The Vardell Report.Majestic Care of Goshen

Across 15 inspections from January 2023 to July 2026, state surveyors documented 84 findings at Majestic Care of Goshen; 84 have a recorded correction; CMS lists 3 enforcement actions in the window.

Inspections

15

2023–2026, complaint and standard

Findings

84

Deficiencies cited by state inspectors

Corrected

84

Of 84 findings, with a recorded correction date

Penalties

3

2 fines; payment not published, 1 closed

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. Jul 242026

   Complaint investigation

   4 findings

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level JImmediate jeopardyCorrected Aug 21, 2026
   • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level FNo actual harm, potential for moreCorrected Aug 21, 2026
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Aug 21, 2026
   • F814Dispose of garbage and refuse properly.Level ENo actual harm, potential for moreCorrected Aug 21, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Jun 122026

   Complaint investigation

   1 finding

   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Jun 28, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Jun 22026

   Complaint investigation

   4 findings

   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Jun 23, 2026
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Jun 23, 2026
   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Jun 23, 2026
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Jun 23, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

4. Feb 32026

   Complaint investigation

   2 findings

   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Feb 25, 2026
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Feb 25, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

5. Jan 72026

   Complaint investigation

   3 findings

   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Jan 20, 2026
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jan 20, 2026
   • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Jan 20, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

6. Sep 102025

   Complaint investigation

   1 finding

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Oct 1, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

7. Jan 232025

   Standard health inspection

   11 findings

   The same visit included a complaint investigation.

   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Feb 12, 2025
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Feb 12, 2025
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Feb 12, 2025
   • F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Level DNo actual harm, potential for moreCorrected Feb 12, 2025
   • F646Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.Level DNo actual harm, potential for moreCorrected Feb 12, 2025
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Feb 12, 2025
   • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Feb 12, 2025
   • F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Level DNo actual harm, potential for moreCorrected Feb 12, 2025
   • F758Implement 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.Level DNo actual harm, potential for moreCorrected Feb 12, 2025
   • F761Ensure 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.Level DNo actual harm, potential for moreCorrected Feb 12, 2025
   • F770Provide timely, quality laboratory services/tests to meet the needs of residents.Level DNo actual harm, potential for moreCorrected Feb 12, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

8. Nov 142024

   Complaint investigation

   3 findings

   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Nov 30, 2024
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Nov 30, 2024
   • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Nov 30, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

9. Sep 122024

   Complaint investigation

   3 findings

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Sep 27, 2024
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Sep 27, 2024
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Sep 27, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

10. Aug 162024

    Complaint investigation

    4 findings

    • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Sep 9, 2024
    • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Sep 9, 2024
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Sep 9, 2024
    • F691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Sep 9, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

11. Aug 12024

    Complaint investigation

    1 finding

    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Aug 13, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

12. Mar 22024

    Standard health inspection

    29 findings

    The same visit included a complaint investigation.

    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Mar 22, 2024
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Apr 16, 2024
    • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Mar 22, 2024
    • F584Honor 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.Level ENo actual harm, potential for moreCorrected Mar 22, 2024
    • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Mar 22, 2024
    • F808Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.Level ENo actual harm, potential for moreCorrected Mar 22, 2024
    • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level ENo actual harm, potential for moreCorrected Mar 22, 2024
    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Mar 22, 2024
    • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Mar 22, 2024
    • F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Level DNo actual harm, potential for moreCorrected Mar 22, 2024
    • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Mar 22, 2024
    • F625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Level DNo actual harm, potential for moreCorrected Mar 22, 2024
    • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Mar 22, 2024
    • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Mar 22, 2024
    • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Mar 22, 2024
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Mar 22, 2024
    • F679Provide activities to meet all resident's needs.Level DNo actual harm, potential for moreCorrected Mar 22, 2024
    • F685Assist a resident in gaining access to vision and hearing services.Level DNo actual harm, potential for moreCorrected Mar 22, 2024
    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Mar 22, 2024
    • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Mar 22, 2024
    • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Mar 22, 2024
    • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Mar 22, 2024
    • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Mar 22, 2024
    • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Mar 22, 2024
    • F758Implement 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.Level DNo actual harm, potential for moreCorrected Mar 22, 2024
    • F791Provide or obtain dental services for each resident.Level DNo actual harm, potential for moreCorrected Mar 22, 2024
    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Mar 22, 2024
    • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Mar 22, 2024
    • F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Mar 22, 2024

    Enforcement Action

    Civil money penalty, $8,018 imposed March 2, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of March 2, 2024, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $8,018 imposed March 2, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of March 2, 2024, the nearest before the penalty date.

