Woodmont Health Campus
1325 Rockport Rd, Boonville, IN 47601 · Government - County · 60 certified beds · (812) 897-4114 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing 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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
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 | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 14.6% | 11.0% | 15.4% | typical |
| Long-stay residents who lose too much weight | 7.6% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.9% | 0.4% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 4.0% | 1.1% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 2.5% | 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 | 6.9% | 3.9% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 11.9% | 11.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 22.5% | 23.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.8% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.4% | 3.6% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 15.9% | 23.3% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.3% | 13.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.5% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 96.1% | 79.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 23.1% | 22.2% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 8.6% | 10.8% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.96 | 1.61 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.98 | 1.44 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
60.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 99 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 64.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 62 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.39 therapist hours per resident per day in 2026Q1 — more than 66% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 9% 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 | 60.5%CMS range 49.1–71.1 | 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 | 11.1%CMS range 8.1–15.9 | 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 | 64.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 59.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 58.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 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 | 96.4% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 3.0% | 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 | 9.1%CMS range 5.2–14.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.16 | 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 60 beds and averages 51.6 residents a day — about 86% occupied, or roughly 8 beds typically open. It runs fairly full. 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 3.11 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.84 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 2.74 hrs/resident/day on weekends vs 3.26 on weekdays — 16% thinner on weekends. RN hours go from 0.66 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 49% 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.
29 citations, most serious first. The 10 most serious are shown; the remaining 19 are one tap away and print in full.
- Potential for harm · D2026-06-11 · 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 interview and record review, the facility failed to ensure a resident's right to privacy for 1 of 3 resident's reviewed for resident rights. An employee took an unauthorized video of a cognitively impaired resident with a personal cell phone. (Resident C) This deficient practice was corrected on May 11, 2026, prior to the start of the survey, and was therefore past noncompliance.Finding includes:Review of facility reported incidents on 6/11/26 at 10:30 A.M., a reported incident dated 5/5/26 at 5:03 P.M. indicated CNA 4 was taking a video in the hallway of Resident C. The video was approximately five seconds long and was taken on the employee's personal cell phone. Review of Resident C's clinical record indicated the resident's diagnoses included but were not limited to cognitive communication deficit, abnormal posture, abnormalities of gait and mobility, lack of coordination, and major depression. The most recent annual Minimal Data Set (MDS) dated [DATE], indicted the resident had severe cognitive…
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 · D2026-03-13 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure pharmaceutical services were available to provide physician prescribed routine medications to 2 of 3 residents reviewed for pharmacy services. Physician prescribed routine medications were not administered due to the medications being unavailable at the facility. (Resident B, Resident C)Findings include:1. During an interview on 3/13/26 at 10:35 A.M., Resident B indicated that staff had informed her on more than one occasion that they were out of her routine medications. During record review on 1/9/25 at 11:20 A.M., Resident B's diagnoses included but were not limited to, heart failure, kidney failure, type II diabetes, anemia, Systemic Inflammatory Response Syndrome (SIRS), and acute upper respiratory infection. Resident B's physician orders included, but were not limited to:- Carboxymethylcellulos sodium 0.5% (artificial tears), administer one drop in each eye three times a day, started 2/23/26.- Ferrous sulfate (iron supplement) 325 milligrams (mg) once a day, started 12/31/25.- Insulin Lispro pen (fast acting…
