Inspection Reports for 1019 Senior Living Vermillion Place
449 MAIN ST, IN, 46016
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 7, 2025, found no deficiencies related to complaint investigations. Earlier inspections showed a pattern of deficiencies primarily involving staff qualifications and training, tuberculosis screening, service plan documentation, and facility maintenance. Prior reports cited issues such as missing criminal background checks, lack of CPR certification, incomplete infection control programs, and absence of key staff like dietary and activity directors. Several complaint investigations were unsubstantiated, though some earlier complaints were substantiated with cited deficiencies. The facility’s recent clean complaint investigations suggest some improvement, but prior licensure surveys revealed ongoing challenges in meeting regulatory requirements.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
98% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
46 residents
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 0
Mar 7, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00451194 and IN00448435.
Findings
No deficiencies related to the allegations in complaints IN00451194 and IN00448435 were cited. The facility was found to be in compliance with applicable regulations regarding these complaints.
Complaint Details
Investigation of Complaints IN00451194 and IN00448435 found no deficiencies related to the allegations; facility was in compliance.
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 0
Nov 15, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00446246 at 1019 Senior Living Vermillion Place.
Findings
No deficiencies related to the allegations in Complaint IN00446246 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Complaint Details
Complaint IN00446246 was investigated and found to have no deficiencies related to the allegations.
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 0
Oct 9, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00443232 and IN00445014 at 1019 Senior Living Vermillion Place.
Findings
No deficiencies related to the allegations in complaints IN00443232 and IN00445014 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Complaint Details
Investigation of Complaints IN00443232 and IN00445014 found no deficiencies related to the allegations; both complaints were not substantiated.
Report Facts
Residential Census: 43
Inspection Report
Renewal
Census: 43
Deficiencies: 3
Aug 7, 2024
Visit Reason
This visit was for a State Residential Licensure Survey conducted on August 6 and 7, 2024, to assess compliance with state regulations for 1019 Senior Living Vermillion Place.
Findings
The facility was found deficient in ensuring that service plans were signed by residents or their representatives for 7 of 7 residents reviewed. Additionally, the facility failed to ensure proper tuberculosis (TB) screening and testing for newly admitted residents and annual TB risk assessments or skin tests for residents residing longer than one year.
Deficiencies (3)
| Description |
|---|
| Failed to ensure service plans were signed by residents or their representatives for 7 of 7 residents reviewed. |
| Failed to ensure residents had tuberculin skin tests completed within required timeframes or documented negative results for 3 of 3 residents reviewed for TB screening upon admission. |
| Failed to ensure residents residing longer than one year had annual TB risk assessments or annual TB skin tests completed for 3 of 4 residents reviewed. |
Report Facts
Residential Census: 43
Residents with unsigned service plans: 7
Residents lacking TB screening upon admission: 3
Residents lacking annual TB screening: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Zoe Kesler | Laboratory Director or Provider/Supplier Representative | Signed the inspection report |
Inspection Report
Renewal
Census: 24
Deficiencies: 13
Nov 2, 2023
Visit Reason
This visit was for a State Residential Licensure Survey conducted on October 31, November 1, and November 2, 2023.
Findings
The facility was found deficient in multiple areas including failure to obtain criminal background checks and references for newly hired employees, lack of CPR and first aid certification for staff on multiple shifts, incomplete job-specific orientation, lack of annual dementia training, incomplete tuberculosis screening, missing signed job descriptions, unclean and stained carpets, menus not approved by a registered dietitian, absence of a dietary manager and activity director, failure to ensure pharmacy recommendations were reviewed by physicians, lack of coordinated mental health service plans, and inadequate infection control program including staff education and resident information.
