Inspection Report Summary
The most recent inspection on May 30, 2025, found the facility in compliance with no deficiencies noted during the complaint investigation. Earlier inspections showed a mixed pattern with several citations related mainly to infection control, life safety code violations, and medication management. Prior deficiencies included issues with cleaning and disinfecting resident glucometers, securing hazardous items on the dementia unit, and multiple life safety code concerns such as obstructed fire alarm pull stations and sprinkler system maintenance. Complaint investigations were mostly unsubstantiated, except for one substantiated infection control issue in April 2025 that was addressed. The facility’s recent clean inspection suggests some improvement following earlier findings, particularly in infection prevention and life safety compliance.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
6.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
62% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
100% occupied
Based on a April 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
May 30, 2025
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00456768 completed on April 16, 2025.
Findings
Envive of Muncie was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00456768 completed on April 16, 2025; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 36
Capacity: 36
Deficiencies: 1
Apr 15, 2025
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00457515, IN00456613, IN00456677, IN00456768, IN00457079) regarding the facility.
Findings
The facility was found deficient in infection prevention and control practices related to the cleaning and disinfecting of resident glucometers during medication administration, affecting 5 of 5 residents reviewed. Other complaints were not substantiated with deficiencies.
Complaint Details
Complaint IN00456768 was substantiated with federal/state deficiencies cited at F880 related to infection prevention and control. Other complaints (IN00457515, IN00456613, IN00456677, IN00457079) had no deficiencies related to the allegations.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure staff followed facility cleaning protocol for resident glucometers to reduce risk of contamination and spread of infection during medication administration. | SS=E |
Report Facts
Residents reviewed for infection control: 5
Census: 36
Total licensed capacity: 36
Medicare residents: 3
Medicaid residents: 30
Other payor residents: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Roberta A Shull | Executive Director | Signed report as facility representative |
| LPN 1 | Named in infection control deficiency for failure to disinfect glucometers | |
| RN 2 | Registered Nurse | Interviewed regarding glucometer cleaning procedures |
| Director of Nursing | Director of Nursing | Interviewed and responsible for monitoring staff compliance with disinfection procedures |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 34
Deficiencies: 0
Dec 26, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00448578.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00448578 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 5
Medicaid census: 26
Other payor census: 3
Inspection Report
Re-Inspection
Census: 40
Capacity: 60
Deficiencies: 0
Oct 31, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
Willowbend Living Center was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinklered except for two storage sheds.
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 20, 2024
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure survey conducted on August 15, 2024.
Findings
Willowbend Living Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 39
Capacity: 60
Deficiencies: 4
Sep 11, 2024
Visit Reason
The survey was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Life Safety Code requirements, including issues with the kitchen hood extinguishing system, obstructed fire alarm pull station, improperly installed sprinkler escutcheon, and lack of properly maintained spare sprinklers. Corrective actions were implemented and acknowledged by facility staff.
Severity Breakdown
SS=E: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to provide an approved method for returning cooking appliances to their approved design location after maintenance and cleaning. | SS=E |
| One manual fire alarm pull station was obstructed by double fire doors held open by a magnetic holder. | SS=E |
| Sprinkler head in Resident Room #101 had an improperly installed escutcheon with a significant gap around the sprinkler head and ceiling. | SS=E |
| Sprinkler system was not maintained with spare sprinklers held in protective slots within the cabinet. | SS=E |
Report Facts
Certified beds: 60
Census: 39
Number of employees potentially affected: 5
Number of residents potentially affected: 12
Number of residents potentially affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Bohannon | HFA | Signed the report as Laboratory Director or Provider/Supplier Representative |
| Maintenance Director | Interviewed and acknowledged deficiencies related to fire safety and maintenance | |
| Regional Support Representative | Interviewed and acknowledged deficiencies related to fire safety and maintenance | |
| Administrator | Present at exit conference acknowledging findings |
Inspection Report
Renewal
Census: 40
Capacity: 40
Deficiencies: 1
Aug 15, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from August 11 to August 15, 2024.
Findings
The facility failed to ensure potentially hazardous items were safely secured on the secured dementia unit, potentially impacting 11 of 13 mobile residents. Hazardous items such as hand sanitizer gel, denture tablets, and razors were found unsecured in an unlocked cabinet.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure potentially hazardous items were safely secured on the dementia unit, exposing 11 of 13 mobile residents to potential harm. | SS=E |
Report Facts
Residents on secured dementia unit: 13
Mobile residents potentially impacted: 11
Residents requiring staff assistance for mobility: 2
Hand sanitizer gel bottles: 2
Denture cleaning tablets: 90
Disposable razors: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Bohanon | HFA | Laboratory Director's or Provider/Supplier Representative's signature on the report |
| Dementia Unit Manager | Interviewed regarding the unsecured cabinet on the dementia unit |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 34
Deficiencies: 0
Feb 27, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00429130 and IN00429151.
