Inspection Reports for Life Care Center of the Willows
1000 ELIZABETH DR, IN, 46383
Back to Facility ProfileInspection Report Summary
The most recent inspection on January 27, 2025, found the facility in compliance with Emergency Preparedness and Life Safety Code requirements, with no deficiencies noted. Prior inspections showed a pattern of deficiencies primarily related to emergency preparedness, life safety code compliance, and resident care issues such as care planning, medication management, and infection control. Several complaint investigations were substantiated, including failures to report abuse and timely report verbal abuse incidents, but enforcement actions such as fines or license suspensions were not listed in the available reports. Earlier findings also included environmental and safety concerns like improper use of extension cords and obstructed corridors. The facility appears to have addressed many life safety and emergency preparedness issues by the most recent survey, indicating some improvement over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
21.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
417% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
65% occupied
Based on a January 2025 inspection.
Census over time
Inspection Report
Re-Inspection
Census: 60
Capacity: 92
Deficiencies: 0
Date: Jan 27, 2025
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 12/17/2024.
Findings
At this PSR survey, Life Care Center of the Willows was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility was verified to be fully sprinklered, with appropriate fire alarm systems and emergency power.
Report Facts
Certified beds: 92
Census: 60
Emergency generator capacity: 230
Inspection Report
Life Safety
Census: 64
Capacity: 92
Deficiencies: 9
Date: Dec 17, 2024
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with emergency preparedness requirements and life safety codes.
Findings
The facility was found not in compliance with emergency preparedness requirements and life safety codes, including failure to conduct required emergency drills, incomplete emergency power system testing, malfunctioning hazardous area doors, improper kitchen appliance safety measures, incomplete fire drill documentation, and inadequate maintenance and testing of electrical equipment.
Deficiencies (9)
Failed to conduct required emergency preparedness exercises including unannounced staff drills and after action reports.
Failed to implement emergency power system inspection, testing, and maintenance requirements including missing monthly load test documentation.
Hazardous area door to oxygen storage room did not self-close and latch properly.
Failed to provide an approved method to ensure cooking appliances are returned to approved design location after maintenance or cleaning.
Failed to provide complete fire drill documentation for 3 of 12 drills and failed to verify fire alarm signal transmission for 1 drill.
Failed to maintain complete written record of monthly generator load testing for November 2024.
Failed to conduct monthly battery conductance or specific gravity testing on emergency generator batteries.
Used a flexible extension cord as a substitute for fixed wiring to power high current draw equipment in resident room 22.
Failed to conduct required maintenance and maintain complete documentation of inspections for Patient Care Related Electrical Equipment (PCREE).
Report Facts
Certified beds: 92
Census: 64
Fire drills missing documentation: 3
Fire drills reviewed: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tami Adams | Executive Director | Named in relation to exit conference and plan of correction |
| Maintenance Director | Interviewed and involved in findings related to emergency preparedness, generator testing, hazardous door, fire drills, and electrical equipment | |
| Maintenance Assistant | Interviewed and involved in hazardous door and electrical equipment findings |
Inspection Report
Annual Inspection
Census: 64
Capacity: 64
Deficiencies: 7
Date: Nov 13, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00446389.
Complaint Details
Complaint IN00446389 was investigated with no deficiencies related to the allegations cited.
Findings
The facility was found deficient in several areas including resident privacy during medication pass, accuracy of Minimum Data Set assessments related to antibiotic use, care plan implementation, pressure ulcer treatment, nutrition/hydration status maintenance, infection prevention during medication pass, and antibiotic stewardship. No deficiencies were cited related to the complaint investigation.
Deficiencies (7)
Failed to ensure resident's privacy was maintained related to electronic medication record left open and unlocked during medication pass for 2 residents.
Failed to ensure Minimum Data Set assessments were accurately completed related to antibiotic use for 2 residents.
Failed to ensure care plans were implemented for 1 resident related to pain and opioid use.
Failed to ensure a resident with a pressure ulcer received necessary treatment as ordered.
Failed to ensure a nutritional supplement was offered and food consumption logs completed for a resident with weight loss.
Failed to ensure infection control measures were implemented related to hand hygiene during medication pass for 2 residents.
