Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ascension Living Sacred Heart Village during CMS and state inspections, most recent first.
Unsanitary storage of dishes and expired food in a unit refrigerator were identified for 99 of 99 residents who consumed food prepared in the kitchen. Wet stainless steel pans and wet lids were observed being stacked for storage, and Unit B’s pantry refrigerator contained expired Glucerna supplements. The refrigerator log also lacked documentation showing daily checks for outdated food and weekly cleaning, and the DSD stated dietary staff had not checked the Glucerna items.
Unsafe medication storage was observed when an RN left multiple residents’ meds preset in open cups in a med cart outside the dining room, including meds for residents with cognitive impairment and residents receiving Schedule II drugs. The RN said she had prepared the meds before confirming the residents were present and acknowledged the cups should not have been left in the cart. A separate observation found a resident’s dialysis folder in the nurse’s workroom containing opened bags of meds and loose tablets stored outside packaging, contrary to the facility’s medication storage policy.
Discolored ceiling tiles were observed in multiple resident rooms and the dining room, including brown rings, black centers, and speckled areas on several tiles. A resident said the ceiling tiles were nasty, and staff interviews and work orders showed ongoing water damage issues, with some stained or moldy tiles noted but not all affected rooms having specific work orders.
A resident with CKD stage 5, ESRD on dialysis, and DM2 did not receive multiple scheduled doses of Flexeril, gabapentin, and Velphoro, and one noon dose was missing documentation. The resident had difficulty opening medication packets, yet meds were found in the dialysis folder, the dialysis RN said routine meds were not being given there except Midodrine, and staff reported no clear policy or clarification process for sending routine meds with the resident.
The facility failed to keep the medication error rate below 5%. An LPN administered Novolog insulin without priming the flexpen, and an RN gave an inhaler during a meal, failed to complete the ordered rinse after inhaler use, and administered eye drops while the resident was eating. These errors resulted in a 10.74% medication error rate.
The facility failed to ensure safe and sanitary food storage and handling practices, affecting all 74 residents. Observations revealed unlabeled and expired food items, improper food handling by dietary aides without changing gloves or performing hand hygiene, and unsanitary conditions in food preparation areas. Staff interviews confirmed non-compliance with facility policies on food safety and hygiene.
The facility breached the privacy of two residents' health information. A resident's catheter bag was visible from the hallway, and another resident's need to use the restroom was loudly communicated in a public area. The facility lacked a specific policy for covering catheter bags, and staff acknowledged the need for private communication of residents' personal needs.
A resident with multiple diagnoses experienced a decline in condition without adequate documentation or assessment by the facility. Despite changes in symptoms and increased confusion, there was a lack of communication with the physician, leading to the resident being sent to the emergency room for low blood pressure and sepsis.
A resident with Alzheimer's and muscle contractures was observed in a Broda chair with their head leaning forward, requiring manual support during feeding. The care plan did not address this positioning issue, despite previous OT recommendations. Staff were unaware of the need for assistive equipment, leading to a deficiency in maintaining the resident's range of motion and comfort.
A resident's catheter bag was observed in contact with the floor, contrary to facility policy and best practices for infection prevention. The resident, diagnosed with obstructive and reflux uropathy, required a Foley catheter and maximal assistance with lower body activities. The facility's policy mandates that catheter bags be kept off the floor, a standard not met in this instance.
Unsanitary storage of dishes and expired food in unit refrigerator
Penalty
Summary
The facility failed to ensure dishes and equipment were stored in sanitary conditions and that unit refrigerators were maintained free of expired foods for 99 of 99 residents who consumed food prepared in the kitchen. During observation, a nested stack of stainless steel 6-inch containers had moisture between 3 of 6 pans, and a dietary staff member was observed taking 6 wet, plate-sized lids out of the dishwashing area and stacking them for storage. The Director of Dining Services stated that items should be dried before storing, nesting, or stacking. On Unit B, the pantry refrigerator contained 2 chocolate Glucerna liquid supplements with expiration dates of 8/1/25 and 1 vanilla Glucerna shake expired on 1/1/26. Review of the Nursing Unit B Refrigerator Log showed missing documentation from 1/1/26 to 1/9/26 for checking outdated food and completing weekly cleaning, even though the log required daily checks for outdated food and cleaning at least weekly. LPN 12 stated dietary staff were responsible for checking the common area refrigerator, and the Director of Dining Services stated dietary staff sign the unit refrigerator log and had not checked the Glucerna supplements in the refrigerators.
