The most recent inspection on February 17, 2025, identified a deficiency related to unsecured hazardous materials accessible to residents. Earlier inspections showed a mix of deficiencies, including issues with staff certifications, financial exploitation by a staff member, and safety concerns such as sanitation and water temperature control. Complaint investigations were mostly unsubstantiated, except for a substantiated case of financial exploitation in April 2024, which resulted in staff termination. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s inspection history shows some recurring themes around staff qualifications and safety measures, with no clear pattern of improvement or worsening over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)2.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% better than Indiana average
Indiana average: 4.2 deficiencies/year
Deficiencies per year
86420
2022
2023
2024
2025
Census
Latest occupancy rate49 residents
Based on a February 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
This visit was for a State Residential Licensure Survey conducted on February 17 and 18, 2025.
Findings
The facility failed to ensure potentially hazardous materials were kept secure behind locked doors to prevent resident access on one of the two survey days. Multiple doors including the Mechanical Room, Beauty/Barber Shop, and Maintenance Director Room were found unlocked with hazardous materials and tools accessible.
Deficiencies (1)
Description
Facility failed to ensure potentially hazardous materials were kept secure behind locked doors to prevent resident access.
Report Facts
Residential Census: 49Blocks of rodent poison: 20Spray can sizes: 12Spray bottle sizes: 7Plastic tube sizes: 6Gel sizes: 16Plastic bottle sizes: 8.25Tube sizes: 4Spray can sizes: 19Isopropyl alcohol concentration: 91
This visit was conducted for the investigation of complaints IN00449159 and IN00449516.
Findings
No deficiencies related to the allegations in complaints IN00449159 and IN00449516 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00449159 and Complaint IN00449516 were investigated and found to have no deficiencies related to the allegations.
This visit was conducted for the investigation of Complaint IN00439091.
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.
Complaint Details
Complaint IN00439091 was investigated and found to have no deficiencies related to the allegations.
This visit was for a State Residential Licensure Survey which included the investigation of Complaint IN00431377 regarding allegations of financial exploitation.
Findings
The facility was found noncompliant for failing to protect a resident from financial exploitation by a staff member who misappropriated resident funds. Additional deficiencies included lack of certified First Aid staff on all shifts, a CNA working without current certification, expired pet vaccinations, and a Dietary Manager lacking required food service management qualifications.
Complaint Details
Complaint IN00431377 was substantiated with state deficiencies cited related to allegations of financial exploitation by a Dietary Aide (DA 2) who misappropriated resident funds and was terminated.
Deficiencies (5)
Description
Failed to ensure a resident was free from financial exploitation for 1 of 5 residents reviewed (Resident B).
Failed to ensure all shifts had at least one staff member working who was First Aid certified for 14 of 14 shifts reviewed.
Failed to ensure a Certified Nursing Assistant (CNA 5) had an active CNA certification prior to working as a CNA.
Failed to ensure pets housed in the facility had current rabies vaccinations and annual veterinary examinations for 2 of 5 residents with pets.
Failed to ensure the Dining Service Director met educational and experience requirements for food service management.
Report Facts
Residents reviewed for misappropriation: 5Shifts reviewed for First Aid certification: 14Expired CNA certification: 1Residents with pets lacking current vaccinations: 2Shifts worked by uncertified CNA: 108
Employees Mentioned
Name
Title
Context
DA 2
Dietary Aide
Named in financial exploitation finding; terminated for misappropriation of resident funds
This visit was conducted for the investigation of Complaint IN00423557.
Findings
No deficiencies related to the allegations in Complaint IN00423557 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Complaint Details
Complaint IN00423557 was investigated and found to have no deficiencies related to the allegations.
This visit was for the investigation of Complaint IN00410084.
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.
Complaint Details
Complaint IN00410084 was investigated and found to have no deficiencies related to the allegations.
This visit was for the investigation of Complaint IN00405193.
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.
Complaint Details
Complaint IN00405193 was investigated and found to have no deficiencies related to the allegations.
This visit was for a State Residential Licensure Survey which included the Investigation of Complaint IN00393470.
Findings
The complaint was substantiated but no deficiencies related to the allegations were cited. Deficiencies were found related to personnel tuberculosis screening documentation, sanitation and safety standards regarding dumpster area maintenance, and water temperature control in resident rooms.
Complaint Details
Complaint IN00393470 was substantiated but no deficiencies related to the allegations were cited.
Deficiencies (3)
Description
Failed to document the time a tuberculin test was administered and read for 3 of 5 employees reviewed.
Failed to ensure dumpster container lids and side panel doors were kept closed and the surrounding ground was free of debris for 4 observations.
Failed to maintain water temperatures between 100 and 120 degrees Fahrenheit for 1 of 3 resident rooms observed.
Report Facts
Employees reviewed for TB test documentation: 5Dumpster observations: 4Resident rooms observed for water temperature: 3Water temperature reading: 125Residential Census: 54
Employees Mentioned
Name
Title
Context
Goodwell Chavunduka
Senior Executive Director
Signed letter requesting desk review and identified as facility representative.
Director of Nursing Services
Interviewed regarding tuberculin test reading requirements and water temperature logs.
Maintenance Director
Interviewed regarding dumpster area maintenance and water temperature observations.
Registered Nurse 2
RN
Employee record reviewed for tuberculin test documentation deficiency.
Certified Nursing Assistant 3
CNA
Employee record reviewed for tuberculin test documentation deficiency.
Cook 5
Employee record reviewed for tuberculin test documentation deficiency.
Dietary Staff 7
Interviewed regarding dumpster area maintenance expectations.
This visit was for the Investigation of Complaint IN00389817.
Findings
Complaint IN00389817 was substantiated, but no deficiencies related to the allegation were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Complaint Details
Complaint IN00389817 - Substantiated. No deficiencies related to the allegation are cited.
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