Inspection Report Summary
The most recent inspection on April 8, 2025, identified deficiencies related to failure to report an allegation of misappropriation of property, incomplete staff training, and improper food labeling and storage. Earlier inspections showed a pattern of deficiencies primarily involving sanitation, food safety, staff certification, and residents’ rights, including a prior issue with a resident possessing a firearm on the premises. Complaint investigations were mostly unsubstantiated, though some substantiated complaints led to cited deficiencies, particularly around infection control, insulin administration, and environmental maintenance. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows ongoing challenges in maintaining regulatory compliance, with some recurring issues but no clear trend of improvement or worsening over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
7% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
94 residents
Based on a April 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 3
Date: Apr 8, 2025
Visit Reason
This visit was for a State Residential Licensure Survey which included the investigation of Complaint IN00457168 regarding allegations of misappropriation of property.
Complaint Details
Complaint IN00457168 involved allegations of misappropriation of property including missing jewelry and money from Resident B's room. The allegation was not reported to the State Department of Health as required.
Findings
The facility failed to submit a required report to the State Department of Health regarding an allegation of misappropriation of property involving Resident B. Additionally, the facility failed to ensure staff received annual dementia and resident rights training for one staff member, and failed to ensure foods in the kitchen walk-in refrigerator were labeled, dated, and tightly covered.
Deficiencies (3)
Failed to submit a required facility reportable to the State Department of Health regarding an allegation of misappropriation of property involving Resident B.
Failed to ensure staff received annual dementia and resident rights training for 1 of 3 staff reviewed (Cook 2).
Failed to ensure foods in a kitchen walk-in refrigerator were labeled, dated, and tightly covered for 2 of 2 observations.
Report Facts
Residential Census: 94
Number of plates with unlabeled/uncovered cake: 16
Number of staff reviewed for annual training: 3
Number of staff missing annual training: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| JanAnn Caudill | Executive Director | Named in relation to re-education on reporting allegations and corrective actions |
| Cook 2 | Staff member found to have missing annual dementia and resident rights training |
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 0
Date: Jan 23, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00450861.
Complaint Details
Complaint IN00450861 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 applicable regulations regarding the complaint.
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 0
Date: Aug 30, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00440217.
Complaint Details
Complaint IN00440217 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.
Report Facts
Residential Census: 109
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 0
Date: May 24, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00434407.
Complaint Details
Complaint IN00434407 was investigated and found to have no related deficiencies; the complaint was not substantiated.
Findings
No deficiencies related to the allegations in Complaint IN00434407 were cited. The facility was found to be in compliance with applicable regulations.
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 5
Date: May 2, 2024
Visit Reason
This visit was for a State Residential Licensure Survey which included the Investigation of Complaint IN00428972.
Complaint Details
Complaint IN00428972 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 ensuring all shifts had at least one First Aid certified staff member, a CNA had an active certification, the dining room was in good repair, dumpster doors were kept closed and the dumpster area was clean, and service plans were signed and dated by residents or their representatives.
Deficiencies (5)
Facility failed to ensure all shifts had at least one working staff member who was First Aid certified for 9 of 21 shifts reviewed.
Facility failed to ensure a CNA had an active CNA certification prior to working as a CNA for 1 of 9 CNAs reviewed.
Facility failed to ensure the dining room was in good repair; black mold on dining room wall, air conditioner leaks, buckled flooring.
Facility failed to ensure side sliding dumpster doors were kept closed when not in use and dumpster area was free of rubbish.
Facility failed to ensure service plans were signed and dated by the resident or resident's representative for 2 of 7 residents reviewed.
Report Facts
Shifts without First Aid certified staff: 9
CNA shifts worked without valid certification: 47
Residential Census: 114
Employees mentioned
| Name | Title | Context |
|---|---|---|
| JanAnn Caudill | Executive Director | Signed the report and involved in corrective action plans |
| CNA 6 | Certified Nursing Assistant | Worked without valid CNA certification |
| QMA 3 | Qualified Medication Aide | Designated First Aid certified staff member without documentation of certification |
| QMA 4 | Qualified Medication Aide | Designated First Aid certified staff member without documentation of certification |
| QMA 5 | Qualified Medication Aide | Designated First Aid certified staff member without documentation of certification |
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 0
Date: Feb 7, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00423650 and IN00422894.
Complaint Details
Investigation of Complaints IN00423650 and IN00422894 found no deficiencies related to the allegations; facility was in compliance.
Findings
No deficiencies related to the allegations in complaints IN00423650 and IN00422894 were cited. The facility was found to be in compliance with applicable regulations regarding these complaints.
Report Facts
Residential Census: 109
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 0
Date: Nov 20, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00419049, IN00420136, and IN00420794.
Complaint Details
Complaints IN00419049, IN00420136, and IN00420794 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00419049, IN00420136, and IN00420794 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Report Facts
Residential Census: 109
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 0
Date: Aug 28, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00415161.
Complaint Details
Complaint IN00415161 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.
