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 8 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
4D
3E
1F
Potential for minimal harm
0A
0B
0C
May 27, 2025Standard inspection · 2 citations
- E
Employ staff that are licensed, certified, or registered in accordance with state laws.
Inspectors wroteBased on interview and record review, the facility failed to ensure a nurse, who was employed to work in the facility in the nursing department, had a valid Indiana nursing license (LPN 3). This deficient practice had the potential to impact 56 of 56 residents who resided in the facility.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on record review and interview, the facility failed to document the transfer process and communication to the receiving health care facility for 1 of 4 residents reviewed for hospitalizations. (Resident 41)
April 19, 2024Standard inspection · 1 citation
- F
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 food was prepared and distributed in a safe, sanitary manner. This deficient practice had the potential to impact 55 of 55 residents who received meals from the facility kitchen.
February 20, 2023Standard inspection · 5 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteA. Based on observation, interview, and record review, the facility failed to properly prevent and/or contain COVID-19 by ensuring infection prevention and control strategies were utilized during a facility COVID-19 outbreak, including failure to follow infection control guidelines upon entering and leaving rooms under transmission-based precautions, and during medication administration.
- E
Implement a program that monitors antibiotic use.
Inspectors wroteBased on interview and record review, the facility failed to implement their antibiotic stewardship program for antibiotic use for 5 of 10 residents prescribed antibiotics for urinary tract infections in December 2022 and January 2023. (Residents 43, 16, 22, 27, and 253)
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and record review, the facility failed to ensure the resident representative was notified immediately of a fall with injury for 1 of 5 residents sampled for falls (Resident B).
- 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 ensure resident fall frequency, injuries and antiplatelet/anticoagulant medications were discussed and documented prior to administration of the above mentioned medications for a resident with recent repeated falls with head injuries for 1 of 5 residents reviewed for falls. (Resident C)
- 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 adequate supervision to prevent falls with injuries for a dependent resident for 1 of 5 residents reviewed for falls. (Resident C)
Fire safety inspections
9 fire safety citations on file: 4 on May 27, 2025, 2 on April 19, 2024, 3 on February 20, 2023.
Every fire safety citation9 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 27, 2025 · Corrected (the home has a date of correction)
- E
Meet other general requirements.
K 100 · May 27, 2025 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 27, 2025 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · May 27, 2025 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · April 19, 2024 · Corrected (the home has a date of correction)
- C
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 19, 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 · February 20, 2023 · 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 · February 20, 2023 · Corrected (the home has a date of correction)
- E
Have an externally vented heating system.
K 522 · February 20, 2023 · Corrected (the home has a date of correction)