Inspection Reports for Greenwood Village South
295 Village Ln, Greenwood, IN 46143, United States, IN, 46143
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 21, 2025, identified deficiencies related to neglect involving a cognitively impaired resident who eloped and issues with updating the resident’s service plan after wanderguard application. Earlier inspections showed a mixed pattern, with prior deficiencies primarily involving life safety code violations such as fire door functionality, electrical panel clearance, and improper use of power strips, as well as care-related issues including call light accessibility, staff reference checks, and medication documentation. Complaint investigations were mostly unsubstantiated except for two substantiated cases involving elopement and neglect, but no fines, immediate jeopardy findings, or license actions were listed in the available reports. The main themes of deficiencies have been resident supervision and safety systems, along with some concerns about staff practices and documentation. The trend shows ongoing challenges with life safety compliance and resident care, with some improvements noted in fire safety compliance after follow-up surveys, but recent issues with resident neglect indicate areas needing continued attention.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
90% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
38 residents
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
Date: Mar 21, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00455803 regarding allegations of neglect related to a cognitively impaired resident exhibiting exit seeking behaviors.
Complaint Details
Complaint IN00455803 was substantiated with state deficiencies cited related to neglect and failure to update the service plan after wanderguard application.
Findings
The facility failed to protect Resident B's right to be free from neglect, as Resident B eloped from the facility and was found 1.1 miles away by police. The wanderguard system did not alarm, and the resident's service plan was not updated after the wanderguard was applied.
Deficiencies (1)
Failed to protect the resident's right to be free from neglect for a cognitively impaired resident with exit seeking behaviors, resulting in elopement.
Report Facts
Residential Census: 38
Distance Resident Walked: 1.1
Speed Limit: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Seegers | Laboratory Director's or Provider/Supplier Representative's signature on report | |
| LPN 1 | Licensed Practical Nurse | Resident B's nurse on day shift on 3/18/25, provided information about the elopement |
| Director of Nursing | Indicated service plan was not updated after wanderguard placement and provided facility policy | |
| Administrator | Provided information about Resident B being found by police |
Inspection Report
Complaint Investigation
Census: 121
Capacity: 149
Deficiencies: 0
Date: Mar 12, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00454532 and IN00455359.
Complaint Details
Investigation of Complaints IN00454532 and IN00455359 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00454532 and IN00455359 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF beds: 121
Census Residential beds: 28
Total Capacity: 149
Census Medicare residents: 15
Census Medicaid residents: 54
Census Other payor residents: 52
Total Census: 121
Inspection Report
Follow-Up
Census: 122
Capacity: 137
Deficiencies: 0
Date: Oct 16, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 08/20/24 was performed to verify compliance with fire safety and licensure requirements.
Findings
At this PSR survey, Greenwood Village South 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. Both buildings surveyed were fully sprinklered with appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 137
Census: 122
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 24, 2024
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure Survey.
Findings
Greenwood Village South was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure Survey.
Inspection Report
Life Safety
Census: 121
Capacity: 137
Deficiencies: 4
Date: Aug 20, 2024
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) to assess compliance with fire safety and life safety code requirements.
Findings
The facility was found not in compliance with several Life Safety Code requirements including failure to maintain portable fire extinguisher signage, fire-rated door functionality, electrical panel working space clearance, and improper use of power strips in patient care areas. Corrective actions and audits were planned to address these deficiencies.
Deficiencies (4)
Failed to maintain a placard near the portable Class K fire extinguisher in the kitchen stating the fixed fire suppression system shall be activated prior to using the extinguisher.
Failed to maintain 1 of 12 fire-rated door locations; the south door of the newly replaced fire doors outside the Redbud Unit did not self-close fully and latch properly.
Failed to ensure access and working space was maintained in 1 of 1 main electrical panel rooms due to storage of combustible boxes and supplies within the working space.
Failed to ensure extension cords including power strips were not used as a substitute for fixed wiring; power strip used in resident room 118 for a cell phone charger and portable oxygen device.
Report Facts
Certified beds: 137
Census: 121
Fire-rated door locations inspected: 12
Fire-rated doors failed inspection: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Seegers | Administrator | Signed the report |
| Plant Operations Supervisor | Interviewed and involved in observations and exit conference | |
| Assistant Director of Plant Operations | Interviewed and involved in observations and exit conference |
Inspection Report
Renewal
Census: 121
Capacity: 160
Deficiencies: 4
Date: Aug 13, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted over August 5, 6, 7, 8, 9, 12, and 13, 2024.
