Inspection Reports for St Paul’s
3602 SOUTH IRONWOOD DRIVE, SOUTH BEND, IN, 46614
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 16, 2025, identified deficiencies related to fire safety in the kitchen and unsanitary food storage and preparation conditions. Earlier inspections showed a pattern of issues primarily involving food safety and sanitation, medication administration authorization, infection control, and incomplete resident documentation. Complaint investigations were conducted on multiple occasions, with all complaints found to be unsubstantiated or unrelated to cited deficiencies. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. The facility’s inspection history indicates ongoing challenges with food service and safety practices, with no clear trend of improvement or worsening over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
52% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
98 residents
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Census: 98
Deficiencies: 2
Date: Jun 16, 2025
Visit Reason
This visit was for a State Residential Licensure Survey conducted on June 16-17, 2025.
Findings
The facility was found deficient in fire safety measures in the kitchen related to improper storage above the fire sprinkler line, and in food and nutritional services due to unsanitary conditions including ice buildup on frozen food, unlabeled and undated opened bread, and dusty steam table pans. Corrective actions and monitoring plans were established to address these issues.
Deficiencies (2)
Fire safety measures were not followed in 1 of 1 kitchens; food items stored above the 18 inch marked line on the wall of the dry storage room equipped with fire sprinklers.
Failure to store and service food in a clean and sanitary manner including ice buildup on frozen Italian sausage, opened and undated bread, and dusty steam table pans.
Report Facts
Residential Census: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Billhimer | Administrator | Signed as Laboratory Director's or Provider/Supplier Representative |
| Dietary Services Director | Interviewed regarding deficiencies in kitchen and food storage |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 0
Date: Apr 2, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00455562.
Complaint Details
Complaint IN00455562 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00455562 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Inspection Report
Renewal
Census: 87
Deficiencies: 3
Date: Aug 1, 2024
Visit Reason
This visit was for a State Residential Licensure Survey conducted on July 31 and August 1, 2024, to assess compliance with state regulations for residential care facilities.
Findings
The facility was found deficient in several areas including failure to ensure Qualified Medication Aides received prior authorization for PRN medication administration, unsanitary food preparation and storage conditions in kitchens and kitchenettes, and inadequate infection control practices related to hand hygiene during blood sugar and insulin administration.
Deficiencies (3)
Qualified Medication Aides (QMA) failed to receive prior authorization from a licensed nurse before administering PRN medications to residents.
Food was stored, prepared, and served in an unsanitary manner related to cooking equipment, cabinets, and drawers in kitchens and kitchenettes.
Infection control measures were not maintained; specifically, hand hygiene was not performed by staff during blood sugar and insulin administration.
Report Facts
Residential Census: 87
Deficient resident records: 2
Residents observed for insulin administration: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Billhimer | Administrator | Signed the report |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 3
Date: Jun 21, 2023
Visit Reason
This visit was for a State Residential Licensure Survey which included the investigation of Complaint IN00402109.
Complaint Details
Complaint IN00402109 was investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies were cited related to the complaint allegations. However, deficiencies were found related to failure to obtain admission weights, unsafe food handling practices by staff, and incomplete emergency information files for residents.
Deficiencies (3)
Facility failed to obtain an admission weight for 1 of 7 residents reviewed (Resident B).
Facility failed to ensure 2 of 4 staff observed preparing and serving food followed safe food handling standards, potentially affecting all 75 residents.
Facility failed to complete an accurate Resident Emergency File for 5 of 7 residents reviewed (Residents B, C, D, E & H) missing photographs and advance directives.
Report Facts
Residents reviewed for weights: 7
Residents affected by missing admission weight: 1
Staff observed not following safe food handling: 2
Residents potentially affected by food handling deficiency: 75
Residents reviewed for emergency file accuracy: 7
Residents with deficient emergency files: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kris Borkowski | LPN/DON | Director of Nursing named in relation to findings on admission weight and emergency file deficiencies |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 0
Date: Sep 7, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00382438.
Complaint Details
Complaint IN00382438 - Unsubstantiated due to lack of evidence.
Findings
Complaint IN00382438 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
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