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 · D2026-03-13 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure residents were free of significant medications errors for 1 of 3 residents reviewed for pharmacy services. A resident received a double dose of insulin and received another resident's medications. (Resident C) Finding includes:During record review on 3/13/26 at 11:00 A.M., Resident C's diagnoses included, but were not limited to, type II diabetes, heart failure, kidney failure, anxiety, and depression. Resident C's most recent annual Minimum Data Set (MDS) assessment, dated 2/2/26, indicated the resident had no cognitive impairment and received insulin, antidepressant, diuretic, anticoagulant, hypoglycemic, and anticonvulsant medications during a seven day look back period. Resident C's nurses progress notes included but were not limited to:12/1/25 at 3:25 P.M. - Time of occurrence: 11/30/25 at 12:30 P.M. - Medication Error. Resident was given insulin twice by two different nurses. Resident received Novolog 10 units twice due to it was not clicked off on the Medication Administration Record (MAR) and nurse was…
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 before2025-09-02 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 failed the obtain the temperature of the food prior to serving the residents for 1 of 1 plating observations. Finding includes:During an observation of plating on 8/28/25 at 6:02 A.M., [NAME] 17 utilized tongs and scoops to place the food items on the plates to serve the residents.During an interview on 8/28/25 at 6:06 A.M., [NAME] 19 indicated a computerized system was used to log the temperatures of the food items. At that time, she pulled up the temperature log on the computerized system, and the log was blank. [NAME] 17 continued plating and indicated temperatures should have been obtained by [NAME] 21. At that time, [NAME] 21 indicated the Dietary Manager should be in the facility at any time, and refused to answer on if the temperature of the food was obtained.On 6/28/25 at 6:09 A.M., the Dietary Manager entered the kitchen and looked on the computerized system to find the temperature log. At that time, he talked to [NAME] 21, and then indicated that [NAME] 17 had to stop plating food, and he began to take the temperature…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-02 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to clarify a Resident's code status for 1 of 1 residents reviewed for advanced directives. A resident's current Physician's Order did not match the signed Indiana Physician Orders for Scope of Treatment form, and staff was unaware of Resident's wishes. (Resident 56)Finding includes:On 8/29/25 at 11:17 A.M., Resident 56's daughter visited while Resident 56 was asleep in bed. At that time, the daughter indicated Resident 56 did not want to be intubated.On 8/27/25 at 10:16 A.M., Resident 56's clinical record was reviewed. Diagnosis included, but were not limited to, metastatic stage 4 cancer.Resident 56's admission Minimum Data Set (MDS) assessment was in progress and had not been completed.Physician Orders included, but were not limited to the following: CODE STATUS: No chest compressions. May intubate, dated 8/22/25A current POST form indicated, Limited Additional Interventions.Do not intubate, signed 8/22/25Resident 56's clinical record lacked a care plan related to code status.During an interview on 8/29/25 at 11:19 A.M.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-02 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation. interview, and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised for 1 of 2 residents reviewed for urinary tract infections (UTI), 1 of 3 residents reviewed for pressure ulcers, and 2 of 5 reviewed for unnecessary medications. Residents who were not on antianxiety medication and no longer had a UTI had care plans that were not removed and a resident with multiple pressure ulcers did not have wound specific care plans. (Resident 6, Resident 18, Resident 45, Resident 1)Findings include:1. On 8/27/25 at 8:04 A.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, severe dementia with psychotic disturbance and adjustment disorder. The most recent quarterly Minimum Data Set (MDS) assessment, dated 8/7/25, indicated Resident 6's cognition was severely impaired and she was taking an antipsychotic, antidepressant, diuretic and opioid medication. Current Physician's Orders lacked an order for an antianxiety…
