Inspection Report Summary
The most recent inspection on April 24, 2025, cited a deficiency for failing to verify annually that some residents were free from infectious tuberculosis. Earlier inspections showed a pattern of deficiencies primarily related to food safety and nutritional services, including improper food storage, preparation, and handling, as well as issues with dietary staff practices and menu approvals. Prior reports also noted problems with individualized service plans, resident evaluations, medication assessments, and infection control documentation. Complaint investigations were mostly unsubstantiated, with no fines or enforcement actions listed in the available reports. The facility’s inspection history indicates some recurring issues, particularly in food safety and resident documentation, with no clear trend of consistent improvement or worsening over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
3.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
17% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
34 residents
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 1
Date: Apr 24, 2025
Visit Reason
This visit was for a State Residential Licensure Survey and included the investigation of Complaint IN00454759.
Complaint Details
Complaint IN00454759 was investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies related to the complaint allegations were cited. However, the facility failed to verify annually that residents were free from infectious tuberculosis for 4 of 7 residents reviewed, lacking annual health statements for Residents 13, 18, 6, and 32.
Deficiencies (1)
Facility failed to verify by statement annually that residents were free from infectious tuberculosis for 4 of 7 residents reviewed (Residents 13, 18, 6, and 32).
Report Facts
Residential Census: 34
Residents reviewed lacking annual health statements: 4
Charts audited weekly: 5
Charts audited bi-weekly: 5
Charts audited monthly: 5
Compliance threshold percentage: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hervey Lawrence | Administrator | Named in relation to inability to provide policy on annual health statements |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 0
Date: Feb 4, 2025
Visit Reason
This visit was conducted for the Investigation of Complaint IN00450834.
Complaint Details
Complaint IN00450834 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 0
Date: Nov 12, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00445919.
Complaint Details
Complaint IN00445919 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations of Complaint IN00445919 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 0
Date: Jun 5, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00434376 and IN00434307 at Primrose Retirement Community of Anderson.
Complaint Details
Investigation of Complaints IN00434376 and IN00434307 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00434376 and IN00434307 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the investigation of these complaints.
Report Facts
Residential Census: 39
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 4
Date: May 3, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00432559, IN00432225, IN00430109, and IN00429616 regarding the facility's compliance with food safety and nutritional services standards.
Complaint Details
The investigation was triggered by four complaints (IN00432559, IN00432225, IN00430109, IN00429616) all related to food safety and nutritional services deficiencies.
Findings
The facility failed to store, prepare, and distribute food under safe sanitary conditions, including undated and unlabeled food items in refrigerators, improper dishwasher temperatures, and inadequate handwashing and food handling practices by dietary staff.
Deficiencies (4)
Failure to store, prepare, and distribute food under safe sanitary conditions, including undated and unlabeled food items in refrigerators.
Dishwasher temperatures were not consistently maintained at required levels, and sanitizer concentration was not properly monitored.
Dietary staff failed to take food temperatures prior to serving and demonstrated improper handwashing and glove use, leading to potential contamination.
Kitchen equipment such as drip pans and exhaust hood had heavy residue and grease buildup.
Report Facts
Residents impacted: 30
Dishwasher temperature readings: 91
Dishwasher temperature readings: 99
Dishwasher temperature readings: 120
Dishwasher temperature readings: 103
Dishwasher temperature readings: 135
Food age in days: 16
Food age in days: 14
Food age in days: 13
Food age in days: 7
Handwashing duration: 15
Completion date for systemic changes: May 15, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LaShelle Crawley | Executive Director | Signed as the facility representative on the inspection report. |
| Dietary Employee 2 | Observed failing to date and label food, improper handwashing, and unsafe food handling practices. | |
| Dietary Employee 3 | Interviewed regarding food storage and dishwasher temperature knowledge. | |
| Dietary Manager | Responsible for instructing employees on food safety, added labeling and cleaning to shift checklists, and monitoring logs. | |
| Administrator | Accompanied surveyor during dishwasher area observation and provided facility policies. |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 0
Date: Feb 2, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00427051 at Primrose Retirement Community of Anderson.