Unsafe Medication Storage and Preset Medications
Penalty
Summary
The facility failed to ensure safe storage of medications for 6 of 15 residents observed. During an observation, an RN opened the top drawer of a medication cart outside the main dining room and multiple residents’ medications were found preset in open cups in the drawer. Cups labeled for Resident 6, Resident 38, Resident 51, Resident 73, and Resident 10 were positioned together in the cart, with pills exposed to air and not covered. The RN stated she had prepared the medications for residents who normally came to the dining room, labeled the cups with first names when the residents did not arrive, and placed the cups in the top of the cart. She stated she should have verified each resident was present before preparing the medications and that preset cups should not be left in the cart because they could spill or mix if the cart was bumped. Resident 6 had diagnoses including bipolar disorder, metabolic encephalopathy, and chronic kidney disease, with a BIMS score of 14 and orders for multiple scheduled medications including Keppra, Vimpat, vitamin D, Flexeril, a probiotic, Requip, and divalproex. Resident 38 had Parkinson’s disease, cerebrovascular disease, and depression, with a BIMS score of 14 and orders for carbidopa/levodopa, buspirone, acetaminophen, senna-s, nifedipine, and escitalopram. Resident 51 had type 2 diabetes, normal pressure hydrocephalus, and hypertension, with a BIMS score of 12 and orders for bumex, cinnamon, hydrochlorothiazide, acetaminophen, vitamin D3, metoprolol succinate ER, metformin, hydralazine, and benazapril. Resident 73 had congestive heart failure and COPD, with a BIMS score of 15 and orders including Norco, a Schedule II medication, along with allopurinol, senna, carafate, pantoprazole, Eliquis, vitamin D3, vitamin B12, oxybutynin ER, folic acid, and certavite with antioxidants. Resident 10 had myasthenia gravis, major depressive disorder, and chronic pain, with a BIMS score of 15 and orders including methadone, a Schedule II medication, Claritin, Zofran, duloxetine, lisinopril, levothyroxine, and aspirin. A second observation found Resident 4’s dialysis folder in the nurse’s workroom containing multiple medications stored in opened plastic bags and loose tablets. The folder held opened bags labeled with Resident 4’s name and dates, containing midodrine, gabapentin, cyclobenzaprine, Velphoro, and Zofran, and additional loose tablets of Zofran and midodrine in the bottom pocket. Resident 4 had chronic kidney disease stage 5, dependence on renal dialysis, and type 2 diabetes, with a BIMS score of 15. Resident 4’s orders included dialysis three times weekly, Velphoro, cyclobenzaprine, gabapentin, Zofran to be sent with the resident to dialysis, and midodrine to be sent with the resident to dialysis. The facility policy stated medications should be stored safely, securely, and properly, accessible only to authorized staff, and that Schedule II medications and other drugs subject to abuse should be stored in a separate area under double lock.
Discolored Ceiling Tiles Not Maintained
Penalty
Summary
The facility failed to ensure ceiling tiles were maintained in 5 of 5 resident rooms reviewed. During observation, Room A-15 had 2 areas of discolored ceiling tiles with irregular brown outlines surrounding black centers. Room A-18 had 6.25 ceiling tiles with 15 round areas of discoloration, including several black-centered areas and one tile with two large discolored areas covering much of the tile. Room A-20 had 6 areas of discoloration on 3 ceiling tiles, including brown rings with black centers and speckled black-to-gray centers. Room A-22 had 3 areas of discoloration on 2 ceiling tiles near an exterior window, and Room A-24 had 5 areas of discoloration on 4 ceiling tiles in a line parallel to the hallway. The main dining room also had 11 ceiling tiles with brown circular or round-shaped areas next to the shared kitchen wall. Resident 45 stated the ceiling tiles in the room were nasty. Open work orders showed one created on 10/21/25 stating all stained ceiling tiles needed replaced on Unit A and in the hallways, and another created on 12/16/25 stating Room A-15 had ceiling tiles with mold on them. The Director of Dining Services stated she had not previously entered a work order for the 11 brown discolored ceiling tiles in the dining room. The Maintenance Director stated water damage had been an ongoing issue and that when mold or mildew were noticed on ceiling tiles, the tiles should be changed right away, but Rooms A-18, A-20, A-22, and A-24 did not have specific work orders identifying black ceiling tiles. Housekeeper 14 stated they would make a work order for ceiling tiles with water damage and, when the tiles become black, would make a second work order describing how the ceiling looked.