Deficiencies (13)
| Description |
|---|
| Failed to obtain criminal background checks upon hire for 3 of 3 newly hired employees and failed to obtain references for 2 of 3 newly hired employees. |
| Failed to ensure a staff member was first aid and CPR certified for 16 of 21 shifts scheduled. |
| Failed to ensure newly hired employees had job-specific orientation completed for 2 of 3 employee records reviewed. |
| Failed to ensure employees employed for greater than one year had three hours of annual dementia training for 2 of 2 employees reviewed. |
| Failed to ensure employees were screened for tuberculosis and obtained completed health screenings upon hire for 3 of 3 newly hired employees. |
| Failed to ensure newly hired employees had signed job descriptions for 2 of 3 newly hired employees. |
| Failed to maintain the facility in a clean sanitary manner regarding carpet stains on both the first and second floors. |
| Failed to ensure menus and/or their substitutions were approved by a registered dietitian and lacked portion size guidance. |
| Failed to employ a dietary manager/food services supervisor or a consultant registered dietitian. |
| Failed to ensure pharmacy recommendations were reviewed and addressed by the resident's physician for 1 of 2 residents reviewed. |
| Failed to employ an activity director. |
| Failed to coordinate service plans related to mental health needs with the resident's mental health care provider for 2 of 2 residents reviewed. |
| Failed to ensure an infection control program was developed to include employee in-service education on infection prevention and offering of information to residents regarding infection transmission and immunizations. |
Report Facts
Newly hired employees lacking criminal background checks: 3
Newly hired employees lacking references: 2
Shifts lacking CPR and first aid certified staff: 16
Employees lacking job-specific orientation: 2
Employees lacking annual dementia training: 2
Newly hired employees lacking TB screening: 3
Newly hired employees lacking signed job descriptions: 2
Residents impacted by carpet stains: 24
Residents impacted by menu deficiencies: 24
Residents impacted by lack of dietary manager: 24
Residents impacted by lack of activity director: 24
Residents impacted by lack of coordinated mental health plans: 4
Residents impacted by infection control deficiencies: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heather Kesler | Executive Director | Signed the report and plan of correction |
| Co-director 1 | Interviewed regarding multiple deficiencies including employee records, policies, and infection control | |
| Co-director 2 | Interviewed regarding multiple deficiencies including employee records, policies, and infection control |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 16
Jan 3, 2023
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaints IN00396133, IN00396340 and IN00397461.
Findings
The facility was found deficient in multiple areas including failure to timely renew the CLIA Certificate of Waiver, failure to conduct quarterly fire drills on each shift, failure to obtain criminal background checks upon hire, lack of CPR and first aid certification for staff, incomplete orientation and dementia training for new hires, lack of annual dementia training for staff, failure to screen employees for tuberculosis, failure to maintain the facility in a clean and homelike manner, failure to follow medication self-administration orders, lack of a qualified food services director, lack of an activities director, failure to complete mental health assessments and care plans, and failure to maintain infection control surveillance and tuberculosis testing.
Complaint Details
Complaint IN00396133 - Unsubstantiated due to lack of evidence. Complaint IN00396340 - Substantiated with state deficiencies cited at R0144. Complaint IN00397461 - Substantiated with state deficiencies cited at R0274.