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 · D2025-09-02 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
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 services provided by the facility met professional standards of quality for 2 of 3 residents reviewed for nutrition and 1 of 4 residents reviewed for urinary tract infections (UTI) and pressure ulcers. Weights were not monitored and discontinuation of contact precautions were not completed as ordered, a dressing was not initialed or dated, staff documented treatments completed on a pressure ulcer that had been healed, and a nurse signed off on a treatment that another staff member completed. (Resident 45, Resident 1, Resident 8)Findings include: 1. On 8/27/25 at 12:45 P.M., Resident 8's clinical record was reviewed. Diagnoses included, but was not limited to, diabetes mellitus type II, chronic kidney disease (CKD), hypertension, lymphedema, edema, obesity (morbid), and dementia with psychotic disturbance. The most recent quarterly MDS assessment, dated 5/16/25, indicated Resident 8's cognition was moderately impaired, was 232 pounds (lbs), 5 foot 6 inches tall, no known weight loss or gain, and was totally dependent…
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 · D2025-09-02 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a resident received ordered treatment and services to promote healing and prevent new ulcers from developing for 1 of 3 residents reviewed for pressure ulcers. A wound specific care plan was not developed, treatment orders were not followed, wound assessments were not completed accurately, and Enhanced Barrier Precautions (EBP) were not used when providing wound care. (Resident 6)Finding includes:On 8/27/25 at 8:04 A.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, severe dementia with psychotic disturbance and pressure ulcer.The most recent quarterly Minimum Data Set (MDS) assessment, dated 8/7/25, indicated Resident 6's cognition was severely impaired, was dependent on staff assistance for toileting, substantial to maximum assistance (staff performs over half the effort) for bed mobility and transferring, and had one facility-acquired unstageable pressure ulcer. Current physician's orders included, but were not limited to, the following:EBP with wound care,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide adequate supervision and prevent falls for 1 of 3 residents reviewed for accidents. Fall interventions were not in place for a resident with multiple falls and neurological (neuro) checks were not fully completed after unwitnessed falls. (Resident 5)Findings include:During an observation on 8/27/25 at 12:55 P.M., Resident 5 was in the recliner with regular white socks on.On 8/27/25 at 8:56 A.M., Resident 5's clinical record was reviewed. Diagnoses included, but was not limited to, fracture of right pubis, hypertension, anxiety disorder, and depression.The most recent quarterly Minimum Data Set (MDS) assessment, dated 8/6/25, indicated Resident 5 was cognitively intact and substantial to maximal assistance of staff (staff performs more than half the effort) for transfers and toileting, and Resident 6 had a fall with fracture in the last 6 months.Resident 5's Physician's Orders included, but was not limited to the following:Call don't fall sign in the bathroom, dated 8/25/25Non-skid strips on 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 · D2025-09-02 · 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
Based on observation, interview, and record review, the facility failed to ensure it was free of a medication error rate of greater than 5 percent for 1 of 5 residents (Resident 31) observed during the medication pass. There were 25 opportunities for error observed with 3 medication errors, resulting in a medication error rate of 12 percent.Finding includes:On 8/28/25 at 7:27 A.M., Licensed Practical Nurse (LPN) 43 was while they prepared and administered medications to Resident 31. They used Anti-bacterial Hand Rub (ABHR) prior to setting up medications. They measured out 10 milliliters (mL) of Docusate Sodium into a medication cup. They put the Tradjenta and Levothyroxine into another medication cup and the Metoprolol Succinate Extended Release (ER) in another. They crushed all the medications, keeping the Metoprolol separated. They labeled that medication cup with BP. They proceeded to mix the crushed medications in both cups with a spoonful of pudding. They took the medications and vitals machine into the resident's room, took her blood pressure (126/55) with the machine, washed…
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 19 citations
- Potential for harm · D2025-09-02 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