Findings
No deficiencies related to the allegations in complaints IN00429130 and IN00429151 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00429130 and IN00429151 were investigated; no deficiencies related to the allegations were cited.
Report Facts
Census Bed Type: 34
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 27
Census Payor Type - Other: 5
Inspection Report
Complaint Investigation
Census: 35
Capacity: 35
Deficiencies: 0
Jan 11, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00425202.
Findings
No deficiencies related to the allegations are cited. Willowbend Living Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Investigation of Complaint IN00425202.
Complaint Details
Investigation of Complaint IN00425202 found no deficiencies related to the allegations.
Report Facts
Census: 35
Total Capacity: 35
Medicare Census: 2
Medicaid Census: 31
Other Payor Census: 2
Inspection Report
Life Safety
Census: 38
Capacity: 60
Deficiencies: 0
Oct 4, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
Willowbend Living Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Participation in Medicare/Medicaid. The facility is a one-story, fully sprinklered building with a fire alarm system and smoke detectors in resident areas. Two storage sheds were not sprinklered.
Report Facts
Facility capacity: 60
Census: 38
Inspection Report
Renewal
Census: 34
Capacity: 34
Deficiencies: 1
Sep 15, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from September 11 to 15, 2023.
Findings
The facility failed to fully implement their antibiotic stewardship policy regarding initiation of antibiotic treatments for 4 of 4 residents reviewed. The facility uses McGeer's Criteria but had not used the Loeb Minimum Criteria for initiation of antibiotics. The Director of Nursing and primary medical providers have been educated on the antibiotic stewardship policy, and a monitoring tool has been implemented to ensure appropriate antibiotic use.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to implement antibiotic stewardship policy regarding initiation of antibiotic treatments for 4 of 4 residents reviewed for infection surveillance (Residents 5, 8, 114, and 27). | SS=D |
Report Facts
Census SNF/NF beds: 34
Census total residents: 34
Medicare residents: 2
Medicaid residents: 30
Other payor residents: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Bohanon | HFA | Laboratory Director or Provider/Supplier Representative signature on report |
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 15, 2023
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure of the facility.
Findings
Willowbend Living Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 35
Capacity: 35
Deficiencies: 0
Aug 22, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00415144.
Findings
No deficiencies related to the allegations are cited. Willowbend Living Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Investigation of Complaint IN00415144.
Complaint Details
Complaint IN00415144 - No deficiencies related to the allegations are cited.
Report Facts
Census: 35
Total Capacity: 35
Medicare Census: 2
Medicaid Census: 32
Other Payor Census: 1
Inspection Report
Complaint Investigation
Census: 37
Capacity: 37
Deficiencies: 0
May 9, 2023
Visit Reason
This visit was for the investigation of Complaint IN00401765.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Complaint IN00401765 - No deficiencies related to the allegations are cited.
Report Facts
Census: 37
Total Capacity: 37
Medicaid Census: 35
Other Payor Census: 2
Inspection Report
Complaint Investigation
Census: 35
Capacity: 35
Deficiencies: 0
Apr 18, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00403760.
Findings
No deficiencies related to the allegations of Complaint IN00403760 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00403760; no deficiencies related to the allegations were cited.
Report Facts
Census Bed Type: 35
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 31
Census Payor Type - Other: 3
Inspection Report
Complaint Investigation
Census: 40
Capacity: 40
Deficiencies: 0
Feb 1, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00395822 and IN00397662.
Findings
Both complaints were substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant federal and state regulations.
Complaint Details
Complaint IN00395822 - Substantiated with no deficiencies cited. Complaint IN00397662 - Substantiated with no deficiencies cited.
Report Facts
Census Bed Type: 40
Census Payor Type - Medicare: 11
Census Payor Type - Medicaid: 28
Census Payor Type - Other: 1
Inspection Report
Re-Inspection
Census: 34
Capacity: 60
Deficiencies: 0
Oct 28, 2022
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 08/29/22 was performed to verify compliance with fire safety and licensure requirements.
