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 48 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
38D
8E
0F
Potential for minimal harm
0A
0B
0C
April 8, 2026Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to arrange transportation to an acute care hospital for a scheduled stay prior to a surgical procedure, causing cancellation of the surgical procedure, for 1 of 3 residents reviewed for quality of care and administration/personnel (Resident B).
February 26, 2026Complaint inspection · 1 citation
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on record review and interview, the facility failed to prepare a resident's food according to a physician's ordered modified diet for 1 of 3 residents reviewed for death (Resident B). This deficient practice was corrected by 2/20/26 prior to the start of the survey and was therefore Past Noncompliance.
January 27, 2026Standard inspection · 10 citations
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteA. Based on observation, interview, and record review, the facility failed to ensure paper towels at handwashing areas were maintained in a sanitary manner for 1 of 2 kitchen observations and 1 of 1 dining observation. B. Based on observation, interview, and record review, the facility failed to ensure food was distributed in a safe and sanity manner and failed to ensure staff assisted residents with their meal in a safe and sanitary manner for 1 of 2 dining observations in the activity room (Residents 59, 1, 19, and 109).
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on record review and interview, the facility failed to ensure consent documents had been obtained for antipsychotics (medications used to manage symptoms of psychosis [a loss of contact with reality], such as delusions [a firmly held false belief that does not match reality], hallucinations [seeing or hearing things that are not there], insomnia [persistent difficulty falling asleep, staying asleep, or waking up too early], and severe agitation) medications for 3 of 5 residents reviewed for unnecessary medications (Residents 11, 59, and 62).
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure call lights were kept within residents' reach for 3 of 32 residents reviewed for call lights (Resident 19, 55, and 10).
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on record review and interview, the facility failed to ensure accurate advance directives were ordered when the POST form was not the same as the physician order and care plan for 1 of 32 residents reviewed for advanced directives (Resident 15).
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased record review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) (screening for serious mental illness and intellectual disability required before admission to a long term care facility) was updated when a psychiatric diagnosis was added to a resident's profile for 1 of 1 residents reviewed for PASRR (Resident 55).
- 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, record review, and interview, the facility failed to assess and initiate a care plan to support the use of elopement risk preventive measures for 1 of 23 residents reviewed for care plans (Resident 34).
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, record review, and interview, the facility failed to ensure the resident was provided the necessary services to maintain grooming and daily care needs for 1 of 32 residents reviewed for daily care needs (Resident 12).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure safe smoking protocols were followed for 1 of 1 residents reviewed for smoking (Resident 9).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, record review, and interview, the facility failed to ensure that nebulizer equipment was properly cleaned and stored after each use for 2 of 2 residents reviewed for oxygen and nebulizer use (Residents 12 and 63).
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was provided routine dental services for 1 of 32 residents reviewed for dental services (Resident 9).
January 6, 2026Complaint inspection · 1 citation
- 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 record review and interview, the facility failed to provide family notification after a resident experienced a significant change in condition and subsequently received life-sustaining interventions to include a ventilator without notification to the emergency contact, for 1 of 3 residents reviewed for quality of care (Resident B).
October 9, 2025Complaint inspection · 2 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 resident's right to be free from neglect, when the facility failed to ensure a resident was provided adequate monitoring and care during the night shift for 1 of 4 residents reviewed for neglect (Resident B). The immediate jeopardy began on [DATE] when staff failed to visualize a resident during the 8-hour night shift and the resident was found deceased on the floor between the bed and wheelchair the next morning at 7:15 a.m. The Administrator, Director of Nursing (DON), Regional Director of Clinical Operations (RDCO), and a RDCO in training were notified of the immediate jeopardy on [DATE] at 4:52 p.m. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy.
- J
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient staffing was provided to care for and supervise the residents that resided at the facility for 1 of 7 residents reviewed for sufficient staffing (Resident B). The immediate jeopardy began on [DATE] when the facility staff failed to provide care and supervision of residents residing at the facility during the eight hour night shift resulting in a resident not being checked on all night and was found deceased on [DATE] at 7:15 a.m. The Administrator, Director of Nursing (DON), Regional Director of Clinical Operations (RDCO), and a RDCO in training were notified of the immediate jeopardy on [DATE] at 4:52 p.m. [...]