Findings
The facility was found deficient in several areas including failure to provide reasonable accommodation for residents due to missing bathroom call light pull cords, failure to complete reference checks for a new employee prior to hire, failure to ensure proper hair covering by kitchen staff, and failure to document medication dispositions upon resident discharge.
Deficiencies (4)
Bathroom emergency call lights lacked pull cords for 4 of 4 randomly observed residents.
Failed to ensure a new staff member's references were checked prior to being hired (Dietary Aide 4).
Staff hair was not properly covered while in the kitchen food preparation area (Lead Cook 8).
Failed to document drug dispositions for 2 of 2 closed resident records reviewed (Resident 60 and Resident 61).
Report Facts
Census SNF/NF: 121
Census Residential: 39
Total Capacity: 160
Census Payor Type Medicare: 13
Census Payor Type Medicaid: 62
Census Payor Type Other: 46
Number of residents affected by call light deficiency: 4
Number of employees reviewed for reference checks: 5
Number of kitchen observations: 3
Number of closed resident records reviewed for drug disposition: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Seegers | Administrator | Signed report and involved in interviews |
| Dietary Aide 4 | Employee whose references were not checked prior to hire | |
| Lead Cook 8 | Employee observed not properly covering hair in kitchen | |
| Director of Nursing | Director of Nursing | Provided policy and interview regarding call light and medication disposition deficiencies |
| Dietary Manager | Provided interview and policy regarding hair covering in kitchen | |
| Unit Manager 2 | Interviewed regarding call light usage |
Inspection Report
Complaint Investigation
Census: 126
Capacity: 163
Deficiencies: 0
Date: Jun 26, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00435844.
Complaint Details
Complaint IN00435844 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
SNF/NF Census: 126
Residential Census: 37
Total Capacity: 163
Medicare Census: 18
Medicaid Census: 60
Other Payor Census: 48
Total Payor Census: 126
Inspection Report
Complaint Investigation
Census: 123
Capacity: 162
Deficiencies: 0
Date: Dec 28, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00421695.
Complaint Details
Complaint IN00421695 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 SNF/NF: 123
Census Residential: 39
Total Capacity: 162
Census Payor Type Medicare: 19
Census Payor Type Medicaid: 61
Census Payor Type Other: 43
Total Census Payor: 123
Inspection Report
Follow-Up
Census: 120
Capacity: 137
Deficiencies: 0
Date: Nov 2, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 09/11/23 was performed to verify compliance with life safety and state licensure requirements.
Findings
At this PSR survey, Greenwood Village South 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. Both buildings 0101 and 0103 were fully sprinklered and had appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 137
Census: 120
Inspection Report
Complaint Investigation
Census: 113
Capacity: 151
Deficiencies: 0
Date: Sep 29, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00416992.
Complaint Details
Complaint IN00416992 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 SNF/NF beds: 113
Census Residential beds: 38
Total licensed capacity: 151
Census Medicare residents: 9
Census Medicaid residents: 61
Census Other payor residents: 43
Total census residents: 113
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 20, 2023
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure Survey completed on August 15, 2023.
Findings
Greenwood Village South was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure Survey.
Inspection Report
Life Safety
Census: 119
Capacity: 137
Deficiencies: 10
Date: Sep 11, 2023
Visit Reason
Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Life Safety Code requirements including fire rated separations, means of egress obstructions, hazardous area door latching, sprinkler system maintenance, smoke detection in new areas, combustible decorations, electrical receptacle testing, power strip usage, oxygen storage ventilation, and therapy room door latching.
Deficiencies (10)
Failed to maintain 2-hour fire rated separation between skilled nursing unit and attached assisted living area; door set missing self-closing devices and fire rating label.
Failed to ensure 2 of 8 means of egress in Dogwood wing were free of obstructions reducing corridor width to less than four feet.
Soiled linen room door inactive leaf failed to latch into door frame; door not separated by smoke resistant partitions.
Ceiling construction in 1 of 8 exterior canopies had a 3-inch gap around sprinkler escutcheon causing potential delay in sprinkler activation.
Two new weigh scale areas were not separated from corridor by smoke resistant partitions and lacked electrically supervised smoke detection.
Combustible Halloween decorations on resident room door covering more than 70% of door surface without flame retardant labeling.
Electrical receptacle testing documentation for all resident sleeping rooms not available for most recent 12 months.
Use of power strips in patient care vicinity as substitute for fixed wiring in resident room and nurse manager office.
