Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 23 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
20D
1E
1F
Potential for minimal harm
0A
0B
1C
February 20, 2026Standard inspection · 6 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, and interview, the facility failed to provide grooming assistance for 1 of 2 residents reviewed for activities of daily living. (Resident 16)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and interview, the facility failed to follow physician's wound treatment orders to promote healing of an arterial ulcer for 1 of 3 residents reviewed for skin conditions. (Resident 2)
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received appropriate catheter maintenance and services to prevent potential urinary tract infections for 1 of 2 residents reviewed for indwelling catheters. (Resident 16)
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, record review, and interview, the facility failed to provide meal assistance to maintain nutritional status for 1 of 4 residents reviewed for nutrition. (Residents 21)
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation and interview, the facility failed to ensure medications were dated when opened and medication was discarded when expired for 1 of 3 medication carts reviewed for medication storage. (100 hall)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and interview, the facility failed to utilize proper hand hygiene and avoid touching food with bare hands during meal tray distribution for 4 of 9 opportunities during room meal tray deliveries on the 200 hall.
January 15, 2026Complaint inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure implementation of care plan interventions to prevent falls for 1 of 3 residents reviewed for falls (Resident C).
December 15, 2025Complaint inspection · 2 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, record review and interview, the facility failed to protect a resident's right to be free from sexual abuse by another resident for 1 of 3 residents reviewed for abuse (Residents B and C) when a cognitively impaired male resident (Resident B) with a history of sexually charged behavior was observed in the lounge with his hand underneath the cognitively impaired female (Resident C) resident's shirt fondling her breast.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interview, the facility failed to immediately report an allegation of sexual abuse to the Administrator for 1 of 3 residents reviewed for abuse. (Resident C)
July 2, 2025Complaint inspection · 2 citations
- E
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review and interview, the facility failed to ensure a cognitively impaired resident was free from staff-to-resident abuse as a result of physical retaliation to a combative resident for 1 of 3 residents reviewed for abuse. (Resident B) This deficient practice had the potential to affect 19 of 77 residents in the facility who resided on the 300 Unit. The deficient practice was corrected on 6/27/25, prior to the start of survey, and was therefore past noncompliance.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interview, the facility failed to identify and immediately report alleged abuse to the administrator for 1 of 3 residents reviewed for resident abuse. (Resident B) This deficient practice had the potential to affect 19 out of 77 residents in the facility who resided on the 300 Unit. The deficient practice was corrected on 6/27/25, prior to the start of survey, and was therefore past noncompliance.
January 14, 2025Standard inspection · 8 citations
- F
Ensure residents have reasonable access to and privacy in their use of communication methods.
Inspectors wroteBased on interview and record review, the facility failed to ensure mail was distributed to residents on Saturdays. This deficiency had the potential to affect 79 of 79 residents who resided in the facility.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was submitted for a resident with a new mental health diagnosis and psychotropic medication for 1 of 1 residents reviewed for PASRR. (Resident 59)
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on record review and interview, the facility failed to develop and implement a comprehensive care plan with individualized interventions to maintain the resident's highest practicable mental, physical, and psychosocial outcome for 1 of 1 resident reviewed for a limited range of motion. (Resident 73)
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's representative was invited to participate in the ongoing care planning process for 1 of 1 residents reviewed for care planning. (Resident 34)
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on interview and record review, the facility failed to provide appropriate restorative care services as recommended by therapy for a resident with limited range of motion for 1 of 1 resident reviewed for restorative care. (Resident 73)
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision for a cognitively impaired resident with a history of falls to prevent repeated falls for 1 of 2 residents reviewed for accidents. (Resident 129)
- D
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Inspectors wroteBased on interview and record review, facility failed to ensure the physician was notified of a resident's significant weight loss for 1 of 3 residents reviewed for nutrition. (Resident 72)
- C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the most recent Indiana Department of Health (IDOH) survey reports were readily available for review. This deficiency had the potential to affect 79 of 79 residents who resided in the facility.
January 22, 2024Standard inspection · 4 citations
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on record review and interview, the facility failed to notify the Long-Term Care Ombudsman of transfers out of the facility for 2 of 3 residents reviewed for hospitalizations (Residents 37 and 66).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care plan interventions to prevent falls for 1 of 5 residents reviewed for falls (Resident 22).
- D
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Inspectors wroteBased on interview, and record review, the facility failed to remove CNA students from CNA duties when they failed to become certified within four months of their hire date (CNA Student 5 and 6).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased upon observation, record review, and interview, the facility failed to ensure accurate records were kept of the administration of controlled medications for 6 of 14 residents reviewed (Residents 22, 47, 56, 58, 66, and 67).
Fire safety inspections
15 fire safety citations on file: 4 on February 20, 2026, 5 on January 14, 2025, 6 on January 22, 2024.
Every fire safety citation15 citations
- E
Have properly located and lighted "Exit" signs.
K 293 · February 20, 2026 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · February 20, 2026 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · February 20, 2026 · Corrected (the home has a date of correction)
- E
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · February 20, 2026 · Corrected (the home has a date of correction)
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · January 14, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · January 14, 2025 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · January 14, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · January 14, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · January 14, 2025 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · January 22, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 22, 2024 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · January 22, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · January 22, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · January 22, 2024 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · January 22, 2024 · Corrected (the home has a date of correction)