Failed to promote antibiotic stewardship by not following up on urine culture results timely for 1 resident.
Report Facts
Census: 64
Total Capacity: 64
Weight loss percentage: 11.75
Observation audits: 10
Observation audits duration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tami Adams | Executive Director | Signed the report |
| LPN 1 | Observed during medication pass with privacy and hand hygiene deficiencies | |
| Director of Nursing | Provided interviews and oversight related to privacy and care plan deficiencies | |
| Clinical Reimbursement Specialist | Interviewed regarding MDS antibiotic coding errors | |
| Infection Prevention Nurse | Interviewed regarding infection control and antibiotic stewardship | |
| Dietary Manager | Interviewed regarding nutrition supplement and meal documentation |
Inspection Report
Renewal
Deficiencies: 0
Date: Nov 13, 2024
Visit Reason
The inspection was a paper compliance review related to the Recertification and State Licensure Survey completed on November 13, 2024.
Findings
Life Care Center of the Willows 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 Recertification and State Licensure Survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 16, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00429836 completed on March 15, 2024.
Complaint Details
Investigation of Complaint IN00429836 completed on March 15, 2024; facility found in compliance.
Findings
Life Care Center of the Willows 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 to the complaint investigation.
Inspection Report
Complaint Investigation
Census: 59
Capacity: 59
Deficiencies: 1
Date: Mar 15, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00429836 regarding allegations of abuse at the facility.
Complaint Details
Complaint IN00429836 was substantiated with federal/state deficiencies cited related to the allegations. Resident B reported abuse by a CNA, but the facility did not report the allegation to the Indiana Department of Health as required by state and federal regulations.
Findings
The facility failed to ensure an allegation of abuse involving Resident B was reported to the Indiana Department of Health as required. The investigation revealed that Resident B reported being mistreated by a CNA, but the allegations were not reported to the appropriate authorities.
Deficiencies (1)
Failure to report an allegation of abuse to the Indiana Department of Health for Resident B.
Report Facts
Census: 59
Total Capacity: 59
Medicare Census: 8
Medicaid Census: 44
Other Payor Census: 7
Inspection Report
Life Safety
Census: 56
Capacity: 100
Deficiencies: 0
Date: Feb 23, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR Subpart 483.90(a).
Findings
At this Life Safety Code PSR, Life Care Center of the Willows 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), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was verified to be fully sprinklered with appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 100
Census: 56
Emergency generator capacity: 230
Inspection Report
Complaint Investigation
Census: 55
Capacity: 55
Deficiencies: 0
Date: Feb 9, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00427500.
Complaint Details
Investigation of Complaint IN00427500 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00427500 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 55
Total Capacity: 55
Medicare Census: 9
Medicaid Census: 43
Other Payor Census: 3
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 6, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey and the Investigation of Complaint IN00424101 completed on January 3, 2024.
Complaint Details
Investigation of Complaint IN00424101 completed on January 3, 2024; facility found in compliance.
Findings
Life Care Center of the Willows 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 to the Recertification and State Licensure Survey and complaint investigation.
Inspection Report
Life Safety
Census: 53
Capacity: 100
Deficiencies: 13
Date: Jan 23, 2024
Visit Reason
The survey was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and related regulations.
Findings
The facility was found not in compliance with several Life Safety Code requirements including corridor width obstructions, emergency lighting record keeping, smoke detector maintenance, hazardous area door self-closing, kitchen hood grease trap installation, fire alarm and sprinkler system policies and maintenance, corridor door latching, sprinkler head obstructions, fire watch plan deficiencies, evacuation plan incompleteness, and improper use of power strips and extension cords.
Deficiencies (13)
Service corridor width was less than the required 44 inches due to equipment obstructing the hallway.
Failed to maintain itemized records of inspections and tests for battery backup emergency lights.
Documentation for preventative maintenance of battery operated smoke alarms in resident rooms was incomplete and some smoke detectors were not tested monthly.
Corridor door to hazardous room was not self-closing and the room contained combustible materials.
Kitchen range hood system lacked a grease drip tray and enclosed metal container as required.
Fire alarm system out-of-service policy did not include required notification procedures via the Indiana Department of Health Gateway.