Deficiencies (16)
| Description |
|---|
| Failed to ensure timely renewal of the Clinical Laboratory Improvement Amendments (CLIA) Certificate of Waiver affecting 5 of 8 residents receiving blood glucose tests. |
| Failed to ensure quarterly fire drills were conducted on each shift. |
| Failed to obtain criminal background checks upon hire for 3 of 3 newly hired employees. |
| Failed to ensure a staff member was first aid and CPR certified for 21 of 21 shifts scheduled. |
| Failed to ensure newly hired employees had dementia training and job-specific orientation completed for 3 of 3 newly hired employees. |
| Failed to ensure employees employed greater than one year had three hours of annual dementia training for 2 of 2 employees reviewed. |
| Failed to ensure employees were screened for tuberculosis upon hire for 3 of 3 newly hired employees and annually for 2 of 2 employees employed greater than one year. |
| Failed to ensure the facility was maintained in a clean and homelike manner; multiple large dark stains on carpets and missing ceiling tiles observed. |
| Failed to ensure a self-administration of medication assessment and physician's orders were followed for 1 of 5 residents observed during medication pass. |
| Failed to employ a qualified food services director. |
| Failed to employ an Activities Director. |
| Failed to ensure a resident diagnosed with bipolar disorder had a mental health individual needs assessment completed prior to admission and was referred to a mental health care provider. |
| Failed to develop a comprehensive care plan with a mental health service provider for a resident diagnosed with bipolar disorder. |
| Failed to ensure a system was in place to analyze patterns of infections for all residents. |
| Failed to ensure a resident received a two-step tuberculosis test upon admission for 1 of 1 recently admitted residents. |
| Failed to ensure annual Tuberculosis risk assessments had been completed for 6 of 6 residents reviewed for annual health assessments. |
Report Facts
Residents affected by CLIA waiver deficiency: 5
Fire drills required per year: 12
New employees without criminal background checks: 3
Shifts without CPR/First Aid certified staff: 21
Residents census: 28
Dates of survey: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Co-Director 2 | Provided information on CLIA waiver, fire drills, employee records, and facility policies | |
| Co-Director 3 | Provided information on criminal background checks and infection control tracking | |
| Director of Nursing | DON | Provided information on CPR/First Aid training, tuberculosis testing, mental health screening, and infection control |
| Qualified Medication Aide 51 | QMA | Named in medication administration observation and criminal background check deficiency |
| Administrator | Provided information on infection control and dietary staffing |
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 0
Nov 17, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00391868.
Findings
Complaint IN00391868 was found to be unsubstantiated due to lack of evidence. Vermillion Place was found to be in compliance with 410 IAC 16.2-5 in regard to the investigation.
Complaint Details
Complaint IN00391868 was unsubstantiated due to lack of evidence.
Inspection Report
Re-Inspection
Census: 29
Deficiencies: 0
Oct 6, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00373881 and IN00372780 completed on 2022-04-14.
Findings
Both complaints IN00373881 and IN00372780 were found to be corrected. Vermillion Place was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of these complaints.
Complaint Details
This visit was related to complaints IN00373881 and IN00372780. Both complaints were corrected as of this visit.
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 0
Aug 15, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00387194.
Findings
Complaint IN00387194 was found to be unsubstantiated due to lack of evidence. Vermillion Place was found to be in compliance with 410 IAC 16.2-5 in regard to the investigation.
Complaint Details
Complaint IN00387194 - Unsubstantiated due to lack of evidence.
Inspection Report
Re-Inspection
Census: 26
Deficiencies: 1
Aug 2, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00373881 and IN00372780 completed on 3/3/22, to verify correction of previously cited deficiencies.
Findings
The facility failed to employ a licensed Health Facilities Administrator (HFA) to organize and implement day-to-day operations, resulting in unkept grounds, lack of a Dietary Manager, lack of a contracted Registered Dietitian, lack of an Activity Director, and failure to implement a plan of correction following the complaint survey. The licensed HFA was on medical leave due to injuries from a fall and was unavailable during the survey.
Complaint Details
Complaint IN00373881 and Complaint IN00372780 were not corrected as of this revisit.
Deficiencies (1)
| Description |
|---|
| Failure to employ a licensed Health Facilities Administrator to organize and implement day-to-day operations, resulting in unkept grounds and lack of key staff positions. |
Report Facts
Residential Census: 26
Blood pressure reading: 60.42
Date of licensed HFA hire: Oct 7, 2015
Date of survey: Aug 2, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator 10 | Licensed Health Facilities Administrator | Named as the facility administrator who was on medical leave due to injuries from a fall. |
| Co-Director 1 | Reported to oversee daily operations but is not a licensed HFA. | |
| Co-Director 2 | Mentioned in relation to employment postings and facility operations. | |
| ADON | Assistant Director of Nursing | Indicated she was the only leadership employee currently in the facility and assumed charge. |
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