Inspection Report Summary
The most recent inspection on April 24, 2025, identified multiple deficiencies including incomplete advocacy agency contact information, failure to notify physicians of abnormal blood sugars, incomplete dementia training for new staff, missing signed job descriptions, incomplete service plans, and unsanitary food storage and preparation practices. Earlier inspections showed a pattern of issues related to medication administration, notification of abnormal blood sugars, infection control, and documentation, with a substantiated complaint in April 2025 regarding unqualified personnel administering medications. Complaint investigations from prior years were mostly unsubstantiated or found no deficiencies related to the allegations. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history reflects ongoing challenges with regulatory compliance, particularly in medication management, staff training, and food safety, without a clear trend of improvement or worsening.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
75 residents
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 75
Deficiencies: 8
Date: Apr 24, 2025
Visit Reason
This visit was for a State Residential Licensure Survey conducted on April 24 & 25, 2025 to assess compliance with state regulations for assisted living facilities.
Findings
The facility was found deficient in multiple areas including failure to provide complete advocacy agency contact information, failure to notify physicians of abnormal blood sugars for residents, failure to make the most recent annual survey and plan of correction readily available, incomplete dementia training for new staff, missing signed job descriptions in employee records, failure to obtain admission weights for residents, incomplete service plans lacking signatures, and unsanitary food storage and preparation practices in the kitchen.
Deficiencies (8)
Failed to provide phone numbers and addresses at admission and post the phone numbers and addresses of advocacy agencies for all residents.
Failed to notify the physician of abnormal blood sugars for 2 of 8 residents reviewed.
Failed to make readily available the most recent annual survey with the plan of correction for all residents.
Failed to ensure newly hired staff members received six hours of initial dementia training for 2 of 5 staff reviewed.
Failed to ensure employee records included signed job descriptions for 4 of 5 staff members reviewed.
Failed to obtain an admission weight for 1 of 8 residents reviewed.
Failed to ensure service plans were completed, dated and signed by staff and resident/representative for 3 of 7 residents reviewed.
Failed to ensure food was stored and prepared in a sanitary manner in the kitchen, including improperly sealed and dated food items and dirty kitchen utensils.
Report Facts
Residents reviewed for blood sugar notification: 8
Residents reviewed for service plans: 7
Staff reviewed for dementia training: 5
Staff reviewed for signed job descriptions: 5
Residents reviewed for admission weight: 8
Residents in census: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Megan Crooks | Executive Director | Interviewed regarding advocacy agency information and facility policies |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 0
Date: Apr 21, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00457091.
Complaint Details
Complaint IN00457091 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: 73
Deficiencies: 1
Date: Apr 1, 2025
Visit Reason
The visit was conducted as an investigation of Complaint IN00456465 regarding allegations related to medication administration by unqualified personnel.
Complaint Details
Complaint IN00456465 was substantiated with state deficiencies cited related to the allegations at R0241.
Findings
The facility failed to ensure medication administration was completed by qualified personnel, with a high school student passing medications under supervision without proper certification. This potentially affected 56 of 73 residents receiving medications.
Deficiencies (1)
Facility failed to ensure medication administration was completed by qualified personnel, with an unqualified high school student passing medications under supervision.
Report Facts
Residents potentially affected: 56
Residential Census: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Megan Crooks | Executive Director | Signed the report as facility representative. |
Inspection Report
Renewal
Census: 80
Deficiencies: 6
Date: Jun 13, 2024
Visit Reason
This visit was for a State Residential Licensure Survey conducted on June 12 and 13, 2024, to assess compliance with state regulations for Brentwood at Elkhart Assisted Living.
Findings
The facility was found deficient in several areas including failure to notify physicians of abnormal blood sugar levels, improper administration and documentation of PRN medications by QMAs, untimely follow-up on pharmacy recommendations, incomplete emergency information files, lack of comprehensive mental health care plans within 30 days for residents with major mental illness, and inadequate infection control program documentation.
