Average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Pulaski Health Care Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities and a history of pressure ulcers experienced a worsening wound that progressed to stage 3 with slough present. Despite care plan requirements to notify the physician and update interventions when the wound worsened, no new treatments or interventions were implemented for over a month, and there was no physician documentation of the change in wound status. The DON confirmed the lack of timely intervention and documentation.
Improper Glove Use During Food Preparation: A cook preparing pureed enchiladas was observed touching food and kitchen items with gloved hands, including scooping food into a blender, handling broth mix with a gloved finger, opening a drawer for a measuring cup, and scooping shredded cheese with gloved hands. She changed gloves without hand hygiene and stated she understood she should not touch food directly after touching other items or surfaces.
Elevated hot water temperatures were found in resident bathrooms on the North and Northeast Units. The Maintenance Assistant checked Rooms NE4, N2, and N3 and found water at 130 degrees F, while the Maintenance Director stated water should be around 111 degrees. The facility policy stated water temperatures should be kept between 100 and 120 degrees F.
The facility did not complete a speech therapy evaluation as ordered for a resident with severe cognitive deficits and special dietary needs, and also failed to document or implement bowel management interventions for another resident with multiple diagnoses and infrequent bowel movements. These deficiencies were identified through record review and staff interviews.
The facility did not maintain accurate and complete medical records for three residents, failing to document required meal, snack, and fluid intakes as ordered in care plans and physician orders. This included missing entries for residents with severe cognitive impairment, those on fluid restrictions due to dialysis, and those dependent on staff for nutrition, with facility leadership unable to provide the missing records when requested.
Incomplete transfer documentation for two residents. One resident with intellectual disabilities, aphasia, and DM had signs of acute change and was sent to the ED, but the record lacked documentation of preparation for transfer, an assessment at the time of transfer, and physician notification related to the transfer. Another resident with chronic respiratory failure, DM, major depressive disorder, and multiple pressure ulcers had hypotension, altered mental status, poor intake, and low urine output before being sent to the ED, but the record lacked a current transfer assessment and documentation that the resident and/or representative was oriented and prepared for discharge.
Failure to document transfer notices, bed-hold information, and handoff details for 3 residents. A resident with COPD, HF, and HTN was sent to the hospital after becoming difficult to arouse and coughing, while two other residents with significant cognitive and medical needs were also transferred for acute changes. In each case, the record lacked the transfer/discharge notice, bed-hold notice, and documentation of key information sent to the receiving provider, including practitioner contact info, representative info, advance directives, ongoing tx, and meds.
A resident with paraplegia, schizoaffective disorder, and chronic pain was receiving amitriptyline 50 mg twice daily, but the record had no care plan related to antidepressant medication use. The MDS showed the resident was cognitively intact and had received multiple medication classes, and the DON and Regional Nurse Consultant acknowledged that a care plan should have been in place even though the medication was being used for pain.
Failure to Apply Ordered Right Hand Splint: A resident with hemiplegia and hemiparesis after a stroke, vascular dementia, and limited ROM was observed sitting in a wheelchair without the ordered right hand splint in place. The care plan and MD order required the splint while up in the wheelchair, and the MAR showed it was documented as given every shift with no refusals, yet the DON and Regional Nurse Consultant stated the resident had been refusing to wear it lately.
Antibiotic Use Without Documented Infection Criteria: Two residents received antibiotics without documentation that infection criteria were met or a rationale for use when criteria were not met. One resident had a UA showing bacteria but McGeer's criteria for UTI were not met, yet cephalexin was ordered without a documented reason. Another resident with an indwelling catheter received ciprofloxacin from hospice for abnormal urine complaints, but there were no UA/C&S orders or other record evidence supporting a UTI diagnosis.
A resident with pressure ulcers on both posterior thighs was found without required dressings in place, despite physician orders for daily wound care and dressing application. CNAs and the DON confirmed the absence of dressings, and it was unclear when the dressings had last been applied, resulting in a failure to provide necessary treatment to promote healing.
Staff failed to use required PPE, specifically gowns, while providing high-contact care to two residents on Enhanced Barrier Precautions due to indwelling urinary catheters and pressure ulcers. Despite physician orders and facility policy mandating gowns and gloves for such care, CNAs only wore gloves and misunderstood the requirements, leading to noncompliance with infection control protocols.
