Inspection Reports for Hellenic Senior Living of Elkhart
2528 BYPASS ROAD, ELKHART, IN, 46514
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 24, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a pattern of deficiencies primarily involving staff training and documentation, medication management, and emergency preparedness. Prior reports cited issues such as incomplete employee records, missed medication authorizations, and gaps in mental health care planning. Complaint investigations were mostly unsubstantiated, with one substantiated complaint in April 2023 that identified deficiencies in staff first aid certification and medication administration oversight. The facility’s recent clean inspection suggests some improvement following previous findings.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
9.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
131% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
97 residents
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 0
Date: Mar 24, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00455247.
Complaint Details
Complaint IN00455247 was investigated and found to have no related deficiencies; the complaint was not substantiated.
Findings
No deficiencies related to the allegations in Complaint IN00455247 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Report Facts
Residential Census: 97
Inspection Report
Renewal
Census: 98
Deficiencies: 7
Date: Jan 31, 2025
Visit Reason
This visit was for a State Residential Licensure Survey conducted on January 30 and 31, 2025 to assess compliance with state regulations.
Findings
The facility was found noncompliant in multiple areas including employee record documentation, staff training, narcotic medication counts, emergency binder completeness, and mental health care planning. Corrective actions and audits were planned to address these deficiencies.
Deficiencies (7)
Failed to ensure employee records included documented references for 4 of 5 staff members reviewed.
Failed to ensure employee records included job specific orientation documentation for 1 of 5 staff members reviewed.
Failed to ensure staff members received dementia training annually for 1 of 5 staff members reviewed.
Failed to ensure staff members received tuberculosis (TB) 2nd step testing upon hire and TB annual risk assessments for 5 of 5 staff members reviewed.
Failed to ensure narcotics were counted and documented every shift for 3 of 3 narcotic count log books reviewed.
Failed to ensure emergency information binders were accurate and complete with all required resident information for 19 of 98 residents.
Failed to ensure a comprehensive care plan for major mental illness was completed for 1 of 7 residents reviewed.
Report Facts
Residents present: 98
Narcotic count log signatures missing: 16
Residents with incomplete emergency binder info: 19
Residents reviewed for mental health care plan: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Robinson | Director of Clinical Services | Signed report and referenced as DON in interviews |
| Business Office Manager | Interviewed regarding employee record deficiencies | |
| QMA 6 | Staff member with missing employee record documentation and TB testing | |
| Server 8 | Staff member with missing employee record documentation and TB testing | |
| ADON | Staff member with missing employee record documentation and TB testing | |
| CNA 9 | Staff member with missing employee record documentation, job orientation, and TB testing | |
| Cook 7 | Staff member missing annual dementia training and TB testing |
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 0
Date: Apr 16, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00428574 at Hellenic Senior Living of Elkhart.
Complaint Details
Complaint IN00428574 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00428574 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 4
Date: Jan 4, 2024
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaints IN00423494 and IN00424063.
Complaint Details
Complaints IN00423494 and IN00424063 were investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies were cited related to the complaints. However, deficiencies were found related to medication administration authorization, insulin administration technique, timely medication availability and administration, and accurate clinical record documentation.
Deficiencies (4)
Failed to ensure authorizations for as needed (PRN) medications administered by a Qualified Medication Aide (QMA) were documented in the medical record for 1 of 7 residents reviewed.
Failed to ensure 1 of 1 nursing staff observed administering injectable medication followed professional standards of practice; specifically, insulin pens were not primed prior to administration.
Failed to ensure medications were obtained timely and administered timely for 3 of 5 residents observed and 1 of 5 clinical records reviewed.
Failed to ensure clinical records had medical diagnoses accurately documented for 1 of 5 residents reviewed.
Report Facts
Residents reviewed for PRN medications: 7
Residents observed for medication administration: 5
Residents with medication administration issues: 3
Residents with clinical record documentation issues: 1
Residential Census: 117
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Perry | Administrator | Provided facility policies and interviews related to medication administration and clinical record documentation |
| LPN 3 | Observed administering insulin incorrectly and interviewed regarding medication administration | |
| Director of Nursing | DON | Interviewed regarding medication administration practices and clinical record documentation |
Inspection Report
Complaint Investigation
Census: 118
Deficiencies: 0
Date: Nov 30, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00422851 and IN00416644 at Hellenic Senior Living of Elkhart.
Complaint Details
Complaint IN00422851 and Complaint IN00416644 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00422851 and IN00416644 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Report Facts
Residential Census: 118
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 0
Date: Aug 16, 2023
Visit Reason
This visit was conducted for the investigation of two complaints, IN00410224 and IN00410493.
Complaint Details
Investigation of Complaint IN00410224 and IN00410493 found no deficiencies related to the allegations; facility was in compliance.
