Inspection Report Summary
The most recent inspection on October 10, 2024, identified several deficiencies including issues with timely physician notification after a resident fall, fire drill frequency, environmental cleanliness, medication labeling and dating, and clinical record accuracy. Earlier inspections showed a pattern of deficiencies related to resident care, documentation, medication management, and safety procedures, with substantiated complaints involving resident-to-resident sexual abuse and failure to update service plans. Complaint investigations also cited problems with infection control, meal provision during isolation, and failure to report and investigate allegations of misappropriation of resident property. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history reflects ongoing challenges with compliance in multiple areas without a clear pattern of sustained improvement.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
13.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
221% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
80 residents
Based on a October 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 80
Deficiencies: 8
Date: Oct 10, 2024
Visit Reason
This visit was for a State Residential Licensure Survey conducted on October 9 and 10, 2024.
Findings
The facility was found deficient in several areas including failure to promptly notify a resident's physician after a fall with injury, failure to conduct quarterly fire drills on each shift, failure to maintain clean and good repair environment related to carpet condition, failure to follow physician's orders for treatment of skin tears and abrasions, failure to keep the kitchen clean and in good repair, failure to properly date insulin pens and vials, failure to properly label over-the-counter medications, and failure to ensure accurate clinical records related to readmission assessment and sutures.
Deficiencies (8)
Failed to promptly notify the resident's physician of a significant change in status related to a fall with injury for 1 of 7 residents reviewed.
Failed to ensure fire drills were conducted quarterly on each shift.
Failed to maintain an environment that was clean and in good repair related to stained, torn and frayed carpet for 3 of 3 units throughout the facility.
Failed to follow physician's orders for the treatment of skin tears and abrasions for 2 of 7 residents reviewed.
Failed to keep the kitchen clean and in good repair related to buildup of grime and grease on food prep equipment, uncovered trash can, dust on lighting fixtures, and undated food in freezer.
Failed to ensure insulin pens and multi-dose insulin vials were dated upon opening and expired pens were not in use for 1 of 2 medication carts observed.
Failed to properly label over-the-counter medications with the resident's full name and physician's name for 1 of 2 medication carts observed and 4 of 4 residents.
Failed to ensure clinical records were accurately documented related to a readmission assessment and sutures for 1 of 7 residents reviewed.
Report Facts
Residential Census: 80
Survey Dates: 2
Deficiency Completion Dates: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in relation to findings about failure to notify physician, audits, and corrective actions | |
| Executive Director | Interviewed regarding fire drills and kitchen sanitation findings | |
| Maintenance Supervisor | Interviewed regarding fire drill records | |
| Culinary Director | Interviewed regarding kitchen sanitation concerns | |
| LPN 1 | Observed during medication cart inspection |
Inspection Report
Follow-Up
Census: 73
Deficiencies: 0
Date: Sep 26, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00437975 completed on 7/18/24.
Complaint Details
Complaint IN00437975 - Corrected
Findings
Rittenhouse Village at Portage was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of Complaint IN00437975.
Report Facts
Residential Census: 73
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 2
Date: Jul 18, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00437975 regarding allegations of resident to resident sexual abuse and failure to update service plans related to sexual behaviors.
Complaint Details
Complaint IN00437975 was substantiated with state deficiencies cited at R0052 and R0217 related to allegations of resident to resident sexual abuse and failure to update service plans.
Findings
The facility failed to prevent resident to resident sexual abuse involving two Memory Care residents (Residents B and C) despite known sexual behaviors. Additionally, the facility failed to update and revise the residents' service plans to reflect these behaviors. Multiple interviews, observations, and record reviews confirmed inappropriate sexual behaviors and inadequate interventions.
Deficiencies (2)
Facility failed to prevent resident to resident sexual abuse despite known sexual behaviors for 2 of 2 Memory Care residents reviewed.
Facility failed to ensure residents' service plans were updated and revised related to sexual behaviors for 2 of 2 residents reviewed.
