Aperion Care Monroe
120 E Miller Dr, Bloomington, IN 47401 · For profit - Corporation · 38 certified beds · (812) 336-1055 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
- it has an abuse, neglect, or exploitation citation (F0602), cited Apr 2024
- it has a citation for mishandling residents’ money or property (F0567)
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
- about 30% 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) | 1 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 improved from 1 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 | 23.4% | 11.0% | 15.4% | worse |
| Long-stay residents who lose too much weight | 1.8% | 5.5% | 5.4% | better |
| 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 | 0.0% | 1.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 47.8% | 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 | 0.0% | 3.9% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 35.5% | 11.9% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 47.4% | 23.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 91.4% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 11.2% | 3.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 20.7% | 23.3% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 58.3% | 13.6% | 17.1% | check this† — see note marked dagger below the table |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.72 | 1.61 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 2.88 | 1.44 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.
‡ 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.
Therapy staffing: this home’s payroll records show 0.33 therapist hours per resident per day in 2026Q1 — more than 54% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| 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 | 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 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 38 beds and averages 31.6 residents a day — about 83% occupied, or roughly 6 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 3.17 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.37 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 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 2.88 hrs/resident/day on weekends vs 3.28 on weekdays — 12% thinner on weekends. RN hours go from 0.36 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 46% 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 more than at the previous inspection — worsening. 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.
25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.
- Potential for harm · Dcited before2026-06-23 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a sanitary environment for 2 of 9 resident rooms and 1 of 1 sit to stand mechanical lift. The sit to stand mechanical lift was dirty and resident rooms had flies and gnats. (room [ROOM NUMBER], room [ROOM NUMBER], Sit to Stand mechanical lift) Findings include:1. On 6/18/26 at 10:45 a.m., the foot platform of the sit to stand lift in the north hallway was observed to contain food crumbs and debris. On 6/19/26 at 9:50 a.m., the foot platform of the sit to stand lift in the north hallway was observed to contain food crumbs and debris. On 6/22/26 at 10:50 a.m., the foot platform of the sit to stand lift in the north hallway was observed to contain food crumbs and debris. 2. On 6/18/26 at 10:50 a.m., numerous flies and gnats were observed flying in room [ROOM NUMBER]. On 6/19/26 at 9:55 a.m., numerous flies and gnats were observed flying in room [ROOM NUMBER]. On 6/22/26 at 11:00 a.m., numerous flies and gnats were observed flying in…
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 before2025-08-06 · 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 staff prepared food in accordance with professional standards for food service safety for 1 of 2 kitchen observations. This had the potential to affect 31 out of 31 residents served from the kitchen.Findings include:During a kitchen tour on 8/3/25 at 10:45 a.m., a large pork loin was observed thawing in the bottom of a three compartment sink with running water flowing onto the meat. The meat was not submerged in water and the water was flowing down the drain.During an interview on 8/6/25 at 12:25 p.m., the Dietary Manager indicated the cook should have had the meat in a deep pot while the water was running onto the meat. On 8/3/25 at 11:05 a.m., the Administrator provided the facility policy, Thawing Foods, and indicated it was the policy currently being used. A review of the policy indicated, . 4. Thawing foods under cool running potable water (This process is not recommended and should only be used in an emergency and if you cook food immediately) . b. Food items should be completely submerged under…