Deficiencies (6)
Failed to inform the physician of blood sugars out of ordered parameter range for 1 of 9 residents reviewed for health services (Resident 6).
Failed to ensure PRN medications administered by a QMA were approved by a licensed nurse for 1 of 8 residents reviewed for medications (Resident 3).
Failed to ensure Pharmacy regimen reviews were followed up on timely for 2 of 8 residents reviewed for Pharmacy recommendations (Residents 3 & 4).
Failed to ensure an emergency information binder was accurate and complete with all required resident information for 3 of 7 residents (Residents 7, 8, & 9).
Failed to complete a comprehensive plan of care within 30 days for 1 of 1 resident reviewed for mental illness (Resident 9).
Failed to maintain an infection control program related to not having an infection control log to monitor infections within the facility.
Report Facts
Residential Census: 80
Deficiencies completion date: Jul 23, 2024
Residents affected by deficiency: 1
Residents affected by deficiency: 1
Residents affected by deficiency: 2
Residents affected by deficiency: 3
Residents affected by deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Ciak | VP of Operations | Signed the report as the provider/supplier representative. |
| Director of Nursing | Interviewed regarding multiple deficiencies including failure to notify physician, PRN medication documentation, pharmacy recommendations, emergency information files, and infection control. |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 0
Date: Nov 30, 2023
Visit Reason
This visit was conducted for the investigation of complaint IN00419405.
Complaint Details
Complaint IN00419405 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaint IN00419405 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the investigation.
Report Facts
Residential Census: 73
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 0
Date: Jun 6, 2023
Visit Reason
This visit was for the Investigation of Residential Complaint IN00409443.
Complaint Details
Complaint IN00409443 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations were cited. Brentwood at Elkhart Assisted Living was found to be in compliance with 410 IAC 16.2-5 in regard to the Investigation of Complaint IN00409443.
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 4
Date: Apr 11, 2023
Visit Reason
This visit was for a State Residential Licensure Survey including the investigation of complaints IN00393300 and IN00402868.
Complaint Details
Investigation of Complaints IN00393300 and IN00402868 found no deficiencies related to the allegations.
Findings
No deficiencies were found related to the complaints. Deficiencies were cited related to food labeling and storage, medication storage and labeling, infection control practices, and missing annual health statements for residents.
Deficiencies (4)
Failed to ensure food was labeled, dated, and stored in a sanitary manner; outdated foods were not removed; coolers were not clean in 1 of 1 kitchens observed.
Failed to date medications when opened, failed to have resident identifiers on ear and eye drop bottles, medication refrigerator had ice buildup and expired supplies, and narcotic medication was not stored safely in 1 medication room and 2 medication carts.
Failed to ensure infection control practices were followed during a blood sugar check, including failure to wash hands before applying gloves.
Failed to obtain annual health statement from physician verifying no evidence of tuberculosis in an infectious stage on admission and yearly thereafter for 5 of 8 residents reviewed.
Report Facts
Residential Census: 68
Dates of survey: April 11 and 12, 2023
Completion dates for systemic changes: Food service changes completed 05/01/2023; Medication service changes completed 05/05/2023; Infection control changes completed 05/01/2023; Annual health statement changes completed 05/05/2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Maupin | Executive Director | Signed report and involved in oversight of audit findings |
| LPN 2 | Observed during medication storage and administration; involved in infection control deficiency | |
| QMA 4 | Observed during medication administration involving spilled medications | |
| Dietary Manager | Interviewed regarding food storage and sanitation deficiencies | |
| Cook 5 | Interviewed regarding food dating and cooler cleanliness |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 0
Date: Sep 1, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00379383.
Complaint Details
Complaint IN00379383 was investigated and found unsubstantiated due to lack of evidence.
Findings
The complaint IN00379383 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with applicable regulations regarding the complaint.
Report Facts
Residential Census: 68
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