    Enforcement Action

    Denial of payment imposed March 2, 2024. Status: Closed, April 16, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of March 2, 2024, the nearest before the penalty date.

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

13. Jan 42024

    Complaint investigation

    1 finding

    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Jan 12, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

14. Oct 232023

    Complaint investigation

    1 finding

    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Nov 3, 2023

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

15. Jan 182023

    Standard health inspection

    16 findings

    • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Feb 10, 2023
    • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Feb 10, 2023
    • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level ENo actual harm, potential for moreCorrected Feb 10, 2023
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Feb 10, 2023
    • F578Honor 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.Level DNo actual harm, potential for moreCorrected Feb 10, 2023
    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Feb 10, 2023
    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Feb 10, 2023
    • F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Level DNo actual harm, potential for moreCorrected Feb 10, 2023
    • F679Provide activities to meet all resident's needs.Level DNo actual harm, potential for moreCorrected Feb 10, 2023
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Feb 10, 2023
    • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Feb 10, 2023
    • F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Level DNo actual harm, potential for moreCorrected Feb 10, 2023
    • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Feb 10, 2023
    • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Feb 10, 2023
    • F758Implement 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.Level DNo actual harm, potential for moreCorrected Feb 10, 2023
    • F761Ensure 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.Level DNo actual harm, potential for moreCorrected Feb 10, 2023

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Quality of Care, Cited in Seven Inspections

   Inspectors cited F684 in January 2023, March 2024, August 2024, September 2024, September 2025, January 2026 and July 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232324242424242425252626262626F684 across all 15 inspections, oldest to newest
2. 2

   Reporting Suspected Abuse, Cited in Five Inspections

   Inspectors cited F609 in January 2023, October 2023, January 2024, March 2024 and February 2026. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232324242424242425252626262626F609 across all 15 inspections, oldest to newest
3. 3

   Help With Daily Living, Cited in Five Inspections

   Inspectors cited F677 in January 2023, March 2024, August 2024, November 2024 and January 2026. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232324242424242425252626262626F677 across all 15 inspections, oldest to newest
4. 4

   Continence and Catheter Care, Cited in Five Inspections

   Inspectors cited F690 in January 2023, March 2024, November 2024, January 2025 and January 2026. This citation covers continence care, catheter care and preventing urinary tract infections. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232324242424242425252626262626F690 across all 15 inspections, oldest to newest
5. 5

   Kitchen and Food Safety, Cited in Five Inspections

   Inspectors cited F812 in January 2023, March 2024, January 2025, June 2026 and July 2026. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232324242424242425252626262626F812 across all 15 inspections, oldest to newest
6. 6

   Protection From Abuse and Neglect, Cited in Three Inspections

   Inspectors cited F600 in January 2023, March 2024 and June 2026. This citation covers whether residents are protected from abuse and neglect by anyone. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232324242424242425252626262626F600 across all 15 inspections, oldest to newest
7. 7

   Care Plans, Cited in Three Inspections

   Inspectors cited F656 in January 2023, March 2024 and August 2024. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232324242424242425252626262626F656 across all 15 inspections, oldest to newest
8. 8

   Pressure Injury Care, Cited in Three Inspections

   Inspectors cited F686 in March 2024, September 2024 and January 2025. This citation covers how the home prevents and treats pressure injuries (bedsores). None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232324242424242425252626262626F686 across all 15 inspections, oldest to newest
9. 9

   Psychotropic Medications, Cited in Three Inspections

   Inspectors cited F758 in January 2023, March 2024 and January 2025. This citation covers how psychotropic drugs are used, including dose reductions and limits on as-needed orders. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232324242424242425252626262626F758 across all 15 inspections, oldest to newest
10. 10

    Telling Families About Changes, Cited in Two Inspections

    Inspectors cited F580 in January 2025 and June 2026. This citation covers whether the resident, their doctor and a family member are told promptly about an injury, a decline or another significant change. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232324242424242425252626262626F580 across all 15 inspections, oldest to newest
11. 11

    Investigating Alleged Violations, Cited in Two Inspections

    Inspectors cited F610 in March 2024 and February 2026. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232324242424242425252626262626F610 across all 15 inspections, oldest to newest
12. 12

    Care Plan Timing and Review, Cited in Two Inspections

    Inspectors cited F657 in January 2023 and March 2024. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232324242424242425252626262626F657 across all 15 inspections, oldest to newest
13. 13

    Provide activities to meet all resident's needs, Cited in Two Inspections

    Inspectors cited F679 in January 2023 and March 2024. The agency describes it this way: Provide activities to meet all resident's needs. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232324242424242425252626262626F679 across all 15 inspections, oldest to newest
14. 14