Complaint Details
Complaint IN00427051 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00427051 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 2
Date: Jan 10, 2024
Visit Reason
This visit was for a State Residential Licensure Survey which included the investigation of Complaint IN00423661 related to food and nutritional services.
Complaint Details
Complaint IN00423661 was investigated and state deficiencies related to the allegations were cited at R0269.
Findings
The facility failed to have resident meal menus reviewed and approved by a Registered Dietician and failed to prevent the consumption of unpasteurized eggs used in food preparation, potentially affecting all 35 residents.
Deficiencies (2)
Facility failed to have resident meal menus reviewed and approved by a Registered Dietician for nutritional requirements.
Facility failed to prevent the consumption of unpasteurized eggs for the preparation of soft-cooked eggs.
Report Facts
Residents affected: 35
Residents affected: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LaShelle Crawley | Executive Director | Signed the report |
| Administrator | Interviewed regarding dietary manager absence and menu approval | |
| Cook 3 | Interviewed about menu development and lack of dietician review | |
| Cook 1 | Interviewed about use of unpasteurized eggs | |
| Cook 2 | Interviewed as interim kitchen manager unaware of unpasteurized egg concerns |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 1
Date: Nov 16, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00420761 related to allegations concerning individualized service plans at the facility.
Complaint Details
Complaint IN00420761 was investigated and found related to the cited deficiency at R0217 regarding individualized service plans.
Findings
The facility failed to ensure that 4 of 4 reviewed residents (Residents B, C, D, and E) had current, individualized service plans that were signed and dated by both the facility representative and the resident or their representative.
Deficiencies (1)
Failure to ensure residents had a signed and dated individualized service plan for 4 of 4 residents reviewed (Residents B, C, D, and E).
Report Facts
Residential Census: 71
Residents reviewed for corrections: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LaShelle Crawley | Director of Nursing | Provided service plans for Residents B, C, D, and E which were not signed/acknowledged by the facility nor the resident/representative |
| Assistant Director of Nursing | Interviewed and observed clinical records for Residents B, C, D, and E; unable to locate service plans |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 0
Date: Jun 21, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00409241.
Complaint Details
Complaint IN00409241 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Inspection Report
Renewal
Census: 31
Deficiencies: 6
Date: Dec 29, 2022
Visit Reason
This visit was for a State Residential Licensure Survey conducted on December 27, 28, and 29, 2022 to assess compliance with state regulations.
Findings
The facility failed to ensure timely evaluations of individual resident needs upon admission and semi-annually for 7 residents, lacked current self-administration medication assessments for 2 residents, failed to maintain signed and dated individualized service plans for 7 residents, did not retain clinical records for discharged resident 101, lacked an infection control program for tracking infections, and failed to obtain annual health statements for 4 residents.
Deficiencies (6)
Failed to ensure each resident had an evaluation of individual needs completed upon admission and/or semi-annually for 7 residents.
Failed to ensure residents who self-administered medication had a current self medication administration assessment completed for 2 residents.
Failed to ensure each resident had a signed and dated individualized service plan for 7 residents.
Failed to maintain clinical records for discharged resident 101.
Failed to develop and maintain an infection control program to include a system to analyze patterns of known infectious symptoms.
Failed to ensure residents had an annual health statement for 4 residents.
Report Facts
Residents reviewed for evaluation deficiency: 7
Residents reviewed for self-administration medication assessment deficiency: 2
Residents reviewed for individualized service plan deficiency: 7
Residents reviewed for annual health statement deficiency: 4
Antibiotic prescriptions: 9
Residents at census during inspection: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diana Guinn | Executive Director | Signed the report and identified facility deficiencies during interviews |
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