Indiana State Department of Health
Division of Long Term Care
 
CONSUMER REPORT
 
 
THIS FACILITY HAS CLOSED
 
LAKEVIEW VILLAGE SENIOR LIVING
 
NURSING HOME
SKILLED NURSING FACILITY / NURSING FACILITY DUALLY CERTIFIED
Created on: 12/20/2019
 
Posted to the Web on: 01/01/2020
 
 



Basic Information

FACILITY CONTACT INFORMATION:
Address: 410 TIOGA RD
City: MONTICELLO
Telephone: (574) 583-6707
Web Site:  
 
NAME CHANGES:
Most recent name change: N/A
Date of most recent name change: N/A
 
LICENSE INFORMATION:
  License number: 18-000216-1
  License effective date: 11/01/2018
  License expiration date: 06/28/2019
 


Administration and Staff

Administrator: 
  Start date: N/A
 
 
Medical director:  
  Start date:   /  /  
 
Wound care specialist:  
  Start date:   /  /  
 
Infection preventionist:  
  Start date:   /  /  
 


Ownership

CURENT OWNERSHIP:
 
Owning corporation: BOARD OF TRUSTEES OF THE FLAVIUS J WITHAM MEMORIAL
N/A
N/A N/A N/A
 
Ownership type:  OTHER
 
Officer(s): BEN KLEIN
            PARESH VIPANI
 
PREVIOUS OWNERSHIP CHANGES:
Name of previous owner: BOARD OF TRUSTEES OF THE FLAVIUS J WITHAM MEMORIAL
Date of last change of ownership:   /  /  
 


Bed Counts and Census

COMPREHENSIVE CARE BEDS:
Number of Medicaid beds (NF):                     0
Number of Medicare beds (SNF):                    0
Number of Medicare/Medicaid beds (SNF/NF):        0
Number of non-certified comprehensive care beds (State Licensed only):     0
Total number of comprehensive care beds:     0
 
RESIDENTIAL CARE BEDS:
 
Total number of residential beds:            0
 
Total number of beds in facility:            0
 
CENSUS:
Facility census:  0
As reported by the facility on: 07/02/2019
 
Number of comprehensive care beds occupied in this facility. 0
As reported by the facility on: 07/02/2019
 
Residential care beds occupied:  0
As reported by the facility on: 07/02/2019
 
Alzheimer Beds:  0
Alzheimer Beds Occupied:  0
As reported by the facility on:   /  /  
 
Ventilator Beds:  0
Ventilator Beds Occupied:  0
As reported by the facility on:   /  /  
 


Sprinklers and Smoke Detectors

This facility is:  
 
Number of comprehensive care resident rooms: 40
Number of comprehensive care resident rooms with battery 
                    operated smoke detectors: 40
Number of comprehensive care resident rooms 
             with hard wired and/or wireless smoke detectors: 0
 
Person completing form - FRANK MILLER
Title of the person who completed the sprinkler, smoke detector form submitted to the ISDH. MAINTENANCE DIRECTOR
Date form completed - 05/23/2019
 


Nurse Aide Training

NURSE AIDE TRAINING PROGRAM APPROVALS:
Nurse aide training and competency evaluation program (NATCEP) approved: 04/08/2016
Nurse aide training and competency evaluation program (NATCEP) expires: 04/01/2018
Nurse aide training and competency evaluation program (NATCEP) banned: Yes
Nurse aide training and competency evaluation program (NATCEP) ban expires: 08/04/2018
 
CLINICAL TRAINING SITES:
This facility is a Clinical training site for the following nurse aide training (NAT) classroom sites: 
     TIPPECANOE SCHOOL CORPORATION
         Approved: 03/10/2009
         Terminated: 11/23/2009
     LAKEVIEW VILLAGE SENIOR LIVING
         Approved: 04/08/2016
         Terminated: 06/02/2016
     IU HEALTH WHITE MEMORIAL HOSPITAL
         Approved: 08/08/2013
         Terminated: 06/02/2016
     TWIN LAKES SCHOOL CORP
         Approved: 09/10/2013
         Terminated: 06/02/2016
     GREENHILL MANOR
         Approved: 05/18/2015
         Terminated: 06/02/2016
 


Complaints

NUMBER OF SUBSTANTIATED COMPLAINTS: 
 
  Current year:  0
  Previous year:  0
  2 years previous:  0

 


Enforcement Actions

 
Federal Certification Actions Imposed
 
Date terminated from Medicare/Medicaid: 06/28/2019
 


Survey History


    The survey report is not posted until the report has been provided to the facility and their plan of correction submitted and approved.
    The survey report therefore will likely not be posted until four to six weeks after the exit date.
        
    In the grid below click on an event ID that is underlined to see the survey report for that event.


 
Event ID
Survey Type
Exit Date

IYWO22
Recertification, Follow Up, Life Safety Code
11/13/2018


IYWO12
Follow Up, Recertification, State Licensure
10/15/2018


IYWO21
Recertification, Life Safety Code
09/25/2018


IYWO11
Recertification, State Licensure
08/31/2018


LSG522
Recertification, Follow Up, Life Safety Code
10/16/2017


LSG512
Recertification, Follow Up, State Licensure
09/11/2017


LSG521
Recertification, Life Safety Code
09/07/2017


LSG511
Recertification, State Licensure
08/04/2017


 
 


Links and Resources

 
CMS nursing home compare page 
 
    In addition to the information provided on this 
    web site, the Centers for Medicare & Medicaid Services (CMS) has a web site 
    which contains information on every Medicare and Medicaid certified nursing 
    home in the country. The CMS nursing home survey results contain summary information 
    about a facility's noncompliance of regulations regarding the care of residents 
    found in the nursing homes. You can locate nursing homes in your area and find 
    information about compliance with federal regulations.
 
Resources and links to other organizations
 
Choosing a Nursing Home
 
Overview of the Survey Process
 
State Wide Grouping of all Scores
   
Overview of current comprehensive facility scores
   
Spreadsheet of current comprehensive facility names and scores
   
Legal Disclaimer for Long Term Care Reports.