Inspection Report Summary
The most recent inspection on April 29, 2025, found no deficiencies related to the complaint investigated at that time. Earlier inspections showed some deficiencies primarily related to food safety practices, such as improper storage and labeling of food items, and recordkeeping issues with emergency medical code status. A substantiated complaint in December 2023 involved misappropriation of a resident’s property by a former employee who was terminated following the investigation. Other complaint investigations were unsubstantiated, and no fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s inspection history shows some recurring issues with food service and documentation, but recent complaint investigations have not identified new deficiencies.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
2.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
145 residents
Based on a April 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 145
Deficiencies: 0
Date: Apr 29, 2025
Visit Reason
This visit was for a State Residential Licensure Survey and included the Investigation of Complaint IN00457778.
Complaint Details
Complaint IN00457778 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 410 IAC 16.2-5 regarding the State Residential Licensure Survey and the complaint investigation.
Report Facts
Residential Census: 145
Inspection Report
Complaint Investigation
Census: 144
Deficiencies: 0
Date: Apr 3, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00454811.
Complaint Details
Complaint IN00454811 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations are cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Inspection Report
Renewal
Census: 143
Deficiencies: 2
Date: May 14, 2024
Visit Reason
This visit was for a State Residential Licensure Survey conducted on May 13 and 14, 2024, to assess compliance with state regulations.
Findings
The facility was found deficient in maintaining sanitary food preparation and serving areas, specifically improper storage of steam table pans. Additionally, the facility failed to maintain accurate emergency medical code status records for two residents.
Deficiencies (2)
Failed to ensure steam table pans were stored in a sanitary manner; pans were wet and contained debris.
Failed to maintain accurate records related to emergency medical code status for 2 of 9 residents reviewed.
Report Facts
Residents affected: 143
Residents reviewed for code status: 9
Residents with inaccurate code status records: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Townsley | Executive Director | Signed the report and provided documents during the survey. |
| Dietary Manager (DM 20) | Observed during kitchen tour and interviewed regarding food storage. | |
| Licensed Practical Nurse 6 | Signed Resident 4's emergency medical code status document. | |
| Qualified Medication Aide (QMA) 21 | Interviewed regarding emergency medical code status documentation. |
Inspection Report
Complaint Investigation
Census: 145
Deficiencies: 0
Date: Feb 29, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00427765.
Complaint Details
Complaint IN00427765 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: 147
Deficiencies: 0
Date: Jan 9, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00425418 and IN00425617.
Complaint Details
Investigation of Complaints IN00425418 and IN00425617 found no deficiencies related to the allegations; facility was in compliance.
Findings
No deficiencies related to the allegations in complaints IN00425418 and IN00425617 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Inspection Report
Complaint Investigation
Census: 148
Deficiencies: 1
Date: Dec 1, 2023
Visit Reason
The visit was conducted for the investigation of Complaint IN00421665 regarding allegations of misappropriation of resident property.
Complaint Details
Complaint IN00421665 was substantiated with findings related to misappropriation of Resident B's property. The employee involved was suspended pending investigation and subsequently terminated. No other residents reported similar issues after investigation.
Findings
The facility failed to ensure residents were free from misappropriation of property for 1 of 7 residents reviewed (Resident B). Fraudulent charges were made on Resident B's debit card by a former employee (HHA 2), who was terminated following the investigation.
Deficiencies (1)
Failed to ensure residents were free from misappropriation of property for 1 of 7 residents reviewed (Resident B).
Report Facts
Residential Census: 148
Fraudulent charges amounts: 45.94
Fraudulent charges amounts: 2.26
Residents interviewed: 3
Residents reviewed for misappropriation: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Townsley | Executive Director | Named as Executive Director involved in investigation and interview of employee HHA 2. |
| HHA 2 | Home Health Aide employee terminated due to misappropriation of Resident B's property. |
Inspection Report
Census: 147
Deficiencies: 4
Date: Apr 20, 2023
Visit Reason
This visit was for a State Residential Licensure Survey conducted on April 20 and 21, 2023.
Findings
The facility failed to ensure food items were properly dated upon opening in the kitchen, and lacked proper temperature monitoring in refrigerators and freezers. Multiple food items were observed without visible open dates, and some refrigerators lacked internal thermometers.
Deficiencies (4)
Food items in the kitchen were not dated upon opening, including ice cream, strawberries, yogurt, and other items.
No thermometer was found inside the walk-in refrigerator and reach-in cooler, and temperature logs were incomplete or improperly recorded.
Uncovered food items were found in the reach-in cooler without visible dates.
Unlabeled and undated containers, including ranch dressing and a thick white liquid, were observed in the dementia unit kitchenette.
Report Facts
Residential Census: 147
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Townsley | Executive Director | Signed the report and involved in scheduling staff in-service for corrective actions |
| Cook 2 | Observed food items without dates and provided information about food handling practices | |
| Dietary Manager | Conducted tour of dementia unit kitchenette and provided information about undated food items |
Inspection Report
Complaint Investigation
Census: 145
Deficiencies: 0
Date: Apr 6, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00405604 and included a Residential COVID-19 Quality Assurance Walk Through.
Complaint Details
Complaint IN00405604 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 410 IAC 16.2-5 regarding the complaint investigation and the COVID-19 Quality Assurance Walk Through.
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