September 4, 2025Complaint inspection · 2 citations
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interview, the facility failed to ensure a thorough investigation of abuse allegations was conducted and a record of the investigation was maintained for 3 of 3 residents reviewed for abuse (Residents H, G, and F).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and interviews, the facility failed to accurately document wound description upon admission to the facility for 1 of 3 residents reviewed for wounds (Resident B), and failed to ensure medications were documented according to physician orders for administration of insulin for 1 of 3 residents reviewed for medication administration (Resident D).
April 10, 2025Complaint inspection · 2 citations
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medications were administered and documented according to physician orders for administration of insulin for 4 of 4 residents reviewed for medication administration (Residents, D, F, B, and E).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure enhanced barrier precautions were followed during a dressing change for 1 of 3 residents reviewed for pressure ulcers (Resident G).
December 31, 2024Complaint inspection · 2 citations
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on interview and record review, the facility failed to ensure adequate nurse staffing for 5 of 6 units schedules reviewed (units 100, 200 A, 200 B, 400, and 500).
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record reviews, and interviews, the facility failed to ensure inulin medications were administered as ordered for 3 of 3 residents reviewed for insulin medications (Residents F, K, and H).
December 9, 2024Standard inspection, Complaint inspection · 10 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 proper handwashing during 2 of 2 dining observations and 1 of 1 kitchen observations and the facility failed to ensure adequate dishwashing temperatures were maintained for 1 of 1 kitchen observations.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the code status (a medical term that indicates a patient's wishes regarding what life-saving measures should be taken if their heart stops beating or breathing stops) was documented and readily available to staff for 1 of 24 residents reviewed for advanced directives ( a written document that tells the health care providers who should speak for a resident and what medical decisions they should make if the resident becomes unable to speak for themselves) (Resident 152).
- 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 ensure notification of a resident discharge had been reported to the Ombudsman (a person who investigates and resolves complaints and represents or protects the interests of another person or group) for 1 of 2 residents reviewed for hospitalization (Resident 6).
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record reviews and interviews, the facility failed to ensure Minimum Data Set (MDS) resident assessments were completed timely for 2 of 2 residents reviewed for MDS records over 120 days old (Residents 42 and 2).
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review and interview, the facility failed to obtain and implement treatment orders upon admission for a stage 4 pressure ulcer (full thickness tissue loss with exposed muscle and/or bone) for 1 of 1 resident reviewed for pressure ulcers (Resident K).
- D
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on record review and interview, the facility failed to ensure there was sufficient weekend staffing for 1 of 4 fiscal year quarters reported for sufficient and competent nurse staffing (4/1/24-6/30/24).
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff was competent in completing tasks accurately for 2 of 5 residents reviewed for medication administration (Residents 51 and M).
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on record reviews and interviews, the facility failed to ensure the correct supporting diagnosis was used to prescribe an antipsychotic for 1 of 5 residents reviewed for unnecessary medications (Resident 1), and failed to attempt a Gradual Dose Reduction (GDR) or provide evidence to support the denial of a GDR for 2 of 5 residents reviewed for unnecessary medications (Resident 48).
- 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, interview, and record review, the facility failed to ensure medication was labeled properly for 1 of 3 medication carts reviewed for medication storage (Resident 51).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper handling of the glucometer (small portable machine that's used to measure how much glucose [type of sugar] is in the blood) meter during medication administration pass for 1 of 4 residents reviewed during medication administration (Resident 51) and the facility failed to maintain a separation of clean and dirty mechanical lift pads and mop heads supplies in the laundry room for 1 of 1 laundry room observations.
June 5, 2024Complaint inspection · 1 citation
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on record review and interview, the facility failed to supervise, monitor, and initiate interventions for a dementia resident with a known history of intrusive wandering behaviors, Resident B, which resulted in her being hit by another resident, for 1 of 3 residents reviewed for abuse (Residents B and C).
May 17, 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 maintain a system for the reconciliation of narcotic medications resulting in two separate occasions of drug diversion for 1 of 3 residents reviewed for medication reconciliation (Resident C).
April 4, 2024Complaint inspection · 2 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 and record review, the facility failed to ensure a resident was transferred to a doctor's appointment in a dignified manner for 1 of 3 residents reviewed for dignity concerns (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 record review and interview, the facility failed to ensure medical records were accurately documented for 1 of 3 residents reviewed for intravenous medication administration (Resident D).