Report Facts
Residential Census: 112
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 2
Date: Jul 26, 2023
Visit Reason
This visit was conducted for the investigation of three complaints (IN00413204, IN00411062, and IN00411186) related to sanitation, safety, and food handling practices at Hellenic Senior Living of Indianapolis.
Complaint Details
The investigation was triggered by complaints IN00413204, IN00411062, and IN00411186. Deficiencies related to these complaints were cited at tags R155 and R273. No residents were found to have been harmed or affected by the deficient practices.
Findings
The facility was found deficient in maintaining a clean staging and dumpster area free of rubbish, and failed to ensure food service staff wore proper hair restraints in the kitchen food preparation area. No residents were harmed, but these deficiencies posed potential risks.
Deficiencies (2)
Facility failed to ensure the staging and dumpster areas were free of rubbish for 2 of 2 observations.
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.
Report Facts
Residential Census: 114
Survey Dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| JanAnn Caudill | Executive Director | Signed the report and involved in monitoring compliance |
| Dietary Manager | Observed during facility tour and kitchen observations; noted hair restraint deficiencies | |
| Cook 2 | Observed during kitchen observations with hair not fully covered | |
| Server 3 | Observed during kitchen observations with hair not covered | |
| Qualified Medication Aide 4 | Observed during kitchen observations with hair not covered | |
| Environmental/Maintenance Director | Responsible for ensuring staging and dumpster areas are free of trash; given instructions during survey |
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 0
Date: Jun 14, 2023
Visit Reason
This visit was conducted for the investigation of two complaints, IN00409753 and IN00409825.
Complaint Details
Complaint IN00409753 and IN00409825 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations in either complaint were cited. The facility was found to be in compliance with applicable regulations regarding these complaints.
Report Facts
Facility number: 14062
Residential Census: 110
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 2
Date: May 19, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00406119 and IN00408970. Complaint IN00406119 resulted in state deficiencies related to sanitation and safety standards, while complaint IN00408970 had no deficiencies cited.
Complaint Details
Complaint IN00406119 was substantiated with deficiencies cited at R0144 related to sanitation and safety standards. Complaint IN00408970 was not substantiated with no deficiencies cited.
Findings
The facility failed to maintain cleanliness and good repair in 1 of 3 rooms and 1 of 2 outside doors observed. Specifically, the East side door was in disrepair with gaps allowing pest entry, and Room 106 had a strong smell of cat urine with two cats present. Corrective actions included plans to replace the door and remediate the odor and damage in Room 106.
Deficiencies (2)
Facility failed to keep the East side door in good repair, with gaps allowing pest entry.
Room 106 smelled strongly of cat urine and had two cats present, indicating failure to maintain cleanliness and reasonable comfort.
Report Facts
Residential Census: 111
Completion Date for Plan of Correction: Jun 30, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| JanAnn Caudill | Executive Director | Signed the report and involved in corrective action communication |
Inspection Report
Follow-Up
Census: 109
Deficiencies: 0
Date: May 10, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the State Residential Licensure Survey completed April 5, 2023, including the PSR to the Investigations of Complaints IN00404718, IN00404885, IN00403205, and IN00404427.
Complaint Details
Complaints IN00404718, IN00404885, IN00403205, and IN00404427 were investigated and found to be corrected.
Findings
Hellenic Senior Living of Indianapolis was found to be in compliance with 410 IAC 16.2-5 regarding the PSR to the State Residential Licensure Survey and the Investigation of the listed complaints. All complaints were corrected.
Report Facts
Residential Census: 109
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 2
Date: Apr 4, 2023
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaints IN00404718, IN00404885, IN00403205, and IN00404427.
Complaint Details
The investigation was related to complaints IN00404718, IN00404885, IN00403205, and IN00404427. State deficiencies related to these allegations were cited at R273.
Findings
The facility was found deficient in sanitation and safety standards related to dumpster area cleanliness and lid closure, and food and nutritional services including improper food labeling, uncovered foods, scoops stored in bulk food containers, and chemicals stored next to food items.
Deficiencies (2)
Facility failed to ensure the dumpster area was free of rubbish and dumpster lids were closed for 3 of 3 dumpster area observations.
Facility failed to ensure foods were served in a sanitary and safe manner; foods were not covered, labeled or dated, scoops were stored in bulk food containers, and chemicals were stored next to food items.
Report Facts
Residential Census: 112
Employees mentioned
| Name | Title | Context |
|---|---|---|
| JanAnn Caudill | Executive Director | Signed the report and referenced in plan of correction. |
| Server 3 | Interviewed regarding dumpster area cleanliness and procedures. | |
| Cook 4 | Interviewed regarding food labeling and storage practices. | |
| Environmental/Maintenance Director | Given instructions to contact vendor for dumpster lid repairs and responsible for ongoing maintenance and checks. | |
| Administrator | Provided current Outdoor Dumpster Procedures document. | |
| Director of Nursing Services | Provided policies on food labeling and storage. | |
| Dining Service Director | Responsible for staff in-service training on food labeling and chemical use. |
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 0
Date: Feb 22, 2023
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00399630, IN00401219, IN00401285, IN00401406, and IN00402150) at Hellenic Senior Living of Indianapolis.
