Inspection Report Summary
The most recent inspection on July 16, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a pattern of deficiencies primarily involving personnel records, employee health screenings, fire safety documentation, medication administration, and food service sanitation. Complaint investigations were generally unsubstantiated or found no deficiencies related to the allegations, with two substantiated complaints not resulting in citations. There were no fines, immediate jeopardy findings, or enforcement actions listed in the available reports. The facility’s inspection history suggests some improvement over time, with the most recent visit showing compliance after prior issues.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
3.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
17% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
82 residents
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 0
Date: Jul 16, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00461693.
Complaint Details
Complaint IN00461693 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00461693 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: 3
Date: May 22, 2025
Visit Reason
This visit was for a State Residential Licensure Survey which included the investigation of complaints IN00459428 and IN00455940.
Complaint Details
Complaint IN00459428 and Complaint IN00455940 were investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies were cited related to the complaints investigated. However, deficiencies were found related to personnel records including missing pre-employment references for 2 employees, incomplete orientation checklists for 2 employees, and missing tuberculosis testing and annual health screenings for 6 employees.
Deficiencies (3)
Facility failed to ensure employees' files contained pre-employment references for 2 of 5 employees reviewed (CNA 3 and CNA 6).
Facility failed to ensure employees completed general and specific orientation checklists for 2 of 10 employees reviewed (CNA 6 and CNA 7).
Facility failed to maintain health records including tuberculosis testing and annual health screenings for 6 of 10 employees reviewed (Dementia Care Director 2, QMA 4, QMA 5, QMA 8, CNA 9, CNA 10).
Report Facts
Residential Census: 83
Employees reviewed for pre-employment references: 5
Employees missing pre-employment references: 2
Employees reviewed for orientation checklists: 10
Employees missing orientation checklists: 2
Employees reviewed for TB testing and health screenings: 10
Employees missing TB testing and health screenings: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Martinez | Executive Director | Signed the report. |
| Director of Nursing | Interviewed regarding missing pre-employment references, orientation documentation, and TB records. | |
| CNA 3 | Certified Nursing Assistant | Employee missing pre-employment references. |
| CNA 6 | Certified Nursing Assistant | Employee missing pre-employment references and orientation checklist. |
| CNA 7 | Certified Nursing Assistant | Employee missing orientation checklist. |
| Dementia Care Director 2 | Employee missing TB testing and health screenings. | |
| QMA 4 | Qualified Medication Assistant | Employee missing TB testing and health screenings. |
| QMA 5 | Qualified Medication Assistant | Employee missing TB testing and health screenings. |
| QMA 8 | Qualified Medication Assistant | Employee missing TB testing and health screenings. |
| CNA 9 | Certified Nursing Assistant | Employee missing TB testing and health screenings. |
| CNA 10 | Certified Nursing Assistant | Employee missing TB testing and health screenings. |
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 8
Date: May 31, 2024
Visit Reason
This visit was for a State Residential Licensure Survey which included the Investigation of Complaint IN00414606.
Complaint Details
Complaint IN00414606 was investigated and no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found deficient in several areas including failure to conduct monthly fire drills for two months, incomplete pre-employment reference checks, insufficient first aid certification coverage for staff, a staff member working without valid CNA certification, incomplete resident service plan reviews and signatures, medication administration error involving incorrect dosage of blood pressure medication, and food service sanitation and safety violations.
Deficiencies (8)
Failed to conduct monthly fire drills for November and December 2023.
Failed to ensure reference checks were completed prior to employment for 1 of 5 employees reviewed (Cook 6).
Failed to ensure staff on duty had first aid certification for 9 of 21 shifts reviewed between 5/22/24 and 5/28/24.
Failed to ensure a staff member working as a CNA held a valid CNA/HHA certification (CNA 1).
Failed to ensure a resident's service plan was reviewed and updated at least semi-annually (Resident 3).
Failed to ensure service plans were signed by the resident, responsible party, or Power of Attorney for 1 of 10 residents (Resident 4).
Failed to ensure the correct dose of blood pressure medication (amlodipine) was provided to 1 of 5 residents (Resident 1).
Failed to maintain food preparation and serving areas in accordance with state and local sanitation and safe food handling standards, including lack of hair coverings, uncovered equipment, improperly stored food items, and blocked electrical panels.
Report Facts
Residential Census: 67
Fire drills missed: 2
Shifts without first aid certification: 9
Residents reviewed for service plans: 10
Medication doses: 5
Medication doses: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mitchell Backs | Executive Director | Named in relation to fire drill deficiencies and interviews |
| QMA 5 | Qualified Medication Aide | Named in relation to medication administration error |
| Cook 6 | Named in relation to missing pre-employment reference checks | |
| CNA 1 | Certified Nurse Aide | Named in relation to lack of valid CNA/HHA certification |
| Nurse Manager | Involved in medication administration error investigation | |
| Dietary Manager | Named in relation to food service sanitation deficiencies |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 0
Date: May 31, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00409654.
Complaint Details
Complaint IN00409654 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00409654 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Inspection Report
Renewal
Census: 55
Deficiencies: 3
Date: Jan 19, 2023
Visit Reason
This visit was for a State Residential Licensure Survey conducted on January 17, 18, and 19, 2023 to assess compliance with state regulations.
Findings
The facility was found noncompliant in several areas including failure to document fire department participation in fire drills, improper food storage and handling practices, and failure to complete required two-step and annual Tuberculin skin testing for residents.
Deficiencies (3)
Failed to provide documentation showing fire department was invited or attended fire drills every six months.
Failed to prevent freezer burn, cover, label, and date foods; discard expired foods; keep perishable foods off the floor; monitor dishwasher temperatures; ensure staff wore hair nets; and keep personal items out of the kitchen.
Failed to administer two-step Tuberculin skin tests and annual TB skin tests for 6 of 7 residents reviewed.
Report Facts
Residents affected: 55
Residents reviewed for TB testing: 7
Residents noncompliant with TB testing: 6
Fire drills required annually: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mitch Backs | Executive Director | Signed report and provided policies during interviews |
| Maintenance Director | Indicated no fire department invitations to drills in 2022 | |
| Director of Food Services | Interviewed regarding food storage and handling deficiencies | |
| Sous Chef | Observed without hair net during cooking | |
| Director of Nursing | Indicated residents should receive TB screening annually and acknowledged missing documentation |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 0
Date: Aug 24, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00388042.
Complaint Details
Complaint IN00388042 was substantiated but no deficiencies related to the allegations were cited.
Findings
The complaint was substantiated; however, 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.
Report Facts
Residential Census: 60
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 0
Date: Aug 1, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00373292.
Complaint Details
Complaint IN00373292 was substantiated but no deficiencies related to the allegations were cited.
Findings
The complaint was substantiated; however, 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.
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