Ascension Living Sacred Heart Village
515 N Main St, Avilla, IN 46710 · Non profit - Church related · 133 certified beds · (260) 897-2841 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure rating is low (2/5)
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 2 of 5 |
| Long-stay residentspeople who live here | 2 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 5 to 3 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 | 24.3% | 11.0% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.4% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.4% | 1.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.4% | 25.2% | 6.5% | better 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 | 3.1% | 3.9% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 33.3% | 11.9% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 24.3% | 23.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.3% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.4% | 3.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 17.1% | 23.3% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 12.2% | 13.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 82.7% | 79.0% | 79.4% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.98 | 1.61 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.80 | 1.44 | 1.80 | typical |
‡ 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.
46.2% 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 29 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.19 therapist hours per resident per day in 2026Q1 — more than 20% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 11% 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 | 46.2%CMS range 30.8–61.7 | 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 | 12.3%CMS range 8.7–18.7 | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 85.7% | 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 | 0.0% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.91 | 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 133 beds and averages 79.1 residents a day — about 59% occupied, or roughly 54 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.62 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.91 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.15 is below 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 3.45 hrs/resident/day on weekends vs 3.69 on weekdays — 7% thinner on weekends. RN hours go from 0.98 to 0.75 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 40% is about the same as the national median of 45%.
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 unchanged from the previous inspection. 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.
17 citations, most serious first. The 10 most serious are shown; the remaining 7 are one tap away and print in full.
- Potential for harm · Fcited before2026-01-09 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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 dishes and equipment were stored in sanitary conditions, unit refrigerators were maintained and were free of expired foods for 99 of 99 residents residing in the facility who consumed food prepared in the kitchen.Findings include:During an observation, on 1/5/26 at 9:16 AM, the following was observed:A nested stack of stainless steel, 6-inch containers had moisture between 3 of 6 pans observed. A dietary staff member was observed taking 6 wet, plate sized, lids out of the dishwashing area and stacking them for storage.During an observation, on 1/05/2026 at 2:00 PM, the Unit B pantry refrigerator had 2 chocolate Glucerna liquid supplements with expiration dates of 8/1/25. 1 vanilla Glucerna shake expired on 1/1/26. A review of the Nursing Unit B Refrigerator Log, on 1/9/26 at 11:10 AM, indicated documentation was missing for ensuring outdated food was discarded and routine weekly cleaning was completed from 1/1/26 to 1/9/26. The log indicated the refrigerator should be checked for outdated food daily and…
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 before2026-01-09 · tag F0761 — failed to label and store drugs safely — patternEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure safe storage of medications for 6 of 15 residents observed (Resident 6, Resident 38, Resident 51, Resident 73, Resident 10, and Resident 4).Findings include:1.During an observation on 01/07/2026 8:51 AM, Registered Nurse (RN) 2 opened the top drawer of a medicine cart positioned outside the main dining room. 3 cups of pills were in a divided compartment of the drawer, positioned together with the cups touching. A cup labeled with Resident 6's first name contained 7 pills. A cup with Resident 38's name contained 8 pills. A cup with Resident 51's name had 10 pills. A cup labeled with Resident 73's name was in the same cart section separated from the others by a box and contained 11 pills. An additional cup of pills was observed in same drawer about 12 inches away from the others. This cup was labeled for Resident 10 and contained 7 1/2 pills. The cups were open to air and not covered. In an interview, on 01/07/2026 8:52 AM, RN 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 · E2026-01-09 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 ceiling tiles were maintained in 5 of 5 resident rooms reviewed. Findings include:During an observation starting on 01/05/2026 at 9:52 AM, the following was observed: Room A-15 had 2 areas of discolored ceiling tiles. 2 round areas with an irregularly round, brown outline surrounding black centers approximately 1/8th of a ceiling tile.Room A-18 had 6.25 ceiling tiles with 15 round areas of discoloration. In a line parallel to the hallway, 5 areas had round black centers measuring approximately 1-4 inches in diameter. An irregularly round brown outline surrounded the black colored areas of discoloration. One ceiling tile in the middle of the room had 2 large areas, covering the width of the tile and 1/3'd of the length. The two large areas had dark to light brown irregularly shaped round rings decreasing in size to the center gray and brown irregular round shape, approximately 5.5 inches in diameter.Room A-20 had 6 areas of discoloration on 3 ceiling tiles. 1 area had approximately 6 inches in diameter…
