Albany Health Care & Rehabilitation Center
910 W Walnut St, Albany, IN 47320 · For profit - Corporation · 102 certified beds · (765) 789-4423 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (33% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- about 28% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 13.3% | 11.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.6% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.2% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.7% | 1.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 45.7% | 25.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 5.7% | 3.9% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 13.0% | 11.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 17.0% | 23.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.5% | 3.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 26.6% | 23.3% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.9% | 13.6% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 83.1% | 79.0% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 25.9% | 22.2% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 11.4% | 10.8% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.18 | 1.61 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.80 | 1.44 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
48.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 66 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 68.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 25 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.29 therapist hours per resident per day in 2026Q1 — more than 46% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 48.5%CMS range 36.8–59.2 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.6%CMS range 7.0–16.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 68.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 52.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 60.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 97.6% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.8% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.2%CMS range 3.6–11.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.05 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 102 beds and averages 79.4 residents a day — about 78% occupied, or roughly 23 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.81 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.69 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.66 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.24 hrs/resident/day on weekends vs 4.04 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.77 to 0.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 33% is below the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.
- Actual harm · G2023-08-16 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent a significant medication error when QMA1 administered the wrong medications to Resident B and Resident C. This deficient practice resulted in Resident B being sent to the hospital where she was diagnosed with accidental drug ingestion and received treatment for lack of adequate oxygen to the body tissues (acute hypoxia), low blood pressure (hypotension), and slow heart rate (bradycardia). Findings include: Review of a 8/14/23 facility-reported incident to the Indiana Department of Health indicated Residents B and C had been administered each other's medications on 8/12/23. Resident B required transfer to the hospital for treatment. The clinical record for Resident B was reviewed on 8/16/2023 at 10:00 a.m. Diagnoses included, hypertension, presence of cardiac pacemaker, cognitive communication deficit, chronic obstructive pulmonary disease, and dementia. The resident was allergic to morphine. The resident's photograph had not been added to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-20 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to provide grooming assistance for 1 of 2 residents reviewed for activities of daily living. (Resident 16) Findings include:During an observation, on 2/16/26 at 10:33 a.m., Resident 16 sat in a wheelchair in the dining room. He was unshaven. During an observation, on 2/17/26 at 10:11 a.m., Resident 16 sat in a wheelchair in his room. He was unshaven. During an observation, on 2/18/26 at 10:55 a.m., the resident sat in a wheelchair in the dining room. He was unshaven. Resident 16's clinical record was reviewed on 2/18/26 at 3:48 p.m. Diagnoses included altered mental status, dementia, other lack of coordination, other reduced mobility, and need for assistance with personal care. A quarterly Minimum Data Set (MDS) assessment, dated 1/19/26, indicated the resident was severely cognitively impaired. He required substantial/maximal staff assistance with personal hygiene. A current care plan, created 12/17/24, indicated the resident needed assistance with his activities of daily living (ADLs) related to activity…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-20 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to follow physician's wound treatment orders to promote healing of an arterial ulcer for 1 of 3 residents reviewed for skin conditions. (Resident 2)Finding includes:During an observation on 2/16/26 at 3:38 p.m., Resident 2 was in bed with a dressing on the right foot. The dressing included an orange bordered gauze, rolled gauze, and a net stocking.Resident 2's clinical record was reviewed on 2/20/26 at 1:50 p.m. Diagnoses included heart failure, type 2 diabetes mellitus, and reduced mobility.A wound treatment order, dated 12/23/25, included the following: Cleanse the pressure injury to the right dorsum foot with povidone iodine (antiseptic for wound), air dry, apply skin preparation, and place a foam dressing on day shift every day for wound healing. This order was discontinued on 2/18/26.A current wound treatment order, dated 2/12/26, included the following: Apply horseshoe pad to the right medial foot, paint area with povidone iodine (antiseptic for wound), and apply Alginate (wound dressing) between toes.