Inspection Reports for Avalon Senior Living
6021 S ARLINGTON AVENUE, IN, 46237
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 3, 2025, found deficiencies related to water temperature regulation, medication monitoring, food sanitation, and medication documentation. Earlier inspections showed a mix of issues, including a substantiated complaint in September 2024 for failure to prevent elopement and protect residents in the memory care unit. Other deficiencies involved a late license renewal application and a missing First Aid certified staff member on one shift. Complaint investigations were mostly unsubstantiated except for the noted elopement case. The facility’s inspection history shows ongoing challenges with medication management, safety protocols, and regulatory compliance, with no clear pattern of overall improvement or decline.
Deficiencies (last 2 years)
Deficiencies (over 2 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
4
3
2
1
0
Census
Latest occupancy rate
75 residents
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 4
Date: Mar 3, 2025
Visit Reason
This visit was for a State Residential Licensure Survey and included the investigation of Complaint IN00454166.
Complaint Details
Complaint IN00454166 was investigated and no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the complaint allegations were cited. However, deficiencies were found related to water temperature regulation in apartments, medication monitoring for a resident, food sanitation practices, and medication disposition documentation.
Deficiencies (4)
Facility failed to ensure water temperatures were maintained between 100 and 120 degrees Fahrenheit for 4 of 11 apartments observed.
Facility failed to monitor residents for effectiveness of medication and notify the physician of undesirable effects for 1 of 7 residents reviewed (Resident 37).
Facility failed to ensure foods were served in a sanitary and safe manner; staff hair was not covered while in the kitchen food preparation area (Cook 2).
Facility failed to ensure drug dispositions for all medications, including non-controlled substances, were accounted for or documented for 2 of 2 closed record residents reviewed (Residents 81 and 82).
Report Facts
Apartments with water temperature issues: 4
Residents reviewed for medication monitoring: 7
Kitchen observations: 4
Residents with medication disposition issues: 2
Resident 37 weight gain: 35
Residential Census: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jerrilynn Morehous | Executive Director | Signed the report and referenced in plan of correction. |
| Director of Maintenance | Interviewed regarding water temperature policy and monitoring. | |
| Administrator | Interviewed regarding water temperature requirements and policies. | |
| Director of Nursing | Interviewed regarding medication monitoring and documentation. | |
| Cook 2 | Observed and interviewed regarding hair covering in kitchen. | |
| Director of Culinary Services | Responsible for inservicing cooks and auditing hair covering compliance. |
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 0
Date: Jan 13, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00445693 and IN00448503 at Avalon Senior Living.
Complaint Details
Complaints IN00445693 and IN00448503 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00445693 and IN00448503 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Residential Census: 76
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 1
Date: Sep 24, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00443559 regarding allegations of resident neglect related to elopement incidents in the memory care unit.
Complaint Details
Complaint IN00443559 was substantiated with state deficiencies cited related to neglect and failure to prevent elopement of residents in the memory care unit.
Findings
The facility failed to protect the rights of 3 residents (Residents B, C, and D) who exited the secured memory care unit without staff supervision, exposing them to unsafe wandering and potential harm. The facility lacked a policy on elopements at the time of the survey.
Deficiencies (1)
Facility failed to protect residents' right to be free from neglect by allowing cognitively impaired residents to exit the secured memory care unit without supervision.
Report Facts
Residential Census: 51
Number of residents affected: 3
Dates of elopement incidents: 9/8/24, 9/11/24, and 9/18/24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jerrilynn Morehous | Executive Director | Signed the report |
| Director of Nursing | Interviewed regarding elopement incidents | |
| CNA 1 | Interviewed about residents exiting the memory care unit | |
| Administrator | Interviewed about facility policy on elopements |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 0
Date: Sep 6, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00437738.
Complaint Details
Complaint IN00437738 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations were cited. Avalon Senior Living was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Inspection Report
Renewal
Deficiencies: 1
Date: May 9, 2024
Visit Reason
This was an offsite Licensure Investigation Survey conducted to review the facility's compliance with license renewal requirements.
Findings
The facility failed to submit a timely renewal application for its residential care license before the expiration date of March 31, 2024. The renewal application was postmarked April 23, 2024, which did not meet the requirement of submission at least 45 days prior to license expiration.
Deficiencies (1)
Failure to submit a renewal application at least 45 days prior to license expiration.
Report Facts
Days late for renewal application: 23
Days required for renewal submission: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jerrilynn Morehous | Executive Director | Signed the report and plan of correction |
Inspection Report
Original Licensing
Census: 18
Deficiencies: 1
Date: Feb 29, 2024
Visit Reason
This visit was for an Initial State Residential Licensure Survey conducted on February 28 and 29, 2024.
Findings
The facility failed to ensure that all shifts had at least one staff member who was First Aid certified for 1 of 14 shifts reviewed. Specifically, on the third shift of 2/22/24, no staff member was verified to be First Aid certified.
Deficiencies (1)
Failed to ensure all shifts had at least one staff member who was First Aid certified for 1 of 14 shifts reviewed.
Report Facts
Residential Census: 18
Shifts reviewed: 14
Completion date for plan of correction: Mar 18, 2024
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