Inspection Report Summary
The most recent inspection on June 6, 2025, found Salem Crossing to be in compliance with all applicable regulations and cited no deficiencies. Earlier inspections showed a pattern of some deficiencies primarily related to resident care, including timely incontinence care, RN staffing coverage, medication labeling, and occasional issues with resident supervision during outings. Complaint investigations mostly found no deficiencies, though a few substantiated complaints resulted in citations for verbal abuse by staff and inadequate supervision during a resident outing. Life safety inspections identified recurring issues with door latching, smoke barriers, and fire safety equipment, but these were addressed through corrective actions and plans of correction. The overall trend shows improvement in compliance, with the most recent inspections free of deficiencies and enforcement actions not listed in the available reports.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
31% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
100% occupied
Based on a April 2025 inspection.
Census over time
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 6, 2025
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure Survey conducted on June 6, 2025.
Findings
Salem Crossing 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 Annual Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 77
Capacity: 77
Deficiencies: 0
Date: Apr 30, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00455610 and IN00458101.
Complaint Details
Investigation of Complaints IN00455610 and IN00458101 found no deficiencies related to the allegations; both complaints were not substantiated.
Findings
No deficiencies related to the allegations in complaints IN00455610 and IN00458101 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type: 77
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 52
Census Payor Type - Other: 20
Total Census: 77
Inspection Report
Complaint Investigation
Census: 78
Capacity: 78
Deficiencies: 0
Date: Mar 11, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00454967.
Complaint Details
Complaint IN00454967 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations were cited. Salem Crossing was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Investigation of Complaint IN00454967.
Report Facts
Census: 78
Total Capacity: 78
Medicare Census: 8
Medicaid Census: 56
Other Payor Census: 14
Inspection Report
Complaint Investigation
Census: 79
Capacity: 79
Deficiencies: 0
Date: Feb 13, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00452031.
Complaint Details
Complaint IN00452031 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
Medicare census: 5
Medicaid census: 57
Other payor census: 17
Inspection Report
Complaint Investigation
Census: 84
Capacity: 84
Deficiencies: 1
Date: Dec 3, 2024
Visit Reason
The visit was conducted as an investigation of Complaint IN00448365 regarding allegations of inadequate supervision and accident hazards during a resident outing.
Complaint Details
Complaint IN00448365 was substantiated with a federal/state deficiency cited at F689 related to inadequate supervision during a resident outing where a resident fell into a lake.
Findings
The facility failed to follow procedures and adequately supervise residents during an outing, resulting in a resident falling and rolling into a lake. The resident was not injured, but the incident revealed inadequate supervision and violation of facility outing policies.
Deficiencies (1)
Failure to ensure resident environment was free of accident hazards and to provide adequate supervision and assistance devices to prevent accidents during an outing.
Report Facts
Census: 84
Total Capacity: 84
Residents on outing: 7
Medicare residents: 8
Medicaid residents: 57
Other payor residents: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Certified Nurse Aide | Named in the finding for inadequate supervision during the outing and received disciplinary action |
| BD 4 | Bus Driver | Named in the finding for inadequate supervision during the outing |
| Director of Nursing | Director of Nursing | Interviewed regarding the incident and facility policies |
| RN 2 | Registered Nurse | Provided information about Resident B's behaviors and condition |
| Administrator | Administrator | Provided facility policies and information about the incident |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 84
Deficiencies: 0
Date: Nov 12, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00447113 and IN00446151.
Complaint Details
Complaint IN00447113 - No deficiencies related to the allegations were cited. Complaint IN00446151 - No deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations in complaints IN00447113 and IN00446151 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
Census SNF/NF beds: 84
Census total residents: 84
Census Medicare residents: 7
Census Medicaid residents: 56
Census other payor residents: 21
Inspection Report
Complaint Investigation
Census: 84
Capacity: 84
Deficiencies: 0
Date: Aug 7, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00437642.
Complaint Details
Complaint IN00437642 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
Medicare residents: 5
Medicaid residents: 62
Other residents: 17
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jul 31, 2024
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey, including an investigation of Complaint IN00434385 completed on June 5, 2024.
Complaint Details
Investigation of Complaint IN00434385 completed on June 5, 2024; facility found in compliance.
Findings
Salem Crossing 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 of the Recertification and State Licensure survey and the complaint investigation.