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 before2025-08-06 · 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 observations, interviews, and clinical records, the facility failed to ensure flies and gnats were not present in 1 of 10 resident rooms (Resident 5, Resident 6, Resident 25), sit to stand lift foot platforms were clean for 2 of 2 sit to stand lifts used by 3 residents (Resident 2, Resident 17, Resident 26), and exposed wires were covered for 1 of 4 communal resident bathrooms observed for environmental concerns. Findings include: 1. On 8/3/25 at 1:47 p.m., 8/5/25 at 2:20 p.m., and 8/6/25 at 10:15 a.m., gnats and flies were observed in the room of Resident 5, Resident 6, and Resident 25 on the privacy curtains, walls, bedside tables, and the residents themselves. During an interview on 8/16/25 at 10:17 a.m., Resident 6 indicated there were flies and gnats in the room all the time unless it was wintertime. During an interview on 8/16/25 at 10:18 a.m., Resident 25 indicated there were almost always gnats and flies in the room. He frequently fashioned a fly and gnat swatter out of paper to combat the pests. 2. On 8/3/25 at 9:45 a.m. and 2:50 p.m., and 8/4/25 at 9:30 a.m. 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 · D2025-08-06 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
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 residents have the right to be informed of and participate in their treatment for 2 of 6 residents reviewed for unnecessary medications. (Resident 7 and Resident 33)Findings include:1. On 8/5/25 at 11:00 a.m., Resident 7's clinical record was reviewed. The diagnoses included, but were not limited to, schizoaffective disorder (a condition characterized by a combination of schizophrenia and mood disorder symptoms), psychosis (a mental health condition where a person experiences a disconnect from reality), generalized anxiety disorder, major depressive disorder, and dementia (a decline in mental ability severe enough to interfere with daily life).A review of the physician's orders indicated the following:On 7/8/25, an order for Lorazepam (a medication used to treat anxiety) 1 mg (milligram) twice daily was prescribed for generalized anxiety disorder.On 7/9/25, an order for Cymbalta (a medication used to treat depression) 60 mg once daily, to be taken with Cymbalta 30 mg to equal 90 mg, was prescribed for major…
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 · D2025-08-06 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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 resident's representative and physician was notified of significant weight loss for 1 of 3 residents reviewed for nutrition. (Resident 25)Findings include: During an interview on 8/3/25 at 1:44 p.m., Resident 25 indicated in the last month, he had lost weight. On 8/5/25 at 12:24 p.m., Resident 25 was observed to be eating lunch. On 8/5/25 at 11:09 a.m., Resident 25's clinical record was reviewed. The diagnoses included, but were not limited to, schizophrenia and hypertension. Resident 25's weight indicated the following:-On 6/3/25, Resident 25 weighed 156 pounds -On 7/9/25, Resident 25 weighed 144 pounds which was a 7.69% weight loss in a month. -On 7/28/25, Resident 25 weighed 140 pounds. The care plan, dated 1/20/23, indicated Resident 25 was at nutritional risk due to schizophrenia. The intervention was to report to the physician as needed of significant weight loss of 5% or greater in a month and to weigh resident and record as ordered. The Nutrition Progress note, dated 7/10/25 at 10:17 am,…
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 · D2025-08-06 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to ensure staff submitted a comprehensive assessment within 14 days of a resident's discharge for 1 of 15 residents reviewed for MDS assessments and timing (Resident 13).Finding includes: On 8/4/25 at 10:19 a.m., Resident 13's clinical record was reviewed. The diagnoses included, but were not limited to dementia, Alzheimer's disease, and sacral pressure ulcer. A 7/17/25 progress note indicated the resident was sent to the hospital for a bleeding sacral wound and was admitted after she had wound surgery to stop the bleeding. A 7/17/25 discharge MDS (Minimum Data Set) assessment was listed as 'in process' and incomplete. The assessment reference date (ARD) was 7/17/25. During an interview on 8/6/25 at 1:19 p.m., the Director of Nursing indicated the facility was aware of the incomplete MDS assessment and the corporate staff was working to complete it.
