Inspection Report Summary
The most recent inspection on April 16, 2025, identified deficiencies related to staffing certifications, pet vaccinations, dietary manager qualifications, and tuberculosis health statements. Earlier inspections showed a pattern of issues including medication administration authorization, documentation of health screenings, service plan signatures, and COVID-19 testing records. Several complaint investigations were substantiated, particularly concerning medication administration by Qualified Medication Aides and incomplete COVID-19 documentation, while others were found unsubstantiated. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s deficiencies have recurred in areas of staffing qualifications, medication management, and health documentation, indicating ongoing challenges without a clear trend of improvement or worsening.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
5% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
55 residents
Based on a April 2025 inspection.
Census over time
Inspection Report
Renewal
Census: 55
Deficiencies: 4
Date: Apr 16, 2025
Visit Reason
This visit was for a State Residential Licensure Survey conducted on April 15 and 16, 2025, to assess compliance with state regulations for the facility Keystone Woods.
Findings
The facility was found deficient in several areas including staffing with insufficient awake staff certified in CPR with hands-on training, failure to ensure required vaccinations for pets, lack of dietary manager certification, and incomplete annual health statements verifying residents were free from infectious tuberculosis.
Deficiencies (4)
Failed to ensure a minimum of one awake staff member certified in CPR with a hands-on training component was on site for 11 of 21 shifts reviewed.
Failed to ensure a pet residing within the facility had received the required vaccinations for 1 of 4 pets reviewed.
Failed to ensure the dietary manager was trained or enrolled in a division-approved program for dietary supervision.
Failed to verify by statement, on admission and annually, that residents were free from infectious tuberculosis for 2 of 7 residents reviewed.
Report Facts
Shifts lacking CPR certified staff: 11
Residents affected by CPR deficiency: 55
Pets reviewed for vaccinations: 4
Pets non-compliant with vaccination: 1
Residents affected by dietary manager deficiency: 55
Residents reviewed for tuberculosis health statements: 7
Residents lacking tuberculosis health statements: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Johnson | Executive Director | Signed report and involved in interviews regarding deficiencies |
| Dietary Manager | Indicated lack of certification in dietary supervision and food handling | |
| Business Director | Provided employee schedules and vaccination records, interviewed about CPR certification and pet vaccinations | |
| Administrator | Interviewed regarding CPR certification requirements, pet vaccination responsibilities, and dietary manager policy | |
| DON | Director of Nursing | Interviewed about missing annual health statements |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 0
Date: Jul 9, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00436438 at Keystone Woods.
Complaint Details
Complaint IN00436438 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00436438 were cited during the investigation.
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 0
Date: May 29, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00434230.
Complaint Details
Complaint IN00434230 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations were cited. Keystone Woods was found to be in compliance with 410 IAC 16.2-5 in regard to the Investigation of Complaint IN00434230.
Report Facts
Residential Census: 57
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 0
Date: Apr 18, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00431610.
Complaint Details
Investigation of Complaint IN00431610 found no deficiencies related to the allegations; facility was in compliance.
Findings
No deficiencies related to the allegations were cited. Keystone Woods was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Report Facts
Residential Census: 56
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 0
Date: Mar 20, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00430285.
Complaint Details
Complaint IN00430285 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations are cited. Keystone Woods was found to be in compliance with 410 IAC 16.2-5 in regard to the Investigation of Complaint IN00430285.
Inspection Report
Renewal
Census: 57
Deficiencies: 4
Date: Feb 29, 2024
Visit Reason
This visit was for a State Residential Licensure Survey conducted on 2/28/24-2/29/24 to assess compliance with state regulations for residential care facilities.
Findings
The facility was found deficient in several areas including failure to ensure service plans were signed by residents, failure to notify physicians of pharmacy medication recommendations, lack of mental health screenings for some residents, and incomplete tuberculosis skin testing procedures.
Deficiencies (4)
Failed to ensure the service plan was signed by the resident for 1 of 7 residents reviewed.
Failed to notify the physician of pharmacy medication recommendations for 1 of 2 residents reviewed.
Failed to ensure mental health screenings were performed for 2 of 7 sampled residents.
Failed to ensure a second-step tuberculin skin test was completed for 1 of 3 residents reviewed.
Report Facts
Residents reviewed for service plans: 7
Residents reviewed for pharmacist drug regimen review: 2
Residents reviewed for mental health screening: 7
Residents reviewed for TB screening process: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cindi Cooper | Executive Director | Signed the report and mentioned in relation to facility oversight |
| Director of Nursing | Interviewed regarding inability to locate signed service plans and documentation of physician notifications | |
| Wellness Director | Received training and responsible for auditing service plans, medication recommendations, mental health screenings, and TB testing |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 1
Date: Jan 31, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00423216 and included a Residential COVID-19 Quality Assurance Walk Through.
Complaint Details
Complaint IN00423216 was investigated and state deficiencies related to the allegations were cited at R407.