Inspection Report
Life Safety
Census: 85
Capacity: 92
Deficiencies: 0
Date: Jul 18, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification survey which exited on 06/19/2024 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this Life Safety Code survey, Salem Crossing was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), 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 fully sprinklered with a fire alarm system and battery operated smoke alarms in all resident sleeping rooms.
Report Facts
Facility capacity: 92
Census: 85
Inspection Report
Life Safety
Census: 81
Capacity: 92
Deficiencies: 8
Date: Jun 19, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 06/19/2024 to assess compliance with emergency preparedness and life safety code requirements.
Findings
The facility was found in compliance with emergency preparedness requirements but had multiple life safety deficiencies including failure to maintain latching hardware on smoke doors, improper swing direction of an emergency exit gate, lack of self-closing device on a hazardous area door, missing sprinkler escutcheon, missing monthly inspection tag on a fire extinguisher, a door that did not fully close and latch, unprotected penetration in a smoke barrier wall, and an electrical receptacle with an open ground.
Deficiencies (8)
Failed to maintain latching hardware on 1 of 1 200 hall smoke doors.
Failed to ensure 1 of 1 exterior gate from the 400 hall exit fenced-in area swung in the direction of egress travel.
Failed to ensure the corridor door to 1 of 1 Human Resources offices near the memory care unit was provided with a self-closing device.
Failed to maintain the ceiling construction in 1 of 1 physical therapy closets in accordance with NFPA 13.
Failed to ensure 1 of 1 fire extinguishers in the beauty shop was inspected on a monthly basis; missing inspection tag and documentation.
Failed to ensure 1 of 1 doors to the 300 hall copy room door would close completely and latch into the door frame without issue.
Failed to ensure the penetrations through 1 of 1 400 hall smoke barrier walls was protected to maintain the smoke resistance.
Failed to ensure 1 of 1 receptacles in the 300 hall pantry near the microwave were properly grounded.
Report Facts
Deficiencies cited: 8
Facility capacity: 92
Census: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Holly Thompson | Executive Director | Named in relation to findings and exit conference |
Inspection Report
Annual Inspection
Census: 84
Capacity: 84
Deficiencies: 3
Date: Jun 5, 2024
Visit Reason
This visit was for the Recertification and State Licensure Survey, including the investigation of Complaints IN00434223 and IN00434385.
Complaint Details
Complaint IN00434223 - No deficiencies related to the allegation were cited. Complaint IN00434385 - Federal/State deficiency related to the allegation was cited at F677.
Findings
The facility was found deficient in providing timely incontinence care for dependent residents, failed to ensure 8 consecutive hours of RN coverage for multiple months, and did not properly label insulin flexpens for several residents. Complaint IN00434223 was not substantiated, while Complaint IN00434385 resulted in a cited deficiency.
Deficiencies (3)
Failed to ensure staff provided necessary incontinence care in a timely manner for 2 of 4 residents observed for Activities of Daily Living.
Failed to schedule 8-hour consecutive RN coverage for 4 of 4 months reviewed (March, April, May, June 2024).
Failed to ensure appropriate pharmacy labeling for 4 of 13 insulin flexpens observed for medication storage.
Report Facts
Census: 84
Total Capacity: 84
Medicare Census: 4
Medicaid Census: 61
Other Payor Census: 19
Deficiency Count: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Holly Thompson | Executive Director | Signed the report and referenced in the interview regarding RN coverage |
| CNA 4 | Certified Nurse Aide | Mentioned in relation to incontinence care for Resident D |
| CNA 5 | Nurse Aide | Provided perineal care and resident rounding |
| CNA 6 | Certified Nurse Aide | Described walking rounds and bed checks |
| CNA 7 | Certified Nurse Aide | Reported checking residents every 2 hours |
| CNA 8 | Certified Nurse Aide | Received shift report and performed bed checks |
| CNA 9 | Certified Nurse Aide | Reported checking and changing residents every 2 hours |
| Scheduler | Acknowledged RN coverage gaps in the schedule | |
| DON | Director of Nursing | Discussed pharmacy labeling policy and RN coverage |
| LPN 2 | Licensed Practical Nurse | Discussed pharmacy labeling requirements for insulin pens |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 81
Deficiencies: 0
Date: Nov 6, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00420559.
Complaint Details
Complaint IN00420559 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 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census Bed Type: 81
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 59
Census Payor Type - Other: 19
Inspection Report
Complaint Investigation
Census: 79
Capacity: 79
Deficiencies: 0
Date: Sep 20, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00417343 and IN00417811 at Salem Crossing.