Sprinkler heads obstructed by storage boxes and foreign material, and some sprinkler heads covered in dust and oily substances.
Fire/smoke damper system was not inspected or maintained as required; last inspection was in 2020.
Emergency fire safety plan did not include response procedures for battery operated smoke alarms not connected to the fire alarm system.
Corridor doors to linen closets and service areas did not latch properly or had impediments preventing closure.
Resident room corridor doors were propped open with trash cans, impeding closure.
Fire damper inspection and maintenance were not performed as required; no documentation available.
Flexible cords and power strips were used improperly as substitutes for fixed wiring, including a microwave plugged into an extension cord and a power strip powering a mini fridge.
Report Facts
Certified beds: 100
Census: 53
Deficiencies cited: 13
Sprinkler heads obstructed: 4
Sprinkler heads in kitchen: 2
Sprinkler heads in main hall: 2
Sprinkler heads in storage room: 1
Sprinkler heads in kitchen: 6
Sprinkler heads in main hall: 10
Resident rooms with propped doors: 2
Linen closet corridor doors: 2
Service corridor doors: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tami Adams | Executive Director | Signed the report and participated in exit conference |
Inspection Report
Annual Inspection
Census: 52
Capacity: 52
Deficiencies: 13
Date: Jan 3, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00424101.
Complaint Details
Complaint IN00424101 was investigated and federal/state deficiencies related to the allegations were cited at F677 and F689.
Findings
The facility was found deficient in multiple areas including resident self-determination, accuracy of assessments, baseline and comprehensive care planning, ADL care, quality of care including skin and mobility management, accident prevention, nutrition and hydration, medication management including unnecessary drugs and psychotropic medication use, laboratory services, antibiotic stewardship, and environmental conditions.
Deficiencies (13)
Failed to honor a resident's preference related to dressing (Resident 21).
Failed to ensure a Minimum Data Set (MDS) assessment was accurately completed related to weight loss (Resident 37).
Failed to develop an initial baseline care plan within 48 hours of admission related to Activities of Daily Living (Resident B).
Failed to develop and implement a comprehensive care plan for a resident with a history of dehydration (Resident G).
Failed to ensure residents received necessary ADL care including bathing, nail care, and shaving for 3 residents (Residents D, B, and C).
Failed to ensure residents received necessary treatment and services related to neck brace orders, monitoring skin discolorations, and skin treatments (Residents D, 36, and 19).
Failed to ensure safety measures to prevent accidents including seizure precautions, fall precautions, and use of post-op helmet (Residents G, F, and E).
Failed to ensure residents' hydration and nutritional needs were met related to providing fluids and monitoring weights (Residents G and 37).
Failed to ensure medication regimen was free from unnecessary drugs and non-pharmacological interventions were attempted prior to pain medication administration (Residents 4, 48, and 105).
Failed to ensure gradual dose reduction was attempted for psychotropic medication (Resident E).
Failed to ensure timely laboratory services for ordered urine culture (Resident E).
Failed to promote antibiotic stewardship by ensuring appropriate use of antibiotic therapy related to urinary tract infection without timely urinalysis and culture (Resident E).
Failed to maintain a safe, functional, sanitary, and comfortable environment related to marred walls, cracked toilet base, chipped paint, dirty floors, and missing baseboard pieces (East and West units).
Report Facts
Survey dates: December 27, 28, 29, 2023 and January 2 and 3, 2024
Census: 52
Deficiency counts: 14
Weight measurements: 138
Weight measurements: 141
Weight measurements: 139
Weight measurements: 136
Weight measurements: 135
Weight measurements: 198
Weight measurements: 176.3
Weight measurements: 138.1
Medication usage: 27
Medication usage: 18
Medication usage: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tami Adams | Executive Director | Signed the report and responsible for ensuring compliance with Plan of Correction |
| LPN 1 | Interviewed regarding pain medication administration and seizure precautions | |
| Assistant Director of Nursing | Interviewed regarding multiple findings including care plans, hydration, medication, and lab services | |
| Social Services Director | Participated in behavior meeting and discussed medication management | |
| Director of Maintenance | Interviewed regarding environmental deficiencies | |
| Director of Housekeeping | Participated in environmental tour | |
| PTA 1 | Interviewed regarding fall prevention and body pillow evaluation | |
| Infection Preventionist | Interviewed regarding treatment documentation and lab specimen pick-up |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 61
Deficiencies: 0
Date: Aug 28, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00409359.
