Inspection Reports for Arbor Glen Independent & Assisted Living Community
5202 ST JOE ROAD, FORT WAYNE, IN, 46835
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 18, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a pattern of deficiencies primarily involving resident care issues such as medication management, documentation, and safety practices, including a substantiated case of sexual abuse by a staff member in March 2025. Complaint investigations were mostly unsubstantiated, except for several substantiated complaints related to medication errors, fire safety, and resident rights violations. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility appears to have addressed prior deficiencies, with the most recent inspections showing compliance and correction of earlier issues.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
10% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
90 residents
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 0
Date: Jun 18, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00459674.
Complaint Details
Complaint IN00459674 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: 84
Deficiencies: 0
Date: May 12, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00457387.
Complaint Details
Complaint IN00457387 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: 98
Deficiencies: 0
Date: Mar 24, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00455235, conducted in conjunction with the Investigation of Complaints IN00454829 and IN00454937.
Complaint Details
Complaint IN00455235 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations of Complaint IN00455235 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding this complaint.
Inspection Report
Re-Inspection
Census: 98
Deficiencies: 0
Date: Mar 24, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00454829 and IN00454937 completed on March 6, 2025, and was conducted in conjunction with the investigation of Complaint IN00455235.
Complaint Details
This visit was related to complaints IN00454829, IN00454937, and IN00455235. Complaints IN00454829 and IN00454937 were corrected. The status of complaint IN00455235 is not stated.
Findings
Arbor Glen Independent and Assisted Living Community was found to be in compliance with 410 IAC 16.2-5 regarding the PSR to Investigation of Complaints IN00454829 and IN00454937. Complaints IN00454829 and IN00454937 were corrected.
Report Facts
Residential Census: 98
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 1
Date: Mar 6, 2025
Visit Reason
This visit was for the investigation of complaints IN00454829 and IN00454937 regarding allegations of inappropriate sexual relationship between a staff member and a resident.
Complaint Details
The investigation was triggered by complaints IN00454829 and IN00454937. The complaints were substantiated with state deficiencies cited at R0052 related to the allegations of sexual abuse involving Resident M and a staff member. The staff member resigned and was no longer in contact with the resident. The resident was monitored for psychosocial impact and protective measures were implemented.
Findings
The facility failed to ensure residents were free from sexual abuse for 1 of 3 residents reviewed (Resident M). A staff member had a sexual relationship with Resident M, which violated company policy. The staff member resigned, and the resident was monitored for psychosocial impact with no ongoing concerns noted.
Deficiencies (1)
Failed to ensure residents were free from sexual abuse for 1 of 3 residents reviewed (Resident M) due to a sexual relationship with a staff member.
Report Facts
Residential Census: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Kathy Bolling | Administrator/ED | Administrator who provided information and signed the report |
| Staff Member 5 | Staff member involved in the sexual relationship with Resident M who resigned |
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 2
Date: Feb 18, 2025
Visit Reason
This visit was for the investigation of complaints IN00452494 and IN00453044. Complaint IN00452494 resulted in state deficiencies related to the allegations, while Complaint IN00453044 had no deficiencies related to the allegations.
Complaint Details
Complaint IN00452494 - State deficiencies related to the allegations are cited at R0214 and R0216. Complaint IN00453044 - No deficiencies related to the allegations are cited.
Findings
The facility failed to ensure semi-annual evaluations of residents' ability to self-administer medications were completed for 2 of 3 residents reviewed (Resident B and Resident D). Additionally, the facility failed to develop and implement a service plan for diabetes management for Resident B. The facility policy requires periodic evaluations and individualized service plans, but these were not consistently followed.
Deficiencies (2)
Failed to ensure evaluation of resident ability to self-administer medications was completed semi-annually for 2 of 3 residents reviewed (Resident B and Resident D).
Failed to ensure a service plan for diabetes management was developed and implemented for 1 of 3 residents reviewed (Resident B).
Report Facts
Residential Census: 82
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Bolling | Administrator/ED | Signed the report and participated in interview regarding medication self-administration evaluations |
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 0
Date: Jan 31, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00452119 and IN00450868 at Arbor Glen Independent & Assisted Living Community.