A resident's privacy was breached when a CNA recorded a video of the resident without consent, using a personal cell phone. The video, taken in the bathroom, was shared among CNAs but not publicly posted. The resident, with varying cognitive status, could not recall the incident. Facility policies prohibited such actions, which CNA 1 had acknowledged. CNA 2 was present but unaware of the sharing intent.
A facility failed to create a comprehensive care plan for a resident on anticoagulant and antiplatelet medications, despite physician orders and medication administration records confirming the resident received aspirin and apixaban. The absence of a care plan to monitor for side effects was acknowledged by the DON.
The facility failed to provide necessary treatment to prevent contractures for two residents. One resident, paralyzed from the waist down, did not receive recommended ROM exercises, and there was no documentation of such care. Another resident with a contracture in his left hand was observed without the prescribed splinting device multiple times, despite a physician's order and care plan indicating its necessity.
A facility failed to monitor a resident receiving hydrocodone-acetaminophen for potential opioid side effects. The resident, with severe cognitive impairment and a history of a femur fracture, was on scheduled opioid medication without a care plan for side effect monitoring. The DON confirmed the lack of monitoring, which was against the facility's pain management policy.
Failure to Timely Update Pressure Ulcer Treatment After Worsening
Penalty
Summary
A resident with diagnoses including anemia, diabetes mellitus, and end stage renal disease was admitted to the facility with two stage 2 pressure ulcers and was dependent on staff for bed mobility and transfers. The care plan indicated that the resident had a pressure wound to the left ischium, which had previously healed but reopened as a stage 2 ulcer after a hospital stay. The care plan required staff to measure and record the wound's description and notify the physician of any changes or worsening. On assessment, the wound was found to have slough, which is only present in stage 3 or higher ulcers, but there was no documentation that the wound treatment or interventions were changed when the ulcer worsened. Further review showed that the wound continued to have slough and did not improve, yet no new treatment orders or interventions were implemented until over a month later. There was also a lack of physician documentation regarding the worsening wound status. During an interview, the DON confirmed that no documentation could be provided to show that interventions were changed when the wound worsened to a stage 3, and acknowledged that a new treatment order was not put in place until a month after the wound had worsened. Facility policy required physician evaluation and documentation of wound progress, especially for wounds not healing as anticipated, but this was not followed in this case.
Improper Glove Use During Food Preparation
Penalty
Summary
The facility failed to serve food under sanitary conditions when a cook preparing pureed enchiladas touched food with gloved hands after touching other items and surfaces in the kitchen. During the follow-up tour of the Main Kitchen, the cook was observed wearing clean gloves while scooping an enchilada from a mixing bowl into a blender with her gloved hands. She then removed one set of gloves while another pair remained underneath. The Dietary Food Manager brought a container of broth mix from the cooler, and the cook opened the container, used a measuring spoon, and then used her gloved finger to remove broth mix into another container. She mixed the broth with water to make beef broth for the enchilada, changed her gloves without performing hand hygiene, opened a drawer with gloved hands to get a measuring cup, and then opened a shredded cheese container and scooped cheese with her gloved hands before placing it into the blender. During interview, she stated she usually washed her hands between glove changes and understood she should not touch food directly after touching other items or surfaces in the kitchen.
Elevated Hot Water Temperatures in Resident Bathrooms
Penalty
Summary
The facility failed to provide a safe, comfortable environment related to elevated hot water temperatures in resident bathrooms on the North and Northeast Units. During the initial tour, water temperatures were felt by hand to be elevated, and the Maintenance Assistant checked Rooms NE4, N2, and N3 and found the water temperature was 130 degrees Fahrenheit. The Maintenance Assistant stated this was the hottest he had seen the water temperature and said rooms were checked randomly once a week. The Maintenance Director stated the water temperature should be around 111 degrees, and the current policy, Weekly Water Temperatures, stated that if water temperature is below or above the set temperature of 100-120, the maintenance supervisor or designee will adjust the mixing valve to bring the water to the proper temperature.
