Inspection Reports for The Mansion on Main

1420 E Main St, New Albany, IN 47150, United States, IN, 47150

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Inspection Report Summary

The most recent inspection on July 16, 2025, found no deficiencies related to the complaint investigated and confirmed compliance with state residential licensure regulations. Earlier inspections showed a mix of findings, including substantiated complaints with deficiencies related to personnel records, food service cleanliness, and a failure to initiate CPR on a resident with a CPR advance directive. Complaint investigations were mostly unsubstantiated except for a few substantiated cases involving documentation and care issues. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. The facility’s record shows improvement over time, with recent inspections consistently free of cited deficiencies.

Deficiencies (last 3 years)

Deficiencies (over 3 years) 1.3 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

69% better than Indiana average
Indiana average: 4.2 deficiencies/year

Deficiencies per year

4 3 2 1 0
2023
2024
2025

Census

Latest occupancy rate 99 residents

Based on a July 2025 inspection.

Census over time

90 95 100 105 110 115 Jan 2023 May 2023 Jun 2024 Jul 2025

Inspection Report

Complaint Investigation
Census: 99 Deficiencies: 0 Date: Jul 16, 2025

Visit Reason
This visit was for a State Residential Licensure Survey and included the Investigation of Complaint IN00461233.

Complaint Details
Complaint IN00461233 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 the applicable state residential licensure regulations.

Report Facts
Residential Census: 99

Inspection Report

Complaint Investigation
Census: 106 Deficiencies: 0 Date: Dec 17, 2024

Visit Reason
This visit was conducted for the investigation of Complaint IN00443130.

Complaint Details
Complaint IN00443130 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

Census: 99 Deficiencies: 0 Date: Jun 20, 2024

Visit Reason
This visit was for a State Residential Licensure Survey conducted on June 19 and 20, 2024.

Findings
The Mansion on Main was found to be in compliance with 410 IAC 16.2-5 in regard to the State Residential Licensure Survey.

Inspection Report

Complaint Investigation
Census: 107 Deficiencies: 0 Date: Jun 12, 2023

Visit Reason
This visit was conducted for the investigation of Complaint IN00409147.

Complaint Details
Complaint IN00409147 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

Follow-Up
Census: 100 Deficiencies: 0 Date: May 3, 2023

Visit Reason
This visit was a Post Survey Revisit (PSR) to investigate Complaint IN00402455 completed on 2023-03-20.

Complaint Details
Complaint IN00402455 was corrected.
Findings
The facility was found to be in compliance with 410 IAC 16.2-5 regarding the PSR to Investigation of Complaint IN00402455.

Inspection Report

Complaint Investigation
Census: 101 Deficiencies: 1 Date: Mar 20, 2023

Visit Reason
This visit was conducted for the investigation of Complaint IN00402455 regarding allegations of neglect related to failure to initiate CPR on a resident with a CPR advance directive.

Complaint Details
Complaint IN00402455 was substantiated with a state deficiency cited at R0052 related to failure to initiate CPR on Resident B.
Findings
The facility failed to initiate CPR on Resident B who had a CPR advance directive. The clinical record lacked documentation of pulse assessment or CPR initiation. Staff responded timely to the call pendant and notified EMS, but CPR was not performed due to circumstances including fire department restrictions and staff certification limitations.

Deficiencies (1)
Failure to initiate CPR on a resident with a CPR advance directive.
Report Facts
Residential Census: 101 Date of incident: Feb 22, 2023 Date of survey: Mar 20, 2023

Employees mentioned
NameTitleContext
LPN 2Licensed Practical NurseResponded to Resident B's call, notified EMS, and was involved in the incident.
CNA 3Certified Nurse AideResponded to Resident B's call pendant and notified LPN 2.
Director of NursingDirector of NursingInterviewed regarding the incident and facility policies on CPR.

Inspection Report

Complaint Investigation
Census: 102 Deficiencies: 3 Date: Jan 4, 2023

Visit Reason
This visit was for a State Residential Licensure Survey including the investigation of Complaints IN00397084 and IN00393841.

Complaint Details
Complaint IN00397084 was substantiated with a related state deficiency cited at R0273. Complaint IN00393841 was substantiated but no deficiencies related to the allegations were cited.
Findings
The facility was found to have deficiencies related to personnel records and food and nutritional services. Specifically, missing employee references and orientation documentation were noted, and the kitchen was found unclean and in disrepair, affecting all residents receiving meals.

Deficiencies (3)
Failed to ensure an employee's references were documented for 1 of 5 personnel files reviewed (LPN 4).
Failed to ensure documentation of general and specific orientation was completed for 2 of 5 personnel files reviewed (CNA 5 and LPN 3).
Failed to ensure the kitchen and equipment were clean and in good repair during 3 of 3 kitchen observations, including frost buildup, grease accumulation, and food particles.
Report Facts
Personnel files reviewed: 5 Residents affected: 102 Survey dates: 2

Employees mentioned
NameTitleContext
Peter HastingsExecutive DirectorSigned the report and provided facility policy.
LPN 4Licensed Practical NursePersonnel file lacked documentation of employee references.
LPN 3Licensed Practical NursePersonnel file lacked documentation of general and specific orientation.
CNA 5Certified Nurse AidePersonnel file lacked documentation of specific orientation.
Executive ChefObserved kitchen deficiencies and conducted in-service training.
Cook 1Interviewed regarding frost buildup in freezer.
Director of NursingDONInterviewed about missing employee references and orientation documentation.
Maintenance DirectorInspected freezer door and reset it to improve alignment.

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