Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 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.
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.
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.
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.
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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