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 32 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
25D
4E
2F
Potential for minimal harm
0A
0B
0C
June 17, 2026Complaint inspection · 2 citations
- G
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 ensure a resident was free from mental abuse by a staff member obtaining a photograph of the resident's genitalia without the resident's permission and showing other staff members resulting in unauthorized photographs taken for 1 of 4 residents reviewed for abuse. (Resident B) Using the reasonable person concept, it is likely this would lead to humiliation, confusion, anxiety, and embarrassment for Resident B.
- 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 mental abuse of a resident by a staff member taking a picture of the resident's genitalia in a timely manner to the Indiana Department of Health (IDOH) for 1 of 4 residents reviewed for abuse. (Resident B)
October 23, 2025Complaint inspection · 3 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 provide dignified incontinent care for 1 of 3 residents reviewed for dignity (Resident D).
- D
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 of verbal abuse for 2 of 4 residents reviewed for abuse. (Resident C and Resident F).
- 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 timely report an incident of alleged verbal abuse to the Executive Director for 1 of 1 resident reviewed for reporting abuse. (Resident C)
May 20, 2025Standard inspection, Complaint inspection · 5 citations
- 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 provide showers as preferred for 2 of 3 residents reviewed for activities of daily living (ADLs). (Resident B and Resident E)
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a chair cushion was in place for a resident with stage 2 pressure ulcers (partial thickness skin loss) for 1 of 1 resident reviewed for pressure ulcers. (Resident E)
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was weighed, as ordered, and a resident was provided with an adaptive drinking device, as ordered, for 2 of 6 residents reviewed for nutrition. (Resident 50 and Resident 59)
- 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 implement interventions when residents were kissing in the common area on the memory care unit for 1 of 1 observation of behaviors (Resident 35 and Resident 53).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control measures were maintained during incontinence care for 1 of 1 resident observed for pressure ulcers. (Resident E)
April 9, 2025Complaint inspection · 1 citation
- 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 routinely document the meal intakes for 1 of 3 residents reviewed for resident assessment. (Resident B)
March 22, 2024Standard inspection, Complaint inspection · 8 citations
- 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 to maintain a clean, sanitary kitchen, ensure the holding refrigerator didn't contain unlabeled and/or expired foods, ensure bread was discarded that contained a fuzzy green, yellow substance, and ensure a cup was not present in the bulk storage bin. This had the potential to affect all 72 residents who receive food from the kitchen.
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident rooms were in good repair related to the walls, headboard, and cove base (soft flexible material along the bottom part of the wall) in a bathroom for 6 of 72 residents reviewed for environment. (Resident 283, 40, 18, 44, 11, and 28)
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on interview and record review, the facility failed to complete a Minimum Data Set (MDS) Assessment for a resident discharged from hospice services (Resident 78) for 1 of 3 resident reviewed for timeliness of significant change assessments.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to accurately indicate the use of hospice services (Resident 43) and failed to accurately code oxygen therapy (Resident 10 and 65) for 3 of 16 resident reviewed for MDS accuracy.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review, the facility failed to ensure continuation of treatment for a resident with pressure ulcers for Resident 55, and failed to ensure Resident 10 and 136's interventions were in place for pressure ulcer prevention and treatment. This affected 3 of 4 residents reviewed for pressure ulcers.
- 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 fall interventions were in place after a fall had occurred for 1 of 2 residents reviewed for accidents. (Resident 55)
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on interview and record review the facility failed to have an ongoing activity program on the dementia care unit for 2 of 3 residents reviewed for activities (Resident C and Resident D).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interview and record review, the facility failed to ensure a dietary staff member did not work while experiencing signs and symptoms of a gastrointestinal illness and ensure 48 hours had passed since symptoms started.
September 26, 2023Complaint 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 ensure a resident identified with non-pressure-related skin concerns had timely and routine assessments and documentation of the same conducted of their skin concerns for 1 of 3 residents reviewed for skin issues. (Resident D)
January 24, 2023Standard inspection · 12 citations
- 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 temperature logs were completed and the sanitizing solution was tested for a chemical dishwasher that resulted in lack of sanitizing solution being distributed for an unknown period of time. This had the potential to affect all 78 residents that receive food from the kitchen.