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-20 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate catheter maintenance and services to prevent potential urinary tract infections for 1 of 2 residents reviewed for indwelling catheters. (Resident 16) Finding includes: During an observation, on 2/16/26 at 3:34 p.m., Resident 16 sat in his wheelchair in his room. His urinary catheter tubing, with cloudy, yellow urine, came from the resident's waistband and went down under the resident's wheelchair into a privacy bag. The catheter tubing under the wheelchair hung within the diameter of a pencil eraser from the floor. During an observation, on 2/17/26 at 10:11 a.m., the resident sat in his wheelchair in his room. His urinary catheter tubing was coiled on his lap. During an observation, on 2/18/26 at 11:51 a.m., the resident sat in his wheelchair in the dining room. His urinary catheter tubing hung down and rested on the floor, then went into a privacy bag. During an observation, on 2/18/26 at 12:07 p.m., the resident propelled himself in his wheelchair out of the dining…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-20 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to provide meal assistance to maintain nutritional status for 1 of 4 residents reviewed for nutrition. (Residents 21) Finding includes:During a dining observation, on 2/18/26 at 12:04 p.m., Resident 21's meal assistance was provided by her visitor who sat on the right side of Resident 21and offered the resident several bites. The resident accepted one bite. The visitor switched seats and moved to a chair located on Resident 21's left side. After moving to Resident 21's left side, the resident consistently accepted every bite of food offered for the rest of the observation. Resident 21 drank fluids from a cup with a straw.During a continuous dining observation, on 2/19/26 at 8:20 a.m., a staff member sat on the right side of Resident 21. Resident 21's neck was bent forward, and her head was hanging downwards. The staff member offered two additional bites, which the resident did not accept. The staff member indicated Resident 21 did not eat well for breakfast and walked over to a kiosk and started charting. At…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-20 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure medications were dated when opened and medication was discarded when expired for 1 of 3 medication carts reviewed for medication storage. (100 hall) Finding includes:During a medication storage observation of the 100 hall medication cart, accompanied by QMA 10 on 2/18/26 at 3:11p.m., the following was observed: Six bottles of eye drops were open and undated. Two metered dose inhalers were open and undated. One bottle of Robitussin DM (cough medicine) was open, undated, and had an expiration date of 9/2024. One bottle of Black Seed herbal supplement was open and undated. Nine bottles of Miralax (laxative) were open and undated. Two bottles of liquid Docusate Sodium were open and undated. One bottle of cough medication liquid was open and undated. One bottle of Lactulose (laxative) was open and undated. Five bottles of Milk of Magnesia (laxative) were open and undated. One bottle of saline nasal spray was open and undated. Two bottles of Flonase (steroid) nasal spray was open and undated. During an interview at the time…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-20 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to utilize proper hand hygiene and avoid touching food with bare hands during meal tray distribution for 4 of 9 opportunities during room meal tray deliveries on the 200 hall. Findings include:During an observation on 2/16/26 at 12:11 p.m., CNA 8 entered room [ROOM NUMBER]-D with a meal tray. She rearranged a book and cup on the overbed table prior to setting up the meal tray. Hand hygiene was not performed. CNA 8 then removed the dinner roll bare handed and set the dinner roll on top of the wrap it came in. On 2/16/26 at 12:19 p.m., CNA 8 entered room [ROOM NUMBER]-W with a meal tray. She took the dinner roll out of a plastic bag with her bare hands and placed it in front of the resident. During an interview on 2/16/26 at 3:03 p.m., CNA 8 indicated she probably should have washed her hands before touching residents' food. She used hand sanitizer after handing out lunch trays to avoid cross contamination. Hand hygiene was utilized for infection…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure implementation of care plan interventions