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 before2026-01-09 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow physician orders related to medication administration for 1 of 18 residents reviewed. (Resident 4)Resident 4's record review began on 01/08/2026 at 1:26 PM. Diagnoses included chronic kidney disease stage 5, dependence on renal dialysis, and type 2 diabetes. Resident 4's current quarterly Minimum Data Set assessment (MDS), dated [DATE], indicated Resident 4 had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact).Resident 4's current physician orders included:Dialysis on Monday, Wednesday, and Friday at an outside dialysis companyThe actual times of administration of medication may be adjusted on a daily basis to accommodate resident's request on administration schedule unless contraindicated due to the action of medication.Velphoro Chews 500mg tablet, by mouth three times a day with meals for chronic kidney diseaseFlexeril, or cyclobenzaprine 10mg tablet, by mouth three times a day for muscle spasmsGabapentin…
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 · D2026-01-09 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
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 ensure a medication error rate of less than 5%. 2 of 14 residents observed were affected (Resident 29 and Resident 7).Findings include: 1.During an observation on 01/07/2026 11:51 AM, Licensed Practical Nurse (LPN) 7 obtained a blood glucose reading of 215 for Resident 29. 9 units of novalog insulin were given by an insulin flexpen. LPN 7 did not prime the novalog flexplen with 2 units of insulin prior to administration. In an interview, on 01/07/2026 11:53AM, LPN 7 indicated she didn't prime the flexpen with 2 units of insulin, and was not sure what the facility policy was for priming. Resident 29's record was reviewed 01/08/2026 12:00 PM. Diagnoses included diabetes mellitus type 2 and long term use of insulin. A current admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident 29 had a Basic Interview for Mental Status (BIMS) score of 10 (moderate cognitive impairment). A current physician's order, dated 12/28/25,…
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 · Fcited before2024-12-19 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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 safe, sanitary food storage and serving practices for 5 of 5 observations. Food prepared in the kitchen was consumed by 74 of 74 residents who lived in the facility. Findings include: During a continuous observation on 12/15/24 from 10:16 AM - 11:00 AM the following observations were made: A countertop had open slotted drains and a brown, murky liquid puddle under the countertop. The opened bag of french fries and bread were not dated in Freezer 1. Freezer 2 had whipped cream in a bag not labeled or dated. The whipped cream was unsealed and open to air. The opened bag of macaroni was not dated in the dry pantry. There was a package of swiss cheese, expired 11/2024, located in Refrigerator 1. 2 of 5 stacked metal pans had moisture between them. The stand mixer had dime sized, dry, yellow flaky material on the paddle. During a continuous observation from 11:34 AM-12:25 PM, Dietary Aide 4 donned gloves and started distribution of food to resident plates. She touched brussel sprouts and bread with gloved…
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 before2024-12-19 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
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 ensure privacy of health information for 2 of 18 residents reviewed (Resident 36 and Resident 72). Findings include: 1) During an observation on 12/15/24 at 10:32 AM, Resident 36 was viewed from the hallway sitting in her room in a wheelchair watching television. A catheter bag was observed attached to the wheelchair frame underneath the seat of the wheelchair. The catheter bag contained about 200 ml of yellow fluid. During an interview on 12/15/24 at 10:36 AM the Weekend Supervisor indicated urine in the catheter bag should not be visible from the hallway. Resident 36's record was reviewed on 12/16/24 at 2:52 PM. Diagnoses included obstructive and reflux uropathy, and encounter for attention to other artificial openings of the urinary tract. Resident 36's current admission Minimum Data Set (MDS) dated [DATE] indicated their Basic Interview for Mental Status (BIMS) score was 6 (cognitively impaired). The MDS indicated Resident 36 needed…
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 before2024-12-19 · 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 interview and record review, the facility failed to ensure ongoing assessment for a change in condition for 1 of 4 residents reviewed (Resident 75) Findings include: Resident 75's record was reviewed 12/27/24 at 10:23 AM. Diagnoses included Cerebral infarction (stroke), diabetes, high blood pressure, and osteoarthritis, A review of progress notes indicated the following: Dated 10/1/24, Resident 75 was afebrile. Orders were obtained for a complete blood count and comprehensive metabolic panel. No reason for the tests or assessment of Resident 75's condition was documented. Dated 10/2/24, Resident 75 was placed on Robitussin. There was no documentation regarding breath sounds, or other condition of the resident. Dated 10/3/24, Resident 75 was placed on an antibiotic Invanz for urinary tract infection symptoms. The resident was afebrile, the urine color was yellow, and there were no complaints of pain on urination. There was no documentation regarding other symptoms of the infection, urine clarity, or presence of pain. Dated 10/4/24, No documentation regarding urinary symptoms…