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 antibiotic use protocols were followed to monitor antibiotic use. Residents received an antibiotic prior to obtaining culture results, and received an antibiotic without an indication for 2 of 2 residents reviewed for urinary tract infections (UTI). (Resident 45, Resident 1)Findings include:1. On 8/27/25 at 9:27 A.M., Resident 45's clinical record was reviewed. Diagnoses included, but were not limited to, stroke and neurogenic bladder. The most recent quarterly Minimum Data Set (MDS) assessment, dated 7/30/25, indicated a moderate cognitive impairment, and an indwelling urinary catheter. Physician orders included, but were not limited to:Macrobid (nitrofurantoin monohyd/m-cryst) (an antibiotic) capsule; 100 mg; amt: 100 mg; oral for UTI, dated 6/25/25 through 6/27/25. levofloxacin (an antibiotic) tablet; 500 mg; amt: 500mg; oral for UTI, dated 6/27/25 through 7/4/25. Macrobid (nitrofurantoin monohyd/m-cryst) capsule; 100 mg; amt: 100 mg; oral twice A Day, dated 8/20/25 through 8/27/25. A current care plan 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 · Dcited before2024-10-29 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to maintain infection control practices to help mitigate the spread of COVID-19. Staff failed to complete proper hand hygiene, touched resident furnishings without performing hand hygiene, and placed a dirty glove on top of a medication cart during 2 of 3 observations of care. (Resident C, Resident D) Findings include: 1. During an observation on 10/29/24 at 10:49 A.M., CNA 7 was providing urostomy care and incontinence care for Resident C. CNA 7 indicated Resident C required Enhanced Barrier Precautions due to the urostomy. Following urostomy care, CNA 7 removed Resident C's soiled brief and provided peri-care. CNA 7 then removed both gloves and completed a 10 second handwashing. CNA 7 then applied new gloves and placed a new brief on the resident. CNA 7 indicated they had forgotten to apply a pad around the urostomy insertion site. CNA 7 removed gloves and completed a 12 second handwashing. CNA 7 applied new gloves and placed a pad around the ostomy insertion site. CNA 7 then removed and disposed of gloves,…
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 before2024-07-26 · 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 storage of food in a safe and sanitary manner and failed to follow proper sanitation for 2 of 2 kitchen observations. Food items were observed unlabeled and open to air. The dishwasher did not reach the proper rinse temperature. Temperature logs were not completed correctly. (Kitchen) Findings include: 1. On 7/21/24 at 9:10 A.M., a box of beef patties and a box of chicken breasts were observed open to air and not labeled in the walk in freezer. On 7/22/24 at 9:34 A.M., a box of beef patties was observed open to air and unlabeled in the walk in freezer. 2. On 7/21/24 at 9:45 A.M., the high temperature dish washer was observed to reach a temperature of 168 degrees during the rinse cycle. On 7/21/24 at 9:56 A.M., Daily Data Sheets were provided for 7/14/24 through 7/20/24 which lacked documentation of food temperatures, dish machine temperatures, refrigerator and freezer temperatures and manual ware washing concentration for the evening shift on 7/14/24, 7/15/24, and 7/20/24. One sheet lacked a 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 · Ecited before2024-07-26 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure care plan conferences were completed. Quarterly care plan conferences were not completed for 4 of 5 residents reviewed for unnecessary medications. (Resident 28, Resident 8, Resident 19, Resident 29) Findings include: 1. On 7/23/24 at 1:59 P.M., Resident 28's clinical record was reviewed. Diagnoses included, but were not limited to, dementia with behaviors and hypertension. Resident 28's clinical record lacked a care conference between 1/2/24 and 6/3/24. 2. On 7/23/24 at 8:12 A.M., Resident 8's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety disorder and depression. Resident 8's clinical record lacked a care conference between 12/12/23 and 5/8/24. 3. On 7/24/24 at 9:21 A.M., Resident 19's clinical record was reviewed. Diagnoses included, but was not limited to, hypertension and anxiety disorder. Resident 19 lacked a care conference between 8/27/23 and 1/3/24 and 5/30/24. 4. On 7/23/24 at 10:39 A.M., Resident 29's clinical record was reviewed. Diagnoses included, but were not…