Complaint Details
Investigation of Complaints IN00452119 and IN00450868 found no deficiencies related to the allegations; facility was compliant.
Findings
No deficiencies related to the allegations in complaints IN00452119 and IN00450868 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Inspection Report
Annual Inspection
Census: 100
Deficiencies: 3
Date: Jan 15, 2025
Visit Reason
This visit was for a State Residential Licensure Survey conducted on January 14 and 15, 2025, to assess compliance with state regulations for Arbor Glen Independent & Assisted Living Community.
Findings
The facility was found deficient in maintaining sanitary kitchen practices, proper clinical record documentation after hospital transfers, and complete documentation related to a resident's death. Specific issues included unsanitary kitchen conditions, incomplete transfer forms for a resident hospitalized after a fall, and incomplete death documentation for a resident.
Deficiencies (3)
Failed to maintain sanitary kitchen practices; floors sticky with debris, food items undated and uncovered in storage areas.
Failed to ensure complete records documentation after hospital transfer for 1 resident; transfer form lacked disposition of personal belongings, chest x-ray, and skin test.
Failed to ensure complete documentation related to resident death; missing vital signs, condition not fully documented, and no record of disposition of personal belongings or medications.
Report Facts
Residential Census: 100
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Kathryn Bolling | Administrator/ED | Signed the report and submitted the Plan of Correction |
| Kathy (Mary K) Bolling | Administrator/ED | Signed the report |
| Lead Cook 2 | Interviewed regarding kitchen sanitation and cleaning practices | |
| Dietary Manager | Interviewed regarding kitchen food labeling and cleaning policies | |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding hospital transfer documentation and death documentation policies |
| Administrator | Administrator | Interviewed regarding death documentation policies |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 0
Date: Oct 21, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00444809 at Arbor Glen Independent and Assisted Living Community.
Complaint Details
Complaint IN00444809 was investigated and found to have no related deficiencies; the complaint was not substantiated.
Findings
No deficiencies related to the allegations in Complaint IN00444809 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Inspection Report
Follow-Up
Census: 101
Deficiencies: 0
Date: Aug 6, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00437309 completed on 2024-07-18.
Complaint Details
Complaint IN00437309 was investigated and found to be corrected.
Findings
The facility was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of Complaint IN00437309.
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 0
Date: Jul 26, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00439516 and IN00439619 at Arbor Glen Independent & Assisted Living Community.
Complaint Details
Investigation of Complaints IN00439516 and IN00439619 found no deficiencies related to the allegations; both complaints were not substantiated.
Findings
No deficiencies related to the allegations in complaints IN00439516 and IN00439619 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 1
Date: Jul 18, 2024
Visit Reason
This visit was for the investigation of complaints IN00436535, IN00437309, IN00438249, and IN00438387. The investigation focused on allegations related to medication administration and nursing care.
Complaint Details
Complaint IN00437309 was substantiated with state deficiencies cited at R0241 related to medication administration by unqualified personnel. Complaints IN00436535, IN00438249, and IN00438387 had no deficiencies related to the allegations.
Findings
The facility failed to ensure that qualified personnel administered insulin to 11 of 81 residents reviewed, as a Qualified Medication Aide (QMA 2) who was not insulin certified administered insulin. The Director of Nursing confirmed the lack of verification of insulin certification for QMA 2, who administered insulin from 7/31/23 through 6/27/24. No deficiencies were found related to the other complaints.
Deficiencies (1)
Failed to ensure qualified personnel administered insulin to 11 of 81 residents reviewed; QMA 2 was not insulin certified but administered insulin.
Report Facts
Residents affected: 11
Residential Census: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Kathryn Bolling | Administrator/ED | Signed the report |
| QMA 2 | Qualified Medication Aide | Administered insulin without certification |
| Director of Nursing | Director of Nursing | Confirmed QMA 2 was not insulin certified and failed to verify certification upon hire |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 0
Date: Mar 18, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00428374.
Complaint Details
Complaint IN00428374 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations are cited. Arbor Glen Independent & Assisted Living Community was found to be in compliance with 410 IAC 16.2-5 in regard to the Investigation of Complaint IN00428374.