to prevent falls for 1 of 3 residents reviewed for falls (Resident C). Finding includes: During an observation, on 1/14/26 at 11:28 a.m., Resident C sat in her wheelchair at a table in the dining room as CNA 3 assisted her with eating. The resident wore nonskid socks and a brace on her right foot/leg. Resident C's clinical record was reviewed on 1/14/26 at 2:39 p.m. Diagnoses included age related physical disability, syncope (fainting) and collapse, difficulty walking, and vascular dementia. The current orders included melatonin 10 mg daily at bedtime for insomnia (4/10/25), metoprolol tartrate 25 mg twice a day for hypertension - hold for systolic blood pressure less than 100 or heart rate less than 60 (7/9/25), and silent pressure alarm to bed (6/2/25). A modification of the quarterly Minimum Data Set (MDS) assessment, dated 11/10/25, indicated the resident was severely cognitively impaired. She used a walker and a wheelchair for mobility. She required…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-15 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to protect a resident's right to be free from sexual abuse by another resident for 1 of 3 residents reviewed for abuse (Residents B and C) when a cognitively impaired male resident (Resident B) with a history of sexually charged behavior was observed in the lounge with his hand underneath the cognitively impaired female (Resident C) resident's shirt fondling her breast. Findings include:During an observation on 12/15/25 at 10:09 a.m., Resident B was seated in a recliner in the North Lounge with his feet elevated and his eyes closed. During an observation on 12/15/25 at 10:46 a.m., Resident C was seated in a Broda chair (high-backed wheelchair) in the hallway near the entrance to the North Lounge by the 300 Unit Nurses' station. She was awake, tracked with her eyes, but was unable to respond verbally when spoken to. Resident B's clinical record was reviewed on 12/15/25 at 1:35 p.m. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, unspecified…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-15 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to immediately report an allegation of sexual abuse to the Administrator for 1 of 3 residents reviewed for abuse. (Resident C) Finding includes:A facility reported incident submitted to Indiana Department of Health (IDOH), dated 11/17/25 at 6:01 p.m. and submitted on 11/18/25, indicated staff were removing residents from the dining room following evening meal and placing them in the North Lounge. Staff assisted a resident to bed and returned to the North Lounge and found Resident B touching Resident C's breast. Review of the facility investigation file included a handwritten statement of the Administrator that indicated the Administrator and DON were notified of the incident between Resident B and Resident C on 11/17/25 at 8:25 p.m. During a telephone interview on 12/15/25 at 12:28 p.m., CNA 3 indicated she found Resident B in the North Lounge with his hand inside the front of Resident C's gown fondling her breast. The residents were separated then CNA 4 reported everything to RN 5. CNA 3 was talking to RN 6 later in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-07-02 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a cognitively impaired resident was free from staff-to-resident abuse as a result of physical retaliation to a combative resident for 1 of 3 residents reviewed for abuse. (Resident B) This deficient practice had the potential to affect 19 of 77 residents in the facility who resided on the 300 Unit. The deficient practice was corrected on 6/27/25, prior to the start of survey, and was therefore past noncompliance. Finding includes: Review of a facility reported incident, dated 6/22/25 at 4:27 p.m., indicated the following: Description added On 6/22/25 the facility was notified Resident B reported to her daughter that she had bruising to bilateral hands due to a staff member holding onto her arms last night. CNA 3 was the staff member involved. Type of Injury included dark purple bruises to bilateral wrists and the left hand. The resident denied pain to the areas. Immediate Action Taken included notifications to the physician, family, DON, and the Administrator. The staff member involved was suspended pending an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · Dcited before2025-07-02 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to identify and immediately report alleged abuse to the administrator for 1 of 3 residents reviewed for resident abuse. (Resident B) This deficient practice had the potential to affect 19 out of 77 residents in the facility who resided on the 300 Unit. The deficient practice was corrected on 6/27/25, prior to the start of survey, and was therefore past noncompliance. Findings include: Review of a facility reported incident, dated 6/22/25 at 2:35 p.m., indicated Resident B's daughter had reported Resident B had bruising to her bilateral hands as a result of a staff member holding onto her arms last night. It was noted Resident B had bruises on her left hand and wrist and to her right wrist. CNA 3 was suspended pending an investigation. During a review of the facility abuse investigation, on 7/1/25 at 11:04 a.m., 13 resident interviews were held with no identified concerns and six non-interviewable residents had skin assessments completed. Statements from Resident B, the perpetrator, and four additional staff members were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-01-14 · tag F0576 — widespreadEnsure residents have reasonable access to and privacy in their use of communication methods.