficiencies related to infection prevention and control and ADL care were cited.
Deficiencies (2)
Failed to provide ADL care including bathing and bathing preferences to 4 of 4 residents reviewed (Residents D, E, F, H).
Failed to ensure proper hand hygiene and glove use for 2 residents observed during care (Residents B and D).
Report Facts
Residents reviewed for ADL care: 4
Census: 80
Total licensed capacity: 80
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 1, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00419136 survey ending on November 1, 2023.
Complaint Details
Investigation of Complaint IN00419136; facility found in compliance.
Findings
Cypress Grove Rehabilitation Center was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Investigation of Complaint IN00419136 and the unrelated deficiency cited during the survey.
Inspection Report
Complaint Investigation
Census: 75
Capacity: 75
Deficiencies: 0
Date: Sep 7, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00416571.
Complaint Details
Complaint IN00416571 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies were cited related to the allegations, and the facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 6
Medicaid census: 38
Other payor census: 31
Inspection Report
Complaint Investigation
Census: 77
Capacity: 77
Deficiencies: 0
Date: Jul 10, 2023
Visit Reason
The visit was conducted to investigate Complaint IN00411805 at Cypress Grove Rehabilitation Center.
Complaint Details
Complaint IN00411805 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies were cited related to the allegations in Complaint IN00411805. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF: 77
Census Payor Type Medicare: 2
Census Payor Type Medicaid: 38
Census Payor Type Other: 37
Inspection Report
Complaint Investigation
Census: 82
Capacity: 82
Deficiencies: 0
Date: Apr 20, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00405714.
Complaint Details
Complaint IN00405714 was investigated and found to have no deficiencies related to the allegation.
Findings
No deficiencies were cited related to the complaint allegation. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 82
Total Capacity: 82
Medicare Census: 2
Medicaid Census: 41
Other Payor Census: 39
Inspection Report
Life Safety
Deficiencies: 0
Date: Feb 28, 2023
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey conducted on 02/28/23.
Findings
Cypress Grove Rehabilitation Center was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Life Safety
Census: 82
Capacity: 90
Deficiencies: 1
Date: Feb 28, 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. However, the Life Safety Code survey found the facility not in compliance due to failure to ensure 2 of 5 electric water heaters had current inspection certificates, which could affect up to 45 residents, staff, and visitors on the east side of the facility.
Deficiencies (1)
Failed to ensure 2 of 5 electric water heaters had current inspection certificates to ensure safe operating condition.
Report Facts
Facility capacity: 90
Census: 82
Electric water heaters inspected: 5
Electric water heaters without current certificates: 2
Residents potentially affected: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Confirmed expiration dates of electric water heaters certificates during observation | |
| Administrator | Participated in exit conference reviewing findings |
Inspection Report
Annual Inspection
Census: 80
Capacity: 80
Deficiencies: 3
Date: Feb 21, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00397900.
Complaint Details
Complaint IN00397900 was substantiated; however, no deficiencies related to the allegations were cited.
Findings
The facility was found to have deficiencies related to nurse staffing information posting, medication storage, and food storage and labeling. The complaint was substantiated but no deficiencies related to the allegations were cited.
Deficiencies (3)
Failed to ensure completed nurse staffing sheets were posted daily with specific hours worked by each discipline for 7 of 7 days during the survey.
Failed to ensure proper storage of medications in medication storage rooms, resident treatment carts, and medication carts; carts were left unlocked and unattended; loose pills and expired medications were found.
Failed to ensure food was stored appropriately; food containers in dry storage, refrigerator, and kitchen shelves were not labeled with complete dates.
Report Facts
Census: 80
Total Capacity: 80
Medicare Census: 3
Medicaid Census: 39
Other Payor Census: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandon Burns | Signed as Laboratory Director's or Provider/Supplier Representative's signature on the report. | |
| RN 6 | Registered Nurse | Interviewed regarding medication storage and handling of expired medications. |
| RN 8 | Registered Nurse | Interviewed regarding loose pills and medication cart security. |
| RN 10 | Registered Nurse | Interviewed regarding expired medications from discharged resident and medication disposal. |
| DON | Director of Nursing | Provided information about medication cart audits and staffing sheet deficiencies. |
| Kitchen Staff 1 | Interviewed about food labeling and storage practices. | |
| Kitchen Manager | Interviewed about food labeling and storage practices. |
Inspection Report
Renewal
Deficiencies: 0
Date: Feb 21, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure survey ending on February 21, 2023.
Findings
Cypress Grove Rehabilitation Center was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 78
Capacity: 78
Deficiencies: 0
Date: Nov 29, 2022
Visit Reason
This visit was for the investigation of Complaints IN00394904 and IN00393791.
Complaint Details
Complaint IN00394904: Substantiated with no deficiencies cited. Complaint IN00393791: Substantiated with no deficiencies cited.
Findings
Both complaints were substantiated, but no deficiencies were cited related to the allegations. The facility was found to be in compliance with relevant regulations.
Report Facts
Medicare census: 3
Medicaid census: 38
Other census: 37
Inspection Report
Complaint Investigation
Census: 78
Capacity: 78
Deficiencies: 0
Date: Oct 19, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00392296, IN00391647, IN00390387, and IN00387645 at Cypress Grove Rehabilitation Center.
Complaint Details
Complaint IN00392296 - Substantiated with no deficiencies cited. Complaint IN00391647 - Substantiated with no deficiencies cited. Complaint IN00390387 - Unsubstantiated due to lack of evidence. Complaint IN00387645 - Substantiated with no deficiencies cited.
Findings
The facility was found to be in compliance with relevant regulations regarding the investigation of the complaints. Three complaints were substantiated with no deficiencies cited, and one complaint was unsubstantiated due to lack of evidence.
Report Facts
Census Bed Type: 78
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 37
Census Payor Type - Other: 39
Inspection Report
Complaint Investigation
Census: 77
Capacity: 77
Deficiencies: 0
Date: Aug 8, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00386550.
Complaint Details
Complaint IN00386550 was investigated and found unsubstantiated due to lack of evidence.
Findings
The complaint IN00386550 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 77
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 37
Census Payor Type - Other: 37
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Jan 8, 2026
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Nov 1, 2023
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Feb 21, 2023
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