Inspection Report
Renewal
Census: 68
Deficiencies: 2
Date: Jan 31, 2024
Visit Reason
This visit was for a State Residential Licensure Survey conducted on January 30 and 31, 2024, to assess compliance with state regulations for Arbor Glen Independent & Assisted Living Community.
Findings
The facility was found deficient in ensuring required immunizations for pets living with residents and maintaining kitchen cleanliness. Specifically, 2 of 16 pets lacked current vaccinations, and the kitchen had issues with deep fryer grease cleanliness and improper drying of steam table pans.
Deficiencies (2)
Failed to ensure 2 of 16 pets living with residents had their required immunizations.
Failed to ensure kitchen cleanliness was maintained, including dirty deep fryer grease and steam table pans not air dried before stacking.
Report Facts
Residents present: 68
Pets with missing immunization records: 2
Residents consuming meals prepared in kitchen: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cook 3 | Dietary manager in training and in charge of the kitchen | Interviewed regarding kitchen cleanliness and cleaning schedules |
| Executive Director | Administrator/Executive Director | Interviewed about kitchen cleaning schedules and oversight |
| Director of Nursing | Director of Nursing (DON) | Provided pet vaccination records and facility policy |
| Business Director | Business Director | Interviewed about pet vaccination requirements |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 0
Date: Dec 27, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00422939 and IN00423584 at Arbor Glen Independent & Assisted Living Community.
Complaint Details
Investigation of Complaints IN00422939 and IN00423584 found no deficiencies related to the allegations; facility was compliant.
Findings
No deficiencies related to the allegations in complaints IN00422939 and IN00423584 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Report Facts
Residential Census: 69
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 2
Date: Nov 6, 2023
Visit Reason
This visit was for the investigation of complaints IN00419785 and IN00420387. Complaint IN00419785 resulted in state deficiencies related to the allegations, while Complaint IN00420387 had no deficiencies cited.
Complaint Details
Complaint IN00419785 was substantiated with state deficiencies cited related to the allegations. Complaint IN00420387 had no deficiencies related to the allegations.
Findings
The facility failed to protect a resident's property from loss and theft, specifically 9 missing Lyrica capsules for Resident B, and failed to report the misappropriation to the Indiana Department of Health as required. The facility conducted an investigation but could not determine the cause of the missing medication. Staff involved were re-educated on medication counts, and corrective actions were implemented to prevent recurrence.
Deficiencies (2)
Failed to ensure a resident's property was protected from loss and theft for 1 of 3 residents reviewed (Resident B) involving 9 missing Lyrica capsules.
Failed to report misappropriation of resident property to the Indiana Department of Health for 1 of 3 residents reviewed (Resident B).
Report Facts
Missing medication capsules: 9
Residential Census: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Notified of missing medication and conducted investigation |
| Qualified Medication Aid 3 | QMA 3 | Counted medication and reported missing capsules |
| Administrator | Administrator | Notified resident, physician, and pharmacy of missing medication; involved in investigation and corrective actions |
| Assistant Director of Nursing | ADON | Involved in investigation and corrective actions |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 1
Date: Jul 11, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00411184 and IN00411781. Complaint IN00411184 had no deficiencies related to the allegations, while complaint IN00411781 resulted in state deficiencies being cited.
Complaint Details
Complaint IN00411184 had no deficiencies related to the allegations. Complaint IN00411781 was substantiated with state deficiencies cited related to fire prevention and safety standards violations.
Findings
The facility failed to ensure fire prevention interventions were initiated for all 114 residents residing in the building. Specifically, Resident F repeatedly violated smoking policies by smoking on her balcony while using oxygen and falling asleep with a lit cigarette, posing a threat to herself and others. Despite multiple education efforts and interventions, the resident continued to violate smoking guidelines.
Deficiencies (1)
Facility failed to ensure fire prevention interventions were initiated for 114 residents, including failure to enforce smoking only in designated areas and prevent smoking on balconies while using oxygen.
Report Facts
Residential Census: 74
Residents in building: 114
Compliance date: Jul 27, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Kathryn Bolling | Administrator/ED | Signed the report and interviewed during inspection |
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 1
Date: Apr 17, 2023
Visit Reason
This visit was for the investigation of complaints IN00406093 and IN00406351. Complaint IN00406093 resulted in state deficiencies related to residents smoking outside designated areas causing a fire; complaint IN00406351 had no deficiencies cited.
