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 28 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
20D
4E
1F
Potential for minimal harm
0A
0B
3C
June 11, 2026Complaint inspection · 1 citation
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's right to privacy for 1 of 3 resident's reviewed for resident rights. An employee took an unauthorized video of a cognitively impaired resident with a personal cell phone. (Resident C) This deficient practice was corrected on May 11, 2026, prior to the start of the survey, and was therefore past noncompliance.
March 13, 2026Complaint inspection · 2 citations
- 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 record review, the facility failed to ensure pharmaceutical services were available to provide physician prescribed routine medications to 2 of 3 residents reviewed for pharmacy services. Physician prescribed routine medications were not administered due to the medications being unavailable at the facility. (Resident B, Resident C)
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of significant medications errors for 1 of 3 residents reviewed for pharmacy services. A resident received a double dose of insulin and received another resident's medications. (Resident C)
September 2, 2025Standard inspection · 9 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 failed the obtain the temperature of the food prior to serving the residents for 1 of 1 plating 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 interview and record review, the facility failed to clarify a Resident's code status for 1 of 1 residents reviewed for advanced directives. A resident's current Physician's Order did not match the signed Indiana Physician Orders for Scope of Treatment form, and staff was unaware of Resident's wishes. (Resident 56)
- 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 ensure the comprehensive care plan was reviewed and revised for 1 of 2 residents reviewed for urinary tract infections (UTI), 1 of 3 residents reviewed for pressure ulcers, and 2 of 5 reviewed for unnecessary medications. Residents who were not on antianxiety medication and no longer had a UTI had care plans that were not removed and a resident with multiple pressure ulcers did not have wound specific care plans. (Resident 6, Resident 18, Resident 45, Resident 1)
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review, the facility failed to ensure services provided by the facility met professional standards of quality for 2 of 3 residents reviewed for nutrition and 1 of 4 residents reviewed for urinary tract infections (UTI) and pressure ulcers. Weights were not monitored and discontinuation of contact precautions were not completed as ordered, a dressing was not initialed or dated, staff documented treatments completed on a pressure ulcer that had been healed, and a nurse signed off on a treatment that another staff member completed. (Resident 45, Resident 1, Resident 8)
- 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 resident received ordered treatment and services to promote healing and prevent new ulcers from developing for 1 of 3 residents reviewed for pressure ulcers. A wound specific care plan was not developed, treatment orders were not followed, wound assessments were not completed accurately, and Enhanced Barrier Precautions (EBP) were not used when providing wound care. (Resident 6)
- 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 and prevent falls for 1 of 3 residents reviewed for accidents. Fall interventions were not in place for a resident with multiple falls and neurological (neuro) checks were not fully completed after unwitnessed falls. (Resident 5)
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it was free of a medication error rate of greater than 5 percent for 1 of 5 residents (Resident 31) observed during the medication pass. There were 25 opportunities for error observed with 3 medication errors, resulting in a medication error rate of 12 percent.
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on interview and record review, the facility failed to ensure antibiotic use protocols were followed to monitor antibiotic use. Residents received an antibiotic prior to obtaining culture results, and received an antibiotic without an indication for 2 of 2 residents reviewed for urinary tract infections (UTI). (Resident 45, Resident 1)
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure posted nurse staffing forms were accurate for 4 of 6 days during the survey. Census information was not correct on the forms.