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 · D2024-12-19 · 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 observation, interview and record review, the facility failed to ensure functional and comfortable positioning for 1 of 3 residents reviewed (Resident 12). Findings include: On 12/15/24 at 12:35 PM, Resident 12 was observed sitting in an adjustable positioning wheelchair (Broda chair) in the dining room. Resident 12 was observed sitting upright with their head leaning forward. Resident 12's chin was observed to be approximately 1 inch from their chest. A staff member was observed lifting Resident 12's head by placing their hand on the resident's forehead. The staff member was observed placing a spoon in Resident 12's mouth while continuing to hold the resident's head up with their hand on the resident's forehead Resident 12's record was reviewed on 12/18/24 at 12:05 PM. Diagnoses included Alzheimer's, hypothyroidism, (underactive thyroid gland) muscle weakness and multiple sites of muscle contractures (tightening that can restrict movement). Resident 12's Quarterly Minimum Data Set, (MDS) dated [DATE],…
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 · D2024-12-19 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure sanitary handling of a catheter bag in 1 of 2 residents reviewed (Resident 36). Findings include: During an observation on 12/15/24 at 10:32 AM, Resident 36 was viewed from the hallway sitting in her room in a wheelchair watching television. A catheter bag was observed attached to the wheelchair frame underneath the seat of the wheelchair. The catheter bag contained about 200 ml of yellow fluid and was in contact with the floor. During an interview on 12/15/24 at 10:36 AM the Weekend Supervisor indicated urine in the catheter bag should be secured to the wheelchair keeping it from contacting the floor. She indicated contact with the floor could increase the risk of infection. Resident 36's record was reviewed on 12/16/24 at 2:52 PM. Diagnoses included obstructive and reflux uropathy, and encounter for attention to other artificial openings of the urinary tract. Resident 36's current admission Minimum Data Set (MDS) dated [DATE]…
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 7 citations
- Potential for harm · E2024-01-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when 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 observation, record review and interview, the facility failed to ensure physician orders were followed and safe handling of respiratory equipment was completed for 4 of 24 residents reviewed. (Resident 9, Resident 24, Resident 36, and Resident 68). Findings include: 1) During an observation on 1/2/24 at 1:35 PM, Resident 9 was laying in her bed. Her nasal cannula (NC) oxygen tubing (a lightweight tube split into two prongs on one end and placed in the nostrils used to deliver supplemental oxygen) was attached to her oxygen condenser (a medical device that gives you extra oxygen) laying on the oxygen condenser unbagged. The oxygen condenser flow meter was turned to 2 liters per minutes (LPM) delivering oxygen via the NC. Her oxygen condenser was positioned at the upper right side of her bed. The resident's portable oxygen condenser (a lightweight transportable oxygen condenser), not in use at that time, was sitting on the floor with NC oxygen tubing attached. The NC oxygen tubing extended from 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 · Dcited before2024-01-08 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
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 ensure privacy was maintained for 2 of 24 residents reviewed (Resident 24, and Resident 32). Findings include: 1) During an observation and interview on 1/2/24 at 9:48 AM, Resident 24's catheter bag partially filled with yellow liquid was visible from his doorway. Qualified Medicine Aide (QMA) 2 indicated Resident 24's catheter bag should be covered. Resident 24's record was reviewed on 1/2/24 at 11:07 AM. Diagnoses included multiple sclerosis, neuromuscular dysfunction of the bladder, and benign prostatic hyperplasia with lower urinary tract symptoms. A review of Resident 24's current quarterly Minimum Data Set (MDS) dated [DATE] indicated he had a Basic Interview for Mental Status (BIMS) score of 14 (cognitively intact). The MDS indicated Resident 24 used an indwelling catheter. A review of Resident 24's current care plan titled .indwelling catheter for diagnosis of neuromuscular bladder . indicated the resident had a problem of…
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 · D2024-01-08 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 investigation of attempted self-harm for 1 of 3 residents reviewed. (Resident 4). Findings include: In an interview on 1/2/24 at 1:48 PM Resident 4 was observed avoiding eye contact during the interview. Resident 4 did not respond verbally to this writer's greetings and continued to look at the floor. Resident 4's record was reviewed on 1/4/24 at 10:16 AM. Diagnoses included Down Syndrome, anxiety disorder, major depressive disorder, Alzheimer's, unspecified dementia, restlessness and agitation. Resident 4's current quarterly Minimum Data Set (MDS) indicated their Basic Interview for Mental Status (BIMS) score was 1 (severe cognitive impairment). The MDS indicated Resident 4 had not displayed any behaviors. The MDS indicated Resident 4 was able to make themselves understood and was able to understand others. Resident 4's current care plan entry dated 2/9/23 indicated the resident's family had reported a history of suicidal ideations. The target goal was for the resident to have no suicidal ideations…