Report Facts
Residential Census: 78
Medication dosage increase: 150
Behavior log review period: 6
Audit frequency: 5
Audit duration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 3 | Registered Nurse | Reported incidents of sexual behaviors between residents and documented progress notes. |
| Memory Care Unit Director | Provided interviews regarding monitoring and interventions for Residents B and C. | |
| CNA 2 | Certified Nursing Assistant | Interviewed regarding Resident C's behavior towards Resident B. |
| CNA 4 | Certified Nursing Assistant | Interviewed regarding observations of Resident C's interactions with Resident B. |
| Director of Nursing | DON | Interviewed about awareness of incidents and responsibility for updating service plans. |
| Administrator | Interviewed about awareness of incidents and facility policies. |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 2
Date: Apr 1, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00430595 regarding state deficiencies related to the allegations cited at R0217 and R0349.
Complaint Details
Complaint IN00430595 was investigated and state deficiencies related to the allegations were cited at R0217 and R0349.
Findings
The facility failed to ensure that service plans were updated and signed by residents according to changes in condition for 2 of 12 residents reviewed. Additionally, the facility failed to follow Physician's Orders related to insulin administration for 3 of 3 residents reviewed.
Deficiencies (2)
Failure to ensure the Service Plan was signed by the resident and revised according to the resident's change in condition for 2 of 12 residents reviewed.
Failure to ensure Physician's Orders were followed related to insulin administration for 3 of 3 residents reviewed.
Report Facts
Residential Census: 87
Residents reviewed for Service Plans: 12
Residents affected for Service Plan deficiency: 2
Residents reviewed for insulin administration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Pawlak | Executive Director | Interviewed regarding service plan and insulin administration deficiencies |
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 3
Date: Feb 1, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00421674, which alleged deficiencies related to resident care and facility compliance.
Complaint Details
Complaint IN00421674 was substantiated with state deficiencies cited at R185, R240, and R349 related to the allegations.
Findings
The facility was found deficient in ensuring functional resident call systems, providing scheduled assistance with activities of daily living (showers), and maintaining accurate and complete clinical records related to skin conditions and wound care for residents.
Deficiencies (3)
Failed to ensure every resident had a functional method to call for assistance (Resident B).
Failed to ensure dependent residents received necessary assistance with showers as scheduled (Residents B, C, and D) and failed to follow up on treatment of a new open area (Resident D).
Failed to maintain accurate and complete clinical records related to pressure areas and open wounds, including lack of documentation and follow-up (Resident C).
Report Facts
Residential Census: 88
Dates of showers given or refused: Multiple specific dates listed for Residents B, C, and D in December 2023 and January 2024
Open area measurement: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Pawlak | Executive Director | Interviewed regarding call light system issues and facility compliance |
| CNA 1 | Interviewed about call light system and pager usage | |
| RN 1 | Registered Nurse | Interviewed regarding skin assessments and clinical record documentation |
Inspection Report
Renewal
Census: 89
Deficiencies: 9
Date: Aug 18, 2023
Visit Reason
This visit was for a State Residential Licensure Survey conducted on August 17 and 18, 2023.
Findings
The facility was found noncompliant in multiple areas including failure to have a current Alzheimer's/Dementia Special Care Unit disclosure form, incomplete fire drill documentation and lack of local fire department participation, incomplete background checks for employees, insufficient staff with current first aid certification, lack of maintenance policies and HVAC inspection, outdated resident service plans, improper PRN medication administration without nurse authorization, unapproved menus by a registered dietician, and medication availability issues.
Deficiencies (9)
Failed to have a current Alzheimer's/Dementia Special Care Unit disclosure form.
Failed to ensure fire drills were conducted quarterly on each shift, staff present were documented, and local fire department invited every 6 months.
Failed to ensure background checks were completed using the Indiana State Police Repository prior to employment for 2 of 5 employees.