- Potential for harm · Dcited before2025-08-06 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 an accurate assessment for 1 of 15 residents reviewed for MDS (Minimum Data Set) assessment accuracy. (Resident 27)Findings include: On 8/4/25 Resident 27's clinical record was reviewed. The diagnoses included, but were not limited to, traumatic brain injury (an injury to the brain caused by an external force) and major depressive disorder. A review of the physician orders dated 3/25/25, indicated Resident 27 was prescribed Alprazolam (a medication used to treat anxiety disorders) for a diagnosis of anxiety. The resident's MAR indicated this remained an active order. A review of the provider progress note, dated 6/10/25, indicated the resident had an active diagnosis of anxiety. A review of the Resident 27's care plan, dated 9/16/24, indicated the resident used anti-anxiety medications.A review of the Quarterly MDS assessment, dated 6/30/25, indicated anxiety was not marked as an active diagnosis. During an interview with the DON (Director of Nursing) on 8/6/25 at 9:40 a.m., she indicated the resident had an active…
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 · D2025-08-06 · 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, interview, and record review, the facility failed to ensure resident received nutritional supplement for a resident with an assessed weight loss for 1 of 3 residents reviewed for nutrition. (Resident 25)Findings include: During an interview on 8/3/25 at 1:44 p.m., Resident 25 indicated in the last month he had lost weight. On 8/4/25 at 12:42 p.m., Resident 25 was observed to be resting in his bed. His lunch tray was observed to be in his room with no ice cream on the lunch tray. On 8/5/25 at 12:24 p.m., Resident 25 was observed to be eating lunch. No ice cream was observed on his lunch tray or on his meal ticket. During an interview on 8/5/25 at 1:45 p.m., Resident 25 indicated he did not get ice cream on his lunch tray. On 8/5/25 at 11:09 a.m., Resident 25's clinical record was reviewed. The diagnoses included, but were not limited to schizophrenia and hypertension. The quarterly Minimum Data Set (MDS) assessment, dated 6/26/25, indicated Resident 25 was cognitively intact. Resident 25's weight indicated the following:-On 6/3/25, Resident 25 weighed 156 pounds…
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 · D2024-10-25 · 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 interview and record review, the facility failed to ensure the written notification required for a transfer and discharge was provided to the resident and the resident representative for 1 of 1 resident reviewed for hospitalization. (Resident 33) Findings include: Residents 33's clinical record was reviewed on 10/22/24 at 2:02 p.m. The diagnoses included, but were not limited to, dementia and fracture of the left femur. Resident 33's progress notes indicated the resident was sent to the hospital on 9/30/24. The clinical record lacked documentation the written notification of the Transfer and Discharge forms were provided to the resident and the resident representative. During an interview on 10/24/24 at 2:45 p.m., the Administrator indicated the forms were sent in writing to the resident representative but was not documented. On 10/25/24 at 12:09 p.m., the Administrator provided the facility's policy,Discharge Transfer of Resident, dated 11/28/12, and indicated it was the policy currently being used by the facility. A review of the policy did not indicate sending 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 · D2024-10-25 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 notification of the bed hold policy required for a resident who transferred to the hospital was provided in writing to the resident or the resident representative for 1 of 1 resident reviewed for hospitalization. (Resident 33) Findings include: Residents 33's clinical record was reviewed on 10/22/24 at 2:02 p.m. The diagnoses included, but were not limited to, dementia and fracture of the left femur. Resident 33's progress notes indicated the resident was sent to the hospital on 9/30/24. The clinical record lacked documentation the written notification which specified the facility's bed hold policy was provided to the resident or the resident representative. During an interview on 10/24/24 at 2:45 p.m., the Administrator indicated the forms were sent in writing to the resident representative but was not documented. On 10/25/24 at 12:09 p.m., the Administrator provided the facility's policy,Bed Hold and Return to Facility, dated 11/28/12, and indicated it was the policy currently being used by the facility. A…
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 15 citations