Oxygen storage and transfilling room exhaust fan not operational, failing to provide required mechanical ventilation.
Therapy room corridor doors did not fully close and latch due to door edges rubbing together.
Report Facts
Certified beds: 137
Census: 119
Deficiencies cited: 10
Corridor width reduction: 4
Soiled linen carts: 2
Power strip audit frequency: 1
Power strip audit duration: 12
Electrical receptacle testing last completed: Mar 10, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Seegers | Administrator | Signed the report |
| Assistant Director of Plant Operations | Interviewed and involved in observations and findings related to fire safety and maintenance | |
| Plant Operations Supervisor | Interviewed and involved in observations and findings related to fire safety and maintenance |
Inspection Report
Complaint Investigation
Census: 125
Capacity: 161
Deficiencies: 0
Date: Sep 1, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00415559 and IN00416268.
Complaint Details
Investigation of Complaints IN00415559 and IN00416268 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00415559 and IN00416268 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF: 125
Census Residential: 36
Total Capacity: 161
Census Medicare: 19
Census Medicaid: 59
Census Other Payor: 47
Inspection Report
Annual Inspection
Census: 121
Capacity: 155
Deficiencies: 6
Date: Aug 15, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted over August 7-15, 2023.
Findings
The facility was found deficient in several areas including failure to provide dignified care during meals, failure to ensure call lights were within reach, inaccurate resident assessments, improper application of medicated creams by CNAs, failure to post accurate nurse staffing hours, and failure to document daily weights for a resident as ordered.
Deficiencies (6)
Failure to provide care in a dignified manner during meal service; residents at the same table were not served simultaneously and assistance was delayed.
Failure to provide reasonable accommodation of needs; a resident's call light was not within reach.
Failure to ensure accuracy of resident assessments; mental illness and insulin administration were inaccurately documented for two residents.
Failure to provide quality of care; a CNA applied medicated pain cream without a physician's order and the facility failed to assess the resident's appropriateness to keep the medication at bedside.
Failure to post nurse staffing information reflecting actual hours worked by staff for 3 of 7 days during the survey period.
Failure to maintain complete clinical records; physician orders for daily weights were not obtained and documented for one resident.
Report Facts
Survey dates: 7
Resident census: 121
Total capacity: 155
Residents affected by meal service deficiency: 7
Residents reviewed for assessment accuracy: 3
Days with missing weight documentation: 88
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Seegers | Laboratory Director or Provider/Supplier Representative | Signed the report |
| Licensed Practical Nurse 75 | Interviewed regarding meal service timing | |
| Qualified Medication Aide 6 | Observed assisting Resident 53 with meal | |
| Qualified Medication Aide 7 | Observed assisting Resident 89 with meal | |
| Licensed Practical Nurse 2 | Interviewed regarding Resident 12's weight documentation | |
| Licensed Practical Nurse 4 | Interviewed regarding CNA scope of practice for medicated creams | |
| Director of Nursing | Provided policies and interview regarding staffing and clinical practices | |
| Corporate Nurse Consultant | Provided policies and interviews regarding resident rights and medication administration | |
| CNA 2 | Certified Nurse Aide | Observed applying medicated cream to Resident 3 |
| CNA 3 | Certified Nurse Aide | Mentioned in relation to medicated cream application |
Inspection Report
Complaint Investigation
Census: 117
Capacity: 150
Deficiencies: 0
Date: Jun 12, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00409778.
Complaint Details
Complaint IN00409778 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00409778 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census SNF/NF: 117
Census Residential: 33
Total Capacity: 150
Census Payor Type Medicare: 15
Census Payor Type Medicaid: 58
Census Payor Type Other: 44
Total Census Payor: 117
Inspection Report
Life Safety
Census: 117
Capacity: 137
Deficiencies: 0
Date: Jan 6, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 11/10/22 by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
Greenwood Village South 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 (LSC). Both buildings surveyed were fully sprinklered with fire alarm systems and smoke detectors installed in all resident sleeping rooms and areas open to corridors.
Inspection Report
Life Safety
Census: 116
Capacity: 137
Deficiencies: 6
Date: Nov 10, 2022
Visit Reason
Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Medicare/Medicaid participation requirements related to Life Safety Code and NFPA 101 standards. Deficiencies included failure to ensure hazardous areas were properly enclosed, cooking facilities maintained according to NFPA 96, sprinkler system maintenance and testing deficiencies, fire door annual inspections not completed timely, and improper securing of oxygen cylinders.