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure mail was distributed to residents on Saturdays. This deficiency had the potential to affect 79 of 79 residents who resided in the facility. Finding includes: During a Resident Council group interview, on 1/10/25 beginning at 1:38 p.m., Resident 3 indicated the facility did not deliver mail to the residents on Saturdays. There was no one at the facility to deliver mail because the administrative offices were closed on the weekends. Residents 45, 67, 30, 53, and 62 indicated they did not receive mail on Saturdays. During an interview, on 1/10/25 at 4:00 p.m., QMA 4 indicated he was uncertain if mail was delivered to the facility residents on Saturdays. During an interview, on 1/10/25 at 4:06 p.m., CNA 6 indicated she did not think the residents received mail on Saturdays. If the facility did receive mail, it went to the business office. During an interview, on 1/10/25 at 4:07 p.m., the Dementia Care Director indicated the residents did not get mail on Saturdays because the business office was closed. During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-14 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was submitted for a resident with a new mental health diagnosis and psychotropic medication for 1 of 1 residents reviewed for PASRR. (Resident 59) Findings include: Resident 59's clinical record was reviewed on 1/9/25 at 3:55 p.m. The most current PASRR was completed on 6/20/23. The application submitted indicated that the resident had no known or suspected mental health diagnoses. No mental health medications were listed. Resident 59's diagnoses included psychotic disorder with delusions due to know physiological condition (9/18/23), unspecified mood (affective) disorder (8/28/23), generalized anxiety disorder (6/29/23), other recurrent depressive disorders (6/29/23), and dementia in other diseases classified elsewhere, mild, with agitation (6/29/23). Physician's orders included escitalopram oxalate (antidepressant) 10 milligrams (mg) daily at bedtime (7/24/24), olanzapine (antipsychotic) 5…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-14 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to develop and implement a comprehensive care plan with individualized interventions to maintain the resident's highest practicable mental, physical, and psychosocial outcome for 1 of 1 resident reviewed for a limited range of motion. (Resident 73) Finding includes: During an interview on 1/7/25 at 12:10 p.m., Resident 73 was laying in bed in his room with his door closed. He indicated he was paralyzed from his chest down. He had received therapy when he admitted a few months ago, but therapy ended. He was waiting for insurance to get more therapy. He had not received any restorative care or passive range of motion on his lower extremities to ensure he did not have a decline while he waited on insurance. He had spoken to two different therapy staff members quite some time ago and requested restorative care, but had not received any. He was concerned about losing the progress he had made in therapy. Resident 73's clinical record was reviewed on 1/9/25 at 5:08 p.m. Diagnoses included paralytic syndrome, constipation, complete…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-14 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure the resident's representative was invited to participate in the ongoing care planning process for 1 of 1 residents reviewed for care planning. (Resident 34) Findings include: During an interview, on 1/8/25 at 11:19 a.m., Resident 34's representative indicated she had been invited one time to a care plan meeting. She had not been invited since that first meeting. She did not know when the meetings were held. Resident 34's clinical record was reviewed on 1/9/25 at 11:54 a.m. Diagnoses included anxiety disorder, delusional disorder, Alzheimer's disease, and unspecified dementia, moderate, with agitation. An annual Minimum Data Set (MDS) assessment, dated 10/29/24, indicated the resident was severely cognitively impaired. An interview about preferences with the resident indicated having her family or a close friend involved in discussions about her care was very important to her. A current care plan indicated Resident 34 did not plan to return to the community and wished to be asked about returning to the community on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-14 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide appropriate restorative care services as recommended by therapy for a resident with limited range of motion for 1 of 1 resident reviewed for restorative care. (Resident 73) Finding includes: During an interview on 1/7/25 at 12:10 p.m., Resident 73 was laying in bed. He indicated he was paralyzed from his chest down. He had received therapy when he admitted a few months ago, but therapy ended. He was waiting for insurance to get more therapy. He had not