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 · E2024-07-26 · 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 sanitary and homelike environment was provided for 3 of 3 resident halls observed and 1 of 1 shower room. Resident toilets were visibly soiled, fracture pans and urine hats were uncovered and placed between the handrail and wall, vitals machine and lift equipment were visibly soiled. The carpet was stained on the 200 Hall. The shower room grout was soiled, tiles were chipped, and there was a broken tile by the bathroom wall. (100 Hall, 200 Hall, 300 Hall, Shower Room) Findings Include: 1. On 7/22/24 at 11:02 A.M., the bathroom of room [ROOM NUMBER] was observed. There was a brown substance on the back of the toilet and an uncovered fractured (flattened) bedpan on the handrail. There were black scuffs on the walls. On 7/26/24 8:21 A.M., the same was observed. 2. On 7/22/24 at 9:14 A.M., the bathroom of room [ROOM NUMBER] was shared by 2 residents and was observed to have an uncovered fractured bedpan on the handrail. On 7/26/24 at 8:22 A.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 · Dcited before2024-07-26 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents observed for incontinence care. Gloves were not changed and hands were not sanitized between dirty and clean tasks. A resident's incontinence pad was laid on the bathroom floor before it was placed on the resident. (Resident 39, Resident 7) Findings include: 1. On 7/25/24 at 10:40 A.M., CNA (Certified Nurse Aide) 48 and CNA 56 were observed providing incontinence care on Resident 39. CNA 48 put on shoes on the resident, transferred resident from her bed to her wheelchair, and pushed Resident 39 into the bathroom. She washed her hands with a 5 second lather and put gloves on. CNA 56 washed her hands with a 10 second lather and put on gloves. CNA 48 then went out of the bathroom and back into the bathroom using a gloved hand to open the door and close it. CNA 48 and CNA 56 assisted the resident to stand from…
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 before2024-03-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure adequate supervision was in place to prevent a resident with a history of exit-seeking behavior from exiting the facility for 1 of 3 residents reviewed for elopement. A resident unknowingly exited the facility and was found in the facility's parking lot approximately 45 minutes later. (Resident C) Finding includes: During a review of facility reported incidents on 3/18/24 at 10:15 A.M., an incident dated 3/13/24 at 7:07 P.M. included that a staff member noted resident C to be sitting in his wheelchair near the heath center sign located outside the health center entrance. During record review on 3/18/24 at 10:45 A.M., Resident C's diagnoses included, but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting non-dominant side, dysphagia, aphasia, depression, unsteadiness on feet, lack of coordination, and history of falling. Resident C's most recent quarterly MDS (Minimum Data Set) assessment, dated 1/12/24, included that the resident's cognition was severely impaired,…
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 · E2024-01-26 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide assistance with bathing for 4 of 5 residents reviewed for activities of daily living (ADLs). Residents did not receive assistance with ADL's (bathing) according to the plan of care and bathing schedule. (Resident B, Resident C, Resident D, Resident F) Findings include: 1. During a review of facility grievances on 1/25/24 at 10:15 A.M., Resident B's family member had submitted a grievance, dated 12/27/23, that included, it had been two weeks since resident had a shower . During record review on 1/25/24 at 12:30 P.M., Resident B's diagnoses included, but were not limited to hemiplegia and hemiparesis following cerebral infarction, heart disease, dementia, weakness, and depression. Resident B's most recent admission MDS (Minimum Data Set) assessment, dated 12/4/23, included that the resident was cognitively intact, had upper and lower one-side extremity impairments, and was dependent for bathing activities. Resident B's care plan included but was not limited to; resident requires staff assistance to…
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 before2023-08-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide adequate supervision and prevent falls for 1 of 3 residents reviewed for accidents. Fall interventions were not in place for a resident with multiple falls. Current physician orders differed from the care plan in place. (Resident B) Finding includes: On 8/15/23 at 1:09 P.M., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, anxiety disorder, and a history of falling. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 5/17/23, indicated Resident B was severely cognitively impaired. The MDS indicated Resident B required an extensive assist of 1 staff member for bed mobility, transfers, and toileting. The MDS indicated Resident B had 2 or more falls since admission/ reentry. Resident B's care plan included, but was not limited to, Resident is at risk for falling R/T [related to]: requires assistance with ADL's [activities of daily living], has balance issues, on antidepressant, hx [history] of falls and has diagnoses of dementia, anxiety,…