Complaint Details
Complaint IN00409359 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00409359 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 61
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 50
Census Payor Type - Other: 4
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 2, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00408213 completed on May 18, 2023.
Complaint Details
Investigation of Complaint IN00408213 completed on May 18, 2023; facility found in compliance.
Findings
Life Care Center of the Willows 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
Re-Inspection
Census: 63
Deficiencies: 0
Date: May 18, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00406256 completed on April 21, 2023, and was conducted in conjunction with the Investigation of Complaint IN00408213.
Complaint Details
Complaint IN00406256 was corrected. Complaint IN00408213 had federal/state deficiencies cited at F609.
Findings
Life Care Center of the Willows was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the PSR to Complaint IN00406256. Federal/state deficiencies related to Complaint IN00408213 were cited at F609.
Report Facts
Census: 63
Medicare census: 14
Medicaid census: 41
Other payor census: 8
Inspection Report
Complaint Investigation
Census: 63
Capacity: 63
Deficiencies: 1
Date: May 18, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00408213 and was conducted in conjunction with a Post Survey Revisit to the Investigation of Complaint IN00406256 completed on April 21, 2023.
Complaint Details
Complaint IN00408213 involved allegations of verbal and physical abuse. The allegation was not immediately reported as required. Resident B reported that a CNA told him to get up and get his own water and laughed at him. The Administrator reported the incident as soon as she received it, but the staff member had not alerted her at the time of the event.
Findings
The facility failed to ensure an allegation of verbal abuse was immediately reported to the Administrator and timely reported to the State Survey Agency for 1 of 3 allegations of verbal and physical abuse reviewed involving Resident B. The staff member delayed reporting the incident, which was only discovered through a Concern & Comment Form found after the fact.
Deficiencies (1)
Failure to ensure an allegation of verbal abuse was immediately reported to the Administrator and timely reported to the State Survey Agency.
Report Facts
Census: 63
Total Capacity: 63
Medicare Census: 14
Medicaid Census: 41
Other Payor Census: 8
Inspection Report
Complaint Investigation
Census: 61
Capacity: 61
Deficiencies: 4
Date: Apr 21, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00406256 related to federal/state deficiencies cited at F656, F684, F692, and F740.
Complaint Details
Complaint IN00406256 was substantiated with federal/state deficiencies cited at F656, F684, F692, and F740 related to care plan development, quality of care, nutrition/hydration, and behavioral health services.
Findings
The facility was found deficient in multiple areas including failure to develop and implement person-centered care plans for self-harming behaviors, failure to provide treatment and care according to professional standards related to neurological consults and insulin administration, failure to maintain proper hydration and nutrition, and failure to provide necessary behavioral health services related to increased self-harming behaviors.
Deficiencies (4)
Failed to develop and implement a person-centered care plan for a resident related to self-harming behaviors.
Failed to ensure residents received treatment and care in accordance with professional standards related to neurological consults and insulin administration.
Failed to provide sufficient fluid intake to maintain proper hydration and health related to lack of timely follow up on laboratory results and failure to clarify and implement correct Physician's admission orders.
Failed to provide necessary behavioral health care and services related to not consulting Physician or Psychiatric services for increased self-harming behaviors.
Report Facts
Census: 61
Total Capacity: 61
Residents with Medicare: 6
Residents with Medicaid: 47
Residents with Other payor: 8
Date of survey completion: Apr 21, 2023
Inspection Report
Re-Inspection
Census: 57
Capacity: 100
Deficiencies: 0
Date: Feb 6, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 01/10/23 was performed to verify compliance with life safety and licensure requirements.
Findings
At this Post Survey Revisit, the facility was found in compliance with Medicare/Medicaid participation requirements, 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.
Report Facts
Facility capacity: 100
Census: 57
Inspection Report
Complaint Investigation
Census: 57
Capacity: 57
Deficiencies: 0
Date: Feb 6, 2023
Visit Reason
This visit was conducted for the Investigation of Complaint IN00400254 and included a COVID-19 Focused Infection Control Survey.