Failure to Complete Ordered Speech Therapy Evaluation and Lack of Bowel Management Documentation
Penalty
Summary
The facility failed to ensure that a speech therapy evaluation was completed as ordered for a resident with severe cognitive deficits and multiple diagnoses, including myasthenia gravis and pervasive developmental disorder. The resident was admitted for a respite stay and had specific dietary needs communicated by family, such as using a slow flow sippy cup, avoiding milk, and having medications crushed in applesauce. Despite a physician's verbal order for a speech therapy evaluation due to these special diet recommendations, there was no documentation that the evaluation was completed, and the speech therapist confirmed she had not evaluated the resident. The administrator was unable to provide an explanation for the missing evaluation. Additionally, the facility failed to document and implement interventions for bowel management for another resident with Alzheimer's disease, developmental disorder, and iron deficiency anemia, who was receiving multiple medications including opioids and was frequently incontinent. Review of bowel movement documentation over a period showed infrequent bowel movements, but there was no evidence of orders for treatment or intervention attempts related to the lack of bowel movements. The facility was unable to provide a policy related to bowel protocols and monitoring when requested.
Failure to Maintain Accurate and Complete Medical Records for Meal and Fluid Intake
Penalty
Summary
The facility failed to ensure that medical records were accurate and complete for three residents, specifically regarding documentation of meal, snack, and fluid intakes. For one resident with severe cognitive deficits and multiple diagnoses, including myasthenia gravis and cyclical vomiting syndrome, numerous meal consumption entries were missing from the Task Meal Consumption Logs for breakfast, lunch, and dinner over several days. The resident's care plan required monitoring of oral intakes due to nutritional risk, but the required documentation was not present for many dates. Another resident, diagnosed with diabetes, dementia, and end stage renal disease on dialysis, had a physician's order for a strict daily fluid restriction. The care plan required monitoring and recording of fluid intake, but the August Vitals Report lacked fluid documentation for multiple meals. A third resident with Parkinson’s disease and Lewy body dementia, who was dependent on staff for eating and drinking, also had missing documentation for snacks and meals over a 30-day period, despite physician orders and care plan interventions requiring daily intake charting. In each case, facility leadership was unable to provide the missing documentation when interviewed.
Incomplete transfer documentation for two residents
Penalty
Summary
The facility failed to ensure documentation for hospital transfers was complete and accurate for 2 residents. For one resident with intellectual disabilities, aphasia, and type 2 diabetes mellitus, the record showed he was observed shivering with cyanotic hands, the physician was notified, and labs and glucose monitoring were ordered. Later documentation indicated he was still in the emergency department, but the record did not include documentation that the resident or representative was prepared for transfer, an assessment at the time of transfer, or communication to the physician related to the hospital transfer. The DON and Regional Nurse Consultant stated they were unable to find any further information related to the transfer. For another resident with chronic respiratory failure, type 2 diabetes mellitus, major depressive disorder, and multiple pressure ulcers present on admission, the record showed she was receiving antibiotics, had low urine output and catheter issues, and the physician was updated on lab results, catheter replacement, and wound treatments. She later had hypotension, altered mental status, pallor, diaphoresis, poor appetite, and difficulty swallowing medications and food, and new orders were received to send her to the ED. Although she was transferred and report was called, the record lacked documentation of a current assessment at transfer and documentation that the resident and/or representative were oriented and prepared for transfer out of the facility. The DON and Regional Nurse Consultant stated there was no further documentation in the record related to the transfer.
Failure to Document Transfer Notices, Bed-Hold Information, and Required Handoff Details
Penalty
Summary
The facility failed to ensure that notice of transfer or discharge forms and bed-hold/reserve bed payment policy information were sent to residents and/or their representatives before and upon hospital transfer, and it also failed to document the information conveyed to the receiving provider for three residents transferred to the hospital. The record review and interview showed no documentation that the required transfer/discharge notice or bed-hold information was provided for any of the three residents reviewed. One resident with chronic respiratory failure, COPD, heart failure, and hypertension was found difficult to arouse, slow to respond, and coughing frequently before being sent to the hospital by physician order. The record documented that report was called to the receiving hospital and papers went with the EMTs, but it lacked documentation of the transfer/discharge notice, bed-hold notice, and the information sent to the receiving provider, including practitioner contact information, resident representative information, advance directive information, ongoing treatments, and medications received at the facility. A second resident with intellectual disabilities, aphasia, and type 2 diabetes was observed shivering with cyanotic hands and later had hospital results returned while still in the ED. A third resident with chronic respiratory failure, type 2 diabetes, major depressive disorder, multiple pressure ulcers, hypotension, and altered mental status was transferred to the hospital after becoming pale, diaphoretic, mouth breathing, and unable to follow directions. For both residents, the record lacked documentation of the transfer/discharge notice, bed-hold notice, and the required information provided to the receiving provider; the DON and Regional Nurse Consultant stated they could not find further documentation related to the transfers.
