Inspection Report Summary
The most recent inspection on July 22, 2024, found deficiencies related to personnel health screening, resident service plan signatures, and food storage practices, though no deficiencies were cited related to the complaint investigated. Earlier inspections showed a range of issues including fire drill compliance, staff certification, resident care, food safety, documentation, and infection control, with no deficiencies linked to complaint allegations. Inspectors cited recurring themes around food storage and safety as well as documentation and staff health screening. Complaint investigations were generally unsubstantiated or found no deficiencies related to the allegations. The inspection history shows some ongoing challenges with regulatory compliance, particularly in food safety and documentation, with no clear pattern of improvement or worsening.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
12% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
48 residents
Based on a July 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 3
Date: Jul 22, 2024
Visit Reason
This visit was for a State Residential Licensure Survey which included the Investigation of Complaint IN00436512.
Complaint Details
Complaint IN00436512 was investigated and no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the complaint allegations were cited. However, deficiencies were found related to personnel health screening, resident service plan signatures, and food storage practices.
Deficiencies (3)
Facility failed to ensure a health screen was conducted prior to working with residents for 2 of 5 employee files reviewed (Dementia Care Director and Qualified Medication Aide 3).
Facility failed to ensure service plans were signed by the resident and/or resident representative for 5 of 7 resident records reviewed (Residents R47, R10, R31, R9, and R44).
Facility failed to ensure adequate food storage regarding expired food in the main kitchen, uncovered seasonings, and lack of thermometer in the holding refrigerator.
Report Facts
Residential Census: 48
Employees lacking health screens: 2
Resident records lacking signed service plans: 5
Containers of seasonings with open lids: 4
Expired mango salsa containers: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Helga A Bradley | Executive Director | Signed the report as Laboratory Director's or Provider/Supplier Representative |
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 8
Date: Apr 19, 2023
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaint IN00403549.
Complaint Details
Complaint IN00403549 was investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies related to the complaint allegations were cited. The facility was cited for failure to conduct monthly fire drills for 7 of 12 months, insufficient staff with CPR and first aid certification on some shifts, failure to assist a resident per service plan resulting in a resident found deceased, failure to serve food at safe temperatures, inadequate food storage and sanitation practices, incomplete clinical documentation for wound treatment, and failure to maintain infection control practices during meal service.
Deficiencies (8)
Failed to ensure fire drills were conducted monthly for 7 of 12 months reviewed.
Failed to ensure a staff member with CPR and first aid certification was on site during all shifts for some days reviewed.
Failed to ensure a resident was assisted per his level of care and service plan for frequent checks; resident later found deceased.
Failed to ensure cold food were served at appropriate temperatures and food temperatures were obtained prior to serving.
Failed to ensure adequate food storage regarding undated and expired food, dishwasher functionality, use of hairnets, and thermometer presence in refrigerators and freezers.
Failed to ensure staff were knowledgeable regarding sanitation standards, food handling, meal service, dish machine monitoring, temperature monitoring, and use of hairnets.
Failed to have complete documentation regarding a wound treatment completed by facility staff without a physician order.
Failed to ensure infection control practices were maintained during meal service for observed residents.
Report Facts
Fire drills missed: 7
Residents present: 30
Dates of fire drills conducted: 5
Days without CPR certified staff: 2
Days without first aid certified staff: 3
Food temperature: 52
Dishwasher temperature: 108
Wound size: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Lay-Wolf | RN, RDCS | Laboratory Director's or Provider/Supplier Representative's signature on report. |
| LPN 5 | Licensed Practical Nurse | Observed assisting residents during meal service without performing hand hygiene between contacts. |
| Resident Care Personnel 3 | Observed preparing food without hairnet and acknowledged no temperature logs for dish machine. | |
| Resident Care Personnel 8 | Observed preparing food without hairnet. | |
| Director of Memory Care | Observed preparing food without hairnet. | |
| Director of Nursing | DON | Interviewed regarding wound care and staff responsibilities. |
| Care Services Manager | CSM | Responsible for audits and corrective actions related to wound care and infection control. |
| Executive Director | ED | Responsible for fire drill compliance and food safety corrective actions. |
| Regional Director of Clinical Services | RDCS | Provided training and interviews related to fire drills, CPR certification, wound care, and infection control. |
| Dietary Manager | DM | Re-trained on food temperature and storage requirements. |
| Dietary Assistant 4 | Observed discarding expired food and interviewed about kitchen practices. |
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 0
Date: Nov 3, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00393411.
Complaint Details
Complaint IN00393411 was investigated and found to be unsubstantiated due to lack of evidence.
Findings
The complaint IN00393411 was found to be unsubstantiated due to lack of evidence, and the facility was found to be in compliance with relevant regulations.
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