Inspection Reports for Hellenic Senior Living of Mishawaka
1540 SOUTH LOGAN STREET, MISHAWAKA, IN, 46544
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 19, 2025, identified multiple deficiencies related to sanitation, safety standards, resident weight monitoring, mental health screenings and care plans, kitchen conditions, and hand hygiene during medication administration. Earlier inspections showed a pattern of issues with medication administration, resident monitoring after falls, and environmental sanitation, with some complaints substantiated and others not. Deficiencies primarily involved resident care documentation, medication and monitoring procedures, and facility cleanliness. Complaint investigations were mostly unsubstantiated except for one in November 2024 where failures in monitoring and evaluating a resident after falls resulted in significant harm. The inspection history indicates ongoing challenges with compliance in several areas without a clear trend of overall improvement.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
74% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
112 residents
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 112
Deficiencies: 6
Date: Mar 19, 2025
Visit Reason
This visit was for a State Residential Licensure Survey, including the investigation of three complaints (IN00449170, IN00451454, and IN00452967).
Complaint Details
The investigation of complaints IN00449170, IN00451454, and IN00452967 found no deficiencies related to the allegations.
Findings
The facility was found deficient in multiple areas including sanitation and safety standards, failure to obtain semi-annual weights for residents, unsanitary kitchen conditions, incomplete mental health screenings and care plans, and failure to perform proper hand hygiene during medication administration. No residents were found to be directly affected by these deficiencies, but all residents could have been potentially impacted.
Deficiencies (6)
Facility failed to maintain a clean environment on 3 of 3 floors (floors 1, 2, and 3) with scuffed doors, stained carpets, and debris in light fixtures.
Failed to obtain semi-annual weights for 2 of 7 residents reviewed.
Failed to maintain sanitary conditions in the kitchen, including broken thermometer in walk-in cooler, food stored on the floor, and incomplete temperature logs.
Failed to ensure mental health screening and assessment was completed for 2 of 5 residents reviewed for mental health needs.
Failed to ensure a care plan was developed in cooperation with a mental health provider for 2 of 5 residents reviewed for mental health needs.
Staff failed to perform hand hygiene before and after administration of eye drops and insulin for 2 of 5 residents reviewed during medication administration.
Report Facts
Census: 112
Residents without semi-annual weights: 2
Residents without mental health screening: 2
Residents without mental health care plan: 2
Residents reviewed for weights: 7
Residents reviewed for mental health needs: 5
Residents reviewed for medication administration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Huttel | Executive Director | Signed the report |
| QMA 3 | Observed failing to perform hand hygiene before and after medication administration | |
| Maintenance Director | Interviewed regarding building maintenance and cleaning schedule | |
| DON | Director of Nursing | Interviewed regarding weight monitoring, mental health screenings, policies, and hand hygiene |
| Culinary Director | CD | Interviewed regarding kitchen sanitation and temperature logs |
| ED | Executive Director | Provided hand hygiene policy |
Inspection Report
Renewal
Deficiencies: 1
Date: Jan 7, 2025
Visit Reason
This was an offsite Licensure Investigation Survey conducted to review the facility's compliance with licensure renewal requirements.
Findings
The facility failed to timely renew their license before the expiration date of November 30, 2024, as the renewal application and payment were received after the required 45-day prior deadline.
Deficiencies (1)
Facility failed to ensure timely renewal of license before expiration on November 30, 2024.
Report Facts
Days late for renewal application: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Huttel | Executive Director | Signed the report as the facility representative. |
Inspection Report
Follow-Up
Census: 120
Deficiencies: 0
Date: Dec 26, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00443940 and IN00436132, completed on November 7, 2024.
Complaint Details
This visit was related to complaints IN00443940 and IN00436132, both of which were corrected.
Findings
Both complaints IN00443940 and IN00436132 were found to be corrected. The facility was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR.
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 2
Date: Nov 21, 2024
Visit Reason
This visit was for the investigation of Complaint IN00446891 related to allegations of failure to provide proper monitoring and evaluation after a resident's falls.
Complaint Details
Complaint IN00446891 - State deficiencies related to the allegations are cited at R0214 and R0052. The complaint involved failure to monitor and evaluate a resident after falls, failure to notify the physician, and failure to document fall assessments.
Findings
The facility failed to ensure proper monitoring, evaluation, and physician notification following multiple unwitnessed falls of Resident B, who was on anticoagulant medication. These failures resulted in significant harm requiring emergency surgery. Additionally, fall assessments were not documented following two of the falls.
Deficiencies (2)
Failed to ensure services for monitoring and evaluation were provided to a resident after an unwitnessed fall and failed to implement interventions to prevent further falls, resulting in significant harm.
Failed to document fall assessments following two falls for Resident B.
Report Facts
Residential Census: 111
Falls: 3
In-service completion date: Nov 22, 2024
Review frequency: 5
Review duration: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Huttel | Executive Director | Signed the report |
| LPN 4 | Licensed Practical Nurse | Named in findings for failure to assess and document after falls |
| Director of Nursing | Named in findings for involvement in fall incidents and failure to ensure proper assessments | |
| Certified Nursing Assistant 5 | Found Resident B after first fall | |
| Regional Nurse Consultant | Provided policies and stated expectations for fall assessments and physician notification |
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 3
Date: Nov 6, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00443940, IN00443664, IN00438450, and IN00436132 regarding medication administration and related care issues.