Findings
The facility failed to maintain COVID-19 testing documentation regarding staff testing and positive infections, affecting all 56 residents. Interviews revealed no documentation or surveillance list of staff tested or positive for COVID-19 during a prior outbreak.
Deficiencies (1)
Failed to maintain COVID-19 testing documentation regarding staff testing and positive infections.
Report Facts
Residents affected: 56
Staff involved: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cindi Cooper | Executive Director | Named as the Executive Director and involved in the Plan of Correction. |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 1
Date: Jul 18, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00410209 regarding medication administration practices at the facility.
Complaint Details
Complaint IN00410209 was substantiated with state deficiencies cited related to the allegations of improper PRN medication administration authorization and documentation.
Findings
The facility failed to ensure Qualified Medication Aides (QMAs) obtained and documented authorization from a licensed nurse or physician before administering PRN medications for 2 of 4 residents reviewed. Interviews revealed lack of documentation and monitoring of authorization for PRN medication administration by QMAs.
Deficiencies (1)
Failure to ensure QMAs obtained authorization to administer PRN medications and document the authorization in the clinical record for 2 of 4 residents reviewed.
Report Facts
Residential Census: 56
PRN medication administrations lacking authorization: 14
PRN medication administrations lacking authorization: 2
Audit frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 6 | Licensed Practical Nurse | Interviewed regarding lack of documentation of authorization for PRN medication administration |
| Director of Nursing | Director of Nursing | Interviewed regarding monitoring and documentation of PRN medication authorization; provided facility policies |
| QMA 5 | Qualified Medication Aide | Interviewed about lack of documentation of authorization for PRN medication administration |
| QMA 2 | Qualified Medication Aide | Interviewed about lack of documentation of authorization for PRN medication administration |
| Administrator | Administrator | Interviewed regarding staff requirements to follow QMA Scope of Practice |
| Wellness Director | Wellness Director | Responsible for conducting audits and ensuring proper authorization and documentation of PRN medication administration |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 0
Date: Apr 10, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00405680.
Complaint Details
Complaint IN00405680 - No State Residential Findings related to the allegations were cited.
Findings
No State Residential Findings related to the allegations were cited. Keystone Woods was found to be in compliance with 410 IAC 16.2-5 in regard to the Investigation of Complaint IN00405680.
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 5
Date: Nov 21, 2022
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaint IN00393109, which was found unsubstantiated due to lack of evidence.
Complaint Details
Complaint IN00393109 was investigated and found unsubstantiated due to lack of evidence.
Findings
The facility was found noncompliant in several areas including failure to complete semi-annual assessments for one resident, failure to ensure service plans were signed by residents or representatives for four residents, incomplete transfer/discharge documentation for two residents, inadequate infection control tracking and reporting for COVID-19 cases, and missing current annual health statements for four residents.
Deficiencies (5)
Failed to ensure semi-annual assessments were completed for 1 of 2 residents reviewed for closed records (Resident 55).
Failed to ensure Service Plans were signed by the resident or their representative for 4 of 7 residents reviewed (Residents 2, 7, 9, 31).
Failed to complete transfer/discharge documentation for 2 of 2 residents reviewed for closed records (Residents 55 and 56).
Failed to utilize proper infection prevention and control tracking and reporting for residents and staff with COVID-19.
Failed to ensure clinical records contained current annual health statements for 4 of 7 residents reviewed (Residents 7, 9, 31, and 39).
Report Facts
Residential Census: 49
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cindi Cooper | Executive Director | Signed the report and mentioned in interviews regarding facility policies and COVID-19 tracking. |
| Director of Nursing | Director of Nursing | Provided information on resident assessments, service plans, transfer documentation, and infection control. |
| Licensed Practical Nurse 4 | Licensed Practical Nurse | Reported COVID-19 positive results to DON and Executive Director. |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Date: Aug 18, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00383836 regarding medication administration practices at the facility.
Complaint Details
Complaint IN00383836 was substantiated. The deficiency related to QMA medication administration was cited at R0240.
Findings
The facility failed to ensure that Qualified Medication Aides (QMA) administered medications within their scope of practice for 1 of 3 residents reviewed. Specifically, QMA 3 administered Trulicity injections, which are outside the QMA scope of practice, to Resident C on multiple occasions without nurse oversight or authorization.
Deficiencies (1)
Qualified Medication Aide administered Trulicity injections, which are outside the QMA scope of practice.
Report Facts
Resident census: 55
Dates QMA administered Trulicity: 3
In-service dates for QMA medication administration: 2
Monitoring period: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| QMA 3 | Qualified Medication Aide | Administered Trulicity injections outside scope of practice |
| Licensed Practical Nurse 5 | Licensed Practical Nurse | Unaware if QMA could administer Trulicity injections, deferred to DON |
| Director of Nursing | Director of Nursing (DON) | Indicated QMA's should not administer Trulicity injections and was unaware of prior administration until informed by QMA 3 |
| Administrator | Facility Administrator | Expressed confusion about QMA administration of Trulicity and confirmed no policy existed for QMA administration of injectable medications other than insulin |
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