Complaint Details
Investigation of Complaints IN00417343 and IN00417811 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00417343 and IN00417811 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Medicare census: 5
Medicaid census: 57
Other payor census: 17
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 28, 2023
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Salem Crossing 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: 82
Capacity: 92
Deficiencies: 0
Date: Jun 5, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Participation in Medicare/Medicaid. The facility is a one-story, fully sprinklered Type V construction with a fire alarm system and battery-operated smoke alarms in resident sleeping rooms.
Report Facts
Facility capacity: 92
Census: 82
Inspection Report
Annual Inspection
Census: 84
Capacity: 84
Deficiencies: 3
Date: May 12, 2023
Visit Reason
This visit was for the Recertification and State Licensure Survey, which included the Investigation of Complaint IN00405762.
Complaint Details
Complaint IN00405762 was investigated with no deficiencies related to the allegations cited.
Findings
The facility was found deficient in ensuring person-centered fall prevention interventions for residents, proper catheter care and handling, and accurate medication storage and controlled substance documentation. No deficiencies were cited related to the complaint investigation.
Deficiencies (3)
Failure to ensure development and implementation of person-centered interventions to prevent falls for 2 of 8 residents reviewed.
Failure to ensure proper indwelling urinary catheter care and handling for 2 of 4 residents reviewed.
Failure to ensure accurate documentation in the Controlled Substances Record sheet and appropriate storage and labeling of medications for medication carts and storage rooms.
Report Facts
Survey dates: 5
Census SNF/NF beds: 84
Medicare census: 7
Medicaid census: 60
Other payor census: 17
Lorazepam medication volume: 25
Lorazepam medication volume expected: 26.25
Tramadol tablets count: 9
Tramadol tablets count recorded: 8
Clonazepam tablets count: 19
Clonazepam tablets count recorded: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 8 | Licensed Practical Nurse | Named in medication storage and controlled substance count deficiencies |
| NA 4 | Nurse Aide | Named in catheter care observation deficiencies |
| LPN 5 | Licensed Practical Nurse | Named in catheter care observation deficiencies |
| CNA 6 | Certified Nurse Aide | Named in catheter care observation deficiencies |
| CNA 7 | Certified Nurse Aide | Named in catheter care observation deficiencies |
| DON | Director of Nursing | Provided interviews and policy information related to catheter care and medication storage |
| Infection Preventionist | Provided interviews and policy information related to medication cart counts and storage |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 19, 2023
Visit Reason
This document is a paper compliance review related to the Investigation of Complaint IN00401566 completed on March 21, 2023.
Complaint Details
This visit was related to a complaint investigation identified as IN00401566. The paper compliance review was completed and found the facility in compliance.
Findings
Salem Crossing 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: 88
Capacity: 88
Deficiencies: 1
Date: Mar 21, 2023
Visit Reason
This visit was for the investigation of Complaints IN00401566 and IN00402089. Complaint IN00401566 resulted in a Federal/State deficiency related to the allegation, while Complaint IN00402089 had no deficiencies cited.
Complaint Details
Complaint IN00401566 was substantiated with a Federal/State deficiency cited at F689 related to resident rights violations involving verbal abuse and disrespect by staff. Complaint IN00402089 was not substantiated with no deficiencies cited.
Findings
The facility failed to ensure residents were treated with dignity and respect for 3 of 5 residents reviewed (Residents B, C, and D). Specific incidents of verbal abuse and disrespectful language by staff were documented and investigated. Staff involved received education or were terminated. The facility implemented corrective actions including staff in-service on resident rights and ongoing monitoring.
Deficiencies (1)
Facility failed to ensure residents were treated with dignity and respect, including staff calling residents names and verbal abuse.
Report Facts
Census: 88
Total Capacity: 88
Residents reviewed for rights: 5
Residents found with dignity and respect issues: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Holly Thompson | Executive Director | Signed the report and provided Resident Rights policy |
| CNA 1 | Certified Nursing Aide | Called Resident B a name and was educated on resident rights |
| NA 4 | Nurse Aide | Involved in verbal abuse incidents with Residents C and D; terminated |
| CNA 2 | Certified Nursing Aide | Witnessed CNA 1 calling Resident B a name and provided interview statements |
| DON | Director of Nursing | Interviewed regarding incidents and staff education |
| Social Service Director | Social Service Director | Interviewed residents and staff, conducted abuse questionnaires |
| Executive Director | Executive Director | Provided policy and interview regarding staff termination |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 76
Deficiencies: 0
Date: Feb 8, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00398449 and IN00400702 at Salem Crossing.