October 29, 2024Complaint inspection, Infection control · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices to help mitigate the spread of COVID-19. Staff failed to complete proper hand hygiene, touched resident furnishings without performing hand hygiene, and placed a dirty glove on top of a medication cart during 2 of 3 observations of care. (Resident C, Resident D)
July 26, 2024Standard inspection · 5 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 storage of food in a safe and sanitary manner and failed to follow proper sanitation for 2 of 2 kitchen observations. Food items were observed unlabeled and open to air. The dishwasher did not reach the proper rinse temperature. Temperature logs were not completed correctly. (Kitchen)
- E
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 interview and record review, the facility failed to ensure care plan conferences were completed. Quarterly care plan conferences were not completed for 4 of 5 residents reviewed for unnecessary medications. (Resident 28, Resident 8, Resident 19, Resident 29)
- 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 ensure a sanitary and homelike environment was provided for 3 of 3 resident halls observed and 1 of 1 shower room. Resident toilets were visibly soiled, fracture pans and urine hats were uncovered and placed between the handrail and wall, vitals machine and lift equipment were visibly soiled. The carpet was stained on the 200 Hall. The shower room grout was soiled, tiles were chipped, and there was a broken tile by the bathroom wall. (100 Hall, 200 Hall, 300 Hall, Shower Room) Findings Include: 1. On 7/22/24 at 11:02 A.M., the bathroom of room [ROOM NUMBER] was observed. There was a brown substance on the back of the toilet and an uncovered fractured (flattened) bedpan on the handrail. There were black scuffs on the walls. On 7/26/24 8:21 A.M., the same was observed. 2. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and interview, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents observed for incontinence care. Gloves were not changed and hands were not sanitized between dirty and clean tasks. A resident's incontinence pad was laid on the bathroom floor before it was placed on the resident. (Resident 39, Resident 7)
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure posted nurse staffing sheets were posted and contained the correct information daily for 1 of 6 days reviewed during the survey. (July 21)
March 20, 2024Complaint inspection · 1 citation
- 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 ensure adequate supervision was in place to prevent a resident with a history of exit-seeking behavior from exiting the facility for 1 of 3 residents reviewed for elopement. A resident unknowingly exited the facility and was found in the facility's parking lot approximately 45 minutes later. (Resident C)
January 26, 2024Complaint inspection · 1 citation
- E
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 assistance with bathing for 4 of 5 residents reviewed for activities of daily living (ADLs). Residents did not receive assistance with ADL's (bathing) according to the plan of care and bathing schedule. (Resident B, Resident C, Resident D, Resident F)
June 9, 2023Standard inspection · 8 citations
- 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 ensure a resident experienced a dignified existence for 1 of 3 residents reviewed for respect and dignity. (Resident 199)
- 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 interview and record review, the facility failed to ensure compliance with the requirements for advance directives. An advanced directive order and DNR (Do Not Resuscitate) form was not signed by the physician for 1 of 2 reviewed for advanced directives. (Resident 24)
- 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 observation, interview, and record review, the facility failed to ensure an intervention was implemented for 1 of 5 residents reviewed for accidents. Resident's bathroom did not have non skid strips placed in front of the toilet. (Resident 24)
- 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 that a resident who needs respiratory care is provided care according to the physician orders and maintenance of the respiratory equipment for 1 of 1 residents reviewed for respiratory care. (Resident 8)
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure behavioral health services were provided to maintain resident's highest practicable well-being. A Resident that required behavioral health monitoring was not evaluated for these services and not monitored for behaviors for 1 of 3 residents reviewed for dignity. (Resident G)
- 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 ensure residents were free from unnecessary medications for 1 of 5 residents reviewed for unnecessary medications and 1 of 1 residents reviewed for antibiotic use. A resident received 9 doses of an antibiotic that were double the ordered dose and a resident's as needed anti-anxiety medication was ordered for greater than 14 days. (Resident 9, Resident 13)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were followed for 2 of 4 observations of resident care. Handwashing was not completed between dirty to clean tasks. Gloves were not changed between dirty and clean tasks. (Resident G, Resident 15)
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure posted nurse staffing records contained the correct information daily for 1 of 6 days during the survey.
Fire safety inspections
19 fire safety citations on file: 6 on September 2, 2025, 6 on July 26, 2024, 7 on June 9, 2023.
Every fire safety citation19 citations
- F
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · September 2, 2025 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · September 2, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 2, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 2, 2025 · Corrected (the home has a date of correction)
- F
Meet other general requirements that are deficient.
K 500 · September 2, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · September 2, 2025 · Corrected (the home has a date of correction)
- F
Conduct risk assessment and an All-Hazards approach.
E 6 · July 26, 2024 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · July 26, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 26, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · July 26, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · July 26, 2024 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · July 26, 2024 · Corrected (the home has a date of correction)
- F
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · June 9, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · June 9, 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 · June 9, 2023 · Corrected (the home has a date of correction)
- E
Install a fire alarm system that can be heard throughout the facility.
K 341 · June 9, 2023 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · June 9, 2023 · Corrected (the home has a date of correction)
- C
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 9, 2023 · Corrected (the home has a date of correction)
- C
Meet other general requirements that are deficient.
K 500 · June 9, 2023 · Corrected (the home has a date of correction)