- E
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 clean tables in the activity/dining room on the locked unit. This affected all 19 residents who used the activity/dining room.
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure accuracy of the MDS (Minimum Data Set) assessment regarding 2 residents' dental status (Resident 61 and Resident 47), indicate the use of BiPap/CPAP device for Resident 39, and indicate dialysis for Resident 43 for 4 of 29 residents reviewed for MDS accuracy.
- E
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 interview and record review, the facility failed to develop and implement care plans for a resident with high blood pressure medications and low thyroid hormone medication (Resident 36), a resident with a catheter (Resident 74), a resident with a BiPap (bilevel positive airway pressure)/CPAP (continuous positive airway pressure) for Resident 39, and low air loss mattress for Resident 50. This affected 4 of 29 reviewed for care plans.
- 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 ensure showers were provided as preferred (Resident 31) and a resident was toileted timely that resulted in incontinence (Resident 46) for 2 of 3 residents reviewed for activities of daily living (ADLs).
- 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 follow-up with a change in a resident's condition of decreased level of consciousness and decreased appetite that was later hospitalized with sepsis for 1 of 3 residents reviewed for change of condition. (Resident G)
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review, the facility failed to ensure a treatment was initiated timely for an identified pressure ulcer after readmission to the facility for 1 of 3 residents reviewed for pressure ulcers. (Resident 47)
- 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 implement fall interventions for a Resident at risk for falls for 1 of 3 residents review for fall management. (Resident 43)
- 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 interview, observation, and record review, the facility failed to promote Resident 234's dignity by utilizing a dignity bag with a urinary catheter drainage bag and failed to ensure Resident 74's urinary catheter drainage bag was kept free of contact with the floor for 2 of 3 residents reviewed for urinary catheter management.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on record review and interview, the facility failed to ensure a pharmacy recommendation was followed up timely by the physician, for 1 of 5 residents reviewed. (Resident 72)
- 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 observation, interview and record review, the facility failed to provide education for the risk of using antipsychotic medications (Residents 36 and 72), and failed to identify and monitor target behaviors for a resident receiving antipsychotic medications (Resident 42). This affected 3 of 5 residents reviewed for unnecessary medications.
- D
Provide or get specialized rehabilitative services as required for a resident.
Inspectors wroteBased on interview and record review, the facility failed to ensure therapy recommendations were followed through and therapy referrals were followed up with timely for 1 of 2 residents reviewed for therapy services. (Resident 62)
Fire safety inspections
26 fire safety citations on file: 11 on May 20, 2025, 5 on March 22, 2024, 10 on January 24, 2023.
Every fire safety citation26 citations
- F
Meet other general requirements that are deficient.
K 300 · May 20, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 20, 2025 · Waiver
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 20, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · May 20, 2025 · Corrected (the home has a date of correction)
- E
Have an enclosure around a vertical opening shaft.
K 311 · May 20, 2025 · Waiver
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · May 20, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · May 20, 2025 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · May 20, 2025 · Corrected (the home has a date of correction)
- E
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · May 20, 2025 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · May 20, 2025 · Corrected (the home has a date of correction)
- C
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 20, 2025 · 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 · March 22, 2024 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · March 22, 2024 · 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 · March 22, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · March 22, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 22, 2024 · Corrected (the home has a date of correction)
- F
Properly install and monitor supervisory attachments on automatic sprinkler systems.
K 352 · January 24, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 24, 2023 · Corrected (the home has a date of correction)
- F
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · January 24, 2023 · Corrected (the home has a date of correction)
- E
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · January 24, 2023 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · January 24, 2023 · 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 · January 24, 2023 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · January 24, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · January 24, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · January 24, 2023 · Corrected (the home has a date of correction)
- E
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · January 24, 2023 · Corrected (the home has a date of correction)