Complaint Details
Complaint IN00398449 - Substantiated with no deficiencies cited. Complaint IN00400702 - Substantiated with no deficiencies cited.
Findings
Both complaints were substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Medicare census: 6
Medicaid census: 52
Other payor census: 18
Inspection Report
Complaint Investigation
Census: 84
Capacity: 92
Deficiencies: 1
Date: Jan 11, 2023
Visit Reason
The inspection was conducted as an investigation of Complaint Number IN00397831 by the Indiana Department of Health in accordance with 42 CFR 483.90(a). The complaint was substantiated and related to the use of portable space heaters in the facility.
Complaint Details
Complaint Number IN00397831 was substantiated. The deficiency related to the allegation was cited at K781.
Findings
The facility was found not in compliance with Medicare/Medicaid participation requirements and Life Safety Code standards due to the use of portable space heaters, which are prohibited by facility policy. The heating element and blower motor for the attic air handler servicing part of the facility failed, leading to temporary use of portable space heaters to prevent freezing pipes. The heaters were monitored and removed once repairs were completed.
Deficiencies (1)
Failure to ensure portable space heaters were not used in health care occupancies according to current written policy which prohibited their use.
Report Facts
Facility capacity: 92
Census: 84
Temperature: -4
Temperature: -6
Number of portable space heaters used: 3
Heater heat output: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Holly Thompson | Executive Director | Interviewed regarding facility policy and findings; participated in exit conference |
| Maintenance Director | Interviewed regarding heating failure, use of portable heaters, and corrective actions |
Inspection Report
Life Safety
Deficiencies: 0
Date: Jan 11, 2023
Visit Reason
Paper compliance investigation of a Life Safety Code complaint was conducted on 01/11/2023.
Complaint Details
Complaint Number IN00397831 was investigated and found in compliance.
Findings
Salem Crossing was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 Edition of the NFPA 101 Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Complaint Investigation
Census: 78
Capacity: 78
Deficiencies: 0
Date: Dec 27, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00391553.
Complaint Details
Complaint IN00391553 was substantiated, but no deficiencies related to the allegations were cited.
Findings
Complaint IN00391553 was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type: 78
Census Payor Type - Medicare: 30
Census Payor Type - Medicaid: 33
Census Payor Type - Other: 15
Inspection Report
Re-Inspection
Census: 88
Capacity: 92
Deficiencies: 0
Date: Sep 30, 2022
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 08/03/22 was performed to verify compliance with fire safety and licensure requirements.
Findings
At this PSR survey, Salem Crossing was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and applicable state and national fire safety codes. The facility was fully sprinklered with appropriate smoke detection systems and had no deficiencies noted.
Report Facts
Facility capacity: 92
Census: 88
Inspection Report
Life Safety
Census: 81
Capacity: 92
Deficiencies: 5
Date: Aug 3, 2022
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements. However, the Life Safety Code survey identified deficiencies including failure to ensure therapy room door latching, corridor doors latching and smoke resistance, smoke barrier door self-closing functionality, and annual inspection/testing of fire door assemblies. Corrective actions and plans of correction were submitted.
Deficiencies (5)
Failed to ensure 1 of 1 therapy rooms was separated from the corridor by a partition capable of resisting the passage of smoke due to door latching mechanism being in 'dogged down' position.
Failed to ensure 3 of over 50 corridor doors had no impediment to closing and latching into the door frame and would resist the passage of smoke.
Failed to ensure doors in 1 of 7 smoke barrier walls would restrict the movement of smoke for at least 20 minutes due to detached self-closing device on smoke barrier door.
Failed to ensure annual inspection and testing of all fire door assemblies were completed in accordance with LSC 19.1.1.4.1.1.
Failed to ensure doors in the corridor door set by the entrance to Alzheimer's wing by Room 401 were equipped with latching hardware to latch the door set into the door frame.
Report Facts
Certified beds: 92
Census: 81
Corridor doors with issues: 3
Smoke barrier walls: 7
Fire walls: 7
Fire door inspection date: Mar 21, 2022
Fire door repair completion date: Nov 4, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in multiple findings related to door latching and fire safety deficiencies | |
| Executive Director | Named in multiple findings and exit conference discussions |
Inspection Report
Re-Inspection
Census: 81
Capacity: 81
Deficiencies: 0
Date: Aug 2, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on June 29, 2022.
Findings
Salem Crossing was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey.
Report Facts
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 53
Census Payor Type - Other: 22
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