Complaint Details
Complaint IN00406093 was substantiated with state deficiencies cited at R0147 related to smoking violations causing a fire. Complaint IN00406351 had no deficiencies related to the allegations.
Findings
The facility failed to ensure residents smoked only in designated smoking areas at least 20 feet from the building, which resulted in a fire caused by a cigarette on Resident B's patio. Resident B admitted to smoking on her patio and thought the cigarette was out, but it caused damage to the building siding. The facility has a smoking policy prohibiting smoking except in designated areas.
Deficiencies (1)
Facility failed to ensure residents smoked in designated smoking areas within 20 feet of the building, resulting in a fire.
Report Facts
Residential Census: 105
Date of fire incident: Apr 9, 2023
Compliance date: Apr 27, 2023
Number of additional smoking areas added: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Kathryn Bolling | Administrator | Provided investigation summary and smoking policy; signed report |
| Chef 3 | Observed Resident B smoking, responded to fire, notified staff and fire department | |
| Director of Nursing | Director of Nursing | Provided smoking assessment indicating Resident B was safe to smoke without supervision |
Inspection Report
Original Licensing
Census: 61
Deficiencies: 0
Date: Mar 9, 2023
Visit Reason
This visit was for a State Residential Licensure Survey conducted on March 8 and 9, 2023.
Findings
Arbor Glen Independent and Assisted Living Community was found to be in compliance with 410 IAC 16.2-5 in regard to the State Residential Licensure Survey.
Report Facts
Residential Census: 61
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 0
Date: Dec 28, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00397299.
Complaint Details
Complaint IN00397299 - Unsubstantiated due to lack of evidence.
Findings
Complaint IN00397299 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 1
Date: Sep 30, 2022
Visit Reason
This visit was for the investigation of Complaint IN00389614 and Complaint IN00390930. Complaint IN00389614 was substantiated with no state residential findings cited, while Complaint IN00390930 was substantiated with state residential findings cited.
Complaint Details
Complaint IN00389614 - Substantiated with no state residential findings cited. Complaint IN00390930 - Substantiated with state residential findings cited at R0297.
Findings
The facility failed to ensure that 3 of 3 residents' medications were administered per physician's orders without medication errors. Specific medication errors involved Residents E, F, and G, including missed doses, incorrect dosages, and administration of wrong medications, leading to adverse events such as hospitalization.
Deficiencies (1)
Failed to ensure 3 of 3 residents' medications were administered per physician's order without medication error (Resident E, Resident F, and Resident G).
Report Facts
Residents with medication errors: 3
Resident census: 48
Incident numbers related to medication errors: 5
Medication doses: 2
Medication administration times: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| QMA 4 | Qualified Medication Aide | Named in medication error findings and was terminated following errors involving Residents E and G. |
| Director of Nursing | Director of Nursing (DON) | Involved in investigation and reporting of medication errors, including Resident E's missed dose and Resident G's medication error. |
| QMA 1 | Qualified Medication Aide | Involved in medication errors related to Resident F and Resident G. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Assessed Resident G after medication error and involved in corrective actions. |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 1
Date: Aug 25, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00384272 and IN00386299. Complaint IN00384272 was substantiated with related state deficiencies cited, while complaint IN00386299 was unsubstantiated due to lack of evidence.
Complaint Details
Complaint IN00384272 was substantiated with deficiencies cited at R0045. Complaint IN00386299 was unsubstantiated due to lack of evidence.
Findings
The facility failed to ensure that required notice prior to discharge was provided to 1 of 3 residents reviewed for transfer-discharges (Resident B). Resident B was discharged without receiving the mandated Transfer and Discharge notice or opportunity to appeal the discharge, violating residents' rights regulations.
Deficiencies (1)
Failed to provide required notice prior to discharge to Resident B, including written notification of transfer or discharge and the reasons for the move.
Report Facts
Residential Census: 46
Complaint IDs: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed and indicated Resident B had not been given a Transfer and Discharge notice but should have received one. | |
| Administrator | Provided facility policy titled 'Involuntary Transfer-Discharge' and indicated Resident B had not been given a Transfer and Discharge notice but should have received one. |
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