Missing Care Plan for Antidepressant Use
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed and in place for a resident receiving an antidepressant medication. Resident 2 had diagnoses including paraplegia, schizoaffective disorder, and chronic pain. The Significant Change in Status MDS assessment dated 7/15/25 indicated the resident was cognitively intact for daily decision making and had received injections, antipsychotic, antidepressant, antibiotic, opioid, and hypoglycemic medications during the 7-day look-back period. The August 2025 Physician Order Summary showed the resident had been receiving amitriptyline 50 mg twice daily since 7/12/25. Record review found no care plan related to antidepressant medication use. During interview, the DON and Regional Nurse Consultant stated there was no care plan initiated for the antidepressant use because the resident was actually taking the medication for pain, and that there should have been a care plan related to the antidepressant use.
Failure to Apply Ordered Right Hand Splint
Penalty
Summary
The facility failed to ensure a splinting device was in place as ordered for a resident with limited range of motion. Resident 13 had diagnoses including hemiplegia and hemiparesis following a stroke affecting the right dominant side, vascular dementia, and cognitive communication deficit. The annual MDS indicated the resident was rarely or never understood and had limited range of motion impairment to one side of the upper and lower extremities. The resident was dependent on staff for toileting, showering, personal hygiene, bed mobility, and transfers. The care plan stated the resident required substantial to total assistance with most ADLs related to the hemiplegia and hemiparesis and directed staff to use a right hand splint while the resident was up in the wheelchair. A physician’s order also required the resident to wear a right hand splint when up in the wheelchair. During multiple observations, the resident was sitting in the wheelchair with the right arm in the lap and no splint observed on the right hand. The August 2025 MAR showed the splint was checked off as administered every shift from 8/1/25 through the morning of 8/21/25, with no documented refusals. During interview, the DON and Regional Nurse Consultant stated the resident had been refusing to wear the splint lately.
Antibiotic Use Without Documented Infection Criteria
Penalty
Summary
The facility failed to ensure that antibiotics were used only when residents met criteria for a true infection or that a documented rationale was provided when infection criteria were not met for two residents reviewed for antibiotic stewardship. One resident with acute kidney failure, unspecified dementia, and congestive heart failure had a physician order for a urinalysis with reflex culture and sensitivity for mental status changes. The urinalysis showed moderate bacteria, but an Observation McGeer's Criteria review indicated the resident had no catheter, no dysuria, no fever, and no pain, and the indicators did not meet McGeer's criteria for a urine infection. Despite this, the resident was ordered cephalexin 500 mg every 12 hours for 8 doses, and there was no rationale documented in the resident's notes for why the antibiotic was given. A second resident with paraplegia, schizoaffective disorder, neuromuscular dysfunction of the bladder, and an indwelling catheter had a hospice nurse call the facility and give a new order for ciprofloxacin 250 mg twice daily for 7 days due to abnormal urine complaints reported by the resident. The medication was administered as ordered, but there were no physician orders for a urinalysis, culture and sensitivity, or other further information related to a urinary tract infection in the record. The DON and Regional Nurse Consultant stated no further testing was completed, and the hospice company started the antibiotic based on reported symptoms without ordering urine testing; they also stated the reported infection did not meet criteria for antibiotic use.
Failure to Provide Ordered Pressure Ulcer Care and Dressing Changes
Penalty
Summary
A resident with a history of transverse myelitis and diabetes mellitus, who was dependent for bed mobility and toileting and had a urinary catheter, was observed to have open pressure ulcers on the right and left posterior thighs without dressings in place. During incontinence care, CNAs noted the absence of dressings on the wounds, and the soiled pad underneath the resident did not contain any dressings. The CNAs were unable to confirm when the dressings had last been present, and one CNA admitted to not paying attention to the dressings during earlier care. Review of the resident's care plan and physician's orders indicated that both pressure ulcers were to be cleansed with normal saline, treated with collagen, and covered with bordered gauze every evening at bedtime. However, during observation and interview, the DON confirmed that no dressings were covering the pressure areas as ordered. The failure to ensure the prescribed wound care and dressing changes were completed as ordered resulted in the resident not receiving the necessary treatment and services to promote healing of the pressure ulcers.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
Staff members failed to use appropriate Personal Protective Equipment (PPE) when providing care to two residents who were under Enhanced Barrier Precautions (EBP). During the transfer of a resident with an indwelling urinary catheter and a pressure area, two CNAs wore gloves but did not wear gowns, despite signage indicating EBP and physician orders requiring EBP for all high-contact care activities. One CNA stated that gowns were only necessary for catheter care, which was inconsistent with the facility's policy and the resident's care plan. In a separate incident, the same CNAs began providing incontinent care to another resident with a urinary catheter and pressure ulcers, wearing only gloves and not gowns. They were stopped and questioned, and one CNA again indicated that gowns were only needed for catheter or wound care. Both residents had care plans and physician orders specifying the use of EBP, and the facility's policy required gowns and gloves for high-contact care activities. The DON confirmed that staff had been educated on EBP requirements.