- Potential for harm · Dcited before2024-10-25 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 accuracy of the Minimum Data Set (MDS) assessment for a 2 of 2 residents reviewed for nutrition. Weight loss and IV (intravenous) nutrition were coded inaccurately. (Resident 7, Resident 31) Findings include: 1. Resident 7's clinical record was reviewed on 10/25/24 at 10:00 a.m. The diagnosis included, but was not limited to, Alzheimer's Disease. A review of the Weights and Vitals Summary for Resident 7 indicated the following: -On 6/24/24, the resident weighed 116 pounds. -On 7/8/24, the resident weighed 110 pounds. -On 8/5/24, the resident weighed 109 pounds. -On 9/4/24, the resident weighed 105 pounds. -On 10/11/24, the resident weighed 101 pounds. This was an assessed 12.93% severe weight loss in 5 months. Resident 7's Annual MDS assessment, dated 10/7/24, indicated the resident weighed 134 and weight loss had not been assessed during the look back period. During an interview on 10/25/24 at 10:15 a.m., the Assistant Director of Nursing indicated the Annual MDS assessment, dated 10/7/24, for Resident 7 had…
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 · D2024-10-25 · 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, interview, and record review, the facility failed to label medications with an open and expiration dates for 1 of 1 medication rooms observed. (Medication Room, Resident 14) Findings include: On 10/24/24 at 11:00 a.m., the refrigerator in the medication room was observed to have a vial of tuberculin PPD (purified protein derivative, a solution to aid in diagnosis of a tuberculosis infection) without an open or expiration date. An Ozempic injector pen (an injectable medication used to treat type 2 diabetes) for Resident 14, was observed without an open date or an expiration date. The Director of Nursing (DON) could not find an open date or an expiration date on either medication. The DON indicated every medication that was opened should have an open date and an expiration date on the vial or the pen. The DON was unsure when to discard medications after they were opened. On 10/24/24 at 11:25 a.m., the Administrator provided the facility's policy on Medication Storage, dated 7/2/19, and indicated it was a current policy being used by the facility. A review of 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 · D2024-10-25 · tag F0800 — isolatedProvide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
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 a resident with a physician order for a carbohydrate controlled diet received the correct diet for 1 of 1 resident reviewed for food. (Resident 35) Findings include: During an interview on 10/21/24 at 2:35 p.m., Resident 35 indicated he had been on a low carbohydrate (carb) diet while in the hospital. He was supposed to be on a low carb diet while in the facility but he had been getting meals with high carbs. For lunch today, he had ham salad on bread. He had gained weight since coming to the facility from eating too many carbs. During an interview on 10/22/24 at 2:37 p.m., Resident 35 indicated lunch today had been chicken and noodles but he was only able to eat the chicken because he was not supposed to have carbs. Resident 35's clinical record was reviewed on 10/22/24 at 2:43 p.m. The diagnosis included, but was not limited to, Type II Diabetes Mellitus. Physician orders, dated 9/1/24 through 9/30/24, for Resident 35 indicated . regular diet, regular texture, regular/thin consistency . A review on 10/25/24 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 · D2024-04-05 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
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 a resident was free from misappropriation of resident property though the diversion of a resident's controlled substance for staff use for 1 of 3 residents reviewed for misappropriation of property. (Resident B) Finding includes: During an interview on 4/5/24 at 9:30 a.m., the Minimum Data Set (MDS) Coordinator indicated on the morning of 3/2/24 she received a call from Licensed Practical Nurse (LPN) 1 who reported 2 cards of oxycodone (a narcotic medication) were missing for Resident B. She contacted all nurses who had worked that week and had them submit urine drug screens. On 3/4/24, all staff, with the exception of LPN 2 met and submitted urine drug screens. On 3/13/24, LPN 2 submitted a urine drug screen which tested positive for oxycodone, oxymorphone, and oxycodone/oxymorphone. On 4/5/24 at 10:30 a.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, sarcopenia (age-related progressive loss of muscle mass and strength), hemiplegia (paralysis) and hemiparesis…
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 before2023-11-16 · 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 food was stored and served in a sanitary manner for 3 of 3 kitchen observations. The hand washing station did not have hot water, the air conditioning unit was dirty, items in the refrigerator and freezer were unlabeled, and the chemical strips used for the 3 compartment sink were expired. This had the potential to impact 30 of 30 residents residing in the facility. Findings include: 1. During an initial tour of the facility kitchen on 11/13/23 at 10:15 a.m., the following was observed: - The hot water in the handwashing sink would not get hot. The Dietary Manager (DM) indicated at that time to use the 3 compartment sink because the water from that pipe would get hot. - The tubing around the wall air conditioning (A/C) unit was dirty with dust and debris and the vent slabs were observed to be dirty with a dark black substance. - The freezer was observed to have 5 packages of frozen meats that were unlabeled. The DM indicated at that time they were hamburger. - The refrigerator was observed to have a…