Deficiencies (6)
Failed to ensure hazardous areas such as soiled linen and trash collection rooms exceeding 64 gallons and combustible storage rooms greater than 50 square feet were separated by smoke resistant partitions and doors with self-closing hardware.
Failed to maintain kitchen cooking equipment in accordance with NFPA 96; deep-fat fryer lacked protective shield between fryer and adjacent cooking equipment.
Failed to maintain automatic sprinkler systems per NFPA 25; issues included Post Indicator Valve not reporting to fire panel, dry system gaskets needing replacement, 10-year dry pendant testing not completed, and 3-year air leak test not completed.
Failed to ensure annual inspection and testing of all fire door assemblies were completed in accordance with NFPA 80; fire door inspection documentation was not available for the most recent twelve month period.
Failed to ensure one of four oxygen cylinders was properly secured from falling in the oxygen storage and transfilling room.
Failed to ensure annual inspection and testing of all fire door assemblies in the Therapy addition were completed in accordance with NFPA 80; inspection documentation was not available for the most recent twelve month period.
Report Facts
Certified beds: 137
Census: 116
Deficiencies cited: 6
Oxygen cylinders improperly secured: 1
Fire door inspection overdue: 12
Inspection Report
Complaint Investigation
Census: 121
Capacity: 149
Deficiencies: 1
Date: Oct 27, 2022
Visit Reason
The visit was conducted for the investigation of Complaint IN00393264, which was substantiated with related federal/state deficiencies cited.
Complaint Details
Complaint IN00393264 was substantiated. The complaint involved a resident who exited the facility unsupervised after transfer from a secured to an unsecured unit. The facility failed to notify the emergency contact that the resident had left the facility.
Findings
The facility failed to provide adequate supervision to prevent elopement for one resident transferred from a secured memory care unit to an unsecured unit, who exited the facility and was found outside approximately 100 yards away. The facility reviewed and updated policies and implemented additional monitoring and auditing procedures to prevent recurrence.
Deficiencies (1)
Failed to provide supervision to prevent elopements for 1 of 3 residents reviewed, resulting in a resident exiting the facility unsupervised.
Report Facts
Residents reviewed for elopement supervision: 3
Residents affected: 1
Census SNF/NF beds: 121
Census Residential beds: 28
Total licensed capacity: 149
Medicare residents: 15
Medicaid residents: 54
Other payor residents: 52
Visual checks frequency: 15
Visual checks duration: 72
Audit duration: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Seegers | Administrator | Signed the report and provided interview information |
| LPN 1 | Licensed Practical Nurse | Nurse caring for Resident B when he exited the facility; answered phone call from emergency contact |
| LPN 2 | Licensed Practical Nurse | Assisted with moving Resident B from secured to unsecured unit and placed wander guard |
| Director of Nursing | Director of Nursing | Provided facility policy and interview information regarding resident transfer and supervision |
| QMA 1 | Qualified Medication Aide | Interviewed regarding awareness of Resident B exiting the facility |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 27, 2022
Visit Reason
Paper compliance review to the Investigation of Complaint IN00393264 completed on October 27, 2022.
Complaint Details
Investigation of Complaint IN00393264; paper compliance review found facility in compliance.
Findings
Greenwood Village South 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 Complaint Investigation.
Inspection Report
Complaint Investigation
Census: 122
Capacity: 149
Deficiencies: 0
Date: Oct 6, 2022
Visit Reason
The visit was conducted for the Investigation of Complaint IN00391921, in conjunction with the Recertification and State Licensure Survey and a State Residential Licensure Survey.
Complaint Details
Complaint IN00391921 was substantiated; however, no deficiencies related to the allegations were cited.
Findings
The complaint IN00391921 was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable federal and state regulations.
Report Facts
Census SNF/NF: 122
Census Residential: 27
Total Capacity: 149
Census Payor Type Medicare: 19
Census Payor Type Medicaid: 54
Census Payor Type Other: 49
Inspection Report
Renewal
Census: 122
Capacity: 149
Deficiencies: 0
Date: Oct 6, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey, conducted in conjunction with the Investigation of Complaint IN00391921.
Complaint Details
Complaint IN00391921 was substantiated; however, no deficiencies related to the allegations were cited.
Findings
The complaint IN00391921 was substantiated but no deficiencies related to the allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
SNF/NF Census: 122
Residential Census: 27
Total Capacity: 149
Medicare Census: 19
Medicaid Census: 54
Other Payor Census: 49
Total Census: 122
Report
Jul 29, 2025
Report
Aug 13, 2024
Report
Aug 15, 2023
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