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 · D2023-06-09 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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 resident experienced a dignified existence for 1 of 3 residents reviewed for respect and dignity. (Resident 199) Findings include: On 6/4/23 at 8:45 A.M., Resident 199 was observed asleep in bed, uncovered, wearing only a brief, with the door to the room wide open. There were no staff in the room. Several staff were in the hallway outside the resident's room across from his door and no one closed his door or covered him. The resident was in a private room. On 6/5/23 at 7:00 A.M. Resident 199 was observed asleep in bed, uncovered, wearing only a brief, with the door to the room wide open. There were no staff in room. Several staff were passing by the room in the hallway and no one closed his door or covered him. During an interview on 6/5/23 at 8:39 AM with LPN 25, she indicated resident was going home on Tuesday with Specialty Home Health. On 6/5/23 at 12:17 P.M. the resident's clinical records were reviewed. The admission…
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 before2023-06-09 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 compliance with the requirements for advance directives. An advanced directive order and DNR (Do Not Resuscitate) form was not signed by the physician for 1 of 2 reviewed for advanced directives. (Resident 24) Finding includes: On 6/5/23 at 1:59 P.M., Resident 24's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus type II and non-pressure chronic ulcer of other part of left foot. The most recent quarterly MDS (Minimum Data Set) Assessment, dated 4/12/23, indicated Resident 24 was an extensive assist of 2 staff for transferring and supervision of 2 staff for bed mobility and toileting. The resident was cognitively intact. Current physician's orders included, but were not limited to, the following: Code Status: DNR, dated 4/11/23 The DNR order lacked a physician or nurse practitioner's signature. A State of Indiana Out of Hospital Do Not Resuscitate Declaration and Order form, dated 4/7/23, lacked a physician or nurse practitioner's signature. Interview on 6/07/23 at 9:45…
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 · D2023-06-09 · 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 observation, interview, and record review, the facility failed to ensure an intervention was implemented for 1 of 5 residents reviewed for accidents. Resident's bathroom did not have non skid strips placed in front of the toilet. (Resident 24) Finding includes: During an interview on 6/4/23 at 9:28 A.M., Resident 24 indicated she was able to transfer herself without help of staff. On 6/5/23 at 1:59 P.M., Resident 24's clinical record was reviewed. Diagnoses included, but were not limited to, history of falls, unsteadiness on feet, abnormalities of gait and mobility, and non-pressure chronic ulcer of other part of left foot. The most recent quarterly MDS (Minimum Data Set) Assessment, dated 4/12/23, indicated Resident 24 was an extensive assist of 2 staff for transferring and supervision of 2 staff for bed mobility and toileting. The resident was cognitively intact. Current physician's orders included, but were not limited to, the following: Non skid strips in front of toilet, dated 5/25/23 A current falls care plan, dated 2/21/22, included but was not limited to, the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
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 that a resident who needs respiratory care is provided care according to the physician orders and maintenance of the respiratory equipment for 1 of 1 residents reviewed for respiratory care. (Resident 8) Findings included: On 6/5/23 at 10:34 A.M., Resident 8 was observed out of bed, dressed, and sitting in wheelchair. A Continuous Positive Air Pressure (CPAP) machine was on her night stand. During an interview, the resident indicated she only uses CPAP when sleeping. Upon inspection, the gross particle filter on the CPAP machine was observed to be covered with white lint-like substance. There was no oxygen concentrator in the room and the resident indicated she was not using oxygen at that time. On 6/6/23 at 11:47 AM the resident's clinical records were reviewed. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus with unspecified complications, obstructive sleep apnea (adult), shortness of breath, and acute respiratory failure. The annual…
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 · D2023-06-09 · 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 observation, interview, and record review, the facility failed to ensure behavioral health services were provided to maintain resident's highest practicable well-being. A Resident that required behavioral health monitoring was not evaluated for these services and not monitored for behaviors for 1 of 3 residents reviewed for dignity. (Resident G) Findings include: During an observation on 6/4/23 at 12:42 P.M., Resident G indicated that she needed to use the restroom. At that time, CNA (certified nurse aide) 3 was passing drinks to other residents as Resident G continued to say she needed to go to the restroom. CNA 3 indicated in a harsh