Inspection Reports for Heritage Assisted Living of Union City
204 STAUDT DRIVE, IN, 47390
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 26, 2025, cited a deficiency related to medication administration documentation, which led to a resident receiving duplicate doses of a controlled pain medication. Earlier inspections showed a mix of deficiencies including staffing issues, unsigned service plans, use of unpasteurized eggs, incomplete TB testing, and medication administration by unqualified personnel, with one substantiated complaint resulting in termination of the Director of Nursing. The main themes across reports involved medication management and documentation, resident service plan signatures, and staff qualifications. Several complaint investigations were unsubstantiated, except for those involving medication errors and staff certification, which were substantiated and addressed. The facility’s inspection history shows ongoing challenges in medication administration and documentation, with some corrective actions taken but no clear pattern of consistent improvement.
Deficiencies (last 2 years)
Deficiencies (over 2 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
4
3
2
1
0
Census
Latest occupancy rate
29 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
Complaint Investigation
Census: 29
Deficiencies: 1
Date: Jun 26, 2025
Visit Reason
This visit was conducted to investigate complaints IN00461905, IN00461276, IN00461072, and IN00460648 at Heritage Assisted Living of Union City.
Complaint Details
Complaint IN00461905 was substantiated with state deficiencies cited. Complaints IN00461276, IN00461072, and IN00460648 had no deficiencies related to the allegations.
Findings
No deficiencies were cited for complaints IN00461276, IN00461072, and IN00460648. For complaint IN00461905, the facility failed to ensure medication administration was properly documented, resulting in a resident receiving duplicate doses of a controlled pain medication.
Deficiencies (1)
Failed to ensure medication administration was documented per facility policy and accepted professional standards to prevent a resident receiving duplicate doses of a controlled pain medication for 1 of 5 residents reviewed (Resident F).
Report Facts
Residential Census: 29
Medication doses given: 2
Completion date for plan of correction: Jul 15, 2025
Survey date: Jun 27, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Fenton | Administrator | Signed the report and is the facility administrator. |
| LPN 3 | Licensed Practical Nurse | Administered duplicate morphine dose and involved in medication documentation error. |
| QMA 2 | Qualified Medication Aide | Withdrew morphine and involved in medication documentation error. |
| DON | Director of Nursing | Notified of medication error and involved in corrective actions. |
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 4
Date: Mar 12, 2025
Visit Reason
This visit was for a State Residential Licensure Survey which included the investigation of Complaint IN00453440.
Complaint Details
Complaint IN00453440 was investigated and no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the complaint allegations were cited. Deficiencies found included lack of First Aid certified staff on some shifts, unsigned resident service plans, use of unpasteurized eggs in food preparation, and incomplete admission tuberculin skin tests for some residents.
Deficiencies (4)
Facility failed to ensure each shift was staffed with at least one staff member certified in First Aid.
Facility failed to ensure service plans were signed by a resident and/or their representative for 3 of 7 clinical records reviewed (Residents 9, 11, and 26).
Facility failed to prevent the utilization of unpasteurized eggs for the preparation of soft-cooked eggs for residents.
Facility failed to ensure admission tuberculin (TB) skin tests were completed for 2 of 7 residents reviewed (Residents 26 and 5).
Report Facts
Shifts lacking First Aid certified staff: 7
Residents with unsigned service plans: 3
Residents reviewed for TB testing: 7
Residents missing admission TB tests: 2
Residents census: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashlyn Graham | Named as the one staff member certified in First Aid during the inspection period. | |
| Nicole Fenton | ED | Laboratory Director or Provider/Supplier Representative who signed the report. |
| LPN 5 | Licensed Practical Nurse | Mentioned in relation to First Aid certification status, but no certification was confirmed. |
| Dietary Manager | Responsible for ordering food supplies including eggs; aware of unavailability of pasteurized eggs from approved vendor. | |
| Cook 4 | Reported use of unpasteurized eggs for resident meals. | |
| Director of Nursing | DON | Interviewed regarding First Aid certification requirements and resident service plans. |
| Administrator | Interviewed regarding First Aid certification, dietary policies, and facility policies. |
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 1
Date: Nov 14, 2024
Visit Reason
This visit was conducted for the investigation of Complaints IN00447081 and IN00447127 regarding medication administration practices at the facility.
Complaint Details
The investigation was triggered by Complaints IN00447081 and IN00447127. The complaints were substantiated with findings that a QMA administered insulin without certification and under direction of the DON, who falsified documentation. The DON was terminated and state authorities were notified.
Findings
The facility failed to ensure injectable medications, specifically insulin, were administered only by qualified personnel. A Qualified Medication Aide (QMA) administered insulin despite not being certified to do so, under direction of the former Director of Nursing (DON). The DON falsified documentation and was terminated. Residents receiving insulin injections were assessed with no adverse effects noted.
Deficiencies (1)
Facility failed to ensure injectable medications were administered by qualified personnel for 2 of 3 residents reviewed for insulin administration.
Report Facts
Residential Census: 23
Insulin doses administered: 2
Medication audit frequency: 4
Medication audit frequency: 3
Medication audit frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Fenton | Administrator | Signed the report and involved in facility administration |
| LPN 6 | Director of Nursing (former) | Directed QMA to administer insulin and falsified documentation; terminated due to findings |
| QMA 4 | Qualified Medication Aide | Administered insulin without certification and outside scope of practice; received training and final warning |
Inspection Report
Complaint Investigation
Census: 19
Deficiencies: 0
Date: Jul 18, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00437895, IN00437683, IN00437164, and IN00434919 at Heritage Assisted Living of Union City.
Complaint Details
Complaints IN00437895, IN00437683, IN00437164, and IN00434919 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations were cited for any of the complaints investigated. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaints.
Report Facts
Residential Census: 19
Inspection Report
Original Licensing
Census: 16
Deficiencies: 3
Date: Mar 28, 2024
Visit Reason
This visit was for an Initial State Residential Licensure Survey and included the investigation of Complaint IN00426960.
Complaint Details
Complaint IN00426960 was investigated and no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the complaint allegations were cited. Deficiencies were found related to failure to obtain signed resident rights acknowledgement for 1 of 7 residents, failure to submit CLIA waiver application prior to laboratory testing affecting 3 residents, and failure to ensure signed service plans for 7 of 7 residents reviewed.
Deficiencies (3)
Failed to ensure a resident rights acknowledgement was obtained for 1 of 7 residents reviewed for resident rights (Resident 18).
Failed to submit the application for certification for the Clinical Laboratory Improvement Amendments (CLIA) waiver prior to obtaining laboratory testing on residents, affecting 3 of 3 residents who required blood glucose monitoring.
Failed to ensure service plans were signed by the resident for 7 of 7 residents reviewed for service plans (Residents B, C, D, 6, 10, 18, and 19).
Report Facts
Residential Census: 16
Residents requiring blood glucose testing: 3
Residents reviewed for resident rights: 7
Residents reviewed for service plans: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Buckingham | RCA, ED | Person responsible for CLIA application correction and receipt. |
| Director of Nursing | Named as responsible party for ensuring signed service plans. |
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