Resident Privacy Breach Due to Unauthorized Video Recording
Penalty
Summary
The facility failed to ensure the privacy of a resident, identified as Resident C, when a terminated employee, CNA 1, used her private cell phone to take a video of the resident without approval. The incident involved CNA 1 taking a video of Resident C in the bathroom, capturing the resident from the shoulders up. The video was shared among CNAs on a group messaging page, although it was not posted on a public social media feed. Resident C, whose cognitive status varied, was unable to recall the incident. The resident's medical records indicated a diagnosis of diabetes mellitus and repeated falls, with an intact cognition assessment at the time of admission. The facility's policies, which CNA 1 had acknowledged, prohibited the use of personal mobile devices for taking photos or videos of residents, emphasizing the confidentiality of resident information. Despite this, CNA 1 recorded the video, claiming it was because the resident was having a good day. CNA 2 was present during the recording but was unaware of the intention to share the video. The facility's confidentiality statement and cell phone policy clearly outlined the prohibition of such actions, indicating that any violation could result in immediate dismissal.
Lack of Care Plan for Anticoagulant and Antiplatelet Medications
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident receiving anticoagulant and antiplatelet medications. The resident, who had diagnoses including hypertension, congestive heart failure, and venous insufficiency, was prescribed aspirin and apixaban. Despite the physician's orders and the Medication Administration Record indicating that the resident received these medications, there was no care plan in place to monitor for side effects associated with these medications. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the absence of a care plan for these medications.
Failure to Provide Necessary ROM Treatment
Penalty
Summary
The facility failed to provide necessary treatment to prevent contractures or decreased range of motion for two residents. Resident 14, who is paralyzed from the waist down, expressed concern about her legs becoming contracted due to not receiving any range of motion (ROM) exercises. Her medical records indicated she was dependent on staff for mobility and had previously received physical therapy, which recommended a home exercise program with ROM assistance from CNAs. However, interviews with staff revealed that Resident 14 was not receiving the recommended ROM exercises, and there was no documentation of ROM in her care records. Resident 12, who has a contracture in his left hand, was observed multiple times without the prescribed splinting device, such as a carrot or washcloth, in place. His medical records included a physician's order for the use of a splinting device every shift, and his care plan noted the need for such devices to manage his contracture. Despite this, observations and interviews indicated that the splinting device was not consistently applied, and the resident sometimes removed it himself, which was not accounted for in his care plan.
Inadequate Monitoring of Opioid Side Effects
Penalty
Summary
The facility failed to ensure adequate monitoring for a resident receiving scheduled opioid medication, specifically hydrocodone-acetaminophen, for pain management. The resident, who was severely cognitively impaired and had a history of a left femur fracture, dementia, and osteoarthritis, was receiving this medication as per a physician's order. However, there were no documented orders or care plans in place to monitor for potential side effects associated with opioid use, such as gastrointestinal issues, confusion, lethargy, or severe constipation. During an interview, the Director of Nursing acknowledged the absence of a care plan or order for side effect monitoring for the opioid medication. The facility's policy on pain management indicated that staff and physicians should monitor for adverse effects of pain medications and adjust or discontinue them based on effectiveness and side effects. This oversight in monitoring for opioid side effects was identified as a deficiency during the survey.
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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 Winamac
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hickory Creek At Winamac | 0 mi | ★★★★★ | 7 | 0 |
| Miller's Merry Manor | 14.8 mi | ★★★★★ | 15 | 0 |
| Parkview Haven | 15.1 mi | ★★★★★ | 0 | 0 |
| Brickyard Healthcare - Knox Care Center | 15.9 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Rochester | 19.7 mi | ★★★★★ | 18 | 0 |
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