Missed and Undocumented Medication Administration for a Dialysis Resident
Penalty
Summary
The facility failed to follow physician orders for Resident 4, a cognitively intact resident with chronic kidney disease stage 5, dependence on renal dialysis, and type 2 diabetes. Resident 4’s orders included dialysis on Monday, Wednesday, and Friday, along with scheduled doses of Velphoro 500 mg three times daily with meals, Flexeril 10 mg three times daily, Gabapentin 200 mg three times daily, Zofran 8 mg three times weekly to send with the resident to dialysis, and Midodrine 5 mg three times weekly to send with the resident to dialysis. The resident’s self-administration assessment noted trouble holding onto objects and opening bottles. Review of the MAR for 12/1/25 through 12/31/25 showed missed second doses of Flexeril 10 mg, Gabapentin 200 mg, and Velphoro 500 mg on multiple dates, and documentation was missing for the noon doses on 12/6/25. During observation, an opened plastic bag in the dialysis communication folder contained midodrine, gabapentin, cyclobenzaprine, and Velphoro tablets. The dialysis RN stated medications sent from the facility were not given at dialysis except Midodrine, and the facility did not send an order sheet or MAR with the resident. The QMA stated the MAR codes were used to indicate out of facility, hold, or refusal, and the RN and DON stated they were not aware of a policy or clarification process for sending routine medications to dialysis.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5%, with 2 of 14 residents observed affected. During an observation, an LPN obtained a blood glucose reading of 215 for a resident with diabetes mellitus type 2 and long-term insulin use, then administered 9 units of Novolog insulin by flexpen without priming the pen with 2 units first. The LPN stated she did not prime the flexpen and was unsure of the facility policy. The resident’s record showed an order for sliding-scale insulin coverage that required 4 units for a blood glucose reading of 215, and the DON stated the pen should be primed with 2 units before administration to ensure the correct dose was received. During another observation, an RN administered medications to a resident while he was eating breakfast. The RN gave the resident an inhaler during the meal, then the resident swallowed pills without a mouth rinse, and the RN administered eye drops while the resident remained at the table with food in front of him. The RN stated the inhaler should not have been given during mealtime due to aspiration risk and that an oral rinse should have occurred after inhaler use; she also stated the eye drops should not have been administered in proximity to the resident’s food. The resident had diagnoses of COPD and dry eyes, and his orders included Anoro Ellipta with rinse and spit after use and artificial tears twice daily. Three medication errors were identified during the medication pass observation, resulting in an error rate of 10.74%.
Deficiencies in Food Storage and Handling Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and serving practices, as observed during multiple inspections. Observations revealed several issues, including a countertop with open slotted drains and a brown, murky liquid puddle underneath. In Freezer 1, an opened bag of french fries and bread were not dated, while Freezer 2 contained whipped cream in an unsealed bag that was not labeled or dated. The dry pantry had an opened bag of macaroni that was not dated, and Refrigerator 1 contained expired swiss cheese. Additionally, two of five stacked metal pans had moisture between them, and the stand mixer had a dry, yellow flaky material on the paddle. During food distribution, Dietary Aide 4 was observed handling food and utensils without changing gloves or performing hand hygiene, even after touching potentially contaminated surfaces. Similarly, Dietary Aide 11 continued to assemble meal trays after picking up a plastic wrap box from the floor without changing gloves or performing hand hygiene. Interviews with staff, including the Dietary Shift Supervisor, Certified Nurse Aide, Registered Nurse, and Director of Nursing, confirmed that the facility's practices did not align with their policies. The Dietary Shift Supervisor acknowledged that bread should be used within a week and that the mixer should not have any residue. The CNA and RN indicated that meals and food items should be labeled and dated, and expired food should not be present in storage areas. The facility's policies on food preparation, storage, and hand hygiene were not adhered to, as evidenced by the presence of expired and unlabeled food items, improper food handling, and lack of hand hygiene practices. These deficiencies affected all 74 residents who consumed food prepared in the facility's kitchen.