tone you can't go right now, you can only go pee every 2 hours. On 6/6/23 at 9:34 P.M., Resident G's clinical record was reviewed. Diagnosis included, but were not limited to, heart failure, hypertension, and overactive bladder. The most recent annual MDS (minimum data set) Assessment, dated 5/12/23, indicated Resident G's cognitive status was severely impaired, and Resident G was occasionally incontinent. During an observation on 6/07/23 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 · D2023-06-09 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 free from unnecessary medications for 1 of 5 residents reviewed for unnecessary medications and 1 of 1 residents reviewed for antibiotic use. A resident received 9 doses of an antibiotic that were double the ordered dose and a resident's as needed anti-anxiety medication was ordered for greater than 14 days. (Resident 9, Resident 13) Findings include: 1. On 6/8/23 at 9:54 A.M., Resident 9's clinical record was reviewed. Diagnoses included, but were not limited to, non-Hodgkin lymphoma, hypo-osmolality, and hyponatremia. The most recent quarterly MDS (Minimum Data Set) Assessment, dated 3/14/23, indicated that the resident was moderately cognitively impaired and an extensive assist of 2 staff for bed mobility and toileting. The current physician's orders included, but was not limited to, the following: Bactrim 400-80 mg (milligram) tablet orally once a day on Tuesday, Thursday, and Saturday for UTI (urinary tract infection) prevention A current ADL (Activities of Daily Living) care plan,…
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 before2023-06-09 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed for 2 of 4 observations of resident care. Handwashing was not completed between dirty to clean tasks. Gloves were not changed between dirty and clean tasks. (Resident G, Resident 15) Findings include: 1. During an observation on 6/8/23 at 8:23 A.M., CNA (certified nurse aide) 6 toileted Resident G in the restroom. CNA 6 donned gloves, used the remote to raise the recliner, opened the door, removed gloves, donned a new pair of gloves and wiped the resident after she used the restroom. CNA 6 failed to sanitize or wash hands between changing gloves. During an interview on 6/9/23 at 8:37 A.M., the IP (infection preventionist) indicated between dirty to clean tasks that hands should be washed for 20 seconds or hand sanitizer should be used. 2. On 6/9/23 at 8:45 A.M., Resident 15's clinical record was reviewed. Diagnoses included, but were not limited to, Osteoarthritis, urinary incontinence, and pain. The most recent MDS Assessment, dated 5/19/23, indicated Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Ccited before2025-09-02 · tag F0732 — widespreadPost nurse staffing information every day.
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 posted nurse staffing forms were accurate for 4 of 6 days during the survey. Census information was not correct on the forms. Finding includes:On 8/27/25 at 12:43 P.M., a posted nurse staffing form was observed at the nurses station. The facility census was listed as 46. At that time, the Administrator indicated the current census was 54.On 8/28/25 at 1:02 P.M., a posted nurse staffing form was observed at the nurses station. The facility census was listed as 46. At that time, the Administrator indicated the current census was 55.On 8/29/25 at 9:10 A.M., a posted nurse staffing form was observed at the nurses station. The facility census was listed as 46. At that time, the Administrator indicated the current census was 55.On 9/2/25 at 8:40 A.M., a posted nurse staffing form was observed at the nurses station. The facility census was listed as 46. At that time, the Administrator indicated the current census was 56. On 9/2/25 at 8:45 A.M., the Administrator indicated the scheduler was responsible 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.
- No harm found · Ccited before2024-07-26 · 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 posted nurse staffing sheets were posted and contained the correct information daily for 1 of 6 days reviewed during the survey. (July 21) Findings include: On 7/21/24 at 10:09 A.M., the Posted Nurse Staffing form was observed sitting on the 100, 200, 300 Hall nurse's station dated 7/19/24. During an interview on 7/25/24 at 1:41 P.M., the ADON (Assistant Director of Nursing) indicated the Scheduler posted the Posted Nurse Staffing form daily in the morning at the beginning of the shift. On the weekend, the 300 Hall nurse posted it in the morning at change of shift. On 7/25/24 at 1:02 P.M., Regional Support 2 provided a Guidelines for Staff Posting policy, revised 5/11/16, which indicated At the beginning of the day the number and amount of hours of licensed nurses (RN [Registered Nurse] and LPN [Licensed Practical Nurse]) and the number and hours of unlicensed nursing personnel, per shift, who provide direct care to residents will be posted .
