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 30 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
26D
4E
0F
Potential for minimal harm
0A
0B
0C
April 16, 2026Complaint inspection · 3 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents were administered medications and accuchecks (blood sugar testing) as ordered, for 3 of 4 residents reviewed for medications and accuchecks. (Residents B, K, and D)
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% for 2 of 5 residents observed during medication pass. Three errors were observed during 27 opportunities for errors during medication administration. This resulted in a medication error rate of 11.1%. (Residents M and N)
- 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 maintain clinical records that were complete and accurately documented related to behavior documentation for 1 of 12 records reviewed. (Resident B)
February 20, 2026Complaint inspection · 1 citation
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a gastrostomy tube (feeding tube) feeding was administered and documented at the rate ordered by the physician to assist with pressure wound healing for 1 of 2 residents reviewed for feeding tubes with pressure ulcers. (Resident E)
December 17, 2025Standard inspection, Complaint inspection · 10 citations
- E
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 ensure residents received the necessary treatment and services related to the lack of assessment and monitoring of skin discolorations for 1 of 2 residents reviewed for non-pressure related skin conditions. The facility also failed to ensure residents received medications as ordered by the physician for 1 of 1 resident reviewed for dialysis, 1 of 2 residents reviewed for constipation/diarrhea, and 1 of 1 resident reviewed for insulin administration. (Residents 10, 8, 3, and 18)
- 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 and interview, the facility failed to ensure a clean and sanitary kitchen related to dirty shelves, carts and the walk in refrigerator in the main kitchen. This had the potential to affect the 109 residents who received meals prepared in 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 and interview, the facility failed to maintain a sanitary, safe, and homelike environment related to accident hazards observed to the hallway on the dementia unit during construction, and dirty resident care equipment on both units. (Cottage, East Unit, [NAME] Unit)
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed related to restraints, antipsychotic medication, and tube feeding for 3 of 26 MDS assessments reviewed. (Residents 59, 11, and 79)
- 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 a resident's care plan was updated related to a suprapubic urinary catheter and enhanced barrier precaution isolation use for 2 of 26 residents whose care plans were reviewed. (Resident 2 and 79)
- 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, record review and interview, the facility failed to ensure a hand splinting device was in place as ordered and restorative nursing care was provided as ordered for 1 of 2 residents reviewed for range of motion. (Resident 81)
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review and interview, the facility failed to monitor nutritional intake for meals for a resident with history of weight loss for 1 of 1 resident reviewed for nutrition. (Resident 5)
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident with a gastrostomy tube (g-tube, feeding tube) received care and services as ordered by a Physician related to treatment of the area around the insertion site for 1 of 1 resident reviewed for tube feeding. (Resident 79)
- 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 maintain clinical records that were complete and accurately documented related to medication administration for 1 of 1 resident reviewed for dialysis. (Resident 8)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure infection control measures were implemented related to an indwelling urinary catheter bag on the floor for 1 of 2 residents reviewed for urinary catheters (Resident 62), glove use during tracheostomy care for 1 of 1 resident reviewed for tracheostomy care (Resident 2) and lack of orders and care plans for enhanced barrier precautions (EBP) for 1 of 3 residents reviewed for transmission based precautions. (Resident 141)
August 9, 2024Standard inspection · 8 citations
- 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, record review, and interview, the facility failed to ensure medications were stored properly, with appropriate labeling and not expired, for 2 of 4 medication carts observed. (East Cart and Cottage Cart)
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation and interview, the facility failed to provide privacy related to a shared bathroom for 1 of 1 resident reviewed for privacy. (Resident 57)
- 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 reviewed and revised to include changes related to resident infections and dialysis access points for 2 of 29 resident care plans reviewed. (Residents 69 and 57)
- 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 ensure a resident with edema was monitored or treated for 1 of 1 resident reviewed for edema (Resident 18), medications were given as scheduled and accuchecks were documented for 2 of 5 residents reviewed for unnecessary medications. (Residents 91 and 120)
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observation, record review, and interview, the facility failed to care for a PICC (peripherally inserted central catheter, intravenous catheter placed into the peripheral veins of the upper arm) line in accordance with professional standards of practice, related to flushing the PICC line for 1 of 5 residents observed during medication pass. (Resident 3)
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident received the necessary care and treatment related to incorrect oxygen flow rate and a humidity bottle not changed for 1 of 4 residents reviewed for respiratory care. (Resident 70)
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, record review, and interview, the facility failed to provide the necessary care and services for residents who received hemodialysis, related to not monitoring the dialysis access site, for 1 of 1 resident reviewed for dialysis. (Resident 57)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident with a peripherally inserted central catheter (PICC) was placed in enhanced barrier precautions (EBP) for high contact resident care activities, and for improper glove use for 1 of 5 residents reviewed during medication administration.
October 25, 2023Complaint inspection · 1 citation
- 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 allegations of abuse were reported to the Indiana Department of Health (IDOH) immediately or within the 2 hour time period for 2 of 6 residents reviewed for abuse. (Residents F and G) The facility also failed to ensure an allegation submitted was not misleading with the facts reported by the resident. (Resident F).
July 14, 2023Standard inspection · 7 citations
- 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 ensure a Care Plan was developed for a resident who received an antidepressant medication for 1 of 24 residents reviewed for Care Plan development. (Resident 64)
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure pressure offloading boots were in place as ordered for 1 of 4 residents reviewed for pressure ulcers. (Resident 90)
- 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 a resident was supervised and orders were obtained for an electronic cigarette for 1 of 1 residents reviewed for smoking. (Resident 44)
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observation, record review and interview, the facility failed to care for a PICC line (peripherally inserted central catheter, intravenous catheter placed into the peripheral veins of the upper arm) in accordance with professional standards of practice, related to flushing the PICC line and changing the PICC site dressings for 1 of 1 resident reviewed for intravenous care. (Resident 90)
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents with pain were assessed and monitored related to lack of non-pharmacological pain interventions, pain was not assessed for severity or location, and parameters were not in place for use of pain medication for 2 of 2 residents reviewed for pain. (Residents 64 and 28)
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and interview, the facility failed to ensure each resident's medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being, related to ensuring a pain medication was available and given as ordered by the Physician for 1 of 5 residents reviewed for unnecessary medications. (Resident 86)
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% for 1 of 7 residents observed during medication pass. Two errors were observed during 27 opportunities for errors during medication administration. This resulted in a medication error rate of 7.41%. (Resident 91)
Fire safety inspections
19 fire safety citations on file: 14 on December 17, 2025, 1 on August 9, 2024, 4 on July 14, 2023.
Every fire safety citation19 citations
- F
Implement emergency and standby power systems.
E 41 · December 17, 2025 · Corrected (the home has a date of correction)
- F
Meet other general requirements that are deficient.
K 300 · December 17, 2025 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · December 17, 2025 · 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 17, 2025 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · December 17, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · December 17, 2025 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · December 17, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 17, 2025 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · December 17, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · December 17, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · December 17, 2025 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of highly flammable decorations.
K 753 · December 17, 2025 · Corrected (the home has a date of correction)
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · December 17, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · December 17, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 9, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 14, 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 · July 14, 2023 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · July 14, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · July 14, 2023 · Corrected (the home has a date of correction)