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 41 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
38D
2E
0F
Potential for minimal harm
0A
0B
0C
May 13, 2026Standard inspection · 4 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on interview, observation and record review, the facility failed to ensure residents maintained dignity by assisting residents with toileting needs in a timely manner, resulting in incontinence for 1 of 4 residents reviewed for resident rights. (Resident 14) Findings Include: The clinical record for Resident 14 was reviewed on 5/7/26 at 12:05 p.m. The resident's diagnoses included, but were not limited to: morbid obesity (body mass index of 40 or higher), essential tremors (progressive neurological disorder that caused involuntary rhythmic shaking), mononeuropathy of bilateral upper limbs (damage to or compression of individual peripheral nerves in both arms or hands), and chronic pain syndrome. The care plan, dated 10/3/25 and revised 12/19/25, indicated Resident 14 had occasional episodes of bladder incontinence. [...]
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observation, interview, and record review, the facility failed to honor a resident's bathing time preference for 1 of 1 resident reviewed for choices. (Resident 14)
- 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 incorporate the recommendations from a resident's PASRR (Preadmission Screening and Resident Review) Level II determination and PASRR evaluation report for 1 of 1 resident reviewed for PASRR. (Resident 14)
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteThe facility failed to accurately and complete document eternal feeding and flush documentations for 1 of 3 residents reviewed for documentation accuracy. (Resident 98) The clinical record for Resident 98 was reviewed on 5/11/2026 at 11:09 a.m. The resident's diagnoses included, but were not limited to, amyotrophic lateral sclerosis (progressive neurological disorder) and ventilator dependence. An annual Minimum Data Set (MDS) assessment, dated 2/14/2026, indicated Resident 98 was cognitively impaired, had verbal outbursts that affected others, did not have weight loss, and was dependent on tube feeding. The assessment indicated Resident 98 had impaired mobility in all four extremities, was dependent on staff for all activities of daily living, and did not take nutrition by mouth. A care plan, dated 6/5/2024 and revised on 2/25/2026, indicated Resident 98 had specialized needs. [...]
August 12, 2025Complaint inspection · 5 citations
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on interview and record review, the facility failed to include the resident's family in a physician follow-up visit with the neurosurgeon's office, at their request, after the resident's back surgery for 1 of 3 residents reviewed for physician appointments. (Resident B)
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment by not providing television (TV) remotes for newly admitted residents to watch TV per their preference for 2 of 3 residents reviewed for accommodation of needs. (Resident B and Resident D)
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on interview and record review, the facility failed to ensure follow up was conducted on care concerns for a resident and the resident's family who had expressed multiple care concerns via email and follow the facility's policy pertaining to grievances for 1 of 3 residents reviewed for quality of care. (Resident B)
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's equipment of an enabler bar was functioning properly, failed to complete a thorough assessment after the resident's fall, and failed to implement fall interventions for a resident at high risk for falls for 1 of 3 residents reviewed for falls. (Resident B)
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review, the facility failed to implement an inventory sheet with resident belongings for newly admitted residents for 3 of 3 residents reviewed for missing items. (Resident B, Resident D and Resident C)
July 18, 2025Complaint inspection · 2 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of verbal abuse was reported to the Indiana Department of Health within two (2) hours of its receipt for 1 of 3 residents reviewed for abuse. (Resident D)
- D
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was referred for home health nursing services upon discharge for 1 of 3 residents reviewed for discharge. (Resident B)
April 30, 2025Standard inspection · 8 citations
- E
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 fall interventions, as care planned; transfer a resident utilizing a gait belt, as required; ensure position change alarm use was monitored for efficacy on an on-going basis; and ensure position change alarm use was aimed at assisting staff to assess for patterns and routines of residents for 4 of 5 residents reviewed for accidents. (Residents 23, 31, 41, and 71)
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide privacy during care for 2 of 2 random observations (Resident 50 and Resident 36).