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 before2024-01-08 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure MD orders were followed for cervical spine fracture management in 1 of 24 resident reviewed for quality of care. (Resident 181). Findings include: During an observation on 1/2/24 at 1:05 PM, Resident 181 was sitting in his recliner watching television. The resident's cervical collar (C-collar) was in a chair across the room. In an interview on 1/2/24 at 1:08 PM, Resident 181 indicated he was supposed to wear the C-collar, but the staff never puts the C-collar back on. Resident 181's record was reviewed on 1/7/24 at 2:47 PM. Diagnoses included a fall from a motorized mobility scooter resulting in C2 odontoid process fracture, bilateral hearing loss, and mild cognitive impairment of unknown origin. Resident 181's current admission Minimum Data Set (MDS), dated [DATE], indicated his Basic Interview for Mental Status (BIMS) score was 10 (moderate cognitive impairment). The MDS indicated in the last month prior to admission he had a fall…
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 · D2024-01-08 · 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 interview and record review the facility failed to ensure fall precaution interventions were made available to direct care staff members for 1 of 2 residents reviewed (Resident 15). This resulted in an injury from a fall that required emergency department intervention for Resident 15. Findings include: On 1/2/24 at 4:00 PM the facility reported Resident 15 had experienced a fall on 1/1/24 at 4:30 PM. The fall resulted in a lip laceration that required sutures. Resident 15's record was reviewed on 1/5/24 at 9:30 AM. Diagnoses included Alzheimer's, major depressive disorder, dementia, restless leg syndrome and contractures to the left hand. A review of Resident 15's most recent annual Minimum Data Set (MDS) dated [DATE] indicated their Basic Interview for Mental Status (BIMS) score was 0 (severe cognitive loss). Resident 15 required maximum assistance to roll left and right in the bed. The resident was dependent on staff to change position from lying in bed to sitting on the side of the bed. The 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.
- Potential for harm · D2024-01-08 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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 ensure tube feeding formula was labeled and dated for 1 of 1 resident reviewed (Resident 71). Findings include: During an observation on 1/2/24 at 9:37 AM Resident 71 was observed sitting in the recliner in her room with a translucent bag of about an inch of tan liquid. A tubing engaged in a tube feeding pump was attached to Resident 71's gastric tube. The bag and tubing were not dated or labeled with the formula type or orders for administration. During an observation on 1/4/24 at 3:02 PM, Resident 71 was observed sitting in the recliner in her room visiting with a guest. A tube feeding bag was observed with about 1/2 inch of tan liquid in the tubing draped over the top of the pole holding the tube feeding pump. No date or label was seen on the bag. Resident 71's record was reviewed on 1/4/24 at 3:10 PM. Diagnoses included amyotrophic lateral sclerosis, progressive bulbar palsy, and dysphagia, oropharyngeal phase. A review of 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.
- Potential for harm · Dcited before2024-01-08 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure insulin in a medication cart was removed when expired for 1 of 29 residents and a medication refrigerator temperature was monitored for 1 of 2 medication rooms reviewed (Resident 16). Findings include: 1. During an observation and interview on [DATE] at 1:21 PM, medication storage was reviewed with Registered Nurse (RN) 3. A lispro insulin pen was in the top drawer of the cart with an open date of [DATE]. The pen was in a plastic bag with a printed label indicating it was for Resident 16. RN 3 indicated the insulin was expired and should have been pulled from the cart and replaced with a new pen. Resident 16's record was reviewed on [DATE] at 12:12 PM. Diagnoses included morbid obesity due to excess calories, pseudocyst of the pancreas, and chronic kidney disease, stage 3. A review of Resident 16's current significant change Minimum Data Set (MDS) dated [DATE] indicated her Basic Interview for Mental Status (BIMS) score was 6…
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 ASCENSION LIVING — 12 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 | 3 of 5 | 2.8 | +0.2 vs chain |
| Health inspection | 3 of 5 | 2.4 | +0.6 vs chain |
| Staffing | 4 of 5 | 3.9 | +0.1 vs chain |
| Quality measures | 2 of 5 | 3.4 | -1.4 vs chain |
The other 11 homes this chain runs (chain average 2.8★, 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 | Since |
|---|---|---|---|
| PROKUPEK, CRAIG | Individual | CONTRACTED MANAGING EMPLOYEE | since 09/01/2015 |
| EIDAM, JOELLEN | Individual | CORPORATE OFFICER | since 09/01/2015 |
| WHEELER, DANE | Individual | CORPORATE OFFICER | since 09/01/2015 |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
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 $547K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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, FY2024). 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 155512. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-09, 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 →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.