- No harm found · Ccited before2023-06-09 · 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 posted nurse staffing records contained the correct information daily for 1 of 6 days during the survey. Findings include: On 6/4/23 at 9:15 A.M., a staffing record was observed posted on the wall next to the nursing station located in the common area dated 6/2/23. During an interview on 6/8/23 at 8:55 A.M., the Administrator indicated she was not sure who was responsible for changing the posted nurse staffing on the weekend. During an interview on 6/8/23 at 9:21 A.M., the Administrator indicated she found out the nurse on night shift changed the posted nurse staffing for the weekend. On 6/8/23 at 11:12 A.M., a policy on Guidelines for Staff Posting, revised 5/11/16, provided by the Administrator, indicated At the beginning of the day the number and amount of hours of licensed nurses (RN and LPN) and the number and hours of unlicensed nursing personnel, per shift, who provide direct care to residents will be posted.
“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 TRILOGY HEALTH SERVICES — 123 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 4.2 | -2.2 vs chain |
| Health inspection | 2 of 5 | 3.5 | -1.5 vs chain |
| Staffing | 2 of 5 | 3.3 | -1.3 vs chain |
| Quality measures | 4 of 5 | 4.8 | -0.8 vs chain |
The other 122 homes this chain runs (chain average 4.2★, per CMS)
Showing 40 of 122; lowest-rated first.
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 |
|---|---|---|---|---|
| GOOD SAMARITAN HOSPITAL | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 05/01/2015 |
| KEYBANK NATIONAL ASSOCIATION | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | — | since 06/20/2025 |
| CORBIN, KATHY | Individual | CORPORATE DIRECTOR | — | since 07/01/2015 |
| MCLIN, ROBERT | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/06/1992 |
| SCHUCKMAN, MATTHEW | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/15/2021 |
| THACKER, ADAM | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2013 |
| TRILOGY HEALTHCARE OF BOONVILLE, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 11/01/2014 |
| DEYNE, JENNIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/02/2025 |
| SASH, KARL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/02/2025 |
| DAVIS, DAVID | Individual | LIMITED PARTNERSHIP INTEREST | — | since 12/31/2019 |
| BARNEY, LEIGH | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 10/03/2025 |
| AMERICAN HEALTHCARE REIT HOLDINGS LP | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| AMERICAN HEALTHCARE REIT INC | Organization | ADP OF THE SNF | — | since 10/01/2018 |
| CONTINENTAL MERGER SUB LLC | Organization | ADP OF THE SNF | — | since 10/01/2021 |
| GAHC3 TRILOGY JV LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| GAHC4 TRILOGY JV LLC | Organization | ADP OF THE SNF | — | since 10/01/2018 |
| PARAGON OUTPATIENT REHABILITATION SERVICES LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| TRILOGY HEALTH SERVICES LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| TRILOGY HEALTHCARE MASTER TENANT IV LLC | Organization | ADP OF THE SNF | — | since 10/03/2025 |
| TRILOGY INVESTORS LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| TRILOGY MANAGEMENT SERVICES LLC | Organization | ADP OF THE SNF | — | since 07/10/2025 |
| TRILOGY PROPCO FINANCE LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| TRILOGY PROPERTY HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| TRILOGY REAL ESTATE BOONVILLE, LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| TRILOGY REAL ESTATE INVESTMENT TRUST | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| TRILOGY REIT HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
CMS files one row per role, so the 36 rows in the source record cover these 26 parties — each is shown once here with every role it holds. Nothing is omitted.
18 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.1M paid to related parties — landlords or management companies under common ownership — equal to about 14% 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 155682. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-02, 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.