Findings
No deficiencies related to the allegations in either complaint were cited. The facility was found to be in compliance with relevant regulations.
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 3
Date: Apr 27, 2023
Visit Reason
This visit was for the investigation of complaints IN00403955 and IN00404124. Complaint IN00403955 resulted in state deficiencies related to the allegations, while complaint IN00404124 had no deficiencies related to the allegations.
Complaint Details
Complaint IN00403955 was substantiated with related deficiencies cited at R0246 and R0296. Complaint IN00404124 had no deficiencies related to the allegations.
Findings
The facility failed to ensure staff met First Aid training certification requirements affecting 24 of 174 shifts reviewed. Additionally, the facility failed to ensure a Qualified Medication Aide (QMA) received authorization from a licensed nurse prior to administering PRN medication for one resident. The facility also failed to ensure nursing staff observed residents consuming their medications during administration for three residents.
Deficiencies (3)
Staff failed to meet First Aid training certification requirements affecting 24 of 174 shifts reviewed.
Qualified Medication Aide administered PRN medication without authorization from a licensed nurse for one resident.
Nursing staff failed to observe residents consuming their medications during administration for three residents.
Report Facts
Shifts not covered with personnel certified in First Aid: 24
Residents observed receiving medication: 5
Residents affected by medication observation deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Huttel | Interim Executive Director | Signed as Laboratory Director's or Provider/Supplier Representative. |
| QMA 5 | Qualified Medication Aide | Named in findings related to unauthorized administration of PRN medication and improper medication observation. |
| Administrator in Training | Interviewed regarding staff certification and facility policies. |
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 15
Date: Jan 24, 2023
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of multiple complaints (IN00399277, IN00395908, IN00393740, IN00392938, IN00387877, IN00375572, IN00375518).
Complaint Details
Complaint IN00399277 - Substantiated with no deficiencies cited. Complaint IN00395908 - Substantiated with no deficiencies cited. Complaint IN00393740 - Substantiated with no deficiencies cited. Complaint IN00392938 - Substantiated with deficiencies cited at R0036. Complaint IN00387877 - Unsubstantiated due to lack of evidence. Complaint IN00375572 - Substantiated with no deficiencies cited. Complaint IN00375518 - Substantiated with no deficiencies cited.
Findings
The facility had multiple deficiencies including failure to notify family of hospital transfers, incomplete transfer/discharge documentation, incomplete semiannual evaluations and weights, lack of CPR and first aid certified staff on all shifts, incomplete orientation documentation, fire drills not completed timely, sanitation issues in laundry and kitchen, incomplete emergency information files, missing comprehensive mental health care plans, and missing annual health statements and tuberculosis screenings.
Deficiencies (15)
Failed to inform resident's representative of hospital transfer for 1 of 15 residents reviewed (Resident G).
Failed to ensure pertinent transfer and resident clinical information was completed for 1 of 3 residents reviewed for hospitalization (Resident 5).
Failed to ensure fire drills were completed timely; only October, November, and December 2022 drills documented.
Failed to ensure CPR and first aid certified staff were present on all shifts.
Failed to ensure general orientation documentation was available for 10 of 10 employee records reviewed.
Failed to ensure dryer vents were free from lint buildup in 6 of 6 dryers reviewed.
Failed to ensure semiannual evaluations were completed for 7 of 15 residents reviewed.
Failed to ensure weights were obtained on admission and semiannually for 9 of 15 residents reviewed.
Failed to ensure service plans were signed by resident or representative for 5 of 15 residents reviewed.
Failed to ensure food was labeled, dated, covered, stored properly, and kitchen sanitation maintained.
Failed to provide transfer and discharge documentation for 3 of 15 residents reviewed.
Failed to maintain complete and accurate emergency information files for 6 of 12 residents reviewed.
Failed to develop comprehensive mental health care plans within 30 days for 5 of 6 residents with major mental illness.
Failed to provide physician's annual health statements for 11 of 15 residents reviewed.
Failed to provide Mantoux tuberculosis screening upon admission and annually for 9 of 15 residents reviewed.
Report Facts
Survey dates: 2023-01-24 to 2023-01-27
Residential Census: 119
Deficiencies cited: 15
Fire drills documented: 3
Employees without CPR certification: 3
Employees without first aid certification: 7
Dryers with lint buildup: 6
Residents missing semiannual evaluations: 7
Residents missing signed service plans: 5
Residents missing annual health statements: 11
Residents missing Mantoux TB screening: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hemmington Mwanza | Executive Director | Signed report and involved in oversight |
| Director of Nursing | Interviewed multiple times regarding deficiencies and policies | |
| Administrator in Training | Provided policies and information during interviews | |
| Chef | Interviewed regarding kitchen sanitation | |
| Maintenance Director | Interviewed regarding dryer lint buildup |
Viewing
Loading inspection reports...