Complaint Details
Complaint IN00399630 - Substantiated with no deficiencies cited. Complaint IN00401219 - Substantiated with no deficiencies cited. Complaint IN00401406 - Substantiated with no deficiencies cited. Complaint IN00401285 - Unsubstantiated due to lack of evidence. Complaint IN00402150 - Unsubstantiated due to lack of evidence.
Findings
The facility was found to be in compliance with relevant regulations regarding the investigated complaints. Three complaints were substantiated but no deficiencies related to the allegations were cited, while two complaints were unsubstantiated due to lack of evidence.
Report Facts
Residential Census: 109
Inspection Report
Follow-Up
Census: 106
Deficiencies: 0
Date: Feb 13, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00397689 completed on December 28, 2022.
Complaint Details
Complaint IN00397689 - Corrected.
Findings
Hellenic Senior Living of Indianapolis was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of Complaint IN00397689. The complaint was corrected.
Report Facts
Residential Census: 106
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 0
Date: Jan 12, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00398291.
Complaint Details
Complaint IN00398291 - Unsubstantiated due to lack of evidence
Findings
Complaint IN00398291 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 investigation.
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 3
Date: Dec 27, 2022
Visit Reason
This visit was for the investigation of complaints IN00395238 and IN00397689, including a COVID-19 Quality Assurance Walk Through.
Complaint Details
Complaint IN00395238 - Substantiated with no deficiencies cited. Complaint IN00397689 - Substantiated with deficiencies cited at R241, R406, and R407 related to insulin administration and infection control.
Findings
Complaint IN00395238 was substantiated with no deficiencies cited. Complaint IN00397689 was substantiated with state deficiencies cited related to insulin administration failures and infection control practices including COVID-19 protocol violations.
Deficiencies (3)
Failed to ensure qualified staff was available to administer insulin to residents with Diabetes Mellitus, resulting in missed insulin doses for three residents.
Failed to implement infection control practices to prevent the spread of COVID-19; COVID-19 positive staff returned to work before completing isolation per facility policy.
Failed to report COVID-19 outbreak cases of employees to the state health department as required.
Report Facts
Residents affected by insulin administration deficiency: 3
Residents census: 109
Dates of missed insulin doses: Multiple dates in December 2022 where residents did not receive insulin or Accucheck monitoring.
COVID-19 positive staff cases: 2
Compliance completion date: Systemic changes and corrective actions to be completed by 2023-01-28.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| JanAnn Caudill | Executive Director | Signed report and involved in directing corrective actions. |
| Director of Nursing (DON) | Interviewed regarding insulin administration issues and involved in corrective action plans. | |
| Qualified Medication Aide (QMA 1) | Reported residents missing insulin doses due to lack of qualified staff. | |
| Administrator | Interviewed regarding COVID-19 positive staff returning to work prematurely and policy awareness. | |
| Employee 1 | Tested positive for COVID-19 and returned to work before isolation completed. | |
| Employee 2 | Tested positive for COVID-19 and returned to work before isolation completed. |
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 0
Date: Nov 14, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00391522, IN00393390, and IN00394048.
Complaint Details
Complaint IN00394048 - Unsubstantiated due to lack of evidence. Complaint IN00391522 - Unsubstantiated due to lack of evidence. Complaint IN00393390 - Substantiated. No deficiencies related to the allegations are cited.
Findings
Complaint IN00394048 and IN00391522 were unsubstantiated due to lack of evidence. Complaint IN00393390 was substantiated but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Residential Census: 114
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 0
Date: Sep 22, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00389253 and IN00390666.
Complaint Details
Complaint IN00389253 - Substantiated with no deficiencies cited. Complaint IN00390666 - Substantiated with no deficiencies cited.
Findings
Both complaints were substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 1
Date: Aug 22, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00388330, which was substantiated with state deficiencies cited related to the allegations.
Complaint Details
Complaint IN00388330 was substantiated. The resident with the handgun was identified as Resident B. The facility contacted local police and state police regarding the firearm. The gun was found to be inoperable at the time. Resident B refused psychological evaluation and denied staff access to his room. Other residents reported feeling unsafe and fearful of Resident B.
Findings
The facility failed to ensure residents' rights were maintained for 8 of 9 residents interviewed. A resident retained a handgun in the facility, violating the admission agreement and causing other residents to feel unsafe.
Deficiencies (1)
Facility failed to ensure residents rights were maintained; a resident retained a handgun in the facility, violating the admission agreement and causing fear among residents.
Report Facts
Residential Census: 116
Number of residents interviewed: 9
Number of residents affected: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding incident with Resident B and firearm; contacted police and state police | |
| Executive Director | Met with resident and wife regarding handgun removal; monitored corrective actions and implemented quality assurance inspections |
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 0
Date: Jul 29, 2022
Visit Reason
This visit was for the investigation of Complaint IN00382935.
Complaint Details
Complaint IN00382935 was unsubstantiated due to lack of evidence.
Findings
The complaint IN00382935 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 investigation.
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