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 · F2023-11-16 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to electronically submit to the Centers for Medicare and Medicaid (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for Quarter 3 (April 1 to June 30) of fiscal year 2023. Findings include: On 11/13/23 at 11:30 a.m., the facility's Payroll Based Journal (PBJ) Staffing Data Report was reviewed. The report indicated the facility had no RN Hours for 4/2/23, 4/9/23, 5/7/23, 5/21/23, 6/4/23, and 6/18/23. The report further indicated the facility failed to have Licensed Nursing Coverage 24 hours per day on 4/2/23, 4/4/23, 4/8/23, 4/14/23, 4/15/23, 4/16/23, 4/21/23, 4/22/23, 4/30/23, 5/2/23, 5/6/23, 5/7/23, 5/8/23, 5/10/23, 5/11/23, 5/12/23, 5/14/23, 5/15/23, 5/16/23, 5/20/23, 5/21/23, 5/22/23, 5/25/23, 5/26/23, 5/27/23, 5/28/23, 5/29/23, 6/3/23, 6/4/23, 6/5/23, 6/8/23, 6/10/23, 6/11/23, 6/18/23, 6/19/23, 6/22/23, 6/23/23, 6/24/23, 6/25/23,…
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 · E2023-11-16 · tag F0727 — failed to provide required RN coverage — patternHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 6 of 120 days reviewed. Findings include: On 11/13/23 at 11:30 a.m., the facility's Payroll Based Journal (PBJ) Staffing Data Report was reviewed. The report indicated the facility had no RN Hours for 4/2/23, 4/9/23, 5/7/23, 5/21/23, 6/4/23, and 6/18/23. On 11/15/23 at 11:46 a.m., the third quarter staffing schedules (4/1/23-6/30/23) were reviewed. The staffing schedules indicated the facility had no RN scheduled on 4/2/23, 4/9/23, 5/7/23, and 6/4/23. A further review of the last thirty days of staffing schedules indicated there were no RN scheduled for 10/21/23 and 10/22/23. During an interview on 11/16/23 at 12:00 p.m. the ADM indicated they were late updating the schedule into a program accessible by computer and thought that may be why the PBJ report triggered so many days. She further indicated the facility did not have any RN coverage on 4/2/23, 4/9/23, 5/7/23, 6/4/23, 10/21/21 and 10/22/23. During an interview on 11/16/23…
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 · E2023-11-16 · tag F0807 — failed to offer suitable drinks — patternEnsure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
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 residents were provided with fresh water on a routine basis for 5 out of 5 residents reviewed for hydration. (Resident 133, Resident 25, Resident 22, Resident 23, Resident 29) Findings include: 1. During an interview on 11/13/23 at 11:33 a.m., Resident 133 indicated she was not getting enough to drink because the facility did not pass water. No water was observed to be at the residents bedside during that time. During an observation on 11/14/23 at 1:59 p.m., Resident 133 was observed to be lying in her bed asleep. There was a gray pitcher with a straw observed on the back dresser that was undated and 3/4 full of warm water with no ice. During an interview on 11/14/23 at 3:16 p.m., Resident 133 indicated she had not known there was a gray water pitcher on the dresser next to the bed and she would have only noticed it if it had been on the bedside table. During an observation on 11/15/23 at 9:45 a.m., Resident 133 was out of the room attending PT (physical therapy). There was a gray pitcher with a straw…
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 before2023-11-16 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure a clean and sanitary environment for 6 of 11 resident rooms and 4 of 4 bathrooms observed. Water temperatures in resident room sink faucets were not hot, floor tiles were not in place and clean, and toilet bases were not clean. (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], Northeast Bathroom, Northwest Bathroom, Southeast Bathroom, Southwest Bathroom) Findings include: 1. On the following dates and times, the hot water temperature for each resident room sink faucet was measured for a period of 3 minutes, with the temperature results documented: - On 11/16/23 from 11:00 A.M. to 11:03 A.M., room [ROOM NUMBER]'s hot water temperature was 77.1 degrees Fahrenheit. - On 11/16/23 from 11:06 A.M. to 11:09 A.M., room [ROOM NUMBER]'s hot water temperature was 64.8 degrees Fahrenheit. - On 11/16/23 from 11:12 A.M. to 11:15 A.M., room [ROOM NUMBER]'s hot water temperature was 76.2…
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 · D2023-11-16 · tag F0567 — failed to protect residents' money held by the home — isolatedHonor the resident's right to manage his or her financial affairs.