Failed to ensure at least one staff member with current first aid certification was on duty for 10 of 21 shifts reviewed.
Failed to have written maintenance policies and failed to have an annual HVAC inspection.
Failed to update resident service plans when changes occurred for 3 of 7 residents reviewed.
Failed to ensure PRN medications were administered only upon authorization by a licensed nurse or physician for 1 of 7 residents.
Failed to serve meals from a menu approved by a registered dietician.
Failed to ensure medications were available at all times for 1 of 7 residents reviewed.
Report Facts
Residential Census: 89
Fire drills completed: 3
Employees with incomplete background checks: 2
Shifts without first aid certified staff: 10
Residents with outdated service plans: 3
Residents reviewed for PRN medication issue: 1
Residents reviewed for medication availability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Steffani Dranchak | RN, Director of Nursing | Interviewed regarding Alzheimer's/Dementia disclosure form and medication administration. |
| Unnamed Maintenance Director | Maintenance Director | Interviewed regarding fire drills, maintenance policies, and HVAC inspection. |
| Unnamed Business Office Manager | Business Office Manager | Interviewed regarding Alzheimer's/Dementia disclosure form and background checks. |
| Unnamed Culinary Director | Culinary Director | Interviewed regarding menu approval and food service. |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 2
Date: Apr 27, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00407163 and IN00407214 regarding state deficiencies related to meal provision and infection control practices.
Complaint Details
Complaint IN00407163 cited deficiencies related to meal provision and infection control. Complaint IN00407214 cited deficiencies related to infection control. Both complaints were substantiated with findings at tags R0268 and R0406.
Findings
The facility failed to ensure meals were provided to a resident in COVID-19 isolation and failed to implement proper infection control guidelines including PPE use, monitoring of COVID-19 positive residents, and disinfecting community materials during a COVID-19 outbreak. These deficiencies had the potential to affect all 79 residents.
Deficiencies (2)
Failed to ensure meals were provided to a resident in COVID-19 isolation.
Failed to ensure infection control guidelines were in place and implemented, including improper PPE use, lack of monitoring residents with COVID-19, lack of policy for monitoring COVID-19 residents, and failure to disinfect community materials after activities during a COVID-19 outbreak.
Report Facts
Residents reviewed: 3
Residents potentially affected: 79
Audit duration: 6
Audit frequency: 5
Audit frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Pawlak | Executive Director | Signed the report |
| Director of Nursing | Director of Nursing | Interviewed regarding infection control and meal provision deficiencies and monitoring plans |
| RN 1 | Registered Nurse | Interviewed regarding monitoring of COVID-19 positive residents |
| LPN 1 | Licensed Practical Nurse | Observed improperly donning PPE in isolation room |
| Activity Director | Activity Director | Interviewed regarding failure to disinfect community materials |
| CNA 1 | Certified Nursing Assistant | Interviewed regarding meal delivery to resident in isolation |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 1
Date: Feb 1, 2023
Visit Reason
The visit was conducted for the investigation of Complaint IN00399437 regarding an allegation of misappropriation of resident property.
Complaint Details
Complaint IN00399437 was substantiated. The allegation involved missing money from Resident C's apartment. The Police were notified, but the facility did not report the incident to the Indiana Department of Health within 24 hours as required. The investigation was incomplete at the time of the survey.
Findings
The facility failed to ensure its abuse policy was followed by not reporting the allegation of misappropriation of resident property to the Indiana Department of Health and not thoroughly investigating the allegation for one resident. The Police were notified, but the IDOH was not, and the investigation was incomplete at the time of the survey.
Deficiencies (1)
Failure to report an allegation of misappropriation of resident property to the Indiana Department of Health and failure to thoroughly investigate the allegation for one resident.
Report Facts
Residential Census: 81
Missing money amount: 150
Timeframe for investigation report: 72
Timeframe for reporting to IDOH: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Pawlak | Executive Director | Named as Administrator responsible for facility management and involved in the investigation |
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