received any restorative care or passive range of motion on his lower extremities to ensure he did not have a decline while he waited on insurance. He had spoken to two different therapy staff members quite some time ago and requested restorative care, but had not received any. He was concerned about losing the progress he had made in therapy. The resident's clinical record was reviewed on 1/9/25 at 5:08 p.m. The resident admitted to the facility on [DATE]. Diagnoses included, paralytic syndrome,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide supervision for a cognitively impaired resident with a history of falls to prevent repeated falls for 1 of 2 residents reviewed for accidents. (Resident 129) Findings include: During an observation, on 1/7/25 at 1:19 p.m., Resident 129 was lying in a bed in the low position with a tall mat beside his bed. The resident was awake and watching television. During an observation, on 1/8/24 at 11:53 a.m., Resident 129 was assisted in his wheelchair to his room. He declined to get into bed. He had a brace on his right wrist. During an observation, on 1/9/24 at 2:48 p.m., Resident 129 was lying in bed, turned onto his left side. A tall mat was beside his bed. During an observation, on 1/10/24 at 3:50 p.m., Resident 129 was lying in bed holding and looking at his remote control. The tall mat was beside his bed. He was had his oxygen on per nasal cannula. During an observation, on 1/13/24 at 3:07 p.m., Resident 129 self-propelled his…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-14 · tag F0710 — isolatedObtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, facility failed to ensure the physician was notified of a resident's significant weight loss for 1 of 3 residents reviewed for nutrition. (Resident 72) Findings include: Resident 72's clinical record was reviewed on 1/10/25 at 8:56 a.m. Diagnoses included Alzheimer's disease, dysphagia, oropharyngeal phase (swallowing difficulty that occurs in the mouth and throat), and other recurrent depressive disorders. Current physician's orders included regular diet, mechanical soft texture with ground meat and thin consistency liquids (7/31/24), super cereal (fortified food supplement) at breakfast (8/13/24), and magic cup (vitamin and mineral rich food supplement) at lunch (9/3/24). A Minimum Data Set (MDS) assessment on 12/14/24 indicated the resident was severely cognitively impaired. The staff assessment of her mood indicated the resident had poor appetite or overeating for two to six days of the assessment period. She required partial to moderate assistance with eating. The resident's weights were as follows: 7/30/24 - 107.4 pounds 11/25/24 - 99.2…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-22 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to notify the Long-Term Care Ombudsman of transfers out of the facility for 2 of 3 residents reviewed for hospitalizations (Residents 37 and 66). Findings include: 1. Resident 37's clinical record was reviewed on 1/18/24 at 9:44 a.m. A nurses note, dated 12/25/23 at 9:56 a.m., indicated the resident was sent to the hospital for altered level of consciousness. A nurses note, dated 12/26/23 at 2:50 p.m., indicated the resident had been admitted to the hospital with altered mental status and lethargy. A nurses note, dated 12/28/23 at 1:05 p.m., indicated the resident returned from the hospital. The facility ombudsman notification binder, provided by the Social Services Designee (SSD) on 1/22/24 at 11:28 a.m., lacked ombudsman notification for the resident's transfer to the hospital. 2. Resident 66's clinical record was reviewed on 1/18/24 at 3:24 p.m. A nurses note, dated 12/15/23 at 1:10 p.m., indicated the resident was sent to the hospital for altered level of consciousness, hallucinations, and to prevent self-harm. A nurses…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement care plan interventions to prevent falls for 1 of 5 residents reviewed for falls (Resident 22). Finding includes: During an observation, on 1/16/23 at 11:46 a.m., Resident 22 ambulated with a rolling walker in the hallway. She was bent over at the waist and pushed the walker in front of her. Another resident had her hand on Resident 22's hip area and encouraged Resident 22 to walk to the dining area. During an observation, on 1/18/24 at 10:28 a.m., the resident ambulated in her room using the footboard of the bed to steady herself. During an observation, on 1/22/24 at 9:40 a.m., the resident ambulated with the rolling walker in the hall wearing purple foam clogs. Resident 22's clinical record was reviewed on 1/18/24 at 3:23 p.m. Diagnoses included dystonia, vascular dementia, anxiety, heart failure, unspecified, low back pain, muscle weakness (generalized), abnormalities of gait and mobility, pain in right knee, delusional…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-22 · tag F0728 — failed to protect against nurse-aide misconduct — isolatedEnsure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and record review, the facility failed to remove CNA students from CNA duties when they failed to become certified within four months of their hire date (CNA Student 5 and 6). Finding includes: Review of employee records on 1/19/23 at 2:49 p.m. indicated CNA Student 5 and CNA Student 6 