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 residents had full access to their facility managed personal funds account during the weekend hours for 1 of 16 residents reviewed for personal funds. (Resident 5) Findings include: During an interview on 11/13/23 at 3:49 p.m., Resident 5 indicated he was unable to get the full amount of money from his personal funds account on the weekends. The facility limited him on how much he could have. Resident 5's clinical record was reviewed on 11/15/23 at 10:00 a.m. The diagnosis included, but was not limited to, chronic obstructive pulmonary disease. The Quarterly Minimum Data Set (MDS) assessment, dated 9/4/23, indicated Resident 5 was cognitively intact. During an interview on 11/16/23 at 4:08 p.m., the Business Office Manager (BOM) indicated the residents would line up outside her office on Friday because they were only allowed to get between $5.00 and $10.00 out of their personal funds account on the weekend. She only kept $40.00 on hand. On 11/16/23 at 4:00 p.m., the BOM provided the facility's policy, 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 · D2023-11-16 · 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 interview and record review, the facility failed to ensure a care plan was developed for a resident with a surgical wound who was on a long term antibiotic for 1 of 1 residents reviewed for antibiotic use. (Resident 9) Findings include: Resident 9's clinical record was reviewed on 11/16/23 at 9:45 a.m. The diagnoses included, but were not limited to, acquired absence of unspecified hip joint and acquired absence of left leg above knee. Current physician orders, dated 11/16/23, indicated Resident 9's orders included, but were not limited to: clindamycin HCL (an antibiotic) 150 mg (milligrams) give 1 capsule by mouth one time a day related to infection and inflammatory reaction due to internal left hip prosthesis. There was no stop dated listed for the antibiotic. The Quarterly Minimum Data Set (MDS) assessment, dated 8/21/23, assessed Resident 9 as taking an antibiotic 7 out of 7 days during the lookback period. A care plan, initiated on 3/21/14, for Resident 9 indicated: FOCUS: . Is at risk for skin breakdown related to: The resident has impaired physical mobility r/t…
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 · D2023-11-16 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to monitor a resident with a new medication order for 1 of 5 residents reviewed for unnecessary medications. Blood sugars were not obtained.(Resident 11) Findings include: On 11/16/23 at 10:36 a.m., Resident 11's clinical record was reviewed. The diagnoses included, but were not limited to, diabetes mellitus and cerebrovascular disease with left hemiplegia (stroke with paralysis on one side of the body). The diabetes mellitus care plan, dated 8/23/22, lacked any monitoring of blood sugar as interventions. The Physician Orders included, but were not limited to: - Blood sugar every morning and every bedtime and to call the physician if blood sugar less than 50 and greater than 500 (start date 10/3/23). - Insulin detemir (a medication used to treat diabetes mellitus), inject 10 units, in the evening (start date 10/3/23). The October 2023 Medication Administration Record lacked documentation of blood sugars. The November 2023 Medication Administration Record lacked documentation of blood sugars. On 11/16/23 at 4:10 p.m., 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 · D2023-08-16 · tag F0659 — isolatedProvide care by qualified persons according to each resident's written plan of care.
