Inspection Report Summary
The most recent inspection on March 24, 2025, found no deficiencies related to the complaints investigated. Earlier inspections showed a pattern of deficiencies primarily involving medication storage and administration, food handling and storage, personnel certification, and documentation of resident care and training. Prior reports also noted substantiated complaints of verbal abuse and safety issues related to smoking policy violations, including a fire incident, but no fines or enforcement actions were listed in the available reports. Most complaint investigations were unsubstantiated or corrected upon follow-up visits. The facility’s inspection history shows some recurring issues but also evidence of correction and compliance in more recent visits.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
19% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
82 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: 82
Deficiencies: 0
Date: Mar 24, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00454601 and IN00455564.
Complaint Details
Complaint IN00454601 and IN00455564 were investigated; no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations in complaints IN00454601 and IN00455564 were cited. The facility was found to be in compliance with relevant regulations.
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 4
Date: Dec 30, 2024
Visit Reason
This visit was for a State Residential Licensure Survey which included the investigation of Complaint IN00431867.
Complaint Details
Complaint IN00431867 was investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies were related to the complaint allegations. Deficiencies were cited related to personnel certification, food and nutritional services, and pharmaceutical services including lack of CPR and first aid certification for staff on certain shifts, improper food labeling and storage, improper handwashing and food handling, and improper medication storage with loose pills found in medication carts.
Deficiencies (4)
Failed to ensure personnel on third shift had CPR and first aid certification for 3 of 7 days reviewed.
Failed to maintain current and accurate personnel records; one CNA had expired certification.
Failed to ensure food was stored and served appropriately; unlabeled food items in freezer, spice rack, and resident refrigerator; improper handwashing and food handling observed.
Failed to ensure proper storage of medication; loose pills found in 3 of 6 medication carts observed.
Report Facts
Survey dates: December 26, 27, and 30, 2024
Personnel certification deficiency days: 3
Certified Nurse Aide reviewed: 12
Medication carts reviewed: 6
Loose pills observed: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katie Goldsberry | Residential Care Administrator | Signed report and involved in facility administration |
| CNA 15 | Certified Nurse Aide | Found to have expired certification during record review |
| Director of Nursing | DON | Interviewed regarding expired CNA certification and medication storage policies |
| Qualified Medicine Aide 7 | QMA | Interviewed regarding medication storage and loose pills |
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 0
Date: Feb 15, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00428110.
Complaint Details
Complaint IN00428110 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: 83
Deficiencies: 0
Date: Jul 6, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00409363.
Complaint Details
Complaint IN00409363 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00409363 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Report Facts
Facility number: 11274
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 12
Date: May 8, 2023
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaints IN00405259 and IN00405141.
Complaint Details
Complaint IN00405259 and IN00405141 were investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies were cited related to the complaints investigated. Deficiencies were cited related to failure to investigate and respond to resident grievances, expired administrator license, lack of dementia-specific training and TB screening for staff, incomplete semiannual resident evaluations and service plans, medication administration errors, failure to follow diet orders, unsanitary food storage conditions, and improper medication storage and record keeping.
Deficiencies (12)
Failed to ensure an investigation and response were completed for resident filed grievances for 2 of 8 residents.
Facility failed to have a licensed administrator; current administrator's license was expired.
Failed to provide documentation of staff completing minimum dementia-specific training annually for 3 of 5 employees reviewed.
Failed to screen employees for tuberculosis annually for 3 of 5 employees reviewed.
Failed to ensure semiannual evaluations were completed or signed by resident or responsible party for 5 of 8 residents reviewed.
Failed to ensure resident weights were obtained as ordered for 4 of 8 residents reviewed.
Failed to ensure service plans were completed or signed by resident and/or responsible party for 6 of 8 residents reviewed.
Failed to ensure medications were given as prescribed for 1 of 5 residents observed; medication cup with loose pills found in medication cart.
Failed to ensure diets were followed as ordered for 1 of 8 residents; resident not provided mechanical soft diet as ordered.
Failed to ensure food was stored appropriately; food not labeled in dry storage or refrigerator, pitchers of liquid unlabeled, damaged kitchen equipment.
Failed to have a written policy and procedure for medication record keeping including narcotic count for 4 of 4 days of the survey.
Failed to ensure proper storage of medication; loose and unlabeled pills found in multiple medication carts.