were hired on 8/9/23. Review of the nursing employee schedules from 12/10/23 through 1/15/23, provided by the Nurse Consultant on 1/19/23 at 4:10 p.m., indicated the following: CNA 5 had worked on 12/11/23, 12/13/23, 12/14/23, 12/15/23, 12/18/23, 12/19/23, 12/20/23, 12/22/23, 12/24/23, 12/27/23, 12/28/23, 1/3/24, 1/5/24, 1/7/24, 1/8/24, 1/10/24, 1/11/24, 1/12/24, 1/14/24, and 1/15/24. CNA 6 worked on 12/11/23, 12/12/23, 12/26/23, 12/30/23, 12/31/23, 1/1/24, 1/3/24, 1/5/24, 1/8/24, 1/13/24, and 1/14/23. During an interview on 1/22/24 at 12:00 p.m., the DON indicated CNA 5 had not yet passed her test. She was uncertain of the status of CNA 6. She was unaware the students had been hired more than 4 months ago. During an interview on 1/22/24 at 12:03 p.m., the Administrator indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-22 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based upon observation, record review, and interview, the facility failed to ensure accurate records were kept of the administration of controlled medications for 6 of 14 residents reviewed (Residents 22, 47, 56, 58, 66, and 67). Findings include: During an observation of the secured unit medication cart, accompanied by LPN 4, on 1/22/24 at 9:46 a.m., the narcotic reconciliation log was reviewed. A reconciliation of controlled medications was performed at this time by LPN 4, with the following concerns observed: Resident 56 had 23 tablets of hydrocodone (a narcotic pain medication) 5-325 tablets. The medication log indicated 24 tablets. Resident 56 had 28 tablets of alprazolam 0.25 mg (anxiolytic). The medication log indicated 29 tablets. Resident 58 had 18 tablets of hydrocodone-acetaminophen 5-325 mg tablets. The medication log indicated 19 tablets. Resident 67 had 27 tablets of pregabalin (anticonvulsant) 100 mg tablets. The medication log indicated 28 tablets. Resident 47 had 26 tablets of diphenoxylate (used to treat diarrhea). The medication log indicated 27 tablets. Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2025-01-14 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the most recent Indiana Department of Health (IDOH) survey reports were readily available for review. This deficiency had the potential to affect 79 of 79 residents who resided in the facility. Finding includes: During a Resident Council group interview, on 1/10/25 beginning at 1:38 p.m., Residents 3, 30, 45, 53, 62, and 67 indicated they did not know where the State Department of Health survey reports were located. During an observation, on 1/10/25 at 3:35 p.m., the State Department of Health survey report was located in a binder placed in a wall pocket on the wall beside the Human Resources office. The most recent survey in the binder was from the Annual Recertification and State Licensure Survey completed on 1/22/24. The report lacked the plan of correction. Review of the facility's IDOH survey history indicated Complaint Investigation Surveys were completed on 5/3/24, 9/13/24, and 10/18/24. During an interview, on 1/14/25 at 10:39 a.m., the Human Resources Director indicated she believed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to TLC MANAGEMENT — 20 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.8 | -1.8 vs chain |
| Health inspection | 2 of 5 | 3.3 | -1.3 vs chain |
| Staffing | 4 of 5 | 3.5 | +0.5 vs chain |
| Quality measures | 4 of 5 | 4.7 | -0.7 vs chain |
The other 19 homes this chain runs (chain average 3.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| RIVERVIEW HOSPITAL | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 04/01/2012 |
| FRIEND, JAYNA | Individual | CORPORATE OFFICER | — | since 04/01/2012 |
| HYATT, DAVID | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2012 |
| ALBANY HEALTHCARE OPERATIONS CO LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2012 |
| TENDER LOVING CARE MANAGEMENT INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2012 |
| GIMRE, JASON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2012 |
| SEDAGHAT, VAHID-DAVID | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2012 |
| GIBSON, CULLEN | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 07/15/2025 |
| OTT, CONNIE | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 07/25/2025 |
| OTT, DWIGHT | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 07/15/2025 |
| OTT, GARY | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 07/15/2025 |
| OTT, RYAN | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 07/08/2025 |
| DWIGHT A. OTT AND GLORIA OTT | Organization | TRUSTEE OF THE SNF | — | since 04/01/2012 |
| OTT FAMILY TRUST | Organization | TRUSTEE OF THE SNF | — | since 04/01/2012 |
| ALBANY HEALTH CARE MANAGEMENT LLC | Organization | ADP OF THE SNF | — | since 04/01/2012 |
CMS files one row per role, so the 20 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted.
6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $3.0M paid to related parties — landlords or management companies under common ownership — equal to about 28% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Indiana Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 155432. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-20, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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