Complaint Details
Complaint IN00400254 was substantiated but no deficiencies related to the allegations were cited.
Findings
The complaint IN00400254 was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant federal and state regulations regarding the complaint investigation and COVID-19 infection control.
Report Facts
Census SNF/NF beds: 57
Census total residents: 57
Census Medicare residents: 8
Census Medicaid residents: 45
Census other payor residents: 4
Inspection Report
Renewal
Deficiencies: 0
Date: Jan 27, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on January 3, 2023.
Findings
Life Care Center of the Willows 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 to the Recertification and State Licensure Survey.
Inspection Report
Life Safety
Census: 59
Capacity: 100
Deficiencies: 4
Date: Jan 10, 2023
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) and the 2012 edition of the NFPA 101 Life Safety Code.
Findings
The facility was found not in compliance with Life Safety Code requirements including deficiencies in fire alarm system maintenance, sprinkler system maintenance and storage, electrical junction box safety, and improper use of power strips in a staff area.
Deficiencies (4)
Failed to ensure fire alarm system was maintained in accordance with NFPA 70 and NFPA 72; missing documentation for smoke detector sensitivity testing within last 24 months.
Failed to ensure sprinkler system was provided with spare sprinklers properly stored in a cabinet with a sprinkler wrench; six sprinklers were stored loose and unsecured.
Failed to ensure electrical junction box was maintained in a safe operating condition; one junction box missing cover with exposed wiring in sprinkler riser room.
Failed to ensure power strip was not used as a substitute for fixed wiring in staff Dietary Office; power strip found in use.
Report Facts
Certified beds: 100
Census: 59
Spare sprinkler heads: 18
Inspection date: Jan 10, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tami Adams | Executive Director | Signed report and mentioned in plan of correction |
| Maintenance Director | Interviewed and involved in findings related to fire alarm testing, sprinkler storage, electrical junction box, and power strip usage |
Inspection Report
Annual Inspection
Census: 57
Capacity: 57
Deficiencies: 13
Date: Jan 3, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00391790 and IN00391933.
Complaint Details
Complaint IN00391790 - Substantiated with no deficiencies cited. Complaint IN00391933 - Substantiated with no deficiencies cited.
Findings
The facility was found to have multiple deficiencies including failure to accommodate resident needs, inadequate restraint monitoring, incomplete care plans, failure to apply therapeutic devices, lack of hearing aid monitoring, incomplete pressure ulcer treatment, catheter care issues, nutritional monitoring failures, improper gastrostomy tube medication administration, inadequate bed rail assessments, infection control lapses, and failure to ensure contracted staff COVID-19 vaccination compliance. Environmental concerns included marred walls, missing floor tiles, and duct taped side rails.
Deficiencies (13)
Failed to accommodate the needs of a resident related to the call light being out of reach.
Failed to ensure physician orders were received and a resident with restraints was assessed and monitored.
Failed to develop and implement care plans related to the use of bed rails and restraints.
Failed to ensure a therapeutic brace was applied daily as ordered for a dependent resident.
Failed to ensure residents received proper treatment and assistive devices to maintain hearing abilities.
Failed to ensure a treatment was in place for a resident with a pressure ulcer.
Failed to ensure a resident received appropriate services related to an indwelling catheter.
Failed to ensure residents maintained acceptable nutritional status related to lack of implementation of dietary recommendations and monitoring intake.
Failed to ensure gastrostomy tube placement was checked prior to medication administration and water flush was instilled via gravity.
Failed to attempt alternative measures and assess the necessity for bed rails quarterly as required.
Failed to ensure infection control guidelines were followed related to handling medications and PPE worn incorrectly during resident care.
Failed to ensure contracted staff were vaccinated or had an exemption in place for COVID-19 vaccination.
Failed to ensure the residents' environment was clean and in good repair related to marred and gouged walls and missing floor tile.
Report Facts
Census: 57
Total Capacity: 57
Medicare Census: 4
Medicaid Census: 45
Other Payor Census: 8
Lab tests: 5
Audit frequency: 5
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