Inspection Report Summary
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/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
49 residents
Based on a February 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 49
Deficiencies: 1
Date: Feb 17, 2025
Visit Reason
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)
Facility failed to ensure potentially hazardous materials were kept secure behind locked doors to prevent resident access.
Report Facts
Residential Census: 49
Blocks of rodent poison: 20
Spray can sizes: 12
Spray bottle sizes: 7
Plastic tube sizes: 6
Gel sizes: 16
Plastic bottle sizes: 8.25
Tube sizes: 4
Spray can sizes: 19
Isopropyl alcohol concentration: 91
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 0
Date: Jan 7, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00449159 and IN00449516.
Complaint Details
Complaint IN00449159 and Complaint IN00449516 were investigated and found to have no deficiencies related to the allegations.
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.
Report Facts
Residential Census: 51
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 0
Date: Jul 30, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00439091.
Complaint Details
Complaint IN00439091 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: 47
Deficiencies: 5
Date: Apr 18, 2024
Visit Reason
This visit was for a State Residential Licensure Survey which included the investigation of Complaint IN00431377 regarding allegations of financial exploitation.
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.
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.
Deficiencies (5)
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: 5
Shifts reviewed for First Aid certification: 14
Expired CNA certification: 1
Residents with pets lacking current vaccinations: 2
Shifts 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 |
| CNA 5 | Certified Nursing Assistant | Worked as CNA with expired certification |
| Keisha Dube | Executive Director | Signed report and plan of correction |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 0
Date: Dec 8, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00423557.
Complaint Details
Complaint IN00423557 was investigated and found to have no deficiencies related to the allegations.
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.
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 0
Date: Jul 20, 2023
Visit Reason
This visit was for the investigation of Complaint IN00410084.
Complaint Details
Complaint IN00410084 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: 57
Deficiencies: 0
Date: May 17, 2023
Visit Reason
This visit was for the investigation of Complaint IN00405193.
Complaint Details
Complaint IN00405193 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: 54
Deficiencies: 3
Date: Feb 9, 2023
Visit Reason
This visit was for a State Residential Licensure Survey which included the Investigation of Complaint IN00393470.
Complaint Details
Complaint IN00393470 was substantiated but no deficiencies related to the allegations were cited.
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.
Deficiencies (3)
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: 5
Dumpster observations: 4
Resident rooms observed for water temperature: 3
Water temperature reading: 125
Residential 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. |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 0
Date: Sep 14, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00389817.
Complaint Details
Complaint IN00389817 - Substantiated. No deficiencies related to the allegation are cited.
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.
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