    Respiratory Care, Cited in Two Inspections

    Inspectors cited F695 in January 2023 and March 2024. This citation covers oxygen, breathing treatments and other respiratory care. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232324242424242425252626262626F695 across all 15 inspections, oldest to newest
15. 15

    Citation F757, Cited in Two Inspections

    Inspectors cited F757 in January 2023 and March 2024. The agency describes it this way: Ensure each resident’s drug regimen must be free from unnecessary drugs. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232324242424242425252626262626F757 across all 15 inspections, oldest to newest
16. 16

    Medication Labeling and Storage, Cited in Two Inspections

    Inspectors cited F761 in January 2023 and January 2025. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232324242424242425252626262626F761 across all 15 inspections, oldest to newest
17. 17

    Infection Control, Cited in Two Inspections

    Inspectors cited F880 in March 2024 and January 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232324242424242425252626262626F880 across all 15 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

   Quality of Care: cited in seven inspections, most seriously at level J.

2. 02

   How are staff trained to report suspected abuse or neglect, and who reports it to the state?

   Reporting Suspected Abuse: cited in five inspections, most seriously at level D.

3. 03

   How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?

   Help With Daily Living: cited in five inspections, most seriously at level E.

4. 04

   How is continence care scheduled, and how do you prevent urinary infections?

   Continence and Catheter Care: cited in five inspections, most seriously at level D.

5. 05

   May we see the kitchen, and what do your own sanitation checks look like week to week?

   Kitchen and Food Safety: cited in five inspections, most seriously at level F.

6. 06

   What happened after the abuse or neglect citation, and what changed in training or supervision?

   Protection From Abuse and Neglect: cited in three inspections, most seriously at level G.

7. 07

   How is a care plan written and reviewed here, and how do families take part in it?

   Care Plans: cited in three inspections, most seriously at level E.

8. 08

   How often are residents checked for pressure injuries and repositioned, and who is responsible for it?

   Pressure Injury Care: cited in three inspections, most seriously at level D.

9. 09

   How many residents take psychotropic medications, and how often are doses reviewed for reduction?

   Psychotropic Medications: cited in three inspections, most seriously at level D.

10. 10

    How quickly will we hear about a fall, an injury or a change in condition, and from whom?

    Telling Families About Changes: cited in two inspections, most seriously at level D.

11. 11

    When an allegation is made, who investigates it, and how are residents protected in the meantime?

    Investigating Alleged Violations: cited in two inspections, most seriously at level D.

12. 12

    How often are care plans revised, and who takes part in the review?

    Care Plan Timing and Review: cited in two inspections, most seriously at level E.

13. 13

    What changed after F679 was cited, and how do you check it now?

    Provide activities to meet all resident's needs: cited in two inspections, most seriously at level D.

14. 14

    Who manages oxygen and breathing treatments on each shift, and how is the equipment checked?

    Respiratory Care: cited in two inspections, most seriously at level D.

15. 15

    What changed after F757 was cited, and how do you check it now?

    Citation F757: cited in two inspections, most seriously at level D.

16. 16

    How are medications stored and secured, and who checks the medication carts?

    Medication Labeling and Storage: cited in two inspections, most seriously at level D.

17. 17

    Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

    Infection Control: cited in two inspections, most seriously at level E.

18. 18

    How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

    No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.

19. 19

    What led to the 2024 fine, and has it been paid?

    An $8,018 civil money penalty was imposed March 2, 2024. CMS publishes the fine, not whether it has been paid. The record holds three enforcement actions in the window.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Indiana state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Indiana state survey agency

  Inspection Jan 18, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Indiana state survey agency

  Inspection Oct 23, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Indiana state survey agency

  Inspection Jan 4, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Indiana state survey agency

  Inspection Mar 2, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Indiana state survey agency

  Inspection Aug 1, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Indiana state survey agency

  Inspection Aug 16, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Indiana state survey agency

  Inspection Sep 12, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Indiana state survey agency

  Inspection Nov 14, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Indiana state survey agency

  Inspection Jan 23, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Indiana state survey agency

  Inspection Sep 10, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Indiana state survey agency

  Inspection Jan 7, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Indiana state survey agency

  Inspection Feb 3, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Indiana state survey agency

  Inspection Jun 2, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Indiana state survey agency

  Inspection Jun 12, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Indiana state survey agency

  Inspection Jul 24, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Penalties, Provider Data Catalog

  Centers for Medicare & Medicaid Services

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗
• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 155689

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.