Privacy Breach in Resident Health Information
Penalty
Summary
The facility failed to ensure the privacy of health information for two residents. In the first instance, a resident was observed sitting in her room with a catheter bag attached to her wheelchair, visible from the hallway. The Weekend Supervisor confirmed that the urine in the catheter bag should not be visible to passersby. The Director of Nursing (DON) later indicated that catheter bags should be covered to prevent visibility, but the facility lacked a specific policy on how to maintain the privacy of catheter bag contents. The resident's medical records showed cognitive impairment and a need for maximal assistance with daily living activities. In the second instance, a Certified Nurse Aide (CNA) loudly communicated a resident's need to use the restroom to other staff members across a dining area, where other residents, staff, and a family member were present and could hear the conversation. The CNA acknowledged that staff should communicate residents' personal needs in low tones and private areas. The DON confirmed that staff should discuss resident needs privately and not disclose personal information in populated areas. The facility's policy on confidentiality, dated December 2019, stated that all resident information should be treated confidentially.
Failure to Document and Assess Resident's Changing Condition
Penalty
Summary
The facility failed to ensure ongoing assessment for a change in condition for a resident diagnosed with cerebral infarction, diabetes, high blood pressure, and osteoarthritis. The resident's medical records revealed a lack of documentation and assessment regarding changes in their condition over a series of days. Initially, orders for blood tests were obtained without documented reasons or assessments. Subsequently, the resident was placed on medications such as Robitussin and Invanz without adequate documentation of symptoms or assessments, such as breath sounds or urinary symptoms. Despite the resident's afebrile status, there was no documentation of other symptoms of infection or changes in urine characteristics. As the resident's condition progressed, there were further lapses in documentation and communication. The resident experienced increased confusion, changes in urine characteristics, and decreased food intake, yet there was no documentation of notifying the physician about these changes. The resident's condition continued to decline, with increased confusion and changes in urinary output, culminating in a physician's order to send the resident to the emergency room due to low blood pressure and sepsis. An LPN interviewed confirmed that staff should assess residents for changes indicating improvement or decline, highlighting the deficiency in ongoing assessment and documentation for this resident.
Failure to Ensure Proper Positioning for Resident
Penalty
Summary
The facility failed to ensure proper functional and comfortable positioning for Resident 12, who was observed sitting in a Broda chair with their head leaning forward, approximately one inch from their chest. This positioning was noted during meal times, where staff had to manually lift the resident's head to feed them. The resident's care plan did not address this specific issue, despite the resident's known diagnoses of Alzheimer's, muscle weakness, and multiple sites of muscle contractures. Resident 12's care plan included interventions for other areas such as passive range of motion and nutritional needs, but it did not mention the forward-leaning head position. The Director of Nursing (DON) acknowledged awareness of the resident's head positioning issue but indicated it was not a new occurrence. The resident had previously received occupational therapy (OT) services, which had focused on improving Broda chair positioning to prevent contractures and improve comfort. However, the care plan and CNA worksheets did not reflect the OT recommendations for head and neck positioning. Interviews with staff revealed a lack of awareness regarding the assistive equipment recommended by therapy for Resident 12's head and neck positioning. The facility's policy required that each resident's care plan reflect their specific positioning needs, but this was not adhered to in Resident 12's case. The deficiency was identified as a failure to provide appropriate care to maintain or improve the resident's range of motion and comfort, as required by the facility's policies.
Deficiency in Catheter Bag Handling
Penalty
Summary
The facility failed to ensure the sanitary handling of a catheter bag for a resident, leading to a deficiency. During an observation, a resident was seen sitting in a wheelchair with a catheter bag attached to the wheelchair frame. The catheter bag, containing approximately 200 ml of yellow fluid, was in contact with the floor. This observation was confirmed by the Weekend Supervisor, who acknowledged that the urine bag should be secured to prevent contact with the floor, as such contact could increase the risk of infection. The resident involved had a diagnosis of obstructive and reflux uropathy and required maximal assistance with lower body activities of daily living. The resident's care plan included maintaining a closed drainage system, and physician orders specified the use of a 16 French 10 ml Foley catheter. The Director of Nursing confirmed that catheter bags should not contact the floor, aligning with the facility's policy dated December 2017, which mandates that catheter tubing and bags be kept off the floor.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Avilla
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kendallville Manor | 4.8 mi | ★★★★★ | 5 | 0 |
| Lutheran Life Villages | 5 mi | ★★★★★ | 2 | 0 |
| Orchard Pointe Health Campus | 6 mi | ★★★★★ | 7 | 0 |
| Miller's Merry Manor | 6.2 mi | ★★★★★ | 11 | 0 |
| Betz Nursing Home | 9.8 mi | ★★★★★ | 1 | 0 |
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