January 24, 2024Complaint inspection · 2 citations
- 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 1 of 3 residents received care and services related to skin impairment (Resident D).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview, and document review, the facility failed to implement a system to monitor and reconcile narcotic medications for 1 of 3 residents reviewed for medications, and failed to ensure medications were available and administered in accordance with physician orders for 1 of 3 residents reviewed medications (Resident D).
October 6, 2023Standard inspection · 11 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 ensure residents had safe smoking materials provided for 1 of 1 resident reviewed for accidents (Resident 65), failed initiate fall follow-up protocols for 1 of 1 resident reviewed for accidents (Resident 25), and failed to ensure safe medication storage for 2 of 4 residents reviewed for accidents (Residents 39 and 254).
- E
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, interview, and record review, the facility failed to ensure expired insulin medications were disposed of properly for 2 of 3 medication carts reviewed for medication storage (Residents 57 and 79) and the facility failed to ensure insulin medication was labeled properly for 1 of 3 medications carts reviewed for medication storage (Resident 97). The facility failed to ensure proper storage of insulin medication for 2 of 3 medication carts reviewed for medication storage (Residents 57 and 88).
- 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 the cleanliness and sanitation of the kitchen and food preparation and storage areas for 2 of 2 kitchen observations.
- 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 interview and record review, the facility failed to ensure a resident was provided showers as preferred for 1 of 3 residents reviewed for choices (Resident 25).
- 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 missing money was reported and handled as an allegation of misappropriation, and failed to report the allegation to the Indiana Department of Health completed for 1 of 1 resident reviewed for missing personal property (Resident 39).
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to assess, document, and conduct a thorough investigation after a resident alleged missing money for 1 of 1 resident reviewed for resident property (Resident 39).
- 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, record review, and interview, the facility failed to ensure care plans were revised for 2 of 24 residents reviewed for care plans (Residents, 98 and 65). Findings Include: 1. On 10/03/23 at 10:51 a.m., while observing Resident 65, in the designated smoking area. The resident dropped ashes several times on her lap blanket. She indicated she had never had a smoking blanket or apron to wear when smoking and she was unable to feel sensation below her waist due to an auto accident resulting in injury to her spine. The Maintenance Technician provided one to one supervision for Resident 65 and indicated smoking blankets or aprons were not provided for the residents. Resident 154 indicated smoking blankets or apron were not available for her to use. Observation of the smoking area lacked evidence of a smoking apron or smoking blanket. [...]
- 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 ensure nail care was provided to a dependent resident for 1 of 32 residents reviewed for activities of daily living (ADL) (Resident 13).
- 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 ensure a hand splint intervention was provided for a resident with a hand contracture (fixed tightening of muscle, tendons, ligaments, or skin) and a compression sleeve intervention was provided for the resident with edema (swelling caused by too much fluid trapped in the body's tissues) for 1 of 1 resident reviewed for limitation in range of motion (ROM) (Resident 13).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage of respiratory equipment for 2 of 2 residents reviewed for respiratory care (Residents 25 and 254). Findings Include: 1. On 10/3/23 at 9:04 a.m., Resident 25's unbagged nebulizer (turns liquid medicine into a mist that can be easily inhaled) mouthpiece and tubing was observed hanging off the nebulizer machine. The resident was resting in bed. On 10/4/23 at 9:45 a.m., Resident 25 was asleep in bed and her unbagged nebulizer mouthpiece and tubing were observed hanging down the side of her bedside table almost touching the floor. On 10/5/23 at 10:03 a.m., Resident 25 was sitting up in her wheelchair and her unbagged nebulizer mouthpiece and tubing was observed sitting on top of her nebulizer machine. A clear substance was noted to be in the medication chamber of the mouthpiece. [...]
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and interview, the facility failed to ensure documented evidence of medication administration for 2 of 5 residents reviewed for unnecessary medications (Resident 33 and 60).
Fire safety inspections
13 fire safety citations on file: 7 on January 27, 2026, 4 on December 9, 2024, 2 on October 6, 2023.
Every fire safety citation13 citations
- F
Implement emergency and standby power systems.
E 41 · January 27, 2026 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · January 27, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · January 27, 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 · January 27, 2026 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 27, 2026 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · January 27, 2026 · Corrected (the home has a date of correction)
- D
Have an externally vented heating system.
K 522 · January 27, 2026 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · December 9, 2024 · 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 · December 9, 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 · December 9, 2024 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · December 9, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 6, 2023 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of highly flammable decorations.
K 753 · October 6, 2023 · Corrected (the home has a date of correction)