Report Facts
Residents present: 90
Survey dates: May 3, 4, 5, 8, 2023
Deficiency completion date: 2023
Loose pills found: 51
Loose pills found: 10
Loose pills found: 5
Loose pills found: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Becky Ougel | Director of Nursing | Named in relation to multiple findings including grievance follow-up, staff training, TB screening, and medication administration |
| RN 5 | Registered Nurse | Named in relation to lack of dementia training and TB screening |
| QMA 7 | Qualified Medication Aide | Named in relation to lack of dementia training and TB screening |
| LPN 9 | Licensed Practical Nurse | Named in relation to lack of dementia training and TB screening |
| Administrator | Named in relation to expired license | |
| QMA 21 | Named in relation to medication administration observation | |
| QMA 17 | Named in relation to medication cart cleaning | |
| LPN 3 | Licensed Practical Nurse | Named in relation to medication administration error |
Inspection Report
Follow-Up
Census: 95
Deficiencies: 0
Date: Mar 28, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00397975 completed on December 30, 2022.
Complaint Details
Complaint IN00397975 was corrected.
Findings
Riverwalk Communities was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of Complaint IN00397975.
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 2
Date: Dec 30, 2022
Visit Reason
This visit was for the investigation of complaints IN00397975, IN00397997, and IN00394464. Complaints IN00397975 and IN00397997 were substantiated, while complaint IN00394464 was unsubstantiated due to lack of evidence.
Complaint Details
Complaint IN00397975 was substantiated with state deficiencies cited. Complaint IN00397997 was substantiated with no deficiencies cited. Complaint IN00394464 was unsubstantiated due to lack of evidence.
Findings
The facility failed to ensure resident safety from an accidental hazard related to smoking policy violations, resulting in a fire involving Resident G's wheelchair. The facility also failed to prevent Resident G from retaining smoking supplies in her room, creating a health and safety hazard. Multiple observations confirmed cigarette ashes and smoking materials inside the building, and staff failed to enforce the smoking policy or conduct room inspections as required.
Deficiencies (2)
Failed to ensure resident safety from an accidental hazard by not following facility smoking policy, resulting in a fire involving Resident G's wheelchair.
Failed to prevent a resident from retaining smoking supplies in their room causing a health and safety issue to other residents (Resident G).
Report Facts
Residential Census: 96
Survey dates: 3
Written warnings given to Resident G: 2
Smoking policy education meeting date: Jan 16, 2023
Town hall meeting date: Jan 25, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Becky Ougel | Director of Nursing | Interviewed regarding the fire incident and smoking policy enforcement |
| Assistant Director of Nursing | Provided information about residents smoking in the building and smoking policy | |
| Director of Clinical Compliance | Interviewed about the fire incident, smoking policy, and room inspections | |
| Housekeeping Supervisor | Reported complaints about residents smoking and lack of notification to management | |
| Local Fire Department Chief Fire Investigator | Investigated the wheelchair fire and determined cause was not battery related | |
| QMA 4 | Qualified Medication Aide | Reported Resident G was in bed when fire alarm went off |
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 2
Date: Nov 7, 2022
Visit Reason
This visit was for the investigation of complaints IN00390847 and IN00390879, in conjunction with a Post Survey Revisit to previous complaints IN00371551 and IN00381248 completed on June 9, 2022.
Complaint Details
Complaint IN00390847 was substantiated with state deficiencies cited related to verbal abuse. Complaint IN00390879 was unsubstantiated due to lack of evidence.
Findings
The facility was found to have substantiated verbal abuse by an employee towards two residents and failed to ensure medications were administered properly to two of three residents reviewed. Deficiencies related to residents' rights and pharmaceutical services were cited.
Deficiencies (2)
Facility failed to ensure residents were free from verbal abuse by an employee towards two residents.
Facility failed to ensure medications were given as prescribed for 2 of 3 residents reviewed for medication administration.
Report Facts
Residential Census: 97
Missed medication doses: 7
Missed medication doses: 10
Inspection Report
Follow-Up
Census: 97
Deficiencies: 0
Date: Nov 7, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00371551 and IN00381248 completed on June 9, 2022, and was conducted in conjunction with the Investigation of Complaints IN00390847 and IN00390879.
Complaint Details
This visit was related to complaint investigations IN00371551, IN00381248, IN00390847, and IN00390879. Complaints IN00371551 and IN00381248 were corrected.
Findings
Riverwalk Communities was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of Complaints IN00371551 and IN00381248. Complaints IN00371551 and IN00381248 were corrected.
Report Facts
Residential Census: 97
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