Complaint Details
Complaints IN00443940, IN00443664, IN00438450, and IN00436132 were investigated. Deficiencies were cited related to medication administration and blood pressure monitoring. Some complaints had no deficiencies cited.
Findings
The facility failed to administer medications as ordered for 3 residents, failed to obtain daily blood pressure assessments for 2 residents as ordered, and failed to notify the physician when medications were not administered or refused for 3 residents. Staff documentation and adherence to medication administration policies were deficient.
Deficiencies (3)
Failed to administer medications as ordered by the physician for 3 of 3 residents reviewed (Residents B, C & D).
Failed to follow physician orders and ensure daily blood pressure assessments were obtained for 2 of 3 residents reviewed (Residents C and D).
Failed to ensure the physician was notified when 3 of 3 residents reviewed did not receive medications as ordered or refused medications as ordered (Residents B, C & D).
Report Facts
Residential Census: 107
Dates medications not administered: 30
Dates blood pressure not documented: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Huttel | Executive Director | Signed the report |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration and documentation concerns |
| Regional Director of Clinical Operations | Regional Director of Clinical Operations | Provided current medication administration policy and confirmed facility practices |
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 10
Date: Mar 6, 2024
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaints IN00428787 and IN00428869.
Complaint Details
Complaint IN00428787 and Complaint IN00428869 were investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies were cited related to the complaints investigated. The facility was found noncompliant in several areas including fire drill documentation, employee dementia training, sanitation and safety standards, evaluation documentation, food and nutritional services, pharmaceutical services, clinical records, emergency information files, and infection control practices.
Deficiencies (10)
Failed to complete a fire drill every quarter on each shift as required.
Failed to ensure dementia training was completed for 2 of 5 employees reviewed.
Failed to ensure dryer vents were free from lint buildup in 2 of 6 dryers reviewed.
Failed to ensure admission weights were completed for 4 of 8 residents reviewed.
Failed to ensure food was labeled/dated and stored in a sanitary manner; walk-in freezer, dishwasher, floors, and walls were not clean; failed to serve meals in a sanitary manner.
Failed to properly secure medications in residents' rooms for 2 of 4 residents reviewed.
Failed to ensure medications were available for administration for 1 of 2 residents reviewed.
Failed to maintain accurate narcotic shift-to-shift count sheets.
Failed to ensure emergency information files were accurate and complete for 3 of 9 residents reviewed.
Failed to ensure infection control practices were followed during an insulin injection observation.
Report Facts
Residents present: 120
Fire drills required: 12
Residents reviewed for weights: 8
Residents with missing admission weights: 4
Employees reviewed for dementia training: 5
Employees missing dementia training: 2
Dryers reviewed for lint buildup: 6
Residents reviewed for medication storage: 4
Residents with unsecured medications: 2
Residents reviewed for medication availability: 2
Residents with unavailable medications: 1
Residents reviewed for emergency information: 9
Residents with incomplete emergency information: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Huttel | Executive Director | Signed the report |
| LPN 7 | Licensed Practical Nurse | Observed failing to wear gloves and improper injection technique during insulin administration |
| Maintenance Director | Interviewed regarding fire drills and medication cabinet lock repair | |
| Director of Nursing | Interviewed regarding medication storage, medication availability, narcotic counts, and emergency information | |
| Culinary Service Director | Interviewed regarding kitchen sanitation and food safety | |
| QMA 6 | Interviewed regarding medication cabinet lock and narcotic counts | |
| Cook 4 | Observed improper glove use and food handling | |
| Server 3 | Observed improper handling of cups during meal service | |
| CNA 5 | Interviewed regarding dryer lint screen cleaning | |
| Administrator | Provided policies and information during survey | |
| Executive Director | Interviewed regarding dementia training policy |
Inspection Report
Complaint Investigation
Census: 123
Deficiencies: 0
Date: Dec 28, 2023
Visit Reason
This visit was conducted for the Investigation of Complaint IN00423637 and included a Residential COVID-19 Quality Assurance Walk Through.
Complaint Details
Complaint IN00423637 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with relevant regulations regarding the complaint and COVID-19 quality assurance.
Inspection Report
Complaint Investigation
Census: 125
Deficiencies: 0
Date: Nov 30, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00420984.
Complaint Details
Complaint IN00420984 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00420984 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Report Facts
Residential Census: 125
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 0
Date: Aug 2, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00414025 and IN00414073.
Complaint Details
Investigation of Complaints IN00414025 and IN00414073 found no deficiencies related to the allegations; facility was in compliance.
Findings
No deficiencies related to the allegations in complaints IN00414025 and IN00414073 were cited. The facility was found to be in compliance with applicable regulations.
Inspection Report
Complaint Investigation
Census: 131
Deficiencies: 0
Date: Apr 27, 2023
Visit Reason
This visit was for a State Residential Licensure Survey and included the investigation of Complaints IN00391811, IN00399182, and IN00392459.
Complaint Details
Complaints IN00391811, IN00399182, and IN00392459 were investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies related to the allegations in the complaints were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the State Residential Licensure Survey and the investigation of the complaints.
Report Facts
Residential census: 131
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