Inspection Report Summary
The most recent inspection on February 18, 2025, identified deficiencies related to medication administration by Qualified Medication Aides and failure to update a resident’s service plan. Earlier inspections showed a pattern of issues including medication management, infection control, service plan documentation, and kitchen sanitation. Prior reports cited problems with narcotic count procedures, unsanitary food preparation areas, incomplete resident and pet records, and COVID-19 isolation practices. Complaint investigations were mostly unsubstantiated except for the latest one, which was substantiated and resulted in cited deficiencies but no fines or enforcement actions were listed in the available reports. The inspection history indicates ongoing challenges with medication administration and documentation, with no clear improvement trend.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
5% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
83 residents
Based on a February 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 2
Date: Feb 18, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00452790, which triggered a review of state deficiencies related to the allegations cited at tags R0117 and R0217.
Complaint Details
Complaint IN00452790 was substantiated with state deficiencies cited at R0117 and R0217 related to medication administration by QMAs and service plan review deficiencies.
Findings
The facility failed to ensure Qualified Medication Aides (QMA) were assigned duties within their training and job description related to medication administration, specifically nebulizer treatments, potentially affecting 5 residents. Additionally, the facility failed to ensure a service plan was reviewed and revised appropriately for one resident, with missing updates related to recent falls and hospice care.
Deficiencies (2)
Qualified Medication Aides were assigned duties outside their scope of practice during medication administration, specifically administering nebulizer treatments.
Failure to review and revise a resident's service plan to include recent falls and hospice care status.
Report Facts
Residential Census: 83
Dates of medication administration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Debby Atsas | Executive Director | Signed the report |
| Director of Nursing | Interviewed regarding QMA scope of practice and service plan issues | |
| Resident Care Director | Responsible for re-education and auditing related to corrective actions | |
| LPN 1 | Interviewed regarding QMA administration of aerosol treatments | |
| QMA 1 | Qualified Medication Aide | Observed administering nebulizer treatment outside scope of practice |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 0
Date: Oct 9, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00443733.
Complaint Details
Complaint IN00443733 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: 79
Deficiencies: 2
Date: Aug 27, 2024
Visit Reason
This visit was conducted for the investigation of two complaints, IN00438560 and IN00440107, related to facility practices and conditions.
Complaint Details
The visit was complaint-related for complaints IN00438560 and IN00440107. Deficiencies related to these complaints were cited at R0273 and R0091 respectively.
Findings
The investigation found deficiencies related to failure to implement narcotic and controlled medication management policies, specifically nursing staff not completing narcotic counts together during shift changes, and unsanitary conditions in the main kitchen including dried food on stove grates, food debris in ovens, and dirt accumulation in storage and preparation areas.
Deficiencies (2)
Failure to implement the Narcotic and Controlled Medication Management policy, with nursing staff not completing narcotic counts together during each change of shift.
Facility failed to ensure food equipment, food storage areas, and food preparation areas were clean in the main kitchen.
Report Facts
Residential Census: 79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Debby Atsas | Executive Director | Signed as Laboratory Director's or Provider/Supplier Representative's Signature |
| LPN 1 | Interviewed regarding narcotic count procedures and concerns about policy changes | |
| QMA 1 | Interviewed about narcotic count practices and use of pill counter application | |
| Director of Nursing | Interviewed about staff shift length restrictions and narcotic count policy implementation | |
| Dietary Food Manager | Interviewed regarding kitchen sanitation and cleanliness |
Inspection Report
Renewal
Census: 81
Deficiencies: 4
Date: Mar 27, 2024
Visit Reason
This visit was for a State Residential Licensure Survey conducted on March 26 and 27, 2024, to assess compliance with state regulations for the facility.
Findings
The facility was found deficient in several areas including failure to have a current Alzheimer's/Dementia Special Care Unit disclosure form, incomplete pet vaccination records, unsigned or outdated resident service plans, and inadequate infection control practices related to COVID-19 isolation protocols.
Deficiencies (4)
Failure to have a current Alzheimer's/Dementia Special Care Unit disclosure form.
Failure to ensure pets were up to date on vaccinations for 2 of 5 pet vaccination records reviewed.
Failure to ensure resident service plans were updated and/or signed by the resident or representative for 5 of 7 service plans reviewed.
Failure to ensure infection control guidelines were in place and implemented, including proper COVID-19 isolation for positive residents.
Report Facts
Residential Census: 81
Deficiencies cited: 4
Pets with missing vaccination records: 2
Residents with unsigned or outdated service plans: 5
Residents reviewed for infection control: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Debby Atsas | Executive Director | Signed the report and involved in administration |
| Administrator | Interviewed regarding dementia disclosure form | |
| Director of Nursing | Interviewed regarding service plans and infection control |
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