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 qualified personnel provided care as indicated by the resident's person-centered plan of care. A QMA (Qualified Medication Aide) assessed a resident's pain level and did not ensure the resident swallowed a routine narcotic pain medication; administered insulin to a resident without training and certification; and reported a change in condition to the Nurse Practitioner without reporting to the nurse. (Resident C, Resident D, Resident E) Finding includes: 1. During an interview on 8/15/23 at 11:29 a.m., the Administrator indicated on 8/1/23, QMA 1 assessed Resident D's pain level prior to administering a routine narcotic pain medication. Then QMA 1 administered the narcotic pain medication but did not stay in Resident D's room to ensure that he swallowed the pill as indicated in Resident D's care plan. QMA 1 should not have assess Resident D's pain level. That required an assessment. QMA 1 should not have walked out of Resident D's room without ensuring that he swallowed the medication. The clinical record for…
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 · D2023-08-16 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to develop and implement a comprehensive plan of care for residents diagnosed with substance use disorder for 3 of 3 residents reviewed. (Resident B, Resident C, Resident D) Finding includes: 1. During an interview on 8/14/23 at 10:16 a.m., Resident B indicated he smoked marijuana in the facility. Resident C offered the marijuana to Resident B. Resident B and Resident C smoked the marijuana in Resident C's room. Resident B had already talked to the Nurse Practitioner. Resident B would never do that again because he doesn't want to get in trouble. Resident B would not have smoked marijuana if it hadn't been offered to him by Resident C. During an interview on 8/14/23 at 10:26 a.m., Resident C indicated he had marijuana and offered to smoke it with Resident B. Resident B and Resident C smoked in Resident C's room with the door open. At that time, Resident C indicated he would not discuss where he got the marijuana nor who he got it from. During an interview on 8/14/23 at 3:02 p.m., the Administrator indicated the incident with…
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 · C2023-11-16 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the daily posted nurse staffing sheet had the actual hours worked by staff for 4 of 4 days of daily posted nurse staffing reviewed. Findings include: During an observation on 11/13/23 at 11:39 a.m., the daily posted nursing staff sheet lacked the the actual hours staff worked. During an interview on 11/16/23 at 3:57 p.m., the Administrator provided the daily posted nursing staff sheets dated 11/13/23 through 11/16/23. At that time, the daily posted nursing staff sheets were reviewed. The Administrator indicated the daily posted nursing staff sheet lacked documentation of the actual hours worked by staff.
“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 APERION CARE — 33 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 | 1 of 5 | 1.9 | -0.9 vs chain |
| Health inspection | 2 of 5 | 2.0 | ≈ chain avg |
| Staffing | 1 of 5 | 1.6 | -0.6 vs chain |
| Quality measures | 2 of 5 | 3.3 | -1.3 vs chain |
The other 32 homes this chain runs (chain average 1.9★, 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 |
|---|---|---|---|---|
| DAVIESS COUNTY HOSPITAL | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 09/01/2017 |
| ARVIN, FAITH | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 03/01/2024 |
| RADADIYA, PRAGNESHKUMAR | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 03/01/2024 |
| STEINER, DERON | Individual | CORPORATE DIRECTOR | — | since 09/01/2017 |
| CONROY, TRACY | Individual | CORPORATE OFFICER | — | since 09/01/2017 |
| RODEWALD, AMANDA | Individual | CORPORATE OFFICER | — | since 09/01/2017 |
| APERION CARE INC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/01/2024 |
| APERION CARE MONROE, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/01/2024 |
| BERKOWITZ, DAVID | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/01/2024 |
| GOLDFARB, BRIAN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/01/2024 |
| HOFFMAN, JOSHUA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/01/2024 |
| MEYSTEL, JAY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/01/2024 |
| MEYSTEL, YOSEF | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/01/2024 |
| SPECTOR, JENNIFER | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/01/2024 |
| TUROFSKY, STEVEN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/01/2024 |
| ULBERT, LISA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/01/2024 |
3 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.
About 92% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $911K paid to related parties — landlords or management companies under common ownership — equal to about 30% 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 155532. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-06, 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.