Findings
Willowbend Living Center was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire regulations, and the 2012 NFPA 101 Life Safety Code. The facility was fully sprinklered except for two storage sheds and had appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 60
Census: 34
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 8, 2022
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure survey conducted on August 1, 2022.
Findings
Willowbend Living Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 37
Capacity: 60
Deficiencies: 16
Aug 29, 2022
Visit Reason
The survey was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the 2012 NFPA 101 Life Safety Code. Multiple deficiencies were identified including issues with smoke barrier doors, means of egress obstructions, exit door accessibility, exit discharge surfaces, emergency lighting, exit signage, hazardous area enclosures, cooking facilities, sprinkler system maintenance, corridor door latching, and electrical safety.
Severity Breakdown
SS=E: 11
SS=F: 4
SS=C: 1
Deficiencies (16)
| Description | Severity |
|---|---|
| Failed to maintain latching hardware on 2 of 8 smoke barrier doors. | SS=E |
| Failed to ensure 2 of over 50 means of egress were continuously maintained free of obstructions or impediments. | SS=E |
| Failed to ensure means of egress through employee exit was readily accessible and doors opened on first try. | SS=E |
| Failed to ensure 1 of 8 exit discharges had a level walking surface, free of obstructions, and constructed of hard packed all-weather travel surface. | SS=E |
| Failed to provide exterior emergency lighting for all exits; unknown if connected to generator. | SS=F |
| Failed to ensure exit sign near Employee Lounge was marked with directional indicators correctly. | SS=F |
| Failed to maintain hazardous area protection for hot oil popcorn popper and storage room door lacked self-closing device. | SS=E |
| Failed to ensure staff were instructed in the use of the UL 300 hood system in the kitchen and correct fire extinguisher use. | SS=E |
| Failed to install kitchen range hood system filters with drip trays as required by NFPA 96. | SS=E |
| Failed to replace sprinkler system gauges every 5 years or document testing by comparison with calibrated gauge. | SS=F |
| Sprinkler heads in laundry area were loaded or covered with foreign material. | SS=F |
| Failed to maintain ceiling construction in kitchen closet around sprinkler heads. | SS=F |
| Failed to ensure corridor doors positively latched into frames to resist passage of smoke. | SS=E |
| Failed to provide ground fault circuit interrupter (GFCI) protection for exterior outlet near kitchen entrance. | SS=E |
| Failed to ensure electrical splices were made in a junction box. | SS=E |
| Failed to maintain documentation of electrical outlet receptacle testing at all resident rooms. | SS=C |
Report Facts
Certified beds: 60
Census: 37
Residents potentially affected: 20
Residents potentially affected: 20
Staff potentially affected: 15
Employees potentially affected: 8
Employees potentially affected: 4
Residents potentially affected: 20
Employees potentially affected: 6
Residents potentially affected: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Named in multiple findings and interviews regarding deficiencies and corrective actions | |
| Administrator in Training | Named in multiple findings and interviews regarding deficiencies and corrective actions | |
| Dietary Manager | Named in kitchen UL 300 hood system training deficiency |
Inspection Report
Renewal
Census: 36
Capacity: 36
Deficiencies: 4
Aug 1, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from July 26 to August 1, 2022.
Findings
The facility was found deficient in multiple areas including failure to assist a resident with meals in a dignified manner, failure to prevent resident-to-resident abuse, improper insulin administration technique, and failure to dispose of expired dairy products.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure a resident was assisted with a meal in a dignified manner. | SS=D |
| Failure to prevent resident to resident abuse in a dependent resident. | SS=D |
| Failure to ensure staff were trained on proper technique when administering insulin from an insulin pen. | SS=D |
| Failure to ensure dairy products were disposed of on the expiration date to avoid resident consumption of expired or contaminated food. | SS=D |
Report Facts
Census: 36
Total Capacity: 36
Deficiencies cited: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 4 | Licensed Practical Nurse | Named in meal assistance dignity finding and insulin administration observation |
| LPN 5 | Licensed Practical Nurse | Named in insulin administration observation |
| CNA 6 | Certified Nurse's Aide | Interviewed regarding resident to resident abuse |
| RN 7 | Registered Nurse | Interviewed regarding resident to resident abuse |
| Cook 10 | Dietary Staff | Named in expired milk handling deficiency |
| Administrator | Interviewed regarding multiple findings including meal assistance, resident abuse, and expired food | |
| Director of Nursing | DON | Interviewed regarding insulin administration and staff education |
| Dietary Manager | Interviewed regarding expired milk handling and policy compliance |
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