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wrote2. The clinical record for Resident 71 was reviewed on 4/24/25 at 11:55 a.m. Her diagnoses included, but were not limited to, rheumatoid arthritis, diabetes mellitus, and stage four pressure ulcer of sacral region. The 1/14/25 Annual MDS (Minimum Data Set) assessment indicated she was cognitively intact. She was totally dependent for toileting hygiene, bathing, lower body dressing, and putting on/taking off footwear. She required substantial/maximal assistance with eating, oral hygiene, upper body dressing, and personal hygiene. An observation and interview were conducted with Resident 71 in her room on 4/24/25 at 11:59 a.m. She was lying in bed with the covers over her. Her call light was clipped to her outer cover but was wedged between her left side enabler bar and mattress. Resident 71 attempted to reach for her call light but was unable to reach it. She indicated, I can't reach it. [...]
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain comfortable sound levels for 1 of 5 residents reviewed for accidents. (Resident 71) The clinical record for Resident 71 was reviewed on 4/24/25 at 11:55 a.m. Her diagnoses included, but were not limited to, rheumatoid arthritis, diabetes mellitus, and stage four pressure ulcer of sacral region. She was admitted to the facility on [DATE]. The 1/14/25 Annual MDS (Minimum Data Set) assessment indicated she was cognitively intact. She was totally dependent for toileting hygiene, bathing, lower body dressing, and putting on/taking off footwear. She required substantial/maximal assistance with eating, oral hygiene, upper body dressing, and personal hygiene. The physician's orders indicated to check the function and placement of her bed and chair alarm every shift, effective 9/11/23. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nail care and oral care for 3 of 3 residents reviewed for activities of daily living (ADLs). (Resident 9, Resident 66 and Resident 23)
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to timely provide optometry services and timely address a resident's missing glasses for 2 of 3 residents reviewed for vision services. (Residents 38 and 91)
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pressure wound interventions for a resident at high risk of developing pressure areas for 1 or 2 residents reviewed for pressure wounds. (Resident 67)
- 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 observation, interview, and record review, the facility failed to implement and provide interventions for a resident with bilateral hand contractures for 1 of 2 residents revived for range of motion (ROM). (Resident 98)
February 10, 2025Complaint inspection · 1 citation
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 3 residents reviewed for pressure ulcers received the care and services required to treat the identified wound and documented the status of the wound routinely. (Resident B)
January 8, 2025Complaint inspection · 2 citations
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation of the root cause of a fall and failed to implement a fall intervention for 1 of 3 residents reviewed for accidents (Resident B).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review, the facility failed to have complete and accurate documentation of a resident's fall for 1 of 3 residents reviewed for accidents (Resident B).
December 9, 2024Complaint inspection · 1 citation
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication administration was conducted in a safe manner and did not include leaving medication at a resident's bedside unattended for 1 of 25 residents rooms observed for unattended medications. (Resident G)
September 5, 2024Complaint inspection · 4 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, interview, and record review the facility failed to ensure residents remained free from physical abuse for 2 of 13 residents reviewed for abuse. (Resident K and Resident M)
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, the facility failed to thoroughly report an allegation of sexual abuse and report resident to resident physical altercations to the Indiana Department of Health (IDOH) for 4 of 13 residents reviewed for abuse (Resident N, Resident P, Resident K and Resident M).
- 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 complete initial assessments after a fall and follow-up assessments after residents had a fall with injury for 2 of 3 residents reviewed for accidents. (Resident D and Resident C)
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and supervise a resident with dementia resulting in the potential for resident-to-resident interaction and failed to monitor and supervise residents on the memory care unit, assess residents, conduct follow-up, and notify family and the physician of inappropriate sexual contact between two residents for 4 of 13 residents reviewed for abuse. (Resident N, Resident P, Resident K and Resident L)
April 19, 2024Complaint inspection · 3 citations
- J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review, the facility failed to protect the residents ' right to be free from sexual abuse for 3 of 3 male residents by a staff member while providing incontinence care. The staff member was on his first night of orientation without the presence of the regular staff member which he was paired with for his orientation for the shift. This action resulted in mental anguish for all 3 residents. (Residents B, C, D and CNA 3) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on, 3-20-24 at approximately 2:00 a.m., when CNA 3 masturbated 1 of 3 residents. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 4-17-24 at 11:55 a.m. [...]
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview and record review, the facility failed to ensure their policies and procedures related to abuse prohibition were implemented for the prohibition of staff to resident abuse, for reporting of an allegation of abuse within two hours of the facility learning of the abuse allegation to the Indiana Department of Health's Long Term Care Division and for ensuring all persons with any facts or observations who might have pertinent information related to the alleged abuse were included in the investigation for 3 of 3 residents reviewed for staff to resident abuse. (Residents B, C, D and CNA 3)
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, the facility failed to report an allegation of staff to resident sexual abuse to the Indiana Department of Health's Long Term Care Division and other state agencies within two hours of the facility being made aware of the abuse. (Residents B, C, D and CNA 3)
February 20, 2024Standard inspection, Complaint inspection · 11 citations
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure beard restraints were utilized while working with food. This had the potential to affect 89 out of 94 residents who receive food from the kitchen.
- D
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on interview and record reviewed, the facility failed to ensure Minimum Data Set (MDS) Assessments were completed timely, or at least every 92 days, for 3 of 4 residents reviewed for MDS timeliness. (Resident 36, 73, and 79)
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and observation, the facility failed to accurately code dental status for Resident 82, failed to accurately code Resident 79's urinary status, and failed to accurately code falls for Resident 93. This affected 3 of 34 residents reviewed.
- 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 observation, interview, and record review, the facility failed to update Resident 12's care plan after refusal to use a lap buddy, failed to update a care plan after Resident 2 had bruising, and failed to update Resident 93's care plan with fall interventions. This affected 3 of 34 residents reviewed for care plan revisions.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a dependent resident with nail care, and failed to ensure facial hair was to a resident's preference. This affected 2 of 7 residents reviewed for activities of daily living care. (Residents 82 and 93)
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview and record review the facility failed to provide in room activities for 1 of 4 residents reviewed for activities (Resident 59).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review the facility failed to date a gastrostomy tube (G-Tube) dressing and failed to date the piston irrigation syringe for 1 of 1 residents reviewed for G-Tube (Resident 49).
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review, the facility failed to ensure wound treatments were signed off as administered, conduct weekly would assessments on a pressure ulcer, and ensure there was not multiple treatments for the same pressure ulcer for 1 of 3 residents reviewed for pressure ulcers. (Resident B)
- 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 observation, interview and record review the facility failed to provide Passive Range Of Motion (PROM) exercises for 1 of 4 residents reviewed for Range Of Motion (ROM) (Resident 49).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased observation, interview and record review the facility failed to ensure fall interventions were implemented and failed to transfer a resident in a safe manner for 2 of 5 residents reviewed for accidents (Resident 87 and Resident 72).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review the facility failed to date oxygen tubing and storage bag, failed to store oxygen tubing in a sanitary manner when not in use and failed to have a physician order for oxygen therapy for 2 of 4 residents reviewed for respiratory therapy (Resident 72 and Resident 2).
Fire safety inspections
33 fire safety citations on file: 15 on May 13, 2026, 4 on April 30, 2025, 14 on February 20, 2024.
Every fire safety citation33 citations
- F
Meet other general requirements that are deficient.
K 300 · May 13, 2026 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · May 13, 2026 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · May 13, 2026 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 13, 2026 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · May 13, 2026 · Corrected (the home has a date of correction)
- E
Meet other general requirements.
K 100 · May 13, 2026 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · May 13, 2026 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · May 13, 2026 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 13, 2026 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · May 13, 2026 · Corrected (the home has a date of correction)
- E
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
K 361 · May 13, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · May 13, 2026 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of highly flammable decorations.
K 753 · May 13, 2026 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · May 13, 2026 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · May 13, 2026 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · April 30, 2025 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · April 30, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · April 30, 2025 · Corrected (the home has a date of correction)
- C
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 30, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 20, 2024 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · February 20, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · February 20, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · February 20, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · February 20, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 20, 2024 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · February 20, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · February 20, 2024 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · February 20, 2024 · 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, 2024 · Corrected (the home has a date of correction)
- C
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · February 20, 2024 · Corrected (the home has a date of correction)
- C
Develop Emergency Preparedness policies and procedures.
E 13 · February 20, 2024 · Corrected (the home has a date of correction)
- C
Develop a communication plan.
E 29 · February 20, 2024 · Corrected (the home has a date of correction)
- C
Establish emergency prep training and testing.
E 36 · February 20, 2024 · Corrected (the home has a date of correction)