Inspection Report Summary
The most recent inspection on April 4, 2025, found no deficiencies related to the complaints investigated, and the facility was in compliance with applicable regulations. Earlier inspections showed a mix of findings, including a substantiated complaint in July 2024 involving neglect due to inadequate supervision that allowed a resident to leave the facility unsupervised, as well as several medication management and infection control deficiencies cited in June 2024. Complaint investigations were mostly unsubstantiated except for the one neglect case, and no fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. Prior follow-up visits indicated that previously identified issues were corrected. The inspection history shows some past challenges primarily around resident supervision and medication practices, but recent visits reflect compliance and correction of earlier deficiencies.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
1.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
64% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
88 residents
Based on a April 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 0
Date: Apr 4, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00447392 and IN00455896.
Complaint Details
Investigation of Complaints IN00447392 and IN00455896 found no deficiencies related to the allegations; facility was in compliance.
Findings
No deficiencies related to the allegations in complaints IN00447392 and IN00455896 were cited. The facility was found to be in compliance with applicable regulations.
Inspection Report
Follow-Up
Census: 88
Deficiencies: 0
Date: Sep 9, 2024
Visit Reason
This visit was for the Post Survey Revisit (PSR) to the Investigation of Complaint IN00437607 completed on July 8, 2024, and was conducted in conjunction with the Investigation of Complaint IN00440983.
Complaint Details
Investigation of Complaint IN00437607 was completed and corrected; visit was in conjunction with Investigation of Complaint IN00440983.
Findings
Complaint IN00437607 was found to be corrected and the facility was in compliance with 410 IAC 16.2-5 regarding the PSR to the Investigation of Complaint IN00437607.
Report Facts
Residential Census: 88
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 0
Date: Sep 9, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00440983 and was conducted in conjunction with the Post Survey Revisit to the Investigation of Complaint IN00437607 completed on July 8, 2024.
Complaint Details
Complaint IN00440983 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00440983 were cited. Meadow Brook Senior Living was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Report Facts
Residential Census: 88
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 1
Date: Jul 8, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00437607 regarding allegations of neglect related to inadequate supervision to prevent resident elopement.
Complaint Details
Complaint IN00437607 was substantiated with state deficiencies cited related to neglect and inadequate supervision leading to resident elopement.
Findings
The facility failed to ensure Resident B was free from neglect by not providing adequate supervision to prevent elopement. Resident B exited the Memory Care Unit courtyard unsupervised through a gate alarm that was difficult to hear, resulting in the resident leaving the facility grounds. The investigation revealed multiple episodes of exit-seeking behavior by Resident B with insufficient interventions documented to prevent elopement.
Deficiencies (1)
Failed to ensure a resident was free from neglect by not ensuring adequate supervision to prevent elopement, resulting in the resident exiting the facility unsupervised.
Report Facts
Residential Census: 87
Exit seeking episodes: 25
Completion date for corrective action: Jul 26, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Certified Nursing Assistant | Named in investigation statement regarding Resident B's elopement incident |
| LPN 2 | Licensed Practical Nurse | Interviewed regarding supervision requirements for residents in courtyard |
| ED | Executive Director | Interviewed regarding door alarm system and incident investigation |
| RNC | Regional Nurse Consultant | Interviewed regarding door and gate alarm system functionality |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 5
Date: Jun 19, 2024
Visit Reason
This visit was for a State Residential Licensure Survey including investigations of complaints IN00432803, IN00423692, and IN00423711.
Complaint Details
Complaint IN00432803 - No deficiencies related to the allegations cited. Complaint IN00423692 - No deficiencies related to the allegations cited. Complaint IN00423711 - State deficiencies related to the allegations are cited at R298.
Findings
The facility was found noncompliant in several areas including failure to ensure survey report results were easily accessible, failure to complete a self-administration medication evaluation for a resident, improper medication storage practices, failure to follow a discontinued medication order timely, improper labeling of medications, and failure to maintain infection control practices during medication administration.
Deficiencies (5)
Failed to ensure Indiana Department of Health's survey report results were easily accessible for visitors and residents.
Failed to ensure a resident's ability to self-administer medications by completing a self-administration evaluation for 1 of 1 resident found to have medications at bedside (Resident V).
Failed to ensure medication storage practices followed accepted pharmacy storage guidelines by having food in a medication room cabinet and bottled water in a medication refrigerator; and failed to ensure a discontinued medication order was followed up on timely (Resident Y).
Failed to ensure proper labeling of medications stored in 1 of 2 medication rooms, including missing open date and missing resident and pharmacy information on medication containers.
Failed to maintain infection control program by staff placing index finger inside medication cups and not performing hand hygiene prior to and after glove use during medication administration for 4 of 5 residents reviewed.
Report Facts
Residents present: 86
Survey dates: 2
Medication administration observations: 5
Medication room and cart audits frequency: 2
Room checks frequency: 5
Medication administration audits frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Allison Roskam | Executive Director | Signed the report |
| LPN 3 | Observed preparing and administering medications with infection control deficiencies | |
| Memory Care Coordinator | Interviewed regarding medication left at bedside and infection control | |
| Regional Clinical Support (RCS) | Conducted medication room observations and interviews | |
| Regional Support (RS) | Interviewed regarding pharmacy communication about discontinued medication | |
| Director of Nursing (DON) | Provided Self-Administration of Medications policy | |
| Wellness Director | Responsible for education, audits, and monitoring corrective actions |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 0
Date: Jun 6, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00410016.
Complaint Details
Complaint IN00410016 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00410016 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Report Facts
Residential Census: 92
Inspection Report
Follow-Up
Census: 80
Deficiencies: 0
Date: Aug 16, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00384914 completed on 7/20/22.
Complaint Details
Complaint IN00384914 was investigated and found to be corrected.
Findings
Meadow